Scandinavian Journal of Gastroenterology

ISSN: 0036-5521 (Print) 1502-7708 (Online) Journal homepage: http://www.tandfonline.com/loi/igas20

A Prospective Randomized Comparison of Two Different Pelvic Pouch Designs T. Öresland, S. Fasth, S. Nordgren, T. Hallgren & L. Hultén To cite this article: T. Öresland, S. Fasth, S. Nordgren, T. Hallgren & L. Hultén (1990) A Prospective Randomized Comparison of Two Different Pelvic Pouch Designs, Scandinavian Journal of Gastroenterology, 25:10, 986-996, DOI: 10.3109/00365529008997624 To link to this article: http://dx.doi.org/10.3109/00365529008997624

Published online: 08 Jul 2009.

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A Prospective Randomized Comparison of Two Different Pelvic Pouch Designs T. ORESLAND, S . FASTH, S. NORDGREN, T. HALLGREN & L. HULTEN Dept. of Surgery 11, Sahlgren’s Hospital, University of Gothenburg, Gothenburg, Sweden

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Oresland T, Fasth S, Nordgren S, Hallgren T, HultCn L. A prospective randomized comparison of two different pelvic pouch designs. Scand J Gastroenterol 1990, 25, 986-996 The clinical, manovolumetric, and functional results of restorative proctocolectomy were studied in patients randomly allocated to construction of either a J-shaped pouch (n = 29) or a pouch fashioned by the folding technique used for the Kock continent ileostomy (K-pouch) ( n = 26). A complete endoanal mucosectomy was performed, and the pouches were all constructed from 30-cm lengths of ileum. There were no deaths and no significant difference in postoperative morbidity. Anal pressures were equal in the two groups. The K-pouch expanded more favourably postoperatively, and its volume at 1 year was significantly greater than that of the J-pouch (355 % 71 ml (SD); range, 225-495, versus 264 +- 81 ml; range, 75-440; p < 0.001). The pouches had similar motility patterns and sensory pressure thresholds. Initially after closure of the loop ileostomy there was a tendency for better functional outcome in K-pouch patients. At 1 year the overall distribution of functional defects did not differ, and the defaecation frequency was about equal in the groups. Key words: Manovolumetry; pelvic ileal pouch; ulcerative colitis T. Oresland, M. D . , Depr. of Surgery 11, Sahlgrenska sjukhuset, S-413 45 Goteborg, Sweden

Whereas most patients with an ileoanal pouch establish a fairly good function with time, excess stool frequency, need for night evacuations, and episodic soiling constitute common functional defects in others (1). Surgical techniques are still evolving in an attempt to improve the results. Previous clinical and experimental studies indicate that both pouch capacity and pouch motility pattern may be important functional determinants (2-5) and that the pouch design might therefore have an important impact on the clinical result. The S-shaped reservoir has been shown to attain a greater capacity than the J-shaped reservoir, whereas the W-configurated reservoir advocated by Nicholls et al. (6,7) is reported to be superior to both the J- and S-shaped reservoirs. Whether these differences are attributed to specific properties of the pouch configuration or simply to the different lengths of ileum used for construction is

not clear, however (8). On the basis of animal experiments, Kock (9) proposed that the doublefolded reservoir was a ‘low-pressure’ reservoir with little or no inherent motility, as the peristalsis of the reservoir segments were oriented in different directions. The large initial circumference would also create advantageous compliance and volume characteristics, as a relatively low pressure within the reservoir should create a wall tension that would favour rapid pouch expansion (10). The pouch folding technique advised by Kock has subsequently proved its merits in the continent ileostomy and urostomy. Experimental and clinical observations indicate that the expanding properties of the Kock pouch (K-pouch)that is, a pouch constructed in accordance with the principles used for the continent ileostomyare superior to those of the J-pouch (10-12). However, the value of most reports in assessing

