van Laarhoven C J H M, Hueting W E, Schipper M E I, Oostvogel H J M, Akkermans L M A, van Vroonhoven T J M V, Gooszen H G
Department of Surgery, St Elisabeth Hospital, Tilburg, The Netherlands.
Dig Surg. 2004;21(5-6):371-8; discussion 379. doi: 10.1159/000081679. Epub 2004 Oct 20.
Ileo-neorectal anastomosis (INRA), an alternative restorative procedure, was developed to reduce the pouch-related complication rate with an (at least) equal functional result.
For this surgical outcome, data of all INRA patients, including bowel function and complications, were prospectively recorded. The reservoir capacity was determined repeatedly by physiologic tests. The anal sphincter complex was assessed by manometry and ultrasound examination. Evaluation of the neorectal mucosa was performed by endoscopy.
An INRA procedure was carried out in 39/53 selected patients (47 ulcerative colitis and 6 familial adenomatous polyposis). Fourteen UC cases were converted to ileal pouch anal anastomosis or proctectomy only, because of impossibility to completely remove the rectal mucosa or short of length of the rectal stump. The median operation time for INRA was 323 min (range 240-518), with 1,400 ml blood loss (400-4,500). The reservoirs were permanently defunctioned in 2 patients--one because of reclassification into Crohn's disease, and one with pouchitis refractory to medical treatment. In 18 out of 37 cases, web-like stenoses occurred at the mucosa-anal level, which were treated by single (9) or repeated (5) dilatation or surgical stenoplasty (2). No pouch-related complications like pelvic sepsis, fistula or sexual dysfunction occurred. Thirteen patients had episodes of 'pouchitis', successfully treated with antibiotics, and 7 other cases, with functioning reservoirs, also had proximal 'non-specific' (i.e. no histological criteria of Crohn's disease found) small bowel inflammation. The median bowel frequency decreased from 15x/24 h initially to 7x/24 h at 2 years. Continence was perfect in 24/37 cases. Twelve out of 37 cases had occasional nocturnal soiling and passive nocturnal fecal incontinence was reported by 2/37 patients. The neorectal compliance volume recovered from 12.5 ml kPa after subtotal colectomy and 11 ml/kPa at 6 months after INRA to a neorectal compliance of 24 ml/kPa at 2 years' follow-up (p < 0.002; Wilcoxon signed rank test).
The INRA procedure shows a low complication rate and reasonable functional results, there was however a considerable conversion rate in these first 53 cases and a high incidence of reclassification to CD.
回肠 - 新直肠吻合术（INRA）是一种替代性的修复手术，旨在降低与贮袋相关的并发症发生率，并获得（至少）同等的功能效果。
为评估该手术效果，前瞻性记录了所有INRA患者的数据，包括肠道功能和并发症。通过生理测试反复测定贮袋容量。通过测压和超声检查评估肛门括约肌复合体。通过内镜检查评估新直肠黏膜。
在53例选定患者中的39例（47例溃疡性结肠炎和6例家族性腺瘤性息肉病）实施了INRA手术。14例溃疡性结肠炎患者因无法完全切除直肠黏膜或直肠残端长度不足，改为仅行回肠贮袋肛管吻合术或直肠切除术。INRA的中位手术时间为323分钟（范围240 - 518分钟），失血1400毫升（400 - 4500毫升）。2例患者的贮袋永久性失功，1例因重新分类为克罗恩病，另1例因药物治疗无效的贮袋炎。37例中的18例在黏膜 - 肛门水平出现网状狭窄，通过单次（9例）或重复（5例）扩张或手术狭窄成形术（2例）治疗。未发生盆腔脓毒症、瘘管或性功能障碍等与贮袋相关的并发症。13例患者发生“贮袋炎”发作，经抗生素治疗成功，另外7例贮袋功能正常的患者也有近端“非特异性”（即未发现克罗恩病组织学标准）小肠炎症。肠道频率中位数从最初的每24小时15次降至2年时的每24小时7次。37例中的24例控便良好。37例中的12例偶尔有夜间弄脏内裤情况，37例中的2例患者报告有被动性夜间大便失禁。新直肠顺应性容积从全结肠切除术后的12.5毫升/千帕和INRA术后6个月的11毫升/千帕恢复至随访2年时的24毫升/千帕（p < 0.002；Wilcoxon符号秩检验）。
INRA手术显示出较低的并发症发生率和合理的功能效果，然而在最初的这53例病例中，转换率相当高，重新分类为克罗恩病的发生率也很高。
