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Background and Aims: Ileal pouch-anal anastomosis (IPAA) has become the standard treatment for patients with ulcerative colitis (UC) who ultimately require a colectomy. Herein, we report results of our 24-year experience with that surgical method at our hospital., Patients and Methods: Data were collected regarding surgical procedures and postoperative pathologic diagnoses for 1,000 UC patients, with early and late complications also noted. The pouch functioning rate was calculated using the Kaplan-Meier method., Results: We performed 1,000 operations for UC over a 24-year period. The mean patient age at the time of operation was 35 years, and the most frequent indication for a colectomy was intractable disease. The overall rates of pouch success after 10 and 20 years were 97% and 89%, respectively. During the study period, 944 patients underwent IPAA at our hospital, of whom 12 (1.3%) were eventually diagnosed with Crohn's disease (CD). Pouch success was higher in patients with UC, with a functioning ileal pouch after 10 and 20 years found in 97% and 92%, respectfully, whereas the proportions of patients with CD and a functioning ileal pouch were lower at 82% and 20%, respectively (p < 0.01)., Conclusion: A restorative proctocolectomy with an IPAA is a safe procedure, with low rates of mortality and major morbidity. We do not recommend routine application of IPAA in any subset of patients with known CD.

A questionnaire survey of ten institutions in Japan revealed that restorative proctocolectomy accounted for 81.8% of the surgical procedures performed in patients with UC in the last 5 years (1989-1993); ileoanal anastomosis (IAA) and ileo-anal canal anastomosis (IACA) were performed in 63% and 33% of these patients, respectively. Comparison of the two series showed that IACA was technically simpler and yielded better continence, but that it entailed a potential risk of recurrence of the disease in the remaining anal canal mucosa. Although IACA seems to be a useful surgical option for UC, until the long-term outcome of the procedure can be elucidated. It may be better regarded as a very low variation of IRA rather than as an improved technical version of IAA.

Total ulcerative colitis (UC) and familial adenomatous polyposis (FAP) are two major diseases that require total removal of the colorectal mucosa. To provide a high quality of postoperative life, various surgical techniques have been used. However, results were far from ideal. Since 1978, we have worked on the ileoanal anastomosis (IAA) technique to achieve both radical removal of the mucosa and preservation of natural anal function. From 1979 to 1991, a total of 155 patients were treated by IAA. To evaluate the surgical results, these patients were divided into three groups: the Tokyo series (49 cases, 1979-1983), Hyogo I series (49 cases 1983-1988) and Hyogo II series (57 cases, 1989-1991). The success rates in terms of preservation of anal continence were: 58% (UC) and 78% (FAP) in the Tokyo series, 84% (UC) and 96% (FAP) in the Hyogo I series and 92% (UC) and 100% (FAP) in the Hyogo II series. The surgical time and blood loss were significantly reduced in the later series. Of the 82 patients followed up for 6 mo in the two Hyogo series, anal continence was normal or nearly normal in 54 patients, with only minor leakage at night in 22 patients. Septic complications in the pelvic caused the majority of surgical failures. We conclude that improved IAA techniques can achieve total removal of the colorectal mucosa and preserve anal function in more than 90% of patients with UC or FAP. However, the skill of an experienced surgeon is still required to achieve this goal. The long-term outcome of anal function after such procedures needs further evaluation.

The water and electrolyte balance was studied in 31 patients with ulcerative colitis (UC) and 22 with familial adenomatous polyposis (FAP) who underwent staged surgery involving colectomy and ileal J pouch-anal anastomosis (IAA), preoperatively, after terminal ileostomy, after high ileostomy, and after ileostomy closure. Serum electrolytes did not differ between each surgical stage. After terminal or high ileostomy, daily urine volume and urinary sodium loss was significantly lower, and daily fecal weight and fecal sodium loss was significantly higher than preoperatively. After ileostomy closure, urinary and fecal sodium loss became closer to preoperative value. Daily urinary potassium loss was significantly higher and fecal loss was lower after terminal and high ileostomy than preoperatively and did not show a significant change after ileostomy closure. The urinary sodium to potassium ratio after ileostomy closure was lower than preoperatively, but was higher than that after terminal and high ileostomy. Plasma aldosterone and renin levels were only significantly increased after high ileostomy. These findings indicate that high or terminal ileostomy caused chronic dehydration, which was compensated for by activation of the renin-aldosterone axis, while the water and electrolyte balance became closer to normal after ileostomy closure following ileoanal anastomosis.