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the comparative merits of different pouch designs is much reduced by various factors, since there appears to be considerable variation in the surgical techniques used, in the methods of selecting patients for operation, and also in the criteria adopted for assessing the functional results. The aim of the present study was therefore to compare the clinical and functional results by means of a randomized prospective trial in which patients were randomly allotted to two different pouch designs, the J-shaped pouch and the Kpouch, the latter constructed in accordance with the specific folding principle used for Kock's continent ileostomy but omitting the nipple valve. PATIENTS AND OPERATIVE METHODS From March 1987 to June 1988 patients with ulcerative colitis without cancer and residing in Sweden were considered for entry to the trial. After proctocolectomy and endoanal distal mucosectomy starting at the dentate line had been completed ( l ) , the distal reach (the ileum folded like a J with limbs 15cm long) was assessed. If satisfactory, the patient was entered into the trial, the choice of J- or K-pouch being made in accordance with a predetermined closed envelope system. The pouch, irrespective of design, was constructed from the terminal 30 cm of ileum, using double running Vicryl sutures. The K-pouch, folded in accordance with the technique described by Kock (9) for the continent ileostomy, is described in Fig. 1. Interrupted 3-0 Vicryl sutures were used for the construction of the ileoanal anastomosis, with exactly the same technique being used in all patients. All patients had a covering loop ileostomy. The details of pre- and post-operative routines are described elsewhere (1). Closure of the ileostomy was in all cases preceded by endoscopy and radiologic examination of the pouch, to ensure intact anastomosis and suture lines. Eighteen patients did not fulfil the inclusion criteria (because of a short mesentery in five). Of the 55 patients accepted, 29 patients were allotted to the J-pouch (age, 30 & 11 years; range, 16-61; 14 women) and 26 to the K-pouch (age, 36 +. 9

Fig. 1 . Construction of a Kock pouch. la. Two 15-cm ileal segments are sutured side-to-side and split open. Note the fingerwide opening left distally to the suture line. l b . The reservoir is formed by folding upwards along a transverse axis. lc and d. The corners of the created pouch are pushed inwards between the mesenteric leaves, bringing the posterior aspect of the pouch anteriorly and the opening for the ileoanal anastomosis distally.

years; range, 21-50; 8 women). Because we had originally intended to keep the trial open for a rather longer period, the allocation to the two trial operations was not quite equal. Ten J-pouch patients and seven patients in the K-pouch group were operated on with proctocolectomy and pouch construction as a primary procedure, whereas the other patients had had a previous colectomy and an ileostomy with preservation of the rectum. There were no significant differences in duration of illness before surgery, with a mean of 6 and 9 years, respectively, nor did the time

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Dirtension pressure

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x cm H20

(j

tran6ducer

1

tranrducer

External

Internal

sphincter

sphincter

P

Fig. 2. Schematic illustration of the manovolumetry set-up. For explanation, see text

with loop ileostomy differ (mean, 14 and 12 weeks, respectively). Manovolumetry

The manovolumetry device (13) consisted of an adjustable reservoir system connected to a highcompliance balloon (length, 12 cm; maximal volume, 600ml) (Fig. 2). Owing to the wide diameter of the reservoirs, the pressure used to distend the balloon could be kept constant despite great variation in volume. The volume change of the pouch was monitored as weight changes of the water reservoir ( 1 g = 1 ml) and recorded on a polygraph (Grass model 7D). The cuff of a disposable endotracheal tube (Mallinckrodt no. 7; outside diameter, 10mm) served as an anal probe for continuous recording of anal pressure. The cuff and its tubing were filled with water and connected to a Statham pressure transducer (P 23 D). Resting anal pressure was measured after 5 min of adaptation to the probe, and maximal squeeze pressure was taken as the best of three squeeze exercises. Volume at each distention pressure (from 5 to 80cm H 2 0 ) was defined as the highest volume recorded during a 1-min distention. The highest volume recorded at a distention pressure of 80 cm H 2 0 was denoted maximal pouch volume. Compliance was calculated as the millilitre volume increase per centimetre H 2 0 pressure increase in different pressure intervals. During each distention the patients were told to report whether they experienced the

sensation of pouch filling and, subsequently, when ‘urge’ or any sensation signalled the need for evacuation. The corresponding pressure and pouch volume at which the sensations were felt were recorded and referred to as ‘first sensation’ and ‘urge’, respectively. Rectoanal reflex sphincter inhibition was defined as 220% reduction of resting anal pressure and disappearance of spontaneous motility on distention of the pouch.

