Col6i'eeial Disease: Original Articles

Col6i'eeial
Disease
Int J Colorect Dis (1989) 4:141-143
9 Springer-Verlag 1989
Original articles
Acute postoperative diverticulitis
J.M. Badia-P6rez, J. Valverde-Sintas, G. Franch-Areas, J. Pla-Comos and A. Sitges-Serra
Department of Surgery, Hospital Nostra Senyora del Mar, Autonomous University of Barcelona, Barcelona, Spain
Abstract. A c u t e d i v e r t i c u l i t i s f o l l o w i n g s u r g e r y is a
severe c o n d i t i o n r e p o r t e d p r e v i o u s l y o n l y a f t e r
h e a r t s u r g e r y . F o u r c a s e s o f d i v e r t i c u l i t i s in t h e
early postoperative period are presented, three of
them after non-cardiac procedures (tracheostomy,
inguinal hernia repair and laminectomy). Adv a n c e d age, a d m i n i s t r a t i o n o f m o r p h i n e , t r e a t m e n t
with steroids, postoperative constipation and intest i n a l m u c o s a l i s c h a e m i a a r e d i s c u s s e d as p o s s i b l e
a e t i o l o g i c a l f a c t o r s l e a d i n g to d i v e r t i c u l a r p e r f o r a tion. A l t h o u g h t h e d i a g n o s i s is o f t e n d i f f i c u l t , e a r l y
treatment offers the best chance of survival.
postoperative pain. Nine days following operation, while she

was making a satisfactory recovery, she developed fever. Several
blood, urine and sputum cultures were negative, and because of
the suspicion of bacterial endocarditis she was treated empirically with antibiotics. Two weeks later she complained of abdominal pain and developed signs of colo-vesical fistula. At that
time physical examination disclosed a hypogastric mass with
localised tenderness. An exploratory laparotomy showed an inflammatory mass in the area of the sigmoid colon, acute diverticulitis and a perivesical abscess. A transverse colostomy
was performed and a drain was placed in the sigmoid area. The
patient tolerated the procedure well and was discharged home to
await definitive surgery.
Case 2
A l t h o u g h d i v e r t i c u l a r d i s e a s e a n d its c l i n i c a l c o n s e quences have become increasingly prevalent among
the p o p u l a t i o n o f t h e W e s t e r n c o u n t r i e s , a c u t e
postoperative diverticulitis has been reported rarely. I n t h e e a r l y p o s t o p e r a t i v e p e r i o d a f t e r a n o n a b d o m i n a l o p e r a t i o n , d i v e r t i c u l i t i s is a p o t e n t i a l l y
life-threatening complication that requires a high
i n d e x o f s u s p i c i o n t o b e d i a g n o s e d . O n l y 18 c a s e s o f
acute diverticulitis following surgery have been
p u b l i s h e d in t h e E n g l i s h l i t e r a t u r e . A l l h a v e o c curred after heart surgery, mostly aorto-coronary
bypass.
Herein we describe four patients with postope r a t i v e a c u t e d i v e r t i c u l i t i s r e c e n t l y t r e a t e d in o u r
Department. Three of them developed the condition after non-cardiac surgery, an occurrence which
has not been previously reported. This complicat i o n s h o u l d be t a k e n i n t o a c c o u n t w h e n a b d o m i n a l
symptoms occur after non-abdominal surgical procedures.
Patients
Case 1
A 57-year-old woman underwent an elective uneventful aortic
valve replacement. The patient received morphine sulphate for
A 70-year-old man was admitted to the hospital because of

sudden coma. A brain scan revealed a thalamic haemorrhage.
He was intubated and treatment with steroids and mechanical
ventilation was initiated. Two days after admission a tracheostomy was performed under general anaesthesia. Fourteen days
after the operation the patient developed high fever, renal and
hepatic insufficiency and complained of left lower quadrant
abdominal pain with involuntary guarding and tenderness. At
laparotomy a perforated sigmoid diverticulum and a mesenteric
inflammatory mass were discovered. A transverse colostomy
with drainage of the pelvic area was performed. After a stormy
postoperative course the patient was discharged to another hospital to improve his neurological condition.
Case 3
A 77-year-old man was operated on under spinal anaesthesia for
a right inguinal hernia. He had an uneventful postoperative
course until 7 days after surgery when he developed abdominal
pain with abdominal distension. A diagnosis of intestinal obstruction was made. A barium enema disclosed diverticula and
a sigmoid perforation. At laparotomy a perforated diverticulum
was found and a left colostomy with drainage was performed.
The subsequent postoperative course was unremarkable with
complete recovery.
Case 4
A 47-year-old man underwent a laminectomy because of a
L5-$1 disc herniation. He had been on steroids for 5 days
before surgery. On the fourth postoperative day he complained
of left lower quadrant abdominal pain with fever, tenderness at
examination and leukocytosis. A diagnosis of acute diverticulitis
was made and he was placed on nasogastric suction and treated
142
with antibiotics and intravenous fluids. The symptoms improved in a few days and he was discharged home on the twenty
fifth postoperative day. One month later a barium enema confirmed diverticulosis of the sigmoid colon.
Discussion
The prevalence of diverticulosis and its complications has been continuously rising during the 20th
century particularly among people living in developed nations [1]. This can be explained by an increase in the elderly population and the lower fibre
content diets in Western countries [1-4]. The probability of developing diverticular disease is estimated to exceed 50% [2, 5] and acute diverticulitis
will develop in 15% of cases of diverticulosis [6].
Acute diverticulitis has been described as a complication in special settings such as renal failure [7],
polycystic kidney disease [8], immunosuppression
[9] and steroid treatment [10]. Renal transplant
recipients can also develop this complication,
although it is usually observed a long time after
transplantation [7, 11].
Acute postoperative diverticulitis, however, has
been rarely described previously in the English literature and only following heart surgery. During
the last 10 years several authors have reported a
total of 26,181 heart surgical procedures with 205
patients developing general surgical complications,
an incidence of 0.78% [13-16, 18-20]. Most of
them were gastroduodenal ulcer (32.7%), cholecystitis (15.6%), small bowel ischaemia or pancreatitis [12 18]. Only in 18 cases was acute diverticulitis diagnosed, representing 6.3% of all abdominal complications (Table 1). Two thirds of
the cases of acute postoperative diverticulitis presented with perforation, and 13 patients (72%)
were operated on. Hartmann's operation was the

most commonly performed procedure (69%), followed by left hemicolectomy and .drainage with
colostomy. The overall operative mortality was
23.5% [13-16, 18-20].
As far as we know, acute diverticulitis following
non-cardiac surgery has not been reported previously.
The pathogenesis of postoperative diverticulitis
is probably multifactorial. Given its high prevalence, the possibility of this association being merely incidental should be considered. The observation
of diverticulitis in patients with coronary disease
may be in part related to the advanced age of this
population, but other factors can also be implicated. It has been suggested that morphine sulphate
can be responsible for diverticular perforation following heart surgery [19]; cardiac surgeons often
use this drug to treat postoperative pain. Painter
[21] demonstrated that morphine increases intraluminal pressure in the sigmoid colon and causes
marked distension of the diverticula, presumably
increasing the risk of perforation. Only one of our
cases received morphine in the postoperative period, namely a woman who underwent an aortic
valve replacement. In the other three patients acute
diverticulitis developed in different disorders or after different surgical procedures. A number of authors have reported an increase of the likelihood of
diverticular perforation in patients receiving steroids [22 24]. Others have suggested that steroids
may also cause perforation in a previously normal
colon [10]. Two of our patients were receiving steroids when diverticulitis supervened. This, by itself
or in conjunction with other factors, may have been
implicated in the pathogenesis of this complication.
Table 1. Acute postoperative diverticulitis series published in the last 10 years

Author
Total
Previous
operation
Presentation
Perforation
Fistula
Treatment
Diverti- Obstrucculitis
tion
Surgical
Hartmann
Lucas 1980
Wallwork 1980
Pinson 1983
Reath 1983
Aranha 1984
Mirvis 1985
Burton 1986
1
1
2
1
8
2
3
Our series 1988
Bypass
Bypass
Bypass
Bypass
Bypass
Bypass
2 bypass
I valve
I valve
1 tracheost.
I herniorr.
I laminect.
1
1
2"
1
2
2
2
2
a No data on treatment; b no data on presentation
Medical
Colostomy
Hemicolectomy
38
143
The role played by low fibre content diets in the
pathogenesis of diverticula has been generally supported [1-4]. People on such diets usually suffer
from chronic constipation, the irritable bowel syndrome or diverticulosis. In the postoperative period
there may be a worsening in the constipation due to
changes in bowel habit, bed rest, drugs, anaesthesia
and the surgical procedure itself. During the recovery phase of colonic motility, postoperative constipation might lead to the generation of high pressures in the lumen of the colon bearing diverticula,
thus being responsible for perforation. This is speculative and further studies are required to examine
this hypothesis. Finally, it has also been proposed
that intestinal mucosal ischaemia induced by hypotension, low flow states, use of vasoconstrictor
drugs, microthrombi or emboli may contribute to
an increased risk of diverticulitis in the early postoperative period [18, 19]. Abdominal complications
in the postoperative period are often difficult to
diagnose. There is usually a substantial delay in
either diagnosis or treatment in all the series reported, especially in the elderly.
One of our patients could be successfully managed conservatively, as is the case in most patients
with acute diverticulitis when the diagnosis is made
promptly. In three of our patients laparotomy
was performed and an extensive pericolic inflammation was found. In these patients we performed
a colostomy and abscess drainage with a good result. Surgical intervention seems to be a reasonable
approach in advanced cases of postoperative diverticulitis [13, 14, 16, 18, 20], despite the fact that
these patients are recovering from a previous, often
major, operation. Hartmann's procedure is the preferred technique and probably the safest, yielding
an acceptable postoperative mortality rate. However, in one third of the patients with postoperative
diverticulitis reported [13, 14, 16, 18, 20], Hartmann's procedure was technically difficult to perform due to extensive pericolic inflammation, and
drainage colostomy was mandatory.
Acknowledgement. We thank Miss Teresa Badia for her excellent
help in improving the manuscript.
References
1. Almy TP, Howell DA (1980) Diverticular disease of the
colon. N Engl J Med 302:324 331
2. Hackford AW, Veidenheimer MC (1985) Diverticular disease of the colon. Surg Clin North Am 65:347-363
3. Sleisenger MH, Fordtran JS (1983) Gastrointestinal disease,
3rd edn. WB Saunders, Philadelphia
4. Goligher JC, Duthie HL, Nixon HH (1984) Surgery of the
anus, rectum and colon, 2nd edn. Balli~re Tindall, London
5. Connell AM (1977) Pathogenesis of diverticular disease of
the colon. Adv Inter Med 22:377-395
6. Schwartz SI, Shires GT, Spencer FC, Storer EH (1984)

Principles of surgery, 4th edn. McGraw Hill, New York
7. Starnes HF, Lazarus JM, Vineyard G (1985) Surgery for
diverticulitis in renal failure. Dis Colon Rectum 28:827 831
8. Scheff RJ, Harter H, Zukerman GR (1979) Diverticular
disease and colonic perforation in patients with polycystic
kidney disease. Gastroenterology 76:1236-1240
9. Perkins JD, Shield CF, Chang FC, Farha GJ (1984) Acute
diverticulitis. Comparison of treatment in immunocompromised and nonimmunocompromised patients. Am J Surg
148:745 748
10. Warshaw AL, Welch JP, Ottinger LW (1976) Acute perforation of the colon associated with chronic corticosteroid therapy. Am J Surg 131:442 446
11. Meyers WC, Harris N, Stein S, Brooks M, Jones RS,
Thompson WM, Stickel DL, Seiger HF (1979) Alimentary
tract complications after renal transplantation. Ann Surg
190:535-542
12. Lawhorne TW, Davis JL, Smith GW (1978) General surgical complications after cardiac surgery. Am J Surg
136:254-256
13. Lucas A, Max MH (1980) Emergency laparotomy immediately after coronary bypass. JAMA 244:1829 1831
14. Wallwork J, Davidson KG (1980) The acute abdomen following cardiopulmonary bypass surgery. Br J Surg
67:410-412
15. Pinson CW, Alberty RE (1983) General surgical complications after cardiopulmonary bypass surgery. Am J Surg
145:133 137
16. Reath DB, Maull KI, Wolfgang TC (1983) General surgical
complications following cardiac surgery. Am Surg
49:11-14
17. Hanks JB, Curtis SE, Hanks BB, Andersen DK, Cox JL,
Jones RS (1982) Gastrointestinal complications after cardiopulmonary bypass. Surgery 92:394-400
18. Aranha GV, Pickleman J, Pifarre R, Scanlon PJ, Gunnar
RM (1984) The reasons for gastrointestinal consultation
after cardiac surgery. Am Surg 50:301-304
19. Mirvis S, Scovill WA, Keremati B, Diaconis JN (1985) Colonic diverticulum perforation: report of two cases as a
complication of coronary artery bypass (Perforated diverticulum after coronary artery bypass). Am J Gastroenterol 70:547-549
20. Burton NA, Albus RA, Graeber GM, Lough FC (1986)
Acute diverticulitis following cardiac surgery. Chest 89:
756-757
21. Painter NS, Truelove SC (1964) The intraluminal pressure
patterns in diverticulosis of the colon. Gut 5:201-213
22. Palmer TH, Mason PJH, Adams AC (1955) Diverticulitis of
the colon with perforation during cortisone and ACTH
therapy. J Maine Med Assoc 46:349 351
23. Fein BT (1961) Perforation and inflamation of diverticula
of the colon secondary to long-term adrenocorticosteroid
therapy for bronchial asthma and pulmonary emphysema.
South Med J 54:355 357
24. Canter JN, Shorb PE (1971) Acute perforation of colonic
diverticula associated with prolonged adreno-corticosteroid
therapy. Am J Surg 121:46-49
Accepted: 21 December 1988
Dr. Josep M. Badia-P~rez
Department of Surgery
Hospital Ntra. Sra. del Mar
Psg. Maritim 25 29
E-08003 Barcelona
Spain
Col6i eeial
Disease
Int J Colorect Dis (1989) 4:144 149
Epidural anaesthesia and postoperative colorectal motilitya possible hazard to a colorectal anastomosis
A. Carlstedt ~, S. Nordgren a, S. Fasth ~, L. Appelgren 2 and L. Hult6n ~
1 Department of Surgery and 2 Department of Anaesthesiology, Sahlgrenska sjukhuset, G6teborg, Sweden
Abstract. The effects of epidural anaesthesia (EDA,

