Early Results with Restorative Proctocolectomy Paul E. Burke, Jacqueline Lappin, John Hyland
Department of Surgery, St. Vincent's Hospital, Elm Park, Dublin 4. Abstract The first 25 restorative proctocolectomies (RP) performed by one surgeon since 1986 are reviewed. Ulcerative colitis (23) and idiopathic megarectum (2) were the indications for surgery. The initial seven patients had a submucosal proctectomy and transanal hand sewn pouch-anal anastomosis. Eighteen patients had a totally stapled RP. One patient with malignancy died from factors unrelated to surgery. Complications developed in eight patients after pouch-anal anastomosis and in four patients after ileostomy closure. There was one pouch failure due to pelvic sepsis. No pelvic sepsis has occurred following a stapled ileal pouch-anal anastomosis with defunctioning ileostomy. After a mean follow up period of 20.5 months all patients are continent (mean stool frequency = 4/day and 0.5/night). Soiling occurred in three patients who had a transanal hand sewn pouch-anal anastomosis. All patents in the stapled group have satisfactory control. Restorative proctocolectomy produces satisfactory operative and functional results which have improved as our experience has increased. Introduction Restorative proctocolectomy was first described by Parks and Nichols in 1978 c~). The concept of the continent ileostomy using an ileal pouch was introduced by Kocl~2)and its transfer to the pelvis as a pouch-anal anastomosis was innovative. Since then it has become the operation of choice for chronic ulcerative colitis o,*). Initial results showed a significant incidence of early postoperative complications as well as long term problems such as frequency of defaecation and occasional incontinence. These problems have now been greatly minimised by a greater understanding of both pouch function ¢5.6),and the physiology of the ano-rectum and its mucosaa~). In addition, advances in anastomotic techniques have occurred which have made the restorative proctocolectomy much simpler than was the case hitherto¢9,1~. The results of a series of restorative proctocolectomies performed for both ulcerative colitis and idiopathic megarectum are reported. As well as presenting our results for analysis, we also wished to highlight how the operation of restorative proctocolectomy has evolved in our practice as it has worldwide and how this may be leading to better results. Patients and Methods Between January 1986 and January 1990 twenty-five patients have undergone proctocolectomy with ileal pouchanal anastomosis at St. Vincent's Hospital. Ulcerative colitis was the indication for surgery in twenty-three patients, and idiopathic megarectum in two. There were twelve males and thirteen females aged between 16 and 64 years (mean = 34.5 years). Of the 23 patients with colitis, eight had an elective restorative proctolectomy. The indications in these eight were: chronic ulcerative colitis unresponsive to medical therapy (4), dysplasia (2), and dysplasia with carcinoma (2). Fourteen patients initially presented as urgent or emergency Correspondence to: Mr. John Hyland, St Vincent's Hospital, Elm Park, Dublin 4. 266
cases and were only considered fit for excisional surgery in the form of a colectomy with end ileostomy and rectal mucous fistula. The indications for surgery in these 14 were: severe fulminant ulcerative colitis which was not responding to maximum medical therapy (10), toxic megacolon (2), perforation (1), and haemorrhage (1). Later all went on to have a restorative proctectomy and temporary defunctioning ileostomy which was subsequently closed (three stage). One other three stage procedure was carried out in a patient who had a previous colectomy and ileorectal anastomosis. Nine of the ten patients (colitic and megarectum) who had an elective restorative proctolectomy also had a defunctioning ileostomy which was subsequently closed (two stage). One patient had a single stage totally stapled procedure, and this was one of the two patients with carcinoma of the colon associated with severe symptomatic colitis. A defuncfioning ileostomy was not performed in this patient and her long term prognosis was thought to be poor, and it was hoped that a single stage procedure woud avoid the necessity for a second admission and thus minimise her hospital stay.
Results Eleven complications - seven major and four minor developed in eight of the 25 patients after the ileal pouch-anal anastomosis. In contrast, six complications occurred in five of the 18 patients who had a totally stapled procedure. Technical factors can be attributed to the one case of haemorrhage in a hand sewn pouch and the case of pelvic sepsis which occurred in one of the first two men whose original hand sewn pouchanal anastomosis was thought to be under tension. The pelvic sepsis was successfully treated by antibiotics and drainage, but the patient was unhappy with the result of the operation and requested that his pouch be removed (pouch failure rate = 4%). In the stapled group, the two technically related complications both resulted in peritonitis. One was due to a delayed perforation in the ileum resulting from trauma by a Babcock tissue forceps which was being used to hold the small bowel during the various intraoperative manoeuvres. The second was leakage at the pouch-anal anastomosis in one patient who
Vol.159
Early results with restorative proctocolectomy 267
No. 9/I0/11112
TABLE I Postoperative complications After Ileal Pouch-anal anastomosis
No.