Follow-up procedure A specially designe-d follow-up form was used to record the full details of each patient’s operative and manovolumetric data and the functional results at each attendance during follow-up study. The patients were assessed preoperatively, before closure of the loop ileostomy, and subsequently at 1, 3 , 6 , and 12 months after closure of the loop ileostomy. The patients were interviewed with regard to functional outcome in accordance with a previously described score system (1) (Table I). A clinical investigation including endoscopy was also performed on each follow-up occasion. Pouchitis was defined as an episode of increased stool frequency with watery and/or bloodstained stools associated with urgency and an inflamed reservoir mucosa on endoscopy, and with symptoms severe enough to require treatment (metronidazole). Data are presented as mean SD and are those obtained at the 1-year follow-up study, if not

*

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Table 1. Arbitrary functional score designed to quantify overall functional result; range, 0-16; score 0 = best possible; score 16 = worst possible Score points 0

1

2

54 0 No

5

26

Illweek Yes

?2/night

No

Yes

No No No No

>l/week >]/week Yes occ.

No No No No No

>]/week >]/week Yes Yes

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No. of bowel movements

Daytime At night Urgency (inability to defer evacuation > 30 min) Evacuation difficulties (>I5 min spent in toilet on any occasion during the week) Soiling, seepage Daytime At night Inability to safely release flatus Perianal soreness Protective pad Daytime At night Dietary restrictions Medication (continuous or occasional) Secial handicap (not able to resume fulltime occupation or participate in social life)

otherwise stated. The statistics used were Student’s t test, chi-square with continuity correction, and linear regression analysis. Since we have previously shown that age is a determinant for functional outcome after restorative proctocolectomy (l), corrections for differences in age were made by using multiple regression analysis to study the effect of age and pouch type on functional score, incorporating a dummy variable for pouch type. The regression model used was y = bo b, + b2 2 , where y is the value of the score and b l , b2 are unknown regression coefficients to be estimated from data, x , = age, x2 = pouch type, where x2 = 1 for K-pouches and x 2 = 0 for J-pouches. If not otherwise stated, p < 0.05 was considered significant.

+

RESULTS Complications There were no clinical leaks; minor anastomotic defects were detected on endoscopy and/or radiography in two patients with a J-pouch and in three patients with a K-pouch. Closure of the loop ileostomy was postponed until radiographic

Permanent

Yes

investigations and inspection under anaesthesia had ensured that the defects were healed. An anastomotic stenosis occurred in one patient in each group and was overcome by dilatation. One patient with a J-pouch had a relaparotomy because of postoperative bleeding. Four patients (three J- and one K-pouch) were reoperated owing to small-bowel obstruction (two before closure of the loop ileostomy). A small-bowel perforation occurring immediately after loop ileostomy closure (K-pouch patient) was treated with exteriorization and subsequent reanastomosis. Other complications in seven patients included minor infections, urinary tract complications, and a case of nonA, nonB hepatitis. Two J-pouch patients had to be excluded owing to unspecific anal ulcerations that failed to heal on diversion. Thus of the 55 patients, 27 in the Jpouch and all 26 in the K-pouch group were available for follow-up study, and all were followed up for at least 1 year. During this time three patients with J-pouches experienced episodes of pouchitis, and one of these pouches eventually had to be removed 1; years after construction because of severe persistent symptoms. Six of the

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patients with a K-pouch had episodes of pouchitis, all responding well to metronidazole treatment.