mepivacaine) and EDA in combination with
atropine and neostigmine on postoperative intestinal motility were studied in 17 patients undergoing operation for cancer of the rectum or sigmoid
colon. Motility was recorded by a volumetric technique. Epidural anaesthesia (EDA) increased motor activity in the small bowel as well as in the left
colon and rectum. Phasic motility dominated in the
small intestine whereas tonic and segmental contractions were recorded from the large bowel. EDA
induced a powerful tonic contraction with a concomitant shortening of the rectum. This effect was
inhibited by atropine. The influence of atropine/
neostigmine on left colonic motor activity was
studied in six patients before and during EDA in a
cross-over fashion. When administered alone,
atropine/neostigmine did not cause any motility increase. Atropine/neostigmine administered during
EDA, however, elicited a significant increase of
motility. The increase of intestinal motor activity
induced by EDA may expose a newly constructed
colorectal anastomosis to undue strain in the immediate postoperative period. When EDA is used in
combination with general anaesthesia, particular
attention should be directed towards the use of
neostigmine for reversing the effect of nondepolarizing muscle relaxants. Atropine appears
under such circumstances not to protect from the
excitatory effects of this drug on colorectal motility.
Anastomotic break-down is a significant cause of

morbidity and mortality in colorectal surgery [1],
particularly after low anterior resection of the rec-
turn [2]. Many factors may contribute to the complication, such as imperfect suturing technique,
tension in the anastomosis, pelvic sepsis and impairment of local blood supply [I, 3-5]. Increasing
attention has recently been paid to the role of the
anaesthesiological technique on the outcome of intestinal surgery [6, 7].
Epidural anaesthesia (EDA) of the thoracolumbar region which is commonly used in combination with general anaesthesia to decrease the
need for intravenous analgesia, and/or to relieve
postoperative pain, causes a blockade of the sympathetic outflow to the bowel and reduces the
neuro-endocrine response to surgical stress [8].
EDA and spinal anaesthesia are considered beneficial because of reported increase of intestinal
blood flow [9, 10] and reduction of peroperative
blood loss [11]. Moreover, since the sympathetic
innervation to the intestine is mainly inhibitory [12,
13], EDA or spinal anaesthesia has been employed
in the prevention or treatment of postoperative paralysis [14, 15]. All these effects of EDA appear
advantageous under certain circumstances. However, interference with postoperative reflex inhibition of motility may be unfavourable since augmented motility may expose a recently constructed
colorectal anastomosis to undue strain and particularly so when EDA is used in combination with
motility stimulating drugs.
It is well known that cholinesterase inhibitors
(e.g. neostigmine) used in doses that reverse the
effects of non-depolarizing muscle relaxants increase intestinal motility [16], and it has been postulated that neostigmine may under such circumstances also interfere with the integrity of a recently
constructed ileorectal anastomosis [17]. Atropine is
routinely given in combination with neostigmine to
145
evade unwanted cholinergic effects, but whether

atropine protects against the motility effects of
neostigmine is controversial [16]. The purpose of
the present investigation was therefore not only to
study the effects of EDA on intestinal motility but
also to compare the effects of the combined use of
atropine and neostigmine on left colonic motility in
patients with and without EDA.
2ocm
Patients and methods

Seventeen patients undergoing operation for cancer of the rectum or sigmoid colon were studied. Mean age at operation was
64 years (range 53 78 years). Informed consent was obtained
from all patients and the study was approved by the Ethical
Committee, University of G6teborg.
Anaesthesia and operative procedure

Pethidine (25 mg i.m.) was used as premedication whereas
atropine was withheld from the premedication and during general anaesthesia.
General anaesthesia. General anaesthesia was induced with thiopental sodium, 3 - 5 mg x kg-1 (Pentothal, Abbott). Endotracheal intubation was performed after the administration of succinylcholine, 1 mg x kg 1 (Celocurin, ACO). Complete muscle
relaxation was maintained by repeated doses of pancuronium
bromide, 1 mg (Pavulon, Organon). Anaesthesia was achieved
by the use of N 2 0 and O 2 (70/30) and repeated doses of fentanyl, 0.1 mg (Leptanal, Janssen). To reverse neuromuscular
blockade at the end of the operation, 2.5 mg of neostigmine was
given 1 - 2 min after the administration of 1 mg of atropine
(atropine/neostigmine). All drugs were administered i.v.
Epidural anaesthesia. Before induction of general anaesthesia,
an epidural catheter was introduced into the epidural space
(L2-L3). For EDA 1 0 - 1 2 ml of mepivacaine, 2% (Carbocaine,
Astra) was used, aiming at a segmental blockade, extending
from T h 6 - T h 8 to L 4 - L 5. The level of the sensory blockade was
assessed postoperatively by testing ventral dermatomes for sensitivity (pin prick, temperature and touch).
Motility recordings. Intestinal motility was observed during the

laparotomy and recorded by means of water-filled latex balloons. Motility recordings were performed immediately after
conclusion of the operation, with the patients still under general
anaesthesia, and at various intervals thereafter during the first
24 hours postoperatively. Each recording lasted 15 to 40 min.
Each balloon was connected to a water reservoir suspended on
a weight recorder (Grass Force Displacement Transducer FT 10
C) operating a Grass polygraph, model 7D. By adjusting the
height of the reservoir the pressure in the balloon was set to
20 cm H20. Intestinal volume changes were recorded as weight
changes of the water reservoir (Fig. 1).
Left colonic motility was recorded in 11 patients, with the
balloon introduced via the anus proximal to a colorectal anastomosis, or via a sigmoid colostomy when applicable. In three of
these patients two recording balloons, separated by 20 cm, were
used. Rectal motility was recorded in eight patients. For recording of small intestinal motility the balloon was introduced into
the distal limb of a loop-ileostomy (n=4).
Fig. 1. Schematic illustration of the motility recording technique
In six patients the effect of atropine/neostigmine on left

colonic motility was studied with and without EDA. These patients were examined in a random cross-over fashion and served
as their own controls. In three of the patients atropine/
neostigmine was administered 2 0 m i n after the induction of
EDA immediately after the conclusion of the operation. The
effect of the same combination of drugs on left colonic motility
was studied 5 - 6 hours later without EDA. In the remaining
three patients, the experiment was carried out in the reverse
order.
The effect of administration of atropine alone on rectal
motility response to EDA was studied in six patients.
Results
Basic motility pattern

Spontaneous colonic or rectal motility was not observed. In the small intestine phasic contractions
with a frequency of 6-10/min were recorded. The
amplitude of the phasic contractions recorded 5 h
postoperatively was higher than those recorded at
conclusion of the operation.
Effects of EDA
Epidural administration of mepivacaine decreased
systolic blood-pressure ( n = l l ) by 3 2 + 1 4 %
(mean _+SD).
Ileum. Direct observation of the small intestine during EDA revealed multiple segmental contractions,
1 - 3 cm long, travelling for several centimetres
along the intestine in both directions, while other
portions of the small bowel were quiescent and
showed no motility.
In two of four patients, studied 4 - 5 hours
postoperatively, the motility recordings showed
146
0
Small bowel
volume (ml)
,J
10
i
>
20
g-
10
Left colonic
volume (ml) 2 0
e~
ul
30
5
Time (min)
10
Fig. 2. The effect of EDA on small bowel and left colonic motility. Note increased phasic contractions in the small intestine and
tonic contraction of the colon in response to EDA
4o
~--E30
that EDA evoked increased amplitude and decreased frequency of phasic contractions with an
irregular pattern in the ileum. The effect, which was
gradual in onset and reached maximum 10-15
minutes after the induction of EDA, persisted
throughout the observation period (Fig. 2).
>
20
._~
cO
o
Left colon. During EDA, forceful segmental tonic

contractions were observed in the left colon. These
contractions were built up over 3 0 - 6 0 s and engaged 10 to 20 cm long segments of the bowel. In
some patients the contractions vanished and reappeared slowly after several minutes. The motility
recordings from the left colon during EDA varied
considerably between different subjects. EDA induced a marked tonic contraction of the left colon,
as reflected by a reduction of balloon volume in 9
of 11 patients (Figs. 2 and 3). Irregular phasic contractions, superimposed on the tonic contraction,
were noted in 7 of these 9 patients. In 2 of the 9
patients the colonic contraction completely emptied the recording balloon. The colonic tone increased gradually 2 - 5 min after the induction of
EDA
Fig. 3. Colonic volume, recorded as mean intraluminal balloon
volume to a constant distension pressure (20 cm H 2 0 ) before
and 5 - 1 0 rain after the administration of EDA in 11 patients.
Note decreased volume i.e. a contraction in 9 patients (p < 0.01,
Wilcoxon signed-rank test)
EDA and reached a maximum after 5 15 min. In

five patients the motor response persisted throughout the recording (15-40 min), whereas the effects
gradually subsided in the remaining four patients,
the basic level being reached within 8 - 1 5 min
(Fig. 4). In 2 of the 11 patients no effect of EDA on
left colonic motility was noted.
Left
colonic volume
proximal balloon
(ml)
20
40
Left
colonic volume
distal balloon
(ml)
20
40
EDA
Time
i
Mepivacaine,
(min)
2%, l O m l
i
Fig. 4. Colonic motor response to EDA. Upper

panel: 50 cm from anal verge. Lower panel: 30 cm
from anal verge. Note the colonic contractions and
superimposed phasic activity. There is no evidence
of propagated motility waves
147
so
10o
150 J
aim
EOA
mepivacaine,
T i m e (min)
Atropine
1 . 0 mg i.v.
2%, l O m l
.
without
10
Fig. 5. The effect of EDA followed by atropine on

rectal motility. Note that atropine abolished the
increased motility elicited by EDA
15
EDA
Left
colonic volume
20
(mi)
with
Left
Atropine
Neostigmine
l m g i.v.
2 , 5 m g i.v.
EDA
colonic volume
20
(ml)
40
Time (rain.)
Atropine
Neostigmine
l m g i.v.
2,5rag i.v.
Fig. 6. Typical record of the effect of atropine and neostigmine

administered before EDA (upper panel), and 20 min after EDA
(lower panel) in one patient. Note the contractions during EDA.
Recordings 5 h apart
In experiments with two synchronous recording

balloons, the contractions appeared simultaneously (Fig. 4) in the left colon during EDA. Propagated motility waves were not observed.
Rectum. At direct inspection a tonic contraction

with a pronounced shortening of the intraperitoneal rectum was observed during EDA.
This tonic rectal contraction with superimposed
phasic contractions was recorded in all eight patients studied. The response occurred 2 - 4 min after
the induction of EDA and reached a maximum
after 5 - 1 0 minutes (Fig. 5). The effect was main-
tained throughout the recording period. The rectal

response to E D A was more uniform than that of
the left colon and caused a more pronounced volume reduction.
The effect of atropine on the rectal motility response to EDA was studied in six patients. Intravenous administration of atropine ( 0 . 5 - 1 . 0 m g )
abolished both the tonic and phasic rectal motility
effects of E D A in all patients (Fig. 5).
A tropine/neostigmine
Administration of atropine/neostigmine in patients
without EDA did not cause any motility effects in
4 out of 6 patients, while a moderate tonic contraction of the left colon was recorded in two patients.
However, when administered during EDA,
atropine/-neostigmine elicited a pronounced motor
response in all patients (Figs. 6 and 7).
148
without EDA
with EDA
40
30
J
o
20
atropine/
neostigmine
T.
atropine/
neostigmine
Fig. 7. Diagrammatic representation of the effect of atropine/

neostigmine on left colonic motility in six patients with and
without EDA. Atropine/neostigmine increased left colonic motor activity when given under the influence of EDA (p < 0.05,
Wilcoxon). Recordings were made 10 rain after administration
of neostigmine. Note that comparison of absolute volumes without and with EDA cannot be made due to the time lapse between
the two investigations
Discussion
The results of the present study show that EDA of

the thoraco-lumbar region causes increased motor
activity in the left colon and the rectum and, in
some experiments, in the small bowel.
Reflex inhibition of gastro-intestinal motility
after abdominal surgery is a well known phenomenon. The resulting paralysis is more pronounced
and longlasting in the large bowel than in the stomach and small bowel [18]. There is strong experimental evidence that the paralysis is caused by a
peritoneo-intestinal spinal reflex operating via efferent sympathetic neurons [12, 19] or via the
adrenals [20]. There is also evidence for an inhibitory reflex transmitted through the prevertebral ganglia [21 ]. The mode of action of the inhibitory reflex
at the effector organ is not fully elucidated but
probably involves an inhibition of excitatory nervous activity on the ganglionic level [12, 22].
The increased motility noted after EDA is most
likely an effect of interruption of the inhibitory
sympathetic outflow to the intestine. The results
are in concert with recent studies in man showing
that motility of the sigmoid colon is increased by
beta-adrenergic antagonists and decreased by betaadrenergic agonists [23, 24], and are further supported by Gelman et al. [25] who observed increased intestinal motility in humans on high epidural anaesthesia. The direct observations and the
intraluminal volumetric recording technique used