8 patients (32%) MAJOR Pouch haemorrhage Pelvic sepsis Peritonitis Pulmonary embolus Cerebral infarction
1 1 2 2 1
MINOR Wound infection Abdominal wall excoriation
3 1
After lleostomy Closure 4 patients (18%) Small bowel leakage Enterocutaneous fistula Small bowel obstruction
2 1 1
had a one stage procedure. This patient subsequently died following a severe episode of hypercalcaemia which was found to be due to bone metastasis (mortality = 4%). The two pulmonary emboli occurred in women who were on prophylactic low dose heparin. As one patient had his pouch removed, and one patient had a one stage procedure, twenty-three patients had their defunctioning ileostomy closed at intervals ranging from three weeks to eight months (mean = 4) after the ileal pouch-anal anastomosis. Four patients developed complications following ileostomy closure (Table I), including the patient who developed peritonitis after her original restorative proctocolectomy. Three of these complications required reoperation: peritonitis from operative trauma to the ileum while closing the ileostomy, leakage from the anastomosis itself, and a leak from the distal end of the ileum of a stapled pouch resulting in an enterocutaneous fistula. One patient developed subacute obstruction which resolved spontaneously. Following closure of the ileostomy two patients required dilatation of their pouch-anal anastomosis (one hand sewn and one stapled) with no long term problems Functional Outcome After a mean follow up period of 20.5 months (range 2-50 months), 20 of the 23 patients are completely continent with no leakage at any time. Three patients have minor soiling and wear a pad, and all three belong to the transanal hand sewn group. The frequency of defaecation ranges from one to ten motions during the day (mean = 4 months) and zero to six at night (mean = 0.5). Four patients complain of anal discomfort or excoriation, and of these, three had a transanal hand sewn anastomosis. One patient complained of symptoms suggestive of pouchitis but these settled after a two week course of Metronidazole. No patients are taking anti-diarrhoeal medication. The two patients with idiopathic megarectum have had an excellent result from their surgery. Both are fully continent, pass three to four bowel motions during the day and none at night, and one has had an uneventful pregnancy with vaginal delivery.
Discussion Our results show that restorative proctocolectomy produces very satisfactory functional results in the majority of patients, with the mean frequency of defaecation and level of continence comparing favourably with the results from other centrest3,4). If patients are given the choice between a stoma and a pouch-anal anastomosis with such functional results, we believe that the majority will opt for reconstruction. Many would argue however that the high incidence of complications after ileal pouch-anal anastomosis and ileostomy closure resulting in 6 patients (24%) requiring a repeat laparotomy is too high a price to pay. However sixty-five percent of the patients had either none or minimal complications, and our results are comparable with those from larger centres particularly in the early parts of their seriesC3,~). Also it is reasonable for us to expect our morbidity rate to fall even further as our experience increases. The early complications can partly be explained by the learning curve in that five of the eleven complications occurred in three of the first seven patients. Two of these complications (pouch haemorrhage and pelvic sepsis) were related to technical aspects of the operation. This is in contrast to only two further technically avoidable complications (instrumental damage to the ileum and anastomotic leakage) in the subsequent 17 totally stapled and one hand-sewn procedure. Our pelvic sepsis rate compares favourably to that of Pemberton and Nichollst3'4~and it is encouraging that pelvic sepsis and other early complications did not account for any early morbidity in those who had a stapled ileal pouch-anal anastomosis with a defunctioning ileostomy. This supports the belief that the stapled pouch-anal anastomosis is both safer and more easily performed than the transanal hand sewn anastomosis~1°>. However, the one pouch-anal anastomosis which was not covered by a defunctioning ileostomy did leak, and we believe that until its safety has been fully evaluated the "one stage" restorative proctocolectomy should only be adopted in the very fit low risk patient. Three of the eleven complications were wound infections. All occurred in patients who had an ileostomy and rectal mucous fistula as a result of their previous colectomy. It may be that avoiding a mucous fistula by oversewing the