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Manovolumetric findings Sphincter status. Maximal squeeze pressure showed an initial postoperative reduction in both groups of patients but recovered within 3 months to preoperative levels with no significant differences between the groups (Fig. 3 , upper panel). The mean preoperative resting anal pressure (RAP) was 70 t 15 mmHg in patients with a J-

*

pouch and 70 16 mmHg in those with a K-pouch (Fig. 3, lower panel). The RAP was significantly reduced as measured immediately before closure of the loop ileostomy (50 2 14 and 47 +- 18 mmHg, respectively), and when compared with preoperative levels, the RAP was still significantly (p < 0.001) reduced at 1 year, the reduction amounting to about 25%. In this respect there were no significant differences between the groups. Despite this marked reduction in sphincter tone, the RAP still remained within the 95% prediction limits for normal age-matched controls

Maxi mum squeeze pressure

270

T

230 I

E E 210

-

190

-

170

-

70

-

60

-

I

Q) 7

0

I

50

-

40

-

1

I

+/ Preop

I

Before

1

1

I

I

I

1

1

3

6

9

12

Months a f t e r ileostomy closure

Fig. 3. Maximal squeeze pressure (upper panel) and resting anal pressure (lower panel) at intervals (mean

?

SE).

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991

400 i

F

300

r

200

:

100

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1 0

3

1

I

1

6

12

Honths a f t e r ileostomy closure

Fig. 4. Maximal pouch volume for J- and K-pouches at intervals after surgery (mean SE).

of our laboratory (lower limit, 46 mmHg) in 13 of 27 paticnts (48%) with J- and in 18 of 26 (69%) with K-pouches. P o u d volume and compliance. Maximal pouch volumes at intervals after the operation are shown in Fig. 4. The pouch volume estimated initially

400

-

E

e z 0

*

after operation was 93 32 ml (range, 45-160) and 106 2 44 ml (range, 35-205) for J- and Kpouches, respectively (NS). Subsequently, however, the K-pouch volume expanded more favourably and proved to be greater than that of the Jpouch at all intervals and distention pressures

1 K

300

J 200

> 100

0

I

I

I

I

1

0

20

40

60

80

Distension pressure, cm Hz0

Compliance i n pressure interval p ( 0.05

Fig. 5. Pouch volumes at increasing distention pressures 12 months after surgery (mean SE) (upper panel). Calculated compliance in the pressure intervals at 0-20, 2040, 40-60, and 60-80 cm H 2 0 (lower panel).

*

T. Oresland et al.

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( p < 0.001). Regardless of pouch design, the most marked volume increase occurred within the first 3 months after ileostomy closure, and approximately 90% of maximal pouch volume at 1 year had been reached at that time. At 1 year the maximal volume of the J pouches was 264 2 81 ml (range, 75-440) and of the K-pouches 355 t 71 ml (range, 225-495 ml) ( p < 0.001). Whereas pouch compliance of the two designs was largely similar in the pressure intervals above 20cm H 2 0 , it was significantly higher in the Kpouch in the low-pressure interval (7.3 versus 10.8 ml/cm H 2 0 ; p < 0.001) (Fig. 5 ) . Motility. The motility pattern of the two pouch designs was similar. When studied at distention pressures up to 40cm HzO, both types showed volume reductions reflecting pouch wall tension that was in excess of the distention pressure used (Fig. 6). Twenty-three of the J-pouches (85%) and 17 of the K-pouches (65%) still showed these ‘high-pressure waves’ when maximally distended at 80cm H 2 0 . Sensory function. While the pressure thresholds for the J- and K-pouches for first sensation of pouch filling (22 10 versus 19 t 7 cm HzO) and for defaecation ‘urge’ (54 21 versus 48 2 15 cm HzO), respectively, were largely similar in the two groups, the corresponding volume thresholds for each sensation were higher in the K-pouch (135 70 versus 188 t 74 ml and 197 66 versus 273 64 ml; p < 0.01). Four patients, three with a J-pouch and one with a K-pouch did not experi-