in the present investigation showed evidence that
the increased motor activity elicited by EDA represented segmental contraction of the intestine,
rather than propulsive motility. The increased
rectal motor activity elicited by EDA was abolished
by atropine which indicates that these contractions
were elicited by cholinergic mechanisms.
Neostigmine is routinely used in anaesthetic
practice to reverse the effect of non-depolarizing
muscle relaxants. Atropine is usually administered
prior to or simultaneously with neostigmine to protect from cholinergic cardiovascular and secretory
effects. When administered before neostigmine, as
in the present study, atropine seemed to protect
from the excitatory effects of neostigmine in the left
colon. The protective effect of atropine as observed
in the present study in patients without EDA is in
concert with observations by Wilkins et al. [16],
studying patients under general anaesthesia for minor surgical procedures. During EDA, however,
neostigmine elicited a clear motor response despite
prior atropine administration. This increased susceptibility to the excitatory effects of neostigmine
during EDA has not previously been demonstrated.
A major issue of relevance for colorectal
surgery is the impact of EDA and the combination
of EDA and atropine/neostigmine on the integrity
of a colorectal anastomosis. In a retrospective
study on 68 patients with a large bowel anastomosis Aitkenhead et al. [11] reported a reduced incidence of anastomotic dehiscence after spinal or
epidural anaesthesia compared with general anaesthesia, although the difference in leak rate was not
statistically significant. The beneficial effect of
EDA was attributed to increased colonic blood
flow, which has been observed after blockade of the
sympathetic nerves both in dogs [9] and man [10].
The reduced systemic blood-pressure elicited by
EDA in the present study is consistent with a reduced peripheral resistance and hence increased
splanchnic blood flow. This potentially beneficial
effect of spinal nerve block versus conventional
general anaesthesia for patients undergoing large
bowel surgery was challenged in a randomised,
prospective study by Aitkenhead et al. [26]. The
leak rates were identical but the operative blood
loss was significantly less in the regional anaesthesia group. It should be observed that the patient
material was heterogeneous and that neostigmine
was not given to patients receiving spinal or epidural block in any of the two studies [11, 26].
Bell and Lewis [17] suggested that administration
of atropine does not completely eliminate the motor effect of neostigmine so that in patients with a
149
newly constructed anastomosis the intestinal contraction might be sufficient to cause disruption of
the suture line. As evidence for this hypothesis they
reported a 36% anastomotic leak rate in patients
undergoing colectomy and ileorectal anastomosis
after atropine/neostigmine compared to 4% in the
control group. Reports on early disruption of colonic anastomoses during EDA have been presented also by others [27, 28], although the combination
of EDA and neostigmine has not received attention.
It is concluded from the present investigation
that EDA increases colorectal motor activity. Under such circumstances, neostigmine, in a dose used
to reverse the effect of muscle relaxants, enhances
this motor response despite atropine treatment. Although a negative impact of EDA on the postoperative course in mixed surgical materials has not
been demonstrated, the effect of a combination of
EDA and neostigmine on the outcome of a low
anterior resection needs further investigation. Even
though a colorectal anastomosis may be considered
satisfactory and without any tension at the operation, it may be exposed to harmful strain by subsequent tonic contractions and shortening of the intestine as induced by EDA. The administration of
neostigmine may under these circumstances further
potentiate this danger.
Acknowledgements. This investigation was supported by grants

from the Swedish Medical Research Council (17X-03117), the
University of G6teborg, G6teborgs L/ikares/illskap, Assar Gabrielsson's fond and AB Skandias 100-gtrs fond.
References
1. Schrock TR, Deveny CW, Dunphy JE (1973) Factors contributing to leakage of colonic anastomoses. Ann Surg
177:513-518
2. Goligher JC, Graham NG, DeDombal FT (1970) Anastomotic dehiscence after anterior resection of rectum and sigmoid. Br J Surg 57:109-118
3. Irvin TT, Goligher JC (1973) Aetiology of disruption of
intestinal anastomoses. Br J Surg 60:461 464
4. Tagart REB (1981) Colorectal anastomosis: factors influencing success. J R Soc Med 74:111-118
5. Fasth S, Hult6n L, Hellberg R, Marston A, Nordgren S,
Schi61er R (1978) Blood pressure changes in the marginal
artery of the colon following occlusion of the inferior mesenteric artery. Ann Chir Gynaecol 67:161 164
6. Aitkenhead AR (1982) Complications following largebowel surgery. Reg Anesth 7:99 104
7. Aitkenhead AR (1984) Anaesthesia and bowel surgery. Br
J Anaesth 56:95 101
8. Pflug AE, Halter JB (1981) Effect of spinal anesthesia on

adrenergic tone and the neuroendocrine responses to surgical stress in humans. Anesthesiology 55:120-127
9. Aitkenhead AR, Gilmour DG, Hothersall AP, Ledingham
I McA (1980) Effects of subarachnoid spinal nerve block
and arterial p C O 2 o n colonic blood flow in the dog. Br J
Anaesth 52:1071 - 1076
10. Johansson K, Ahn H, Lindhagen J, Tryselius U (1988) Effect of epidural anaesthesia on intestinal blood flow. Br J
Surg 75:73-76
11. Aitkenhead AR, Wishart HY, Peebles Brown DA (1978)
High spinal nerve block for large bowel anastomosis. Br J
Anaesth 50:177-182
12. Hult6n L (1969) Extrinsic nervous control of colonic motility and blood flow. Acta Phys Scan [Suppl] 335:81-115
13. Garry RC (1933) The nervous control of the caudal region
of the large bowel in the cat. J Physiol 77:422 431
14. Wagner GA (1922) Zur Behandlung des Ileus mit Lumbalanaesthesie. Zentralbl Gyn/ikol 46:1225
15. Fasano M, Waldvogel HH, Muller CA (1979) Prophylaxie
de l'il6us paralytique apr6s chirurgie du colon par blocage
sympathique p6ridural continu. Helv Chir Acta 46:245- 248
16. Wilkins JL, Hardcastle JD, Mann CV, Kaufman L (1970)
Effects of neostigmine and atropine on motor activity of
ileum, colon and rectum of anaesthetized subjects. Br Med
J 1:793-794
17. Bell CMA, Lewis CB (1968) Effect of neostigmine on integrity of ileorectal anastomoses. Br Med J 3:587 588
18. Wells C, Tinckler LF, Rawtinson K (1961) Postoperative
gastrointestinal motility. Lancet 2:136
19. Kewenter J, Pahlin PE, Storm B (1970) The effect ofperiarterial nerve stimulation on the jejunal and ileal motility in
cat. Acta Phys Scand 80:353-359
20. Kock N G (1959) The intestino-intestinal inhibitory reflex.
Acta Phys Scand 47 [Suppl 164]:30 33
21. Kreulen DL, Szurszewski JH (1979) Reflex pathways in the
abdominal prevertebral ganglia: evidence for a colo-colonic
reflex. J Physiol 295:21-32
22. Kewenter J (1965) The vagal control of the jejunal and ileal
motility and blood flow. Acta Phys Scand [Suppl 251]
65:1-68
23. Abrahamsson H, Lyren/is E, Dotevall G (1983) Effects of
adrenoceptor blocking drugs on human colonic motility.
Dig Dis Sci 28:590-594
24. Lyren/is E, Abrahamsson H, Dotevall G (1985) Effects of
beta-adrenoceptor stimulation on rectosigmoid motility in
man. Dig Dis Sci 30:536-540
25. Gelman S, Feigenberg Z, Dintzman M, Levy E (1977) Electroenterography after cholecystectomy. The role of high
epidural analgesia. Arch Surg 112:580 583
26. Worsley MH, Wishart HY, Peebles Brown DA, Aitkenhead
A R (1988) High spinal nerve block for large bowel anastomosis. Br J Anaesth 60:836-840
27. Bigler D, Hjorts6 NC, Kehlet H (1985) Disruption of colonic anastomosis during continuous epidural analgesia.
Anaesthesia 40:278 280
28. Treissman DA (1980) Disruption of colonic anastomosis
associated with epidural anaesthesia. Reg Anaesth 5:22 23
Accepted: 18 January 1989
Dr. A. Carlstedt
Sahlgrenska sjukhuset
S-413 45 G6teborg
Sweden
Coloi'ee/al
Disease
Evaluation of ileal W pouch-anal anastomosis for

restorative proctocolectomy
K. Hatakeyama, K. Yamai and T. Muto
Department of Surgery, Niigata University School of Medicine, Niigata, Japan
Abstract. Clinical defaecatory function, neorectoanal m a n o m e t r y and p o u c h o g r a p h y were assessed in 16 patients treated by restorative proctoc o l e c t o m y with ileal W-reservoir. The d u r a t i o n after ileostomy closure was 6 to 28 m o n t h s (mean 17
months). There were no operative deaths and no
failures where the reservoir had to be removed.
Partial a n a s t o m o t i c dehiscence occurred in one patient, and intestinal obstruction requiring laparot o m y in two. A n a s t o m o t i c stricture, which could be
corrected easily by dilatation, occurred in three patients. Daily stool frequency was 4.3-t-1.2 at 6
m o n t h s after ileostomy closure, 3.8_+1.2 at 12
months, and 3.3 1.0 at 24 months. The clinical
score for neorectal function gradually and steadily
i m p r o v e d with time as well as daily stool frequency.
In the m a n o m e t r i c and p o u c h o g r a p h i c studies,
m e a n anal canal length (3.4 0.6 cm), m e a n maximal anal sphincter resting pressure (57.1
cm
water) and m e a n maximal reservoir resting pressure (4.3 2.0 cm water) tended to be less than normal controls but not significantly so. N e o r e c t o a n a l
inhibitory reflex disappeared completely or was
greatly decreased in all patients. However, all were
capable o f spontaneously controlled defaecation.
There was an inverse linear relationship between
daily stool frequency and maximal tolerated reservoir volume (p<0.01). There were inverse linear
relationships also between daily stool frequency
and horizontal diameter o f the reservoir m e a s u r e d
on p o u c h o g r a p h y ( p < 0 . 0 5 ) , and daily stool frequency and dilatation ratio o f the reservoir
(p<0.01). F r o m these results, we conclude that a
large and wide reservoir allows better defaecatory
function.
Between January, 1984 and December, 1988, 22 patients underwent ileal W pouch-anal anastomosis. Of these, 16 patients
whose follow-up period after ileostomy closure was 6 to 28
months (mean 17 months) were assessed. There were seven
males and nine females. Thirteen had ulcerative colitis and 3
FAP. The mean age was 36 years (range 17-61 years). There
were no deaths. There were no patients in whom the reservoir
had to be removed due to complications. The patients were
checked at 3 to 6 months intervals, and details of stool frequency, continence, night evacuation, discrimination between
stool and gas, anal discomfort and use of antidiarrhoeal medication were recorded. A clinical score of the neorectal function, a
modification of Peck's criteria [6], was calculated from these
factors as shown in Table 1. The operative technique reported by
Nicholls [7] was used in this series (Fig. 1).
Restorative p r o c t o c o l e c t o m y with ileal reservoir

has become an accepted f o r m o f treatment for ul-
The examination was performed with patients in the left lateral

position. Manometric study was performed using a continu-
cerative colitis and familial a d e n o m a t o u s polyposis

(FAI:'), while straight ileoanal anastomosis has become less frequent because o f the severe urgency,
frequency, night evacuation and per
excoriation which follow the operation.
F o u r types o f reservoir have been reported: Sshaped [1], J-shaped [2], H - s h a p e d [3] and Wshaped [4]. M o r e than half o f the patients with
S-type reservoirs need to use a catheter for evacuation [4] and the J-type reservoir is associated with a
higher frequency o f defaecation and night evacuation [5]. However, Nicholls reported that W-type
reservoirs resulted in b o t h spontaneous defaecation
and i m p r o v e d function [4].
In this study the defaecatory function, neorectoanal m a n o m e t r y and p o u c h o g r a p h y by barium
enema have been assessed in 16 patients with ileal
W p o u c h - a n a l anastomosis.

