Reconstruction of malfunctioning ileoanal pouch procedures as an alternative to permanent ileostomy.

During the past 13 years, 261 patients with ulcerative colitis and 29 with colonic polyposis underwent endorectal pullthrough (ERP) at UCLA Medical Center. Of the first 111 consecutive patients to undergo ERP, 5 returned to a permanent ileostomy because of persistent symptoms related to reservoir stasis. Transabdominal shortening of the reservoir was performed in 38 of the 111 patients; 24 experienced marked clinical improvement. Fourteen of the 38 patients had persistent stasis and required shortening of the ileal spout either transanally (5 patients) or via an abdominoperineal approach (9 patients). Eighteen of the initial 111 patients underwent one-stage abdominoperineal reservoir reconstruction. During the past 4 years, 8 of 149 consecutive patients with a primary lateral isoperistaltic reservoir underwent subsequent abdominoperineal reservoir reconstruction. Fourteen of 18 patients with a straight pullthrough with reservoir underwent reconstruction to a lateral isoperistaltic reservoir. An aggressive operative approach to the management of pouchitis and reservoir stasis (diarrhea, frequency, urgency, incomplete emptying) has resulted in only 4 of the last 246 consecutive patients returning to a permanent ileostomy. Several changes in the operative technique have evolved during the 13-year period. Important features for optimal pouch function appear to include: (1) a short rectal muscle cuff, (2) a small ileal reservoir, (3) a short ileal spout, (4) removal of all rectal mucosa, and (5) aggressive correction of rectal strictures.