*

*

*

* *

0

1

Time, min Fig. 6. Typical motility pattern on rapid volume distention (40 cm H 2 0 ) . Note pronounced volume reductions reflecting pouch contractions.

ence any ‘urge’ even at maximal distention (not included in calculations). Refrex inhibition. Reflex rectoanal inhibition was abolished in all patients. However, at the 1year follow-up it had reappeared in three patients, two with a J-pouch and one with a K-pouch. Functional outcome The mean daytime frequency decreased from 5.5 (median, 5; range, 3-11) at 1 month to 4.6 (median, 4; range, 3-9) at 1 year in the J-pouch patients and from 5.7 (median, 6; range, 4 8 ) to 4.9 (median, 5 ; range, 3-8) in patients with a Kpouch (NS). At the 1-year follow-up study 14 of the 27 J-pouch patients (53%) had 5 4 evacuations duringwaking hours, whereas 10 of the 26 patients (38%) with K-pouch had this low frequency (NS). Whereas 22 of 27 J-pouch patients (81%) and 17 of 26 patients (65%) with a K-pouch needed to evacuate at night ( 1 /week 22 /night

Urgency Evacuation difficulties Soiling, seepage daytime at night

Two Pelvic Pouch Designs

J ( ~ 2 7 )

K

52 33 15

39 38 23

56 33

38 50

11

12

993

(n=26)

nJ

k

BK

Inability to safely release flatus Perianal soreness Protective pad daytime at night Dietary restrictions Medication Social handicap I

0

20

60

40

80

100

R Fig. I . Percentage distribution of the score points at 1 year after surgery

pouch patients (22%) and 15 of 26 patients (58%) with a K-pouch ( p < 0.05) at least occasionally had problems with perianal soreness. Twenty-two of 27 J-pouch patients (81%) and 18 of 26 patients with a K-pouch (69%) stated that they preferred to rely on constipating drugs (NS). The gradual improvement with time after operation and the subsequent functional result at 1 year is shown in Fig. 8, in which the different aspects of functional imperfections have been amalgamated into the score system. Whereas the K-pouch patients tended to score more favourably than patients with a J-pouch during the immediate postoperative period (score 6.8 versus 8.4; p = 0.06), there were no significant differences in the overall functional results at any interval.

DISCUSSION The impact of the pelvic pouch design on the functional result is controversial. It has been claimed that the S-shaped pelvic pouch is more capacious than the J-configurated pouch and that it is therefore functionally superior, with less frequency, less urgency, and better overall continence (6, 14). There is also evidence to show that the W-configurated pouch is in these respects superior both to the J- and S-shaped reservoirs (7, 15, 16). Others have claimed that, although there may be initial differences between different pouch designs, the results become equal with the passage of time (17). Objections can be raised to these studies, however, as historical controls were

994

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e

.K O J

:il

’;

u m

T

T

-I-

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0 2

1

3

6

12

Months a f t e r ileos t o my closure Fig. 8. Age-adjusted score points at intervals after surgery (mean

5

SE).