Patients
Neorectoanal manometry
151
1. Operative
technique in constructing the ileal
W pouch.
Four loops of the
terminal ileum,
each 12 cm long,
are used
Fig.
f
ously perfused catheter, with 3 lumens 5 cm apart. The perfusion
system was connected to a polygraph and a multichannel pen
recorder running at 2.5 mm/s. The following parameters were
examined: anal canal length, maximal anal sphincter resting
pressure, maximal reservoir resting pressure, maximal tolerated
reservoir volume, reservoir compliance and neorectoanal inhibitory reflex. Anal canal length was measured as equivalent to
the high pressure zone as the catheter was withdrawn from the
anus. The maximal anal sphincter resting pressure was the
highest pressure registered in the anal canal with the patient at
rest. The maximal reservoir resting pressure was the highest
pressure registered in the reservoir with the patient at rest. The
neorectoanal inhibitory reflex was defined by the short decrease
in pressure in the anal canal when the balloon in the neorectum
was distended in increments of 20 ml of air. After inserting a
large latex rubber balloon into the centre of the reservoir, a
series of 20 ml increments of air were introduced to a maximum
of 480 ml. The maximal tolerated reservoir volume was noted
when the patient had a constant feeling of impending defaecation. Reservoir compliance was given by the slope of the volume/pressure curve9
Pouchography
After manometry, a barium study of the neorectum was performed; size and shape of the reservoir as well as angulation
F i g . 2. Pouchogram by barium sulphate (anterior-posterior

view), a, horizontal diameter of the ileal reservoir; b, horizontal
9
diameter of the pelvic cavity. Dilatation r a t l o = ~ x 100 (per

cent)
were assessed by anterior-posterior and lateral views. Horizontal diameter of the reservoir and pelvic cavity at the level of the
top of the femoral heads was measured in the anterior-posterior
view as shown in Fig. 2. The dilatation ratio of the reservoir was
then expressed as the percentage of the former divided by the
latter9
152
Statistical analysis
Student's t-test was used to compare mean values of normally
distributed data and the Mann-Whitney U-test was used for
normally non-distributed data. Linear regression analysis using
the differences in the sums of squares was applied to the data
obtained on both manometric study and stool frequency, and
pouchographic study and stool frequency.
Table 1. Derivation of clinical score in neorectal function

Factors
Degree
Score
Mean daily stool frequency
__<3 times/day
4 6 times/day
__>7 times/day
None
Occasionally
Always
None
< 3 times/week
> 4 times/week
Possible
Occasionally impossible
Always impossible
None
Occasionally
Always
None
Occasionally
Every day
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
Incontinence
Night evacuation
Results
Postoperative complications (Table 2)
Discrimination between
stool and gas
There was one patient with a partial dehiscence of

the ileoanal anastomosis; healing occurred without
intervention. An anastomotic stricture requiring dilatation occurred in three patients (including the
patient with an anastomotic leak). Pelvic infection
occurred in two patients (not including the patient
with an anastomotic leak). Intestinal obstruction
due to adhesions and requiring laparotomy occurred in two patients, and there was one patient
with an anovaginal fistula which necessitated an
operation. There were no patients with clinical evidence of pouchitis.
Feeling of discomfort
in anus
Function
Mean daily stool frequency after ileostomy closure
gradually decreased with time (Table 3). Mean frequency at 6 months was 4.3 + 1.2 (mean _+SD), at
12 months 3.8_+1.2 and at 24 months 3.3_1.0,
respectively.
Clinical score of neorectal function after
ileostomy closure also gradually improved with
time except for one patient who had undergone
haemorrhoidectomy 6 months earlier (Fig. 3). All
except this patient had normal continence and no
faecal soiling during the day. There were two patients with minimal leakage at night: one was a 61
year old man, another a 51 year old woman. All
patients were capable of spontaneously controlled
defaecation, and had no sexual or urinary dysfunction. Antidiarrhoeal medication was necessary in
seven patients.
Neorectoanal manometry
Manometric results are shown in Table 4. Mean
anal canal length was 3.4_+ 0.6 (mean _+SD) cm and
mean maximal anal sphincter resting pressure was
57.1 _+9.7 cm water. These values tended to be less
than the normal range but not significantly so.
Antidiarrhoeal medication
Table 2. Postoperative complications in 16 patients

Postoperative complications
No. of
patients
Ileoanal anastomosis
Dehiscence
Stricture requiring dilatation
Pelvic infection
Intestinal obstruction requiring laparotomy
Anovaginal fistula
Pouchitis
Failure
1
3
2
2
1
Table 3. Changeover time in mean daily frequency after ileostomy closure

Months after ileostomy closure
No. of
patients
Mean daily
frequency
(mean _+S D)
12
18
24
16
16
11
5.4___1.4 4.3+1.2
3.8_+1.2 3.6_+0.8 3.3_+1.0
Mean maximal reservoir resting pressure was

4.3 __ 2.0 cm water and mean reservoir compliance
was 8.4 _+3.5 ml/cm water. Neorectoanal inhibitory
reflex disappeared completely or was greatly decreased in all patients.
There was an inverse linear relationship between daily stool frequency and maximal tolerated
reservoir volume as shown in Fig. 4 (p<0.01). As
the reservoir volume measured intra-operatively
153
i~
W 6 84
18
OA
05
(lJ
2I,o 3
---~2
fo
t-tO
5"0
'7"-
"F
&
112
IS
I~
2li
2'4
Months after i[eostomy closure
Fig. 3. Changeover time in clinical score of the neorectal function after lie 9149 closure
6'
6"0
7"0
8"0
9"0 cm
Horizontal diameter of iteat reservoir
Fig. 5. Relationship between mean daily stool frequency and

horizontal diameter of the ileal reservoir, y = --0.0488x +7.762;
r =0.5007; p < 0 . 0 5
~ 6
IlJ
0- S
OA
r
o,_
g5
&
4,
o
o
% 3'
% 3
2'
=I'D 2
"tO
1'
=
tO
179
IlJ
y.-
260
360
460
560 m[
&'0
Maximal tolerated reservoir volume

maximal tolerated reservoir volume, y = - 0 . 0 1 2 1 x + 8 . 1 0 ;
r=0.8298; p < 0 . 0 1
5"0
6'0
7"0 %
Dilatation ratio of ileal reservoir

dilatation ratio of the ileal reservoir, y : - 0 . 0 8 3 5 x + 8 . 7 3 2 ;
r=0.6252; p<0.01
Table 4. Manometric results in controls and in patients with ileal W pouch-anal anastomosis (Mean SD)
Controls
Patients
No. of
patients
Length of
anal canal
(cm)
Maximal
anal sphincter
resting pressure
(cm water)
Maximal reservoir
resting pressure
(cm water)
Reservoir
compliance
(ml/cm water)
Neorectoanal
inhibitory
reflex
20
16
4.1 0.5
3.4-t-0.6 a
66.2 24.5
57.1+ 9.7 ~
5.4 1.8
4.3___2.0 a
5.3 _ 3.3
8.4
a
+
- or
" Not significant as compared with normal controls
had been 200 to 250 ml, all reservoir volumes rose

significantly after the operation. There was no linear relationship between daily stool frequency and
reservoir compliance.
Pouch9
study
There was an inverse linear relationship between
daily stool frequency and horizontal diameter of
the reservoir (p < 0.05, Fig. 5), and daily stool frequency and dilatation ratio of the reservoir
(p<0.01, Fig. 6). There was, however, no significant relationship between daily stool frequency and
angulation.
Discussion
Restorative proctocolectomy with ileal J and W
pouch-anal anastomosis is, with experience, a safer
154
operative procedure resulting in better defaecatory

function [5, 7]. Of the postoperative complications,
anastomotic dehiscence is one of the most serious
which may necessitate the removal of the reservoir.
However, in our experience with 16 W-reservoirs
there was only one patient with anastomotic dehiscence and there were no patients in whom the
pouch had to be removed. These favourable results
may be due to the fact that no patients were on
steroids at the time their reservoirs were constructed. It is reported that anastomotic complications occur less frequently with a short rectal cuff
than a long one [8]. In the early cases a rectal cuff
of 4 - 5 cm from the dentate line was left but in
recent cases we have left a short cuff of 1 - 2 cm in
length. Intestinal obstruction due to adhesions requiring laparotomy occurred in two patients
(12.5%). This is a similar frequency to that reported by Nicholls and Lubowski [7] and Dozois
[5]. Anastomotic stricture was seen in 3 patients.
However, it was corrected easily by dilatation and
there were no patients who required reoperation.
All patients were capable of spontaneous defaecation, and none needed catheterization for evacuation, as was necessary with the S-reservoir [1].
Daily stool frequency and clinical score of the neorectal function greatly improved with time. These
results are very similar to those which have been
reported by Nicholls [7]. Defaecation occurs less
frequently with the W-reservoir than with the J-reservoir reported by Utsunomiya et al. [2] and Dozois [5]. Indeed, Nicholls et al. reported that the
number of daily evacuations in patients with the
W-reservoir (mean 4.1 + 1.3) was significantly less
than those with the J-reservoir (mean 5.5+1.6;
p < 0.02) [4]. In addition, taking the first 17 W-reservoirs, function was much better (mean 3.0_+0.9)
than with the J-reservoir [7]. Improved defaecatory
function may occur with the passage of time. On
the other hand, Keighley et al. in a prospective randomized trial [9] recently reported that median frequency of defaecation and other functions was not
significantly different between the J-reservoir using
two 20-cm loops and the W-reservoir using four
10-cm loops. This fact might have resulted from the
use of the longer J-reservoir and the shorter W-reservoir. However, larger randomized studies and
longer follow-up are necessary.
In our manometric study, the mean anal canal
length, mean maximal anal sphincter resting pressure and mean maximal reservoir resting pressure
tended to be low. Lower anal pressures were seen
by Keighley et al. [10] and Becker [11]. However,
we recognised a tendency for the anal canal pressure to increase 6 and 12 months after ileostomy
closure. Impaired internal anal sphincter function

may be caused by excessive anal stretching and/or
injury during mucosectomy. The reservoirs were
more distensible than the normal rectum in our
study, while Keighley et al. [10] reported that the
pelvic reservoir was less distensible and sepsis had
little influence on reservoir compliance. In addition, none of our patients had a normal neorectoanal inhibitory reflex - this supports Keighley's
result [10]. However, reservoir compliance and neorectoanal reflex are likely to be unrelated to functional results in our experience.
There is an inverse linear relationship between
maximal tolerated reservoir volume and frequency
of defaecation in patients with the three reservoir
designs (S-, J- and W-) [4]. We had the same result
with the W-reservoir. In addition, there were inverse linear relationships between daily stool frequency and horizontal diameter of the reservoir,
and daily stool frequency and dilatation ratio of the
reservoir. These results indicate that not only capacitance [4] but also horizontal width of the reservoir have a major influence on frequency of defaecation. The horizontal width of the reservoir is
similar to that of the rectal ampulla. The shape of
the W-reservoir most resembles a spheroid [4].
Large horizontal width might be one of the important factors associated with decreased frequency.
We therefore recommend the patient to defer defaecation for as long as possible in order to improve
capacitance. In no instances has pouchitis resulted
from this training.
In our study only a small number of patients
was investigated and the follow-up period is still
short. A larger number of patients and continued
assessment are necessary. Repeated manometric
and pouchographic studies will also be necessary.
At this stage, however, we conclude that a large and
wide reservoir has a better function in defaecation
than a small and narrow one. Investigations to determine optimal capacity of the reservoir to improve frequency and avoid pouchitis are necessary.
References
1. Parks AG, Nicholls R J, Belliveau P (1980) Proctocolectomy
with ileal reservoir and anal anastomosis. Br J Surg 67: 533538
2. Utsunomiya J, Iwama T, Imajo M, Matsuo S, Sawai S,
Yaegashi K, Hirayama R (1980) Total colectomy, mucosal
proctectomy and ileoanal anstomosis. Dis Colon Rectum
23:459 466
3. Fonkalsrud EH (1984) Endorectal ileoanal anastomosis
with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy. Ann Surg 199:151 157
155
4. Nicholls R J, Pezim ME (1985) Restorative proctocolectomy
with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs. Br J Surg 72:470-474
5. Dozois R R (1985) Ileal J pouch-anal anostomosis. Br J Surg
72 [Suppl]: 80-82
6. Peck DA (1980) Rectal mucosal replacement. Ann Surg
191:294-303
7. Nicholls RJ, Lubowski DZ (1987) Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg 74:564-566
8. Cohen Z, Grant DR, McHugh S, McLeod RS, Stern H
(1985) Restorative proctocolectomy: clinical results and
manometric findings with long and short rectal cuffs. Br J
Surg 72 [Suppl]: 128
9. Keighley MRB, Yoshioka K, Kmiot W (1988) Prospective
randomized trial to compare the stapled double lumen
pouch and sutured quadruple pouch for restorative proctocolectomy. Br J Surg 75:1008-1011
10. Keighley MRB, Yoshioka K, Kmiot W, Heyen F (1988)

Physiological parameters influencing function in restorative
proctocolectomy and ileo-pouch-anal anastomosis. Br J
Surg 75:997 1002
11. Becker JM (1984) Anal sphincter function after colectomy,
mucosal proctectomy, and endorectal ileoanal pull-through.
Arch Surg 199:526-531
Accepted: 20 March, 1989
Dr. K. Hatakeyama
Niigata University School of Medicine
Asahi-Machi 1-757
Niigata 951
Japan
Book review
A. Waekenheim, A. Bodoz: Computed Tomography of the Abdomen in Adults. Berlin, Heidelberg, New York: Springer 1988. V,
159 pp., 357 figures. ISBN 3-540-16540-1. Softcover, DM 35.00
This book contains some 357 illustrations forming 85 radiological exercises, aimed at students and practitioners, to provide
a simple and interesting way to learn something of the normal
and abnormal computerized tomographic (CT) anatomy of the
abdomen. It is divided into two sections; the first being the CT
images without any clinical detail except for a comment on
whether the scans are post enhancement, and the second with
line drawings where all the anatomical points are numbered and
referenced in the initial few sections of normal anatomy, but
thereafter only the relevant anatomical features are numbered
and referred to in the next, though to avoid confusion the same
numbering is used throughout. The accompanying text is brief
but informative with short notes as to the main pathological
features of the disease process and its differential diagnosis on
CT. The index is skimpy and the book is meant to be read as a
series of exercises and not used for reference.
Separating the CT images from the legends makes for difficulties flipping backwards and forwards through the pages and
I doubt that someone unused to CT images would always be
able to fuse the two satisfactorily. There is no explanation in the
book as to the workings of CT, both of the actual machine but
more importantly the basis for image formation. Hounslow
Units are mentioned in the text, but I could not find an overall
explanation of these. Assuming that students do not have any
knowledge of CT this could be confusing.
Although this is a useful little book, these are disadvantages
when comparing it to many other texts on CT, that explain the
technique and also give a complete exposition of its uses in the
head and body. To limit it to the abdomen causes problems as
in practice many disorders require pelvic as well as abdominal
CT. A different layout and slight expansion of scope would
make this approach more interesting, and as it stands these
exercises have limited appeal.
C. I. Bartram (London)
155
4. Nicholls R J, Pezim ME (1985) Restorative proctocolectomy
with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs. Br J Surg 72:470-474
5. Dozois R R (1985) Ileal J pouch-anal anostomosis. Br J Surg
72 [Suppl]: 80-82
191:294-303
7. Nicholls RJ, Lubowski DZ (1987) Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg 74:564-566
8. Cohen Z, Grant DR, McHugh S, McLeod RS, Stern H
(1985) Restorative proctocolectomy: clinical results and
manometric findings with long and short rectal cuffs. Br J
Surg 72 [Suppl]: 128
9. Keighley MRB, Yoshioka K, Kmiot W (1988) Prospective
randomized trial to compare the stapled double lumen
pouch and sutured quadruple pouch for restorative proctocolectomy. Br J Surg 75:1008-1011
10. Keighley MRB, Yoshioka K, Kmiot W, Heyen F (1988)