Objective: To find out whether the extent of inflammation of the anorectal mucosa affects the quality of the mucosectomy and postoperative function in patients undergoing total colectomy with mucosal proctectomy and ileoanal anastomosis., Design: Prospective study., Setting: University hospital., Subjects: 33 patients with ulcerative colitis and 17 with familial adenomatous polyposis., Interventions: With the patient in the prone jackknife position, the anorectal columnar mucosa above the dentate line was removed transanally by the forceps coagulation technique., Main Outcome Measures: Score of histological appearance on light microscopy., Results: All the patients with ulcerative colitis had moderate (n = 17, 52%) or severe (n = 16, 48%) inflammation, and their mean histological score was 12 (range 7-16). The patients with polyposis had little or no inflammation, and a mean histological score of 0.4 (range 0-2). The mucosectomy became more difficult as the severity of the inflammation increased, but there were no significant differences between the two groups in operating time, blood loss, or bowel function postoperatively., Conclusion: Though mucosectomy is technically more difficult in the presence of severe inflammation, there were no adverse effects on bowel function postoperatively.

During past nine years, our Department performed 115 J-pouch ileoanal anastomosis in a three stage procedure, of whom 7 (6.1%) experienced pouch failure. Pelvic or intra-abdominal sepsis was the major cause of pouch failure. Our current technique, the technical pitfalls of this procedure and possible countermeasures are described. Most of the septic complications can and should be prevented by careful patient management and proper surgical techniques.

Method of bowel function and quality of life (QOL) is more importantly questioned in IAA than IACA. UC patients have less complete IAA function than in the FAP; the former, nevertheless, were more favorably satisfied of the result than in the latter. UC series was found to include the patient with "anal personality" who tended to be more tolerable with bowel dysfunction. Daily stool frequency, nocturnal stool and soiling frequency were found proportionally related with patient's satisfaction rate and grade of frustration tension. A standardized integrated clinical category system was designed from the stand point of patient satisfaction. Well organized care and management system on post IAA course could accelerate functional recovery and could even step up QOL.

We investigated the daily life and opinions of patients after total proctocolectomy and ileal J-pouch-anal anastomosis. Eighty patients answered a questionnaire, completed Cattell's anxiety scale, and recorded bowel function for one month. Both colitis and polyposis patients defecated five times daily, had 1.6 episodes of nocturnal motions weekly, and soiled twice weekly. However, colitis patients were more satisfied with their bowel function and surgical outcome than were polyposis patients. This difference had a close relationship to the personality factors of ego strength and frustration. All patients with either disease who defecated less than three times daily, had no nocturnal motions, and had no soiling showed normal ego strength and frustration and were completely satisfied with their bowel status and operation. In contrast, patients defecating more than seven times daily or more than once per week nocturnally and soiling more than four times weekly had high frustration and were dissatisfied. Thus, satisfaction with surgery correlated not only with the objective outcome but also with personality and lifestyle.

Physicians treating patients with ulcerative colitis are confronted with the difficult task of deciding whether medical or surgical treatment is best for their patients. There are no definitive criteria to indicate when medical therapy should be exchanged for definitive surgery. Even in patients who respond well to glucocorticoid treatment, the side effects of these drugs may necessitate surgery. We reviewed the steroid complications of our operative cases retrospectively. Although ulcerative colitis was usually in remission, severe steroid complications were no longer tolerable and definitive surgery was required. We also reviewed the literature regarding the adverse effects of steroid. Because of advances in sphincter-preserving surgery, re-evaluation of the treatment of ulcerative colitis is necessary. Although conservative treatment remains the first choice, tolerance of irreversible side effects (especially in children) no longer seems to be justified. In such patients, early definitive surgery may offer more than it appears to sacrifice.