rectal stump will help to reduce the incidence of wound complications. The most disappointing aspect of the results was two serious complications, both of which required a further laparotomy, resulting from closure of the ileostomy itself. One cannot attribute these complications to the learning curve, although ileostomy closure was associated with a 7% incidence of peritonitis in the first 180 patients reported from the Mayo Clinic~1~, and relaparotomy rate after conventional anastomosis is 10-15% 03,14). The morbidity associated with ileostomy closure is one of the arguments for a one stage procedure in patients who are not steroid dependen( 9>. As well as reducing morbidity this would avoid an additional hospital admission. If one is to do a one stage restorative proctocolectomy, then the totally stapled technique described is the procedure of choice because by the use of a single enterotomy for the applications of the long limbed stapler and the subsequent incorporation of this enterotomy into the
268 Burke et al. pouch-anal anastomosis. The functional results after a restorative proctocolectomy justify its position as the preferred operation for the surgical treatment of ulcerative colitis. The significant incidence of some form of soiling in the hand sewn transanal group in contrast to an absence of soiling in the stapled group appears to support the theory that avoiding the stretching of the internal anal sphincter - which occurs with an anal retractor during a transanal procedure - helps to maintain the resting anal sphincter pressure and preserve continencets.9~. By transecting the anal canal at or just above the dentate line, it is not necessary to perform a rectal mucosectomy. Overall our results show that restorative proctocolectomy achieves the objectives of removing the diseased bowel, and restoring the patient's ability to function relatively normally from a physical point of view without an ileostomy. The advent of improved operative techniques have made it technically easier to operform a restorative proctocolectomy and this in turn has helped to reduce morbidity and guarantee consistently reproducible results. We believe that restorative proctocolectomy is a significant advance in the treatment of conditions which require total excision of the colon and rectum and should now be the operation of choice in patients with ulcerative colitis. References 1. Parks, A. G., Nicholls, R. J. Proctocolectomy without ileostomy for ulcerative colitis. Br. Med. J. 1978: 2, 85-88. 2. Koch, N. G. Intraabdominal 'reservoir' in patients with a permanent ilenstomy: preliminary ~servations on a procedure resulting with fecal
I.J.M.S. Sept./Oct./Nov./Dee., 1990
continence in five ileostomy patients. Arch. Surg. 1969: 99, 223-231. 3. Pemberton, J., H., Kelly, K. A., BeaR, R. W., Dozois, R. R., Wolff, B. G., Ilstmp, D. M. Ileal pouch-anal anastomosis for chronic ulcerative colitis: long term results. Ann. Surg. 1987: 206, 504-513. 4. Nicholls, R. J. Restorative proctocolectomy with various types of reservoir. World J. Surg. 1987:11,751-762. 5. O'Connell, P. R., Pemberton, J. H., Brown, M. L., Kelly, K. A. Determinants of stool frequency after ileal pouch-anal anastomosis. Am. J. Surg. 1987: 153, 157-165. 6. O'Connell, P. R., Rankin, D. R. Wetland, L. H., Kelly, K. A. Enteric bacteriology, absorption, morphology and emptying after ileal pouchanal anastomosis, Br. J. Surg. 1986: 73, 909-914. 7. Johnston, D., Holdsworth, P. J., Nasmyth, D. G. et al. Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal procteetomy and endoanal anastomosis. Br. J. Surg. 1987: 74, 940-944. 8. Scott, N. A., Pemberton, J. H., Barkel, D. C., Wolff, B. G. Anal andileal pouch manometric measurements before ilcostomy closure are related to functional outcome after ileal pouch-anal anastomosis. Br. J. Surg. 1989: 76, 613-616. 9. Kmiot, W. A., Keighley, M.'R. B. Totally stapled abdominalrestorative proetocolectomy. Br. J. Surg. 1989: 76, 961-964. 10. Williams, N. S. Restorative proctocolectomy is the first choice elective surgical treatment for ulcerative colitis. Br. J. Surg. 1989: 76, 11091110. 11. Taylor, B. A., Dozois, R. R. The Jileal pouch-anal anastomosis. World J. Surg. 1987: 11,727-734. 12. Metealf, A. M., Dozois, R. R., Be.art, R. W. Jr., Kelly, K. A., Wolff, B. G. Temporary ileostomy for ileal pouch-anal anastomosis: Function and complications. Dis. Colon Rectum 1986: 29, 300-304. 13. Daly, D. W., Brooke, B. W. lleostomy and excision of the large intestine for ulcerative colitis. Lancet 1967: 2, 62-64. 14. Jones, P. F., Munro, A., Ewer, W. B. Coleetomy and fleoreetal anastomosis for colitis: report on a personal series with a critical review. Br. J. Surg. 1977: 64, 615-625.