Physiological parameters influencing function in restorative
proctocolectomy and ileo-pouch-anal anastomosis. Br J
Surg 75:997 1002
mucosal proctectomy, and endorectal ileoanal pull-through.
Arch Surg 199:526-531
Accepted: 20 March, 1989
Dr. K. Hatakeyama
Niigata University School of Medicine
Asahi-Machi 1-757
Niigata 951
Japan
Book review
A. Waekenheim, A. Bodoz: Computed Tomography of the Abdomen in Adults. Berlin, Heidelberg, New York: Springer 1988. V,
159 pp., 357 figures. ISBN 3-540-16540-1. Softcover, DM 35.00
This book contains some 357 illustrations forming 85 radiological exercises, aimed at students and practitioners, to provide
a simple and interesting way to learn something of the normal
and abnormal computerized tomographic (CT) anatomy of the
abdomen. It is divided into two sections; the first being the CT
images without any clinical detail except for a comment on
whether the scans are post enhancement, and the second with
line drawings where all the anatomical points are numbered and
referenced in the initial few sections of normal anatomy, but
thereafter only the relevant anatomical features are numbered
and referred to in the next, though to avoid confusion the same
numbering is used throughout. The accompanying text is brief
but informative with short notes as to the main pathological
features of the disease process and its differential diagnosis on
CT. The index is skimpy and the book is meant to be read as a
series of exercises and not used for reference.
Separating the CT images from the legends makes for difficulties flipping backwards and forwards through the pages and
I doubt that someone unused to CT images would always be
able to fuse the two satisfactorily. There is no explanation in the
book as to the workings of CT, both of the actual machine but
more importantly the basis for image formation. Hounslow
Units are mentioned in the text, but I could not find an overall
explanation of these. Assuming that students do not have any
knowledge of CT this could be confusing.
Although this is a useful little book, these are disadvantages
when comparing it to many other texts on CT, that explain the
technique and also give a complete exposition of its uses in the
head and body. To limit it to the abdomen causes problems as
in practice many disorders require pelvic as well as abdominal
CT. A different layout and slight expansion of scope would
make this approach more interesting, and as it stands these
exercises have limited appeal.
C. I. Bartram (London)
Coloi'ee|al
Disease
Manovolumetric characteristics and functional results

in three different pelvic pouch designs
T. Hallgren, S. Fasth, S. Nordgren, T. Oresland, L. Hallsberg, and L. Hult6n
Department of Surgery II, Sahlgrenska sjukhuset, University of G6teborg, G6teborg, Sweden
Abstract. Different pouch designs and techniques

for the perineal approach have been on trial in an
attempt to improve results after restorative proctocolectomy. The l-year results of two currently advocated procedures, the J-pouch and the S-pouch,
were compared with the results obtained in patients
with a pelvic pouch fashioned according to the
folding technique used for the Kock continent
ileostomy, all pouches having been constructed
from equal 30 cm lengths of ileum. The maximal
volume of the S- and Kock pouches at one year was
420 ml (250-570) (median and (range)) and 410 ml
(244-490) respectively, while it was significantly
less, 305ml (200-445) in the J-pouch (p<0.05).
The compliance of the J-pouches was also significantly lower at all distension pressures. The median
day-time defaecation frequency was four and was
equal in the three groups. Although there was a
tendency towards a more favourable overall functional result with less soiling, and less need for night
evacuations among patients with a Kock-folded
pouch compared to the other pouch types these
differences failed to reach statistical significance.
The favourable properties of the Kock pouch, wellknown also from the continent ileostomy and
urostomy, suggest that its design should be considered an interesting alternative even for restorative
proctocolectomy. These encouraging results have
yet to be confirmed in a comparative randomized
trial.
In many specialist centres restorative proctocolectomy (endo-anal mucosal proctectomy, formation

of an ileal reservoir and ileo-pouch-anal anastomosis) has become the preferred treatment for ulcerative colitis and familial polyposis [1]. Although patient satisfaction is high the functional results are
not perfect, with a high evacuation frequency, need
for night evacuations, and faecal and/or mucous
seepage. For the reservoir construction several different designs have been on trial and different techniques have also been employed for the perineal
phase of operation in an attempt to improve results
[2, 31.
Experimental studies imply that both pouch capacity and pouch motility pattern [4] may be important determinants, not only for the evacuation
frequency, but also for continence function, suggesting that pouch design might have an important
impact on the ultimate clinical result. There is clinical evidence to show that the S-shaped reservoir
attains a larger capacity than the J-shaped pouch,
and that this is associated with a significantly lower
defaecation frequency and possibly also with a better continence function [5]. However the W-configurated pouch is reported to be superior both to the
J- and S-pouch [6, 7]. Clinical evidence also suggests that a pelvic pouch fashioned according to the
technique used for the Kock continent ileostomy
may be advantageous for the reasons just stated [8].
Whether these differences in volume and clinical
function are attributed to the dynamic characteristics of the pouch or simply to different lengths of
ileum used for pouch construction is doubtful.
The aim of the present study therefore was to
compare in a pilot-study the manovolumetric characteristics and functional outcome in patients with
S- and J-configurated pouches with those with a
Kock pouch, all constructed from equal lengths of
ileum.
Patients and techniques

A Kock pouch (segment length 2 x 15 cm) folded and sutured
according to the technique described by Kock [9] for the continent ileostomy, omitting the nipple-valve, was constructed in
11 consecutive patients (median age 35 years, range 18-46). The
technique used for its construction appears in Fig. 1. Eleven
patients with a J-pouch (2 x 15 cm) and 11 with an S-pouch
(3 x 10 cm), matched for age and sex, were selected from our
previous experience for comparison. The mucous proctectomy
157
Table 1. Functional markers listed for score calculation
Score
No. of bowel movements

Daytime
At night
Urgency (inability to defer
evacuation > 30 min.)
Evacuation difficulties
( > 15 min spent in toilet on
any occasion during the week)
Soiling or seepage
Daytime
At night
Perianal soreness
Protective pad
Daytime
At night
Dietary restrictions
(avoid certain items that
deteriorate pouch function)
Medication
(continous or occasional)
Social handicap
(not able to resume full time
occupation or participate in
social life)
_<4
0
No
5
> l/week
yes
26
~2/night
No
yes
No
No
No.
> 1/week
> l/week
occ.
No
No
No
> 1/week
> l/week
yes
No
yes
No
yes
Permanent
an arbitrary score for assessment of the overall functional result

(Table 1).
Manovolumetry
Fig. 1. a Construction of a Kock pouch. Two 15 cm ileal segments are sutured side-to-side and split open. Note the fingerwide opening left distally to the suture line. b The reservoir is
formed by folding upwards along a transverse axis. e and d The
corners of the created pouch are pushed inwards between the
mesenteric leaves bringing the posterior aspects of the pouch
anteriorly and the opening for the ileoanal anastomosis distally
was performed in all patients by the endo-anal approach, coring
out the mucosa in strips from the pectinate line. The muscular
coat of the rectum was transected 1 - 2 cm above the puborectalis sling. A covering loop ileostomy was used in all cases.
The operation technique and postoperative routines have been
described in detail previously [10]. Eleven patients with a well
established abdominal continent ileostomy constructed from
30 cm of the terminal ileum were also included for comparison
of volumetric findings.
Clinical assessment of function

All patients were followed regularly at 1, 3, 6 and 12 months
postoperatively and details of function including evacuation frequency, need for night evacuations and continence were assessed. Recording of number of bowel movements and occurrence of soiling was based on self-monitoring diaries for 2 weeks
before each visit. Functional variables were listed according to
Anorectal/pouch manovolumetry was performed preoperatively

and at each postoperative visit using a technique which permits
simultaneous recording of anal pressure and pouch volume under isobaric distension by means of a high compliance
polyethylene balloon insufflated with air (for details see [11]).
Pouch volume was determined at 20, 40, 60 and 80 cm HzO
distension pressure. The volume recorded at 80 cm HzO was
defined as maximal pouch volume, which was as a rule associated with low abdominal or pelvic discomfort or urgent need for
evacuation of the pouch. The pouch volume in 11 patients with
a well established continent ileostomy was studied with a similar
technique for comparison. Chi-square analysis and Student's
t-test were used for the statistical analysis.
Results
Complications
There were no major postoperative complications.
I n t h r e e p a t i e n t s in w h o m a m i n o r a n a s t o m o t i c
d e f e c t w a s d i s c o v e r e d b y r o u t i n e r a d i o l o g y t h e les i o n h e a l e d s u c c e s s f u l l y o n p r o l o n g e d i l e o s t o m y diversion with a subsequent uneventful postoperative
course. Three patients were treated successfully by
simple finger dilatation for an anastomotic stric-
158
500
Table 2. Resting anal pressure (cm H 2 0 ) before and one year

after operation
Pouch
S
J
K
Preop.
At one year
Median Range
Median Range
95
84
100
88
68
85
65-150
68-135
77 125
40-110
3 4 - 98
5 4 - 95
% decrease
~,
400
uJ
10
19
15
.J
300
1o
2
S-pouch
J-pouch
K-pouch
200
Table 3. Maximal pouch volume (80 cm H 2 0 ) at one year
Pouch design
Volume (ml)
100
Median
S-pouch
J-pouch
K-pouch
Continentileostomy
420
305
410
640
Range
250
200
244390
570
445
490
1050
12
MONTHS
Fig. 2. Maximal pouch volume (median values at 80 cm H 2 0 )
at intervals postoperatively. K-pouch = Kock pouch
500
ture while one patient with an S-pouch developed a

stenosis due to outlet ischaemia and required
monthly dilatation for one year.
400
Ul
300
Manovolumetry
Resting anal sphincter pressure before operation
and at 1 year postoperatively is shown in Table 2.
The decline of resting sphincter pressure, which
was similar in patients with J- and Kock pouches,
was significantly less in those with an S-pouch
(p < 0.05). However, differences in maximal pouch
volume as measured before ileostomy closure were
statistically insignificant (Fig. 2). Pouch volume estimations at intervals after ileostomy closure
showed that the most marked volume increase occurred within the first 3 months and, regardless of
pouch design, 80 90% of maximal pouch volume
at 1 year had been reached at that time (Fig. 2).
While pouch volume was similar in the S- and Kock
pouches, it was significantly less (/)<0.01) in the
J-pouches at all distension pressures (Fig. 3). The
maximal pouch volume at 1 year was 410 ml (250570) in the Kock pouches and 420 ml (244 490) in
patients with S-pouches (n.s.), compared with
305ml (200-445) for the J-pouches (p<0.05)
(Table 3). Measurements given are median and
range, patients with a continent ileostomy did not
tolerate 80 cm H20 pouch distension. When measured at 60 cm H20 the reservoir volume was
640 ml (390-1,050 ml), significantly more than the
pelvic Kock pouch (p < 0.01).
200
a.
ouch
III
y
100
-'- S p~176
"-=- J-pouch
20
'
40
60
80
100
DISTENSIONPRESSUREcm H20
Fig. 3. Pouch volumes at different distension pressures at one
year
Function
The day- and night-time stool frequency was initially high but declined with time. The median daytime frequency at I year follow-up was four and
was similar in all groups (Table 4). The need for
night evacuation tended to be more common in
patients with an S-pouch than in patients with the
other pouch designs. None of the patients was incontinent for faeces but mucous seepage, mainly by
night, occurred in two and three patients with a Jand S-configurated pouch respectively, but in only
one of the patients with a Kock pouch. However,
differences with respect to functional defects failed
159
Table 4. Evacuation frequency daytime
Pouch
Median
Range
S
J
K
4
4
4
2 7
3 6
3 6
Table 5. Functional defects at one year
Night evacuation
Soiling by night
Antidiarrhoeals
S-pouch
n=ll
J-pouch
n=ll
K-pouch
n=ll
4
3
8
2
2
8
1
1
6
Table 6. Functional score at one year
Design
Median
Range
S-pouch
J-pouch
K-pouch
3.5
3
2
0 9
0- 5
1- 7
to reach statistical significance (Table 5), nor did

the overall functional result as expressed in functional score differ significantly between groups
(Table 6).
Discussion
Previous reports have suggested that S- and Wreservoirs attain a larger capacity than the J-shaped
and that this is associated with an improved function [5 7, 12, 13]. The favourable expanding properties of the S-shaped pouch have been ascribed to
a greater relative degree of outflow resistance while
the spherical form of the W-pouch was considered
to be of great advantage in providing the greatest
volume for any given length of ileum [13, 14]. However, the length of ileum used for construction of
the different pouch types in these studies was unequal with a consistently shorter length being used
for the J-pouches which was sometimes only half of
that used for the two other pouches [5, 6], a difference that might well have influenced the results.
The results of the present study where length of
intestine used for pouch construction and pouch
volume before ileostomy closure was equal provide
evidence that the compliance of the J-shaped
pouch, when compared with the other pouch types,
was still significantly lower at all intervals, postoperatively, and that its maximal volume measured at
the 1 year follow-up was about 25% smaller. These
observations also confirm the findings in a recent
experimental study on rats comparing the same