used for comparisons, and there was considerable H z O , whereas at higher pressures the compliance variation in the surgical techniques used. More- of the K-pouch was mostly similar to that of the over, the length of ileum used for construction of J-configurated pouch. Moreover, with regard to the different designs differs, a fact that might also the motility pattern, no convincing differences influence the results, as there is strong evidence could be demonstrated. Both pouch models to show that the longer the ileal segment used, showed high-pressure contractions on distention, the bigger the subsequent pouch (5). Since the although these contractions appeared to be sometechnique used in the present study was uniform, what less frequent in the K-pouches. the length of ileum was equal, and patients were Although the hypothesis proposed by Kock is chosen at random, our results may be considered attractive, the spherical form of the K-pouch per reasonably accurate. Made from 30-cm lengths of se may well explain its superior expansion. ileum, the K-pouches constructed in accordance According to geometric formulae it can be calwith the double-folding technique recommended culated that the more cylindrical J-pouch conby Kock expanded more favourably than the J- structed from a 30-cm length of ileum would yield shaped reservoirs and attained a maximal volume a volume that is approximately 30% lower than that was about 50% greater. This observation is the spherical K-pouch constructed from an equal in accordance with a recent experimental study length of ileum. The favourable results obtained comparing different pouch designs in rats (10). with the spherical W-configurated pouch reported The present observation that the volume of the by Nicholls et al. (6) may also be in accordance K-pouch was greater and showed less variability with this view. Nevertheless, the wide range in than the J-pouch is in accordance with Kock’s volume expansion especially for J-pouches hypothesis (9,lO). indicating that the prerequi- demonstrated in the present study indicates that sites for a high muscle tone are eliminated by not only original limb length and design of the the double-folding technique. The fact that the pouch but also other factors may influence pouch compliance of the pelvic K-pouches was sig- expansion. The dimension and the viscoelasticity nificantly greater than that of the J-pouches would of the terminal ileum may vary, as may the degree also support such a view. However, this difference of postoperative fibrosis. The pelvic space is was largely dependent on the better ‘unfolding’ another variable that may limit the expansion of ability of the K-pouch at pressures below 20 cm the pouch (8). The observation that the intra-

Comparison of Two Pelvic Pouch Designs

abdominal continent ileostomy usually reaches

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a volume double that demonstrated for the pelvic K-pouches in this study supports this idea (12, 18). The threshold volumes for first sensation of pouch filling and ‘urge’ to defaecate were significantly higher in patients with a K-pouch. This difference might only be a reflection of the better volume expansion of the K-pouch, since the corresponding pressure thresholds required to elicit these sensory modalities were the same. The different volume thresholds in the two reservoir settings cast doubt on the hypothesis that the receptors for appreciation of filling and urge are located in the pelvic floor musculature (19.20). The present study has shown a tendency towards a functional advantage for the K-pouch with a better overall functional outcome as reflected by the score in the initial period after loop ileostomy closure, but these initial differences vanished with the passage of time. There were no major differences in defaecation frequency, and the functional defects were almost equally distributed in the two groups. This finding is somewhat surprising, considering the abovementioned significant volume difference throughout the follow-up period. In another randomized study of J- and W-pouches constructed of equal lengths of terminal ileum the investigators also failed to demonstrate any functional differences between the pouch models (21). However, the overall variability in functional outcome after restorative proctocolectomy is far from fully explained. We have previously shown that although a high pouch volume capacity, a high compliance, and the absence of high-pressure contractions in the J-pouch are determinants for a good functional outcome, these factors still only explain about 20% of the variability (5). Similar observations have been made by Becker & Raymond ( 2 2 ) , who found that diagnosis (ulcerative colitis or polyposis) and pouch capacity taken together accounted for only 10% of the total variance of stool frequency. Since pouch characteristics are perhaps of less importance than other as yet unexplored factors and known factors such as volume and quality of the ileal effluent (23), it is not too surprising that this study failed to show

995

any difference in functional outcome between the two pouch models. The choice of reservoir type should be based on the personal experience and preferences of the surgeon, taking into account ease of construction and caudad reach into the anal canal. From these points of view we found the K-pouch no different from the J-pouch. However, it seems reasonable to create a reservoir with a good volume capacity, using a minimal length of ileum. The K-pouch had better volume characteristics than the Jpouch and should. at least from a theoretical point of view, be a better option, minimizing the risk of malfunction due to a low volume capacity. In the present series, initial functional outcome tended to be better, and, if anything, the postoperative complication and reoperation rate was lower in the K-pouch group. ACKNOWLEDGEMENTS The authors thank Lena Hallsberg for technical assistance and Kjell Pettersson, Dept. of Statistics, University of Gothenburg, for statistical advice. This investigation was supported by grants from the Swedish Medical Research Council (17X-03117), the University of Gothenburg, Goteborgs Lakaresallskap, Assar Gabrielssons fond. and AB Skandias 100-5rs fond.