Department of Surgery, St. Vincent's Hospital, Elm Park, Dublin 4. Abstract The first 25 restorative proctocolectomies (RP) performed by one surgeon since 1986 are reviewed. Ulcerative colitis (23) and idiopathic megarectum (2) were the indications for surgery. The initial seven patients had a submucosal proctectomy and transanal hand sewn pouch-anal anastomosis. Eighteen patients had a totally stapled RP. One patient with malignancy died from factors unrelated to surgery. Complications developed in eight patients after pouch-anal anastomosis and in four patients after ileostomy closure. There was one pouch failure due to pelvic sepsis. No pelvic sepsis has occurred following a stapled ileal pouch-anal anastomosis with defunctioning ileostomy. After a mean follow up period of 20.5 months all patients are continent (mean stool frequency = 4/day and 0.5/night). Soiling occurred in three patients who had a transanal hand sewn pouch-anal anastomosis. All patents in the stapled group have satisfactory control. Restorative proctocolectomy produces satisfactory operative and functional results which have improved as our experience has increased. Introduction Restorative proctocolectomy was first described by Parks and Nichols in 1978 c~). The concept of the continent ileostomy using an ileal pouch was introduced by Kocl~2)and its transfer to the pelvis as a pouch-anal anastomosis was innovative. Since then it has become the operation of choice for chronic ulcerative colitis o,*). Initial results showed a significant incidence of early postoperative complications as well as long term problems such as frequency of defaecation and occasional incontinence. These problems have now been greatly minimised by a greater understanding of both pouch function ¢5.6),and the physiology of the ano-rectum and its mucosaa~). In addition, advances in anastomotic techniques have occurred which have made the restorative proctocolectomy much simpler than was the case hitherto¢9,1~. The results of a series of restorative proctocolectomies performed for both ulcerative colitis and idiopathic megarectum are reported. As well as presenting our results for analysis, we also wished to highlight how the operation of restorative proctocolectomy has evolved in our practice as it has worldwide and how this may be leading to better results. Patients and Methods Between January 1986 and January 1990 twenty-five patients have undergone proctocolectomy with ileal pouchanal anastomosis at St. Vincent's Hospital. Ulcerative colitis was the indication for surgery in twenty-three patients, and idiopathic megarectum in two. There were twelve males and thirteen females aged between 16 and 64 years (mean = 34.5 years). Of the 23 patients with colitis, eight had an elective restorative proctolectomy. The indications in these eight were: chronic ulcerative colitis unresponsive to medical therapy (4), dysplasia (2), and dysplasia with carcinoma (2). Fourteen patients initially presented as urgent or emergency Correspondence to: Mr. John Hyland, St Vincent's Hospital, Elm Park, Dublin 4. 266
cases and were only considered fit for excisional surgery in the form of a colectomy with end ileostomy and rectal mucous fistula. The indications for surgery in these 14 were: severe fulminant ulcerative colitis which was not responding to maximum medical therapy (10), toxic megacolon (2), perforation (1), and haemorrhage (1). Later all went on to have a restorative proctectomy and temporary defunctioning ileostomy which was subsequently closed (three stage). One other three stage procedure was carried out in a patient who had a previous colectomy and ileorectal anastomosis. Nine of the ten patients (colitic and megarectum) who had an elective restorative proctolectomy also had a defunctioning ileostomy which was subsequently closed (two stage). One patient had a single stage totally stapled procedure, and this was one of the two patients with carcinoma of the colon associated with severe symptomatic colitis. A defuncfioning ileostomy was not performed in this patient and her long term prognosis was thought to be poor, and it was hoped that a single stage procedure woud avoid the necessity for a second admission and thus minimise her hospital stay.
Results Eleven complications - seven major and four minor developed in eight of the 25 patients after the ileal pouch-anal anastomosis. In contrast, six complications occurred in five of the 18 patients who had a totally stapled procedure. Technical factors can be attributed to the one case of haemorrhage in a hand sewn pouch and the case of pelvic sepsis which occurred in one of the first two men whose original hand sewn pouchanal anastomosis was thought to be under tension. The pelvic sepsis was successfully treated by antibiotics and drainage, but the patient was unhappy with the result of the operation and requested that his pouch be removed (pouch failure rate = 4%). In the stapled group, the two technically related complications both resulted in peritonitis. One was due to a delayed perforation in the ileum resulting from trauma by a Babcock tissue forceps which was being used to hold the small bowel during the various intraoperative manoeuvres. The second was leakage at the pouch-anal anastomosis in one patient who
Vol.159
Early results with restorative proctocolectomy 267
No. 9/I0/11112
TABLE I Postoperative complications After Ileal Pouch-anal anastomosis
No.