three types of pouches [15], implying that the expanding properties of the Kock type and S-shaped
reservoir are superior to that of the J-configurated
pouch.
The observation in the present study that the
functional result in patients with a J-pouch was
largely the same as in the other two groups may
appear therefore somewhat conflicting. It has been
demonstrated however that the threshold volume,
i.e. the pouch volume at which high pressure waves
are generated, should be the important determinant
both for stooling frequency and continence. If this
threshold is reached at about 50% of maximal
pouch volume [4] it may well be that the capacity of
about 300 cc attained for the J-pouches in the present series of patients, although markedly lower
than in the other two pouch types, would still be
adequate. Although a reliable comparison cannot
be made due to difference in methodology, the previously reported average capacity of the J-pouches
[6] appears to be smaller than in the present study.
While the spherical form of W- or Kock folded
pouches may exhibit a more satisfactory dynamic, it
has been clearly demonstrated that the capacity of
a J-configurated pouch will increase and its function improve with increasing limb lengths used for
construction [16], implying that increased length of
intestine included in a pouch may compensate for
its unfavourable geometry. However, apart from
pouch design and limb lengths, other factors may
also influence future pouch expansion. The dimension and the viscoelasticity of the terminal ileum
may vary and the pelvic space is another variable
that may limit the expansion of the pouch. Such
factors may explain why ileal pouches, irrespective
of shape and size, sometimes expand so differently
and often in an unpredictable manner. The observation that the continent ileostomies used for comparison in the present study attained a volume that
was 50% larger than the pelvic Kock pouches constructed from equal lengths of ileum is particularly
intriguing, implying that the prerequisites for expansion may be less favourable when the pouch is
positioned into the pelvis. A similar observation
has been made by others [17].
Postoperative decrease in resting anal tone has
been considered responsible for imperfections in
continence and faecal or mucous soiling has been
demonstrated to occur more frequently in patients
with low anal pressure [5, 18, 19]. This appeared
not to be so in the present study however, and such
functional defects were observed with a similar frequency irrespective of pouch design. One explanation for these conflicting results may be that the
160
reduction in sphincter tone in the present study was

less pronounced (about 10-20% below preoperative level) as compared to that reported by others
[5, 18, 20-22].
The Kock pouch represents a different type of
ileal pouch design to the J- and S-pouch. Being
double folded the reservoir has been demonstrated
to exhibit "a specific dynamic response to distension" [23]. Its ability to accommodate increasing
volumes without generation of high pressure waves
has been studied both in patients with continent
ileostomy and urostomy [23, 24]. The manovolumetric data obtained in the present study show
convincingly that the double-folded reservoir, even
when used for the construction of a pelvic pouch
with an ileoanal anastomosis, expands to attain a
large capacity. In this respect it is comparable to
the S-shaped pouch but superior to the J-configurated pouch which is constructed from equal
lengths of small intestine.
Although there was also a tendency towards a
more favourable overall functional result with less
soiling and less need for night evacuation among
patients with a Kock pouch, these differences failed
to reach statistical significance. Nevertheless the
results are certainly worthy of further trials which
would be best conducted in a prospective randomized study, taking into account the obvious shortcomings of the present study. Such a study is now
in progress.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Acknowledgements. This investigation was supported by grants

from the Swedish Medical Research Council (17X-03117), the
University of G6teborg, G6teborgs Lfikares/illskap, Assar
Gabrielssons fond and AB Skandias 100-firsfond.
19.
20.
References
1. Hult6n L (1985) The continent ileostomy (Kock's pouch)
versus the restorative proctocolectomy (pelvic pouch),
World J Surg 9:952-959
2. Williams NS, Johnston D (1985) The current status of mucosal proctectomy and ileo-anal anastomosis in the surgical
treatment of ulcerative colitis and polyposis. Br J Surg
72:159-168
3. Nicholls RJ (1987) Restorative proctocolectomy with various types of reservoirs. World J Surg 11:751-762
4. O'Conell PR, Pemberton JH, Brown ML, Kelly KA (1987)
Determinants of stool frequency after ileal pouch-anal anastomosis. Am J Surg 153:157-164
5. Nasmyth DG, Johnston D, Godwin PGR, Dixon MF,
Smith A, Williams NS (1986) Factors influencing bowel
function after ileal pouch-anal anastomosis. Br J Surg
73:469-473
6. Nicholls RJ, Pezim ME (1985) Restorative proctocolectomy
with ileal reservoir for ulcerative colitis and familial ade-
21.
22.
23.
24.
nomatous polyposis: a comparison of three reservoir designs. Br J Surg 72:470 474

Harms BA, Hamilton JW, Yamamoto DT, Starling JR
(1987) Quadruple-loop (W) ileal pouch reconstruction after
proctocolectomy: Analysis and functional results. Surg
102:561 567
Hult6n L, Fasth S, Nordgren S, Oresland T (1988) Kock's
pouch converted to a pelvic pouch - a case report. Dis
Colon Rectum 31:467 469
Kock NG (1969) lntra-abdominal 'reservoir' in patients
with permanent ileostomy. Arch Surg 99:223 231
()resland T, Fasth S, Nordgren S, Hult6n L (1989) The
clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients. Int J
Colorect Dis 4:50 56
Akervall S, Fasth S, Nordgren S, C)resland T, Hult6n L
(1988) Manovolumetry: a new method for investigation of
anorectal function. Gut 29:614-623
Nicholls R J, Moskowitz RL, Shepherd NA (1985) Restorative proctocolectomy with ileal reservoir. Br J Surg 72:$76
$79
Nicholls RJ, Lubowski DZ (1987) Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg 74:567-568
Thomson WHF, Simpson AHRW, Wheeler JL (1987)
Mathematical prediction of ileal pouch capacity. Br J Surg
74:567 568
Berglund B, Brevinge H, Kock NG, Lindholm E (1987)
Expansion of various types of ileal reservoirs in situ. Air
experimental study in rats. Eur Surg Res 19:298-304
Keighley MRB, Yoshioka K, Kmiot W (1988) Prospective
randomised trial to compare the stapled double lumen
pouch and the sutured quadruple pouch for restorative
proctocolectomy. Br J Surg 75:1008-1011
Luukkonen P, J/irvinen H (1987) Pelvic ileal reservoirs: experimental assessment of reservoir capacity in three reservoir designs. Ann Chir Gynecol 76:294-297
Keighley MRB, Yoshioka K, Kmiot W, Heyen F (1988)
Physiological parameters influencingfunction in restorative
proctocotectomy and ileo-pouch-anal anastomosis. Br J
Surg 75: 997-1002
Nicholls RJ, Belliveau P, Neil M, Wilks M, Tabaqchali S
(198l) Restorative proctocolectomy with ileal reservoir: a
pathophysiological assessment. Gut 22:462-468
Neal DE, Williams NS, Johnston D (1982) Rectal, bladder
and sexual function after mucosal proctectomy with and
without a pelvic reservoir for colitis and polyposis. Br J Surg
69:599 604
Harms BA, Hamilton JW, Yamamoto DT, Starling JR
(1987) Quadruple-loop (W) ileal pouch reconstruction after
proctocolectomy: analysis and functional results. Surgery
102:561-567
Sharp FR, Bell GA, Seal AM, Atkinson KG (1987) Investigations of the anal sphincter before and after restorative
proctocolectomy. Am J Surg 153:469 472
Kock NG (1969) Intraabdominal reservoir in patients with
permanent ileostomy. Arch Surg 99:223-231
Norl6n L, Trasti H (1978) Functional behaviour of the continent ileum reservoir for urinary diversion. Scand J Urol
Nephrol [Suppl] 49:33-42
Accepted: 22 May 1989

Prof. Leif Hult6n
Department of Surgery II
Sahlgrenska sjukhuset
S-413 45 G6teborg
Sweden
Col6i'eeml
Disease
Int J Colorect Dis (1989) 4 : 1 6 1 - 1 6 3
Rectodynamics- quantifying rectal evacuation

M.A. Kamm, C.I. Bartram and J.E. Lennard-Jones
St. Mark's Hospital, London, U K
Abstract. A new technique is described which allows the graphic quantitation of voluntary rectal
evacuation. The subject is asked to evacuate 100 ml
of barium sulphate paste as rapidly and completely
as possible. Using a weight transducer it is possible
to determine the maximum emptying rate, time to
achieve maximum emptying and proportion of
barium evacuated. Normal subjects evacuate
quickly and completely. Patients with severe constipation demonstrate a variable evacuation disturbance.
A technique is described which enables rectal evacuation to be quantified in a manner comparable to

the urodynamic method employed to study bladder
emptying. The technique is simple and inexpensive
and does not involve radiation.
A control group of healthy women has been
compared to patients with severe idiopathic constipation. In addition to infrequent defaecation, these
patients often complain of marked difficulty with
rectal evacuation and the need to strain excessively
B, 2].
(microtrast Oesophageal Cream, Nicholas Laboratories

Limited, Slough, U.K.) with density of 2 gm per ml was introduced into the lower rectum using a plastic syringe and a piece
of soft rubber Foley catheter. This paste was selected because of
its similar density to faeces and its ready availability.
The subject was then seated on a specially constructed commode lined with a disposable plastic bag which lay on a tray
supported by a weight transducer (Uniweigh, Maygood Instruments Ltd, UK). The transducer was connected to an amplifier
(Lectromed MX2P, Jersey) and chart recorder (Lectromed
recorder MX216, Jersey).
The subjects were asked to strain and evacuate the rectum
as quickly and completely as possible. After the test was completed the contents were examined to ensure that only barium
had passed.
The tray weight recording was evaluated to determine the
maximum rate of emptying, the proportion of barium evacuated, and the time taken to achieve maximum evacuation.
Results
For each of the obtained recordings it was easy to

determine the time taken to evacuate, the proportion of barium evacuated, and the maximum rate of
emptying (Fig. 1).
Table 1. Rectal emptying measurements in controls and patients with "slow transit" and "normal transit" constipation
Methods
Twelve healthy female volunteer controls (mean age 30, range
2 3 - 4 2 ) and 23 females with severe idiopathic constipation
(mean age 35, range 2 0 - 6 7 ) were studied. Nineteen of the patients had "slow transit constipation" [1] with a spontaneous
bowel frequency of once per 1 - 4 weeks. The four other patients
had a normal bowel frequency of twice or more per week, but
complained of extreme difficulty with rectal evacuation. All
patients had a history of constipation for more than one year,
none experienced diarrhoea, and all had a normal diameter
rectum and colon on barium enema. Secondary causes of constipation had been excluded.
No bowel preparation was performed, but subjects were
asked to evacuate prior to performing the study. With the subject in the left lateral position 100 ml of barium sulphate paste
Controls
Number studied
Max emptying
rate (mg/s)
12
110
(15-250)
Time to evacuate
(s)
7
(3 28)
Proportion
evacuated (%)
1O0
(90-100)
Slow
transit
constipation
19
Normal
transit
constipation
4
45
(0-120)
2
(0-90)
11
(6 >300)
> 200
(7 >300)
87
(0 100)
13
(0 100)
Median for each group presented. Range in brackets below

median
162
Weight
(g)
200]
C Max,Rate
Weight
(g)
,/
200]
.................
:ooj..................
//J
a
ol
~r-
,oo1
Time (s)
Max. Rate -~. / /
0 1 2 3
Time (s)
Fig. 1. a Typical tracing from a control subject showing rapid

(4 s) and complete (100%) evacuation, b Tracing from a subject
with "slow transit constipation". Note the decreased maximum
rate of emptying, the incomplete evacuation (83%) and the
prolonged time (33 s) taken to evacuate
100 '
~ m l n
I . . . .
,,,,,,,
ii
CONII:IOLS
SLOW TRANSIT
NORMAL TRANSIT
CONSTIPATED SUBJECTS
Fig. 2. Proportion of instilled barium paste evacuated in the

three groups studied. Cross bar represents the median of each
group
>300
.......................................................................................
The control subjects uniformly achieved rapid

evacuation of 90 100% of the barium paste within
30 s. The 23 constipated subjects varied in their
ability to evacuate the rectum from a complete inability to evacuate to normal rapid emptying. Half
[12] the patients evacuated less than 90% of the
barium and nine of the 23 took more than 40 s to
evacuate as much barium as they could (Table 1).
Of the 4 subjects with "normal transit constipation", 2 were completely unable to evacuate, 1
evacuated slowly and incompletely, and 1 fell within the normal range (Figs. 2-4). Of the 19 subjects
with "slow transit constipation" 2 were completely
unable to evacuate, 4 evacuated slowly and incompletely, and a further 4 patients evacuated incompletely but within the normal time period
(Figs. 2 - 4 ) .
In the constipated group as a whole, there was
a significant positive correlation between the maximum emptying rate and the proportion of barium
evacuated (r = 0.75, p < 0.0001).
Discussion
This study has demonstrated that normal rectal
evacuation is rapid and complete. In patients with
severe constipation the evacuation abnormality is
280 -
260 240 220'
-g
200'
.~
180'
uJ
200 "
160"
c,_
140"
120'
Lu
100"
100
V80"
60"
40"
"I
20"
0
-4CONTROLS
I.
9~,
SLOW TRANSIT
NORMAL TRANSIT
co.;~o_s
SLOW TRANSIT
.!
NORMAL TRANSIT
Fig. 3. Time to achieve maximum rectal evacuation in the three