REFERENCES 1. Oresland T, Fasth S, Nordgren S, Hulten L. The clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients. Int J Colorect Dis 1989. 4, 5C56 2. Taylor BM, Cranley B, Kelly KA. PhillipsSF, Beart RW. Dozoiz RR. A clinico-physiological comparison of ileal pouch-anaf and straight ileoanal anastomosis. Ann Surg 1983, 198, 462-468 3. O’Connell PR, Pemberton JH, Brown ML, Kelly KA. Determinants of stool frequency after ileal pouch-anal anastomosis. Am J Surg 1987. 153. 157164 4. Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs. Br J Surg 1985,72,470-474 5. Oresland T, Fasth S. Nordgren S, Akervall S, Hulten L. Pouch size: the important functional determinant after restorative proctocolectomy. Br J Surg 1990, 77, 265-269

Downloaded by [University of Sydney Library] at 18:10 14 March 2016

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6. Nicholls RJ, Moskowitz RL, Shepherd NA. Restorative proctocolectomy with ileal reservoir. Br J Surg 1985, 72, S76-79 7. Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg 1987, 74, 567-568 8. Luukkonen P, Jarvinen H. Pelvic ileal reservoirs: experimental assessment of reservoir capacity in three reservoir designs. Ann Chir Gynaecol 1987, 76, 294-297 9. Kock NG. Intra-abdominal ‘reservoir’ in patients with permanent ileostomy. Arch Surg 1969.99.22323 1 10. Berglund B, Brevinge H, Kock NG, Lindholm E. Expansion of various types of ileal reservoirs in situ. An experimental study in rats. Eur Surg Res 1987, 19, 29g304 11. Hulten L, Fasth S. Nordgren S , Oresland T. Kock’s pouch converted to a pelvic pouch-a case report. Dis Colon Rectum 1988, 31, 467-469 12. Hallgren T, Fasth S, Nordgren S, Oresland ‘T, Hallsberg L, Hulttn L. Manovolumetric characteristics and functional results in three different pelvic pouch designs. Int J Colorect Dis 1989. 4. 156160 13. Akervall S, Fasth S, Nordgren S, Oresland T, HultCn L. Manovolumetry: a new method for investigation of anorectal function. Gut 1988, 29, 614623 14. Nasmyth DG, Johnston D, Godwin PGR. Dixon MF, Smith A, Williams NS. Factors influencing bowel function after ileal pouch-anal anastomosis. Br J Surg 1986, 73, 46%473 ,_

Received 23 January 1990 Accepted 16 March 1990

15. Harms BA, Hamilton JW, Yamamoto DT, Starling JR. Quadruple-loop (W) ileal pouch reconstruction after proctocolectomy: Analysis and functional results. Surgery 1987, 102, 561-567 16. Everett WG. Experience of restorative proctocolectomy with ileal reservoir. Br J Surg 1989, 76, 77-81 17. McHugh SM, Diamant NE, McLeod R, Cohen Z . Spouches vs. J-pouches. A comparison of functional outcomes. Dis Colon Rectum 1985, 30, 671-677 18. Berglund B, Kock NG, Myrvold HE. Volume capacity and pressure characteristics of the continent ileostomy reservoir. Scand J Gastroenterol 1984, 19, 683-690 19. Lane RHS, Parks AG. Function of the anal sphincters following colo-anal anastomosis. Br J Surg 1977, 64, 596-599 20. Scarli AF, Kiesewetter WB. Defecation and continence: some new concepts. Dis Colon Rectum 1970, 13, 81-107 21. Keighley MRB, Yoshioka K. Kmiot W. Prospective randomized trial to compare the stapled double lumen pouch and the sutured quadruple pouch for restorative proctocolectomy. Br J Surg 1988, 75, 1008-101 1 22. Becker JM, Raymond JL. Ileal pouch-anal anastomosis. A single surgeon’s experience with 100 consecutive cases. World J Surg 1986,204,375-383 23. O’Connell PR, Rankin DR, Weiland LH, Kelly KA. Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis. Br J Surg 1986, 73, 909-914