8 patients (32%) MAJOR Pouch haemorrhage Pelvic sepsis Peritonitis Pulmonary embolus Cerebral infarction
1 1 2 2 1
MINOR Wound infection Abdominal wall excoriation
3 1
After lleostomy Closure 4 patients (18%) Small bowel leakage Enterocutaneous fistula Small bowel obstruction
2 1 1
had a one stage procedure. This patient subsequently died following a severe episode of hypercalcaemia which was found to be due to bone metastasis (mortality = 4%). The two pulmonary emboli occurred in women who were on prophylactic low dose heparin. As one patient had his pouch removed, and one patient had a one stage procedure, twenty-three patients had their defunctioning ileostomy closed at intervals ranging from three weeks to eight months (mean = 4) after the ileal pouch-anal anastomosis. Four patients developed complications following ileostomy closure (Table I), including the patient who developed peritonitis after her original restorative proctocolectomy. Three of these complications required reoperation: peritonitis from operative trauma to the ileum while closing the ileostomy, leakage from the anastomosis itself, and a leak from the distal end of the ileum of a stapled pouch resulting in an enterocutaneous fistula. One patient developed subacute obstruction which resolved spontaneously. Following closure of the ileostomy two patients required dilatation of their pouch-anal anastomosis (one hand sewn and one stapled) with no long term problems Functional Outcome After a mean follow up period of 20.5 months (range 2-50 months), 20 of the 23 patients are completely continent with no leakage at any time. Three patients have minor soiling and wear a pad, and all three belong to the transanal hand sewn group. The frequency of defaecation ranges from one to ten motions during the day (mean = 4 months) and zero to six at night (mean = 0.5). Four patients complain of anal discomfort or excoriation, and of these, three had a transanal hand sewn anastomosis. One patient complained of symptoms suggestive of pouchitis but these settled after a two week course of Metronidazole. No patients are taking anti-diarrhoeal medication. The two patients with idiopathic megarectum have had an excellent result from their surgery. Both are fully continent, pass three to four bowel motions during the day and none at night, and one has had an uneventful pregnancy with vaginal delivery.
Discussion Our results show that restorative proctocolectomy produces very satisfactory functional results in the majority of patients, with the mean frequency of defaecation and level of continence comparing favourably with the results from other centrest3,4). If patients are given the choice between a stoma and a pouch-anal anastomosis with such functional results, we believe that the majority will opt for reconstruction. Many would argue however that the high incidence of complications after ileal pouch-anal anastomosis and ileostomy closure resulting in 6 patients (24%) requiring a repeat laparotomy is too high a price to pay. However sixty-five percent of the patients had either none or minimal complications, and our results are comparable with those from larger centres particularly in the early parts of their seriesC3,~). Also it is reasonable for us to expect our morbidity rate to fall even further as our experience increases. The early complications can partly be explained by the learning curve in that five of the eleven complications occurred in three of the first seven patients. Two of these complications (pouch haemorrhage and pelvic sepsis) were related to technical aspects of the operation. This is in contrast to only two further technically avoidable complications (instrumental damage to the ileum and anastomotic leakage) in the subsequent 17 totally stapled and one hand-sewn procedure. Our pelvic sepsis rate compares favourably to that of Pemberton and Nichollst3'4~and it is encouraging that pelvic sepsis and other early complications did not account for any early morbidity in those who had a stapled ileal pouch-anal anastomosis with a defunctioning ileostomy. This supports the belief that the stapled pouch-anal anastomosis is both safer and more easily performed than the transanal hand sewn anastomosis~1°>. However, the one pouch-anal anastomosis which was not covered by a defunctioning ileostomy did leak, and we believe that until its safety has been fully evaluated the "one stage" restorative proctocolectomy should only be adopted in the very fit low risk patient. Three of the eleven complications were wound infections. All occurred in patients who had an ileostomy and rectal mucous fistula as a result of their previous colectomy. It may be that avoiding a mucous fistula by oversewing the