Endorectal ileal pullthrough with isoperistaltic ileal reservoir for colitis and polyposis

Seventy-eight patients with ulcerative colitis refractory to medical therapy and eight with colonic polypisis have undergone total colectomy mucosal proctectomy, endorectal ileal pull-through with ileoanal anastomosis, and diverting ileostomy at the UCLA Medical Center during the past 7 years. Seventy-seven patients underwent a second stage operation with construction of a lateral isoperistaltic ileal reservoir, 12 to 30 cm long, and closure of the ileostomy. A reservoir 10 to 15 cm long appears optimal for children, and one 20 cm long appears to function best for adults. Major complications were either related to obstruction of the reservoir outlet from leaving a rectal muscle cuff longer than 6 cm, and/or constructing the reservoir too long in the early experience (16 patients), or from cuff abscesses (four patients). Out of the 77 patients, these problems led to reservoir removal in three, temporary ileostomy in eight, and reservoir revision in 16. Persistent cuff abscess was the cause for reservoir removal in two of four patients. Continence was achieved in all patients within 2 weeks. Good to excellent results were obtained in 65 patients. At one year, 78% were completely continent during the day, 18% had minor seepage, and four per cent had occasional soiling. Frequency of defecation in patients without complications, or those surgically corrected, was seven per 24 hours within 3 months. There were no deaths. Six patients were found to have unsuspected cancer at operation. No patient experienced bladder dysfunction or abnormal sexual function. Although a technically difficult operation, the long-term results indicate that the pullthrough operation is a good alternative to proctocolectomy with ileostomy.