groups studied. Cross bar represents the median of each group.
Those subjects unable to evacuate represented as > 300 s
Fig. 4. Maximum rectal emptying rate in the three groups studied. Cross bar represents the median of each group
163
variable; even in subjects with a normal bowel frequency a profound disorder of evacuation may exist. Constipation is a complex disorder with a colonic and an ano-rectal component. This test analyses only the latter and the results suggest a spectrum of evacuation abnormality in a group of
patients who appear clinically homogeneous.
In a recent review of videoproctography in 58
patients with idiopathic constipation, the only significant findings were that 78% took longer to
evacuate and 57% evacuated incompletely when
compared with a control group [3]. The technique
described here quantifies these parameters.
Some patients demonstrated a complete inability to evacuate during the test. This is not necessarily due to lack of cooperation; proctography in
such patients demonstrates appropriate pelvic floor
descent on straining [3]. The abnormality in such
patients may be due to failure of relaxation of the
puborectalis and external anal sphincter muscles [2,
4], or the internal anal sphincter, or internal
mucosal prolapse or intussusception [5]. The
pathogenic role of each of these abnormalities in
causing constipation remains controversial [6].
This test should prove valuable not only in
defining the degree of functional anorectal motor
abnormality but also in formulating a treatment
plan and predicting prognosis. For example, in the
surgical treatment of patients with solitary rectal
ulcer syndrome it has been found that patients who
are symptomatically improved by surgery have
rapid evacuation on proctography preoperatively
[71.
Rectodynamics is a simple screening test of
rectal evacuation. It allows quantification of some
of the features of evacuation which may be helpful
both in diagnosis, in monitoring the progression of

the underlying condition, and in determining the
response to treatment. In laboratories with facilities for proctography, the combination of this technique with rectal pressure measurements, electromyography and fluoroscopic observation should
enable a more integrated assessment of anorectal
disorders.
References
1. Preston DM, Lennard-Jones JE (1986) Severe chronic constipation of young women: 'idiopathic slow transit constipation'. Gut 27:41 48
2. Turnbull GK, Lennard-Jones JE, Bartram CI (1986) Failure
of rectal expulsion as a cause of constipation: why fibre and
laxatives sometimes fail. Lancet I:767 769
3. Turnbull GK, Bartram CI, Lennard-Jones JE (1988) Radiological studies of rectal evacuation in adults with idiopathic
constipation. Dis Col Rectum 31:190-197
4. Read NW, Timms JM, Barfield L J, Donnely TC, Bannister
JJ (1986) Impairment of defaecation in young women with
severe constipation. Gastroenterology 90:53-60
5. Bartolo DCC, Roe AM, Virjee J, Mortensen NJM (1985)
Evacuation proctography in obstructed defaecation and
rectal intussusception. Br J Surg [Suppl] S111 - $116
6. Swash M, Kamm MA (in press) Pathophysiology of incontinence and constipation. In: Phillips SF, Pemberton JH,
Shorter RG (eds) The large intestine: physiology, pathophysiology and diseases. Raven Press, New York
7. Finlay IG, Bartram CI, Nicholls RJ (1987) Can video proctography and anorectal physiology predict outcome after rectopexy for the solitary rectal ulcer syndrome? Gut 28:A 1361
Accepted: 20 February 1989
Dr. M. Kamm
St. Mark's Hospital
City Road
London EC1V 2PS, U K
C,ol6i eeial
Disease
Conservative management of Bowen's disease of the anus

O. 0 . Rasmussen and J. Christiansen
Department of Surgery D, Glostrup Hospital, University of Copenhagen, Denmark
Abstract. Bowen's disease of the anus is usually

treated by wide local excision including macroscopic normal areas if random biopsies show dysplasia. Skin grafting will often be necessary, since
areas of microscopic dysplasia may be found at a
considerable distance from the gross affected site.
In this study of 11 patients with Bowen's disease of
the anus we report the results of a more conservative approach. All patients were treated by local
excision of the gross affected areas only, and none
of the patients required skin grafting. Seven patients were followed for a median of 34 months
without macroscopic recurrence, including 3 patients with histologically proven dysplasia in the
resection margins. Two patients, one with and one
without dysplasia in the resection margins, developed recurrence within a year. One patient with an
area ofinvasive carcinoma was first treated by local
excision, but required an abdominoperineal excision 3 months later. One patient lost to follow-up
had invasive carcinoma after 3 years. It is concluded that a conservative surgical approach in
Bowen's disease of the anus is justified, provided
the patients are followed closely.
Bowen's disease of the anus is a slowly progressing

intraepidermal carcinoma, which may be either localized or more diffusely affect the anal canal, perianal area and the vulva. Due to the potentially
invasive nature of the disease many centers recommend wide local excision including total excision of
anal mucosa, based on multiple frozen sections of
the surgical margins and random biopsies [1-3].
Since microscopic dysplasia is often found in large
areas of the perianal skin, skin grafting is usually
necessary [1, 4]. Total excision of the anal mucosa
and perianal skin does not, however, prevent recur-
rence, since Bowen's disease in the grafted skin has

been reported [4]; furthermore, skin grafting may
impair normal anal function, especially after total
excision of anal mucosa.
In this study we report the results of a conservative surgical approach in patients with Bowen's disease of the anus.
Material and methods

Eleven patients, 7 females (median age 52 years, range 46 69)
and 4 males (55 years, 37 70) were treated for Bowen's disease
of the anus and followed from I to 12 years (median 20 months)
(Table 1). After excision of macroscopic affected areas with
Bowen's disease confirmed by microscopic examination the patients were followed by anal inspection and anoproctoscopy at
3 months intervals during the first year, and subsequently every
6 months. Patients with gross evidence of recurrent disease were
submitted to re-excision of these areas.
Results
Bowen's disease was an incidental finding at routine histologic examination of resected specimens
for benign anal diseases in 7 patients, while 4 patients presented with a tumour at gross anal inspection. The symptoms and clinical findings are shown
in Table 1. Median duration of symptoms was 12
months (1-36). Two women were treated for carcinoma in situ of the uterine cervix 10 and 12 years
before Bowen's disease was diagnosed; one of these
patients also had vulvar involvement. Three of 7
patients where Bowen's disease was an accidental
finding had a re-excision of residual macroscopic
affected areas. In 2 patients resection margins were
free from dysplastic changes while the margins were
involved in one patient. The remaining 4 patients
had no gross areas left and had no further surgery.
Two of these patients had dysplastic changes in the
165
Table 1. Patient data
Age/Sex
Symptoms
Clinical
findings
63/M
Pain, bleeding Anal margin

tumour
50/F
Pain, itching,
bleeding
46/F
Histology
Related
findings
Treatment
Excision
margins
Follow-up
CIS
Local excision
Free
Recurrence after
12 mo
Anal canal
tumour,
tickened
perineal skin
CIS
and IC
Local excision
Not free
APE after 3 mo
N F R after 19 mo
Pain
Anal margin
tumour
CIS
Local excision
Not free
4 re-excisions in 9 mo
N F R after 20 mo
69/F
Pain
Anal canal
tumour
CIS
Local excision
Unknown
Re-excision after
1 & 12 mo a
IC after 36 mo
N F R 10 yr after APE
62/F
Pain, bleeding
Haemorrhoids
CIS
Haemorrhoidectomy
Not free
N R after 15 mo
CIS of vulva
and cervix
10 yr before
52/F
Itching
Condylomata
CIS
Local excision
Not free
N R after 17 mo
51/M
Bleeding
Haemorrhoids
CIS
Local excision
Free
N R after 47 mo
70/M
Bleeding
Haemorrhoids
CIS
Haemorrhoidectomy
Free
N R after 38 mo
56/F
Pain
Haemorrhoids
CIS
Local excision
Free
N R after 11 mo
37/M
Pain, itching,
bleeding
Fissure in ano
CIS
Local excision
Unknown
N R after 34 mo
49/F
Itching,
bleeding
Fistula in ano
CIS
Local excision
Not free
N R after 36 mo
CIS of cervix
12 yr before
CIS = carcinoma in situ; IC = invasive carcinoma; APE = abdomino-perineal excision; N R : - n o recurrence; N F R = no further recurrence
Lost to follow-up
resection margins. All 7 patients have been without

gross evidence of recurrence at follow-up.
The four patients with Bowen's disease presenting as a tumour had a re-excision, but free resection
margins were obtained in only one patient. All patients had a recurrence from 3 to 12 months after
the primary excision. Two patients developed invasive carcinoma and were treated by abdomino-perineal excision. Both are without recurrence after
11 years and 12 years respectively. One patient had
two further local excisions and is without recurrence 12 months later. The last patient awaits re-excision (Table 1).
The histology in patients presenting with a tumour did not differ from the patients without tumour and the epithelial dysplasia could not be
characterized as more severe.
Discussion
The results of the present series seem to justify a
conservative approach in the treatment of Bowen's
disease of the anus with excision of gross lesions

only, provided the patients are under close surveillance. The degree of intervention is considerably
less, and normal anal function is maintained. The
frequency of invasive carcinoma was not higher
than reported in series where extensive excisions
with skin grafting were used [4] and apart from the
patient lost to follow-up who presented with invasire carcinoma 2 years later, there have been no
recurrences more than one year after the initial
treatment.
More frequent local recurrences may be suspected when gross lesions are excised only, and in
this study patients presenting with a tumour seem
to have a particularly high risk of recurrence. The
non-invasive recurrences, however, have been managed by limited excision without skin grafting.
When Bowen's disease involves the anal canal half
the cases will involve the anal transitional zone, i.e.
up to 2 cm above the dentate line [8]. If total excision of the anal mucosa and skin grafting is performed anal continence may be impaired [9], while
local excision of lesions in the anal canal and heal-
166
ing by secondary intention does not usually influence anal continence as demonstrated in the present
series. Continuing normal anal continence after total excision of the anal canal followed by skin grafting has, however, been reported in two patients [4];
detailed information on anal continence following
skin grafting of the anal canal is unfortunately seldom presented.
Even though we did not look for papilloma
virus in this series, a viral aetiology must be suspected in the two female patients with previous
genital affection.
Since all series of Bowen's disease of the anus
are small, with around 3 12 patients [2-7] firm
conclusions on the advantage or disadvantage of
different treatment regimens are difficult. The present series indicates, however, that a conservative
surgical approach based on excision of gross lesions only does not seem to be inferior to wide
excision guided by random biopsies.
References
1. Harrison EG Jr, Beahrs OH, Hill JR (1966) Anal and perianal malignant neoplasms: pathology and treatment. Dis Colon Rectum 9:255-267
2. Strauss R J, Fazio VW (1979) Bowen's disease of the anal and

perianal area. Am J Surg 137:231-234
3. Seckel BR (1985) Skin grafts for circumferential coverage of
perianal wounds. Surg Clin North Am 65:365-371
4. Reynolds VH (1984) Preservation of anal function after total
excision of the anal mucosa for Bowen's disease. Ann Surg
199:563-568
5. Gordon BS (1956) Unsuspected lesions in anal tissue removed for minor conditions. Arch Surg 73:741-746
6. Grodsky L (1967) Unsuspected anal cancer discovered after
minor anorectal surgery. Dis Colon Rectum 10:471 478
7. Scoma JA, Levy EI (1975) Bowen's disease of the anus: report of two cases. Dis Colon Rectum 18:137 140
8. Fenger C (1987) The anal transitional zone. Acta Path Microbiol Immunol Scand [Suppl] 289; 95:32-35
9. Goligher J (1984) Surgery of the anus, colon and rectum,
5th edn. Bailli~re Tindall, London
Accepted: 20March 1989
Dr. J. Christiansen
Department of Surgery D
Glostrup Hospital
DK-2600 Copenhagen
Denmark
Int J Colorect Dis (1989) 4:167
Col6i'eeial
Disease
171
Endo-rectal repair of rectocele

J.C. Sarles, A. Arnaud, I. Selezneff and S. Olivier
Service de Chirurgie Digestive, H6pital Sainte Marguerite, Marseille, France
Abstract. Rectocele may cause colorectal symptoms particularly difficulty in evacuation. It is

readily identified on clinical examination of the
perineum but the pathophysiological abnormality
can easily be defined by defaecography. Between
1984 and 1988 we have operated on 16 patients who
presented with difficulty in evacuation associated
with rectocele. We have used a simple endo-anal
repair aimed to restore a firm recto-vaginal septum.
Excellent functional results were obtained in 11 patients, 4 were considerably improved and one patient had a poor result.
Rectocele is in effect a hernia of the anterior rectal

wall including the posterior vaginal wall. For a long
time this lesion has been considered to be part of a
genital prolapse similar to cystocele and the surgical treatment has been carried out exclusively
through the vaginal route. From 1965 several
workers [1, 2] have maintained that anorectal
symptoms can be associated with rectocele. These
have included outlet obstruction, proctitis and disturbances of continence. Various endo-anal procedures for repair have been described. Considerable
progress has recently been made into the pathophysiology of constipation. This has resulted in the
identification of rectal stasis and that this can be
responsible for a disorder of evacuation, excessive
perineal descent [3], internal rectal prolapse [4] and
rectocele.
The routine use of defaecography [5] has enabled an objective assessment of rectocele and has
confirmed its association with constipation by
demonstrating retention of contrast during straining. Furthermore, defaecography has identified associated abnormalities with rectal stasis.
In this study we report a series of 16 patients

who presented with constipation to whom a surgical treatment of rectocele was offered.
Patients
Between 1984 and 1988, 76 patients attended the Department
with chronic idiopathic constipation associated with symptoms
and signs of obstructive defaecation. These included excessive
straining, a feeling of blockage at the anorectal level, the need
for digital evacuation and a sensation of incomplete evacuation.
In some cases other symptoms were also present. These included
disturbances of continence, pain or pelvic heaviness inexplicable
on the basis of clinical examination, signs of local proctitis
associated with bleeding, mucus and tenesmus. All patients had
a full proctological examination including rectoscopy and
colonoscopy to exclude an obvious physical disorder.
Defaecography as described by Mahieu was carried out in
all patients in an attempt to identify the anatomical abnormalities occurring during attempted defaecation. Rectocele was considered present on the defaecogram when, during straining,
anterior rectal prolapse was identified passing into the rectovaginal septum, involving the extrusion of a part of the ampulla
(Fig. 1).
Anorectal manometry was carried out using three pressure
probes (Marquat, Paris). Resting pressure (RP), maximal
squeeze pressure (MSP) and pressure during rectal distension
and during straining were measured. Rectal sensitivity to distension was also measured, measuring the volume of distension of
the rectal balloon just required to be recognised by the patient.
Manometric examination was carried out pre- and postoperatively for comparison in 12 patients. Results were evaluated
using the paired t-test.
These tests enabled Hirschprung's disease and anismus to
be excluded.
In all 16 patients (mean age 54.4 years, range 24-73 years),
a rectocele appeared to be the principal abnormality associated
with the defaecation disorder.
All patients were initially submitted to a conservative treatment including dietary advice with regard to bulk laxatives. In
some patients biofeedback was tried when manometric results
showed associated anismus. However, conservative treatment
had failed in all patients and as a result surgical repair of the
rectocele was advised.
168
Fig. 1. Defaecography before (A)