rectal stump will help to reduce the incidence of wound complications. The most disappointing aspect of the results was two serious complications, both of which required a further laparotomy, resulting from closure of the ileostomy itself. One cannot attribute these complications to the learning curve, although ileostomy closure was associated with a 7% incidence of peritonitis in the first 180 patients reported from the Mayo Clinic~1~, and relaparotomy rate after conventional anastomosis is 10-15% 03,14). The morbidity associated with ileostomy closure is one of the arguments for a one stage procedure in patients who are not steroid dependen( 9>. As well as reducing morbidity this would avoid an additional hospital admission. If one is to do a one stage restorative proctocolectomy, then the totally stapled technique described is the procedure of choice because by the use of a single enterotomy for the applications of the long limbed stapler and the subsequent incorporation of this enterotomy into the
268 Burke et al. pouch-anal anastomosis. The functional results after a restorative proctocolectomy justify its position as the preferred operation for the surgical treatment of ulcerative colitis. The significant incidence of some form of soiling in the hand sewn transanal group in contrast to an absence of soiling in the stapled group appears to support the theory that avoiding the stretching of the internal anal sphincter - which occurs with an anal retractor during a transanal procedure - helps to maintain the resting anal sphincter pressure and preserve continencets.9~. By transecting the anal canal at or just above the dentate line, it is not necessary to perform a rectal mucosectomy. Overall our results show that restorative proctocolectomy achieves the objectives of removing the diseased bowel, and restoring the patient's ability to function relatively normally from a physical point of view without an ileostomy. The advent of improved operative techniques have made it technically easier to operform a restorative proctocolectomy and this in turn has helped to reduce morbidity and guarantee consistently reproducible results. We believe that restorative proctocolectomy is a significant advance in the treatment of conditions which require total excision of the colon and rectum and should now be the operation of choice in patients with ulcerative colitis. References 1. Parks, A. G., Nicholls, R. J. Proctocolectomy without ileostomy for ulcerative colitis. Br. Med. J. 1978: 2, 85-88. 2. Koch, N. G. Intraabdominal 'reservoir' in patients with a permanent ilenstomy: preliminary ~servations on a procedure resulting with fecal
I.J.M.S. Sept./Oct./Nov./Dee., 1990
continence in five ileostomy patients. Arch. Surg. 1969: 99, 223-231. 3. Pemberton, J., H., Kelly, K. A., BeaR, R. W., Dozois, R. R., Wolff, B. G., Ilstmp, D. M. Ileal pouch-anal anastomosis for chronic ulcerative colitis: long term results. Ann. Surg. 1987: 206, 504-513. 4. Nicholls, R. J. Restorative proctocolectomy with various types of reservoir. World J. Surg. 1987:11,751-762. 5. O'Connell, P. R., Pemberton, J. H., Brown, M. L., Kelly, K. A. Determinants of stool frequency after ileal pouch-anal anastomosis. Am. J. Surg. 1987: 153, 157-165. 6. O'Connell, P. R., Rankin, D. R. Wetland, L. H., Kelly, K. A. Enteric bacteriology, absorption, morphology and emptying after ileal pouchanal anastomosis, Br. J. Surg. 1986: 73, 909-914. 7. Johnston, D., Holdsworth, P. J., Nasmyth, D. G. et al. Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal procteetomy and endoanal anastomosis. Br. J. Surg. 1987: 74, 940-944. 8. Scott, N. A., Pemberton, J. H., Barkel, D. C., Wolff, B. G. Anal andileal pouch manometric measurements before ilcostomy closure are related to functional outcome after ileal pouch-anal anastomosis. Br. J. Surg. 1989: 76, 613-616. 9. Kmiot, W. A., Keighley, M.'R. B. Totally stapled abdominalrestorative proetocolectomy. Br. J. Surg. 1989: 76, 961-964. 10. Williams, N. S. Restorative proctocolectomy is the first choice elective surgical treatment for ulcerative colitis. Br. J. Surg. 1989: 76, 11091110. 11. Taylor, B. A., Dozois, R. R. The Jileal pouch-anal anastomosis. World J. Surg. 1987: 11,727-734. 12. Metealf, A. M., Dozois, R. R., Be.art, R. W. Jr., Kelly, K. A., Wolff, B. G. Temporary ileostomy for ileal pouch-anal anastomosis: Function and complications. Dis. Colon Rectum 1986: 29, 300-304. 13. Daly, D. W., Brooke, B. W. lleostomy and excision of the large intestine for ulcerative colitis. Lancet 1967: 2, 62-64. 14. Jones, P. F., Munro, A., Ewer, W. B. Coleetomy and fleoreetal anastomosis for colitis: report on a personal series with a critical review. Br. J. Surg. 1977: 64, 615-625.