The protein tyrosine kinase (PTK) activity was measured in the inflamed colonic mucosa of 12 patients with ulcerative colitis and in the normal colonic mucosa of 12 control patients with colon cancer. The specific PTK activity in the particulate fraction obtained from ulcerative colitis mucosa was significantly increased compared with that of normal mucosa (5.10 +/- 0.60 pmol/min/mg versus 2.12 +/- 0.44 pmol/min/mg protein; p less than 0.05). Inflamed ulcerative colitis mucosa also showed a significantly higher total PTK activity in the particulate fraction than normal mucosa (2.60 +/- 0.42 pmol/min/g versus 0.91 +/- 0.16 pmol/min/g tissue; p less than 0.05). Mucosal samples from ulcerative colitis patients were divided into those with mild and those with severe inflammation on histologic examination (n = 6 each). The particulate PTK activity of severely inflamed mucosa was significantly higher than that of mildly inflamed mucosa (p less than 0.05). These results suggest that colonic inflammation in ulcerative colitis is associated with alterations in cellular PTK activity.

Fecal bile acids (FBA) were analyzed by gas-liquid chromatography in 29 patients [17 with ulcerative colitis (UC) and 12 with adenomatosis coli (AC)] and 5 healthy volunteers. Seven UC and 9 AC patients had undergone total colectomy and J-shaped ileal pouch-anal anastomosis (JAA). The mean daily FBA output was similar for JAA and terminal ileostomy patients (approximately 370 mg/day), and was about 1.5 times that of healthy Japanese volunteers (approximately 235 mg/day). The output of unconjugated bile acids, secondary bile acids, and 7-dehydroxylated bile acid was higher in JAA patients with UC than in terminal ileostomy patients, but there were no significant differences between the groups. The total fecal bacterial count in JAA patients was 10 times that in terminal ileostomy patients but was 1/10 of that in healthy volunteers. In patients with defunctioning high ileostomy, FBA output increased markedly (maximum, 3054 mg/day), and serum cholesterol levels were also significantly lower (P less than 0.05). These results suggest that after JAA the bile acid metabolism and fecal bacterial flora undergo more normalization than after terminal ileostomy.

Protein kinase C (PKC) activity was measured in the inflamed colonic mucosa of 24 patients with ulcerative colitis and in the normal colonic mucosa of 10 patients with other benign diseases. The particulate fraction activity in ulcerative colitis mucosa was significantly increased compared with that of normal mucosa (320 +/- 47 versus 200 +/- 30 pmol/min/mg protein; p less than 0.05). Inflamed ulcerative colitis mucosa also showed significantly increased total PKC activity in the particulate fractions compared with normal mucosa (147 +/- 26 versus 37 +/- 8 pmol/min/mg tissue; p less than 0.05). Mucosal samples from ulcerative colitis patients were divided into 12 with mild and 12 with severe inflammation by histologic examination. The particulate PKC activity of severely inflamed mucosa was significantly lower than that of mildly inflamed mucosa (p less than 0.05). These results indicate that colonic inflammation in ulcerative colitis may be associated with altered cellular PKC activity.

Localized giant pseudopolyposis is a rare complication in patients with ulcerative colitis which progresses to a huge intramural polypoid mass. Our case described here is a 30-yr-old female with chronic ulcerative colitis who developed localized giant pseudopolyposis with unexpected infiltrating adenocarcinoma. This case is one of an unusual form of cancer presentation in ulcerative colitis, and it indicates that we should be aware of the possibility of occult adenocarcinoma inside a large pseudopolyposis with no superficial dysplasia.

Background: This study included 16 patients without complications, eight patients with ulcerative colitis, and eight patients with familial adenomatous polyposis. All patients underwent colectomy, mucosal proctectomy, and ileoanal anastomosis in the jackknife position with complete removal of the rectoanal columnar mucosa above the dentate line (IAA) through the anus., Methods: The patients were divided into two groups: eight patients with the rectal cuff about 7 cm from the dentate line, "the medium-cuff group," and eight patients who underwent resection of the rectal stump above the levator, leaving a cuff of 2 cm, "the minimum-cuff group.", Results: In the medium-cuff group the percent recovery of maximum resting pressure and maximum squeeze pressure 12 months after IAA were not significantly decreased, the rectoanal inhibitory reflex recovered in 87.5% of patients, and all patients regained continence. In the minimum-cuff group, however, the percent recovery for both pressures remained significantly reduced, the reflex never recovered, and only 25% of the patients were continent after 12 months (p less than 0.05). There was no significant difference in capacity or distensibility of the ileal pouch between the groups., Conclusions: These results indicate that the medium-cuff method was associated with a superior functional result compared with the minimum-cuff method in the early postoperative period and the cuff in the lower rectum connected with the visceral nerves should be preserved to achieve better bowel function in the patient undergoing IAA. The initial mucosectomy through the anus in the prone jackknife position is useful for this purpose.

We report a case of vipoma of the pancreas in conjunction with ulcerative colitis in a 20-yr-old woman. Twenty months after the onset of ulcerative colitis, the patient complained of watery diarrhea and was found to have an electrolyte disorder. A pancreatic tumor was detected by ultrasonography and computed tomography, along with an elevation of serum vasoactive intestinal polypeptide (VIP). The secretory diarrhea diminished dramatically, and the serum VIP level decreased into the normal range immediately after resection of the pancreatic tumor. Immunohistochemical staining revealed a pancreatic vipoma. Despite removal of the vipoma, she underwent restorative proctocolectomy and ileal J-pouch anal anastomosis 2 yr later due to progression of the ulcerative colitis. Postoperative course was uneventful, with excellent functional results. Knowledge of this rare condition accompanying ulcerative colitis may help in the management of the patient with an atypical clinical course.

A patient with ulcerative colitis previously treated with restorative proctocolectomy and ileal J-pouch anal anastomosis had recurrent pelvic abscess and poor functional results for 3 years postoperatively. To improve the quality of life, the J pouch was converted to a Kock's pouch. The successful result implies that Kock's continent ileostomy is a good replacement for failed pelvic pouch.

Since 1978, J. Utsunomiya has performed total colectomy, mucosal proctectomy and ileoanal anastomosis (IAA) in 105 patients and analysed their results in 97 patients consisting of 61 of familial polyposis (FP) and 36 of ulcerative colitis (UC) those who have been observed for two months to 10 years after operation. The operative procedures were classified in the three modalities. I. the "end to end-long cuff", II. "J-pouch-long cuff" and III. "J-pouch-short cuff" procedure. The success rate has been improved to 93.0% in the procedure III. compare with 74.1% in the II and 61.5% in the I. This improvement was achieved by preservation of reservoir continence, reduction of pelvic sepsis and less damaging of the internal sphincter during operation. Through a series of evolutional modification, the surgical technique has been established to the present method which is constructed with the four principal components: direct anastomosis of J-ileal pouch to the anus, short rectal cuff mucosectomy, anoabdominal approach at prone jack-knife position and routine use of defunctioning ileostomy. With this technique, both FP and UC patients enjoyed excellent or good function in 90% of the cases. Sex of the patient did not influence the functional result, but older patients showed poorer results compared with the younger patients. This procedure can provide a function comparable with ileorectal anastomosis with a technical difficulty similar to that of the abdominal pouch. All patients with FP or UC who require colectomy are candidates for IAA unless they are 60 years or older. For UC a three stage surgical procedure of IAA proceeded by open rectal excluding colectomy could improve the result.(ABSTRACT TRUNCATED AT 250 WORDS)

The ideal surgical treatment for ulcerative colitis is the ileoanal anastomosis (IAA), which, however, is not yet generally accepted as a practical procedure because of a suboptimal fecal function, frequent postoperative complications and technical difficulties. Based on one (U.) of the authors experiences on 36(34) polyposis and 19(12) colitis (paracentesis indicate the number of cases in (U.)'s previous appointment, Tokyo Medical and Dental University, 1977-1983). The practical procedure of IAA can be achieved by combining the following basic principles; a direct anastomosis of J-shape ileal pouch to the anal sphincteric mechanism, temporarily exclusion of the anastomosis by a loop-ileostomy, mucosectomy confined to the lower rectum leaving the short muscular cuff, and meticulous dissection of inflamed mucosa of the anal canal minimizing the damage to the internal sphincter which is achieved by the prone ano-abdominal approach. At elective operation, the procedure can be performed either as primary surgery or as the secondary following rectum preserving operation, in which, coeco-rectal anastomosis is advisable for preserving the ileocolic vessels that is helpful for J-pouch construction. In emergency surgical program, IAA is still be preserved as a final restructive surgery following colectomy with an open rectal exclusion or Turnbull' s total colonic exclusion. In this occasion, an ascendicostomy is advisable for preserving the ileocolic vessels.