Manometric study in ulcerative colitis patients with modified ileal pouch--anal anastomosis

Sphincter-saving operations and construction of intestinal reservoirs aim at additional improvement quality of life of patients with restorative proctocolectomy. The conventional ileoanal anastomosis affects the function of the anal sphincters. There is a need for operative techniques that provide sufficient intraluminal anal pressure and thus a better postoperative continence and quality of life.

Ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy was carried out in 42 consecutive ulcerative colitis patients (age range: 19-55 years and mean age of 35.52 years). There were 17 males (40.48%) and 25 females (59.52%). IPAA was performed at dentate line, according to a standard method, in 20 patients (47.62% of the cases; mean age of 35.20 years), 19 of which were in 1986-1995 and one patient in 1998. In 1996-2002, however, IPAA was performed after plicating the demucosed segment of rectal residual in 22 patients (52.38% of the cases; mean age of 35.82 years). This modification consisted in strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of rectal residual. The basal anal-canal and squeeze pressures were recorded prior to the operation as well as 1 month afterwards and then every 6 months for 2 years. Kelly-Hohlschneider's continence scores after Herold's modification were applied in 14 consecutive patients.

Thanks to strengthening the internal anal sphincter by this segment, the basal pressure increased from a preoperative value of 68+/-6 mmHg up to 80+/-6 mmHg at the end of the second postoperative year (P<0.001). This favourable effect could be explained with the additional contractile potential of the plicated rectal segment resulting from the interference of the contractile potential of the internal anal sphincter with that of the smooth muscle cuff.

The modified IPAA creates a novel and probably functionally active anatomical substrate. The basal anal-canal pressure is maintained sufficiently high through the tone of the smooth muscle cuff and internal anal sphincter. Our preliminary results suggest that the presented technique for performing IPAA may contribute to better functional results.