and after (B) endo-rectal repair
Fig. 2. The rectal mucosa is incised 1 cm above the pectinate

line
Fig. 3. Dissection of the rectal mucosa at a height of 8 - 1 0 cms
Preoperative preparation
All patients were prepared preoperatively by oral bisacodyl or
polyethyleneglycol. They were also given antibiotics including
metronidazole 2 days preoperatively and cefuroxime (250 mg
i.v.) 1 h before surgery.
The patient was placed in the jackknife position with the
buttocks parted by adhesive strapping. Spinal anaesthia was
routinely used except in patients on anticoagulants.
Operative technique
After thorough cleaning of the anal region including the vagina
with betadine, a gentle anal dilatation to two fingers was carried
out using a Parks retractor. With the retractor in place, the
anterior surface of the rectum was exposed and the rectal mucosa was incised anteriorly about 1 cm above the dentate line
(Fig, 2). The upper margin of this incision was then held by
Babcock forceps and the submucosal plane was then dissected
using pointed scissors to 8 10 cm from the anal verge (Fig. 3).
Haemostasis was established by diathermy although the submu-
S(
~i!~ ~i;~.~,~:..5
Fig. 4. The rectal muscular layer is tacked with polyglycolic acid

sutures 000
169
Table 1. Preoperative symptoms
No. of patients
(%)
Difficulty in evacuation
- with digitation
without digitation
Fig. 5. After tightening the threads a solid anterior rectal wall is

restored
16 (100)
12 (75)
4 (25)
Incontinence
4 (25)
Mucous discharge
4 (25)
Bleeding
3 (18.75)
Perineal discomfort
2 (12.50)
a solid muscular bar (Fig. 5). An excision of the rectal mucosa

was performed which was at least 6 cm in longitudinal length
and the mucosal flap sent for histological section (Fig. 6). The
mucosal defect resulting after the excision was closed by a second layer of polyglycolic acid sutures (000) (Fig. 7). No pressure
dressing within the rectum was required and no other operative
manoeuvre carried out except for in one case in whom a localised haemorrhoidectomy was performed.
Postoperative
care
No particular postoperative manoeuvre was necessary. Normal

oral alimentations resumed at 48 h and a mild laxative was given
to facilitate defaecation. Patients returned home on average
8 days postoperatively.
Results
Fig. 6. Tracing of the excision line of the mucosa
.5
.,..,::.?.
Fig. 7. Final aspect after mucosal suture
cosal plane if correctly dissected is largely avascular. Care was

taken to carry this dissection not only upwards anteriorly but
also on both sides. The bare area resulting was then plicated
using interrupted polyglycolic acid sutures (00) taking bites of
rectal muscle wall every 5 mm (Fig. 4). These were sufficiently
deep to take the recto-vaginal septum, taking care not to perforate the vaginal mucosa. The sutures were then tied to produce
Table 1 shows the preoperative symptoms. Previo u s g y n a e c o l o g i c a l o r o b s t e t r i c f e a t u r e s in t h e hist o r y i n c l u d e d d i f f i c u l t d e l i v e r i e s (7 p a t i e n t s ) , p a r i t y :

1.87 a v e r a g e (2 p a t i e n t s w e r e n u l l i p a r o u s ) , t o t a l
h y s t e r e c t o m y (9 p a t i e n t s ) , p r e v i o u s o p e r a t i o n f o r
g e n i t a l p r o l a p s e (3 p a t i e n t s ) . N o p a t i e n t s p r e s e n t e d
with uterine or vesical prolapse with the exception
of one patient with a small cystocele. Three patients
h a d m i n i m a l stress i n c o n t i n e n c e . T h r e e p a t i e n t s
had previously been operated on for haemorrhoids.
Associated proctological lesions included haemorr h o i d a l p r o l a p s e (4 p a t i e n t s ) a n d a n a l f i s s u r e
(2 p a t i e n t s ) .
A solitary rectal ulcer was clinically recognised
in t h r e e p a t i e n t s a n d t h e h i s t o l o g i c a l e x a m i n a t i o n
o f t h e r e s e c t e d m u c o s a r e v e a l e d in 10 c a s e s t y p i c a l
abnormalities of this condition.
Defaecation revealed a considerable variation
in t h e a n o r e c t a l a n g l e w h i c h w a s o n a v e r a g e 90.65 ~
but with a range of 65-120 ~ Length of the long
axis o f t h e r e c t o c e l e w a s o n a v e r a g e 46.25 m m w i t h
a range of 25-70 mm. Associated defaecographic
a b n o r m a l i t i e s i n c l u d e d d e s c e n d i n g p e r i n e u m (9 p a -
170
Table 2. Manometer study
Patients
1
2
3
4
5
6
7
8
9
10
11
12
Mean
Range
SD
Resting pressure
Squeeze pressure
Rectal sensation threshold
Before op.
Before op.
Before op.
After op.
30
30
40
30
50
30
10
30
50
30
30
20
31.66
10-50
11.14
p=0.08
30
10
20
10
20
30
20
40
30
30
30
20
24.17
10-40
9.003
After op.
56
40
44
52
80
60
120
90
100
60
32
24
32
36
80
70
60
72
120
61
80
80
24
42
69
57.2
24-120
24-90
32.2
19.3
p=0.101
132
104
64
48
144
168
144
112
100
72
88
112
152
156
96
136
160
132
112
120
272
92
80
92
128.67
112
64 272
48-168
54.70
33.94
p=0.33
Discussion
Table 3. Surgical results
No. of patients (%)

1. Symptom free
2. Improved
3. No change in symptoms
After op.
11 (68.75)
4 (25)
I (6.25)
Follow-up: 12.7 months (median: 9; range: 2 24)
tients), puborectalis dysfunction (5 patients), internal rectal prolapse (3 patients), rectal spasm (3 patients) and herniation of the pouch of Douglas
(1 patient).
Clinical anorectal examination did not reveal
any specific abnormalities other than on digital examination which showed a weakness of the anterior
rectal wall.
Table 2 shows the results of manometric studies
before and after operation. There was no significant difference between the two pairs of values.
Results of surgery were assessed clinically by
personal follow-up visit in all patients. In five patients a postoperative defaecography was carried
out and this showed a complete resolution of the
rectocele in all cases (Fig. 1).
The results of the operation are summarised in
Table 3. No death or any postoperative complication occurred. Of the four patients who were improved, mucus discharge persisted in one, another
had persisting incontinence of flatus and two
needed to take laxatives.
Endo-anal repair of rectocele was initially described by Sullivan in 1968 as a supplementary procedure to haemorrhoidectomy [6]. It was recommended by Shepayak [7] in treating constipation.
Basically three types of rectocele can be distinguished. These include low, medium and high. Low
rectocele follows obstetric damage to the anal
sphincter. High rectocele forms part of a complete
genital prolapse. The present technique has been
applied to intermediate rectal prolapse occurring
immediately above the level of the levator, a type
which is by far the most common. Although the
role of rectocele causing difficulties in defaecation
has been long misunderstood, it should not be dismissed. If one relies upon visual rectal examination
in making a diagnosis, rectocele is extremely common but many patients with rectocele have no difficulty in defaecation. By the same token the presence of a rectocele in a patient with constipation
does not necessarily indicate that the anatomical
abnormality is causative. Three points seem to us
important in correctly defining the role of rectocele
in constipation. The necessity for digital vaginal
manoeuvre to evacuate appears to us be significant
and in effect is a practical therapeutic test. Defaecography not only by demonstrating the rectocele but also by presenting evidence of retention of
stools at that level is important. The technique furthermore allows the recognition of associated lesions, particularly internal rectal prolapse, which
may also play a role in difficulty in evacuation.
171
Physiological tests allow recognition o f sphincter
d y s f u n c t i o n not only sphincter h y p e r t o n y but also
anismus.
A n i s m u s is frequently observed in c o n s t i p a t i o n
a n d because it is associated with rectocele it is logical initially to try medical t r e a t m e n t including
biofeedback.
T h e surgical technique that we h a v e used is very
similar to that described by K h u b c h a n d a n i [8].
H o w e v e r , we have n o t felt it useful to c a r r y out the
plication using transverse sutures as he described.
The a n a t o m i c a l lesion is in effect due to a weakness
o f the circular muscle o f the lower rectum, the horizontal fibres o f which are spread a p a r t a n d attenuated by the progressive distension o f the anterior
rectal wall. Thus, vertical plication sutures have
seemed to us m o r e likely to reconstitute the rectovaginal septum. We h a v e also felt t h a t the resection
o f the excessive rectal m u c o s a is a essential p a r t o f
the p r o c e d u r e a n d this can only be carried out using
the endo-rectal a p p r o a c h . F o r this, a p p r o a c h e s per
v a g i n a m or by a c o m b i n e d a p p r o a c h are less effective.
The indications for surgical t r e a t m e n t o f rectocele via the e n d o - a n a l route m u s t adhere to the
following principles. T h e y should only be applied
to rectoceles just a b o v e the level o f the pelvic floor
a n d there should be no associated genital or vesical
prolapse. W h e n there is a significant internal rectal
prolapse, a slight degree o f associated rectocele
should be o p e r a t e d on only if the p a t i e n t gives a
history o f digital evacuation. I f this s y m p t o m does
n o t exist we w o u l d feel t h a t a r e c t o p e x y is indicated
as the o p e r a t i o n will correct n o t only the internal
p r o l a p s e but also a n y small associated rectocele.
W h e n there is a m i n o r degree o f internal rectal
prolapse, we feel t h a t e n d o - a n a l t r e a t m e n t o f the
rectocele should be carried out as the first procedure, given the m i n o r nature o f this procedure,
p r o v i d e d t h a t the s y m p t o m s a n d signs are a p p r o priate for its use.
W h e n anismus is t h o u g h t to be the cause o f
s y m p t o m s , an a t t e m p t at t r e a t m e n t by b i o f e e d b a c k
should have priority over surgical repair. T h e failure to recognise a n i s m u s can be the cause o f a p o o r
functional result after repair. By c o n t r a s t with
s o m e a u t h o r s [6, 8, 9], we h a v e never a t t e m p t e d to

correct an a s y m p t o m a t i c rectocele as in this circ u m s t a n c e surgery is unlikely to help.
Conclusions
O u r experience in these 16 cases suggests t h a t repair
o f rectocele via an e n d o - a n a l route is b o t h a simple
a n d effective m e a n s o f dealing with s y m p t o m s o f
difficulty in e v a c u a t i o n associated with rectocele.
Patients m u s t h a v e been very carefully selected and
d e f a e c o g r a p h y is a n essential c o m p o n e n t o f this
assessment.
References
1. Marks MM (1967) The rectal side of the rectocele. Dis Colon
Rectum 10:387 388
2. Pitchford CA (1967) Rectocele: a cause of anorectal pathologic changes in women. Dis Col Rect 10:464 466
3. Parks AG, Porter NH, Hardcastle JD (1966) The syndrome
of the descending perineum. Proc R Soc Med 59:477-482
4. Ihre T (1972) Internal procidentia of the rectum. Treatment
and results. Scand J Gastroent 7:643 646
5. Mahieu P, Pringot J, Bodart P (1984) Defecography: I Description of a new procedure and results in normal patients.
Gastrointest Radiol 9:247-251
6. Sullivan ES, Leaverton GH, Hardwick CE (1968) Transrectal
perineal repair: an adjunct to improved function after
anorectal surgery. Dis Colon Rectum 11:106 114
7. Shepayak S (1985) Transrectal repair of rectocele: an extended armamentarium of colorectal surgeons. Dis Colon
Rectum 28:422-433
8. Khubchandani IT, Sheets JA, Stasik JJ, Hakki AR (1983)
Endorectal repair of rectocele. Dis Colon Rectum 26:792
796
9. Block IR (1986) Transrectal repair of rectocele using obliterative suture. Dis Colon Rectum 29:707-711
Prof. J.-C. Sarles
Service de Chirurgie Digestive
H6pital Sainte Marguerite
270 Boulevard Sainte-Marguerite
B.P. 29
F-13274 Marseille Cedex 09
France
C,oloi'ee|al
Disease
Enhanced growth of tumour cells in healing colonic anastomoses

and laparotomy wounds
D. Skipper 1, M.J. Jeffrey 2, A.J. Cooper 1, P. Alexander 3 and I. Taylor I
i University Surgical Unit, 2University Histology Department and 3Department of Medical Oncology,
Southampton General Hospital, Southampton, UK
Abstract. In the past, it has been noted that experimental tumour cells innoculated into the peritoneal cavity or into the lumen of the bowel will
grow at a recently formed colonic anastomosis.
However, it has previously been unclear whether
the healing process enhances tumour growth or
whether the presence of a suture line merely allows
the tumour cells to gain access to the tissues. In the
present study, using the hooded Lister rat, we have
confirmed these findings by showing that growth of
the syngeneic MC28 sarcoma and OES5 breast carcinoma occurs preferentially at colonic anastomoses and laparotomy wounds after intraperitoneal injection, and at colonic anastomoses after
intraluminal injection. In previous studies using the
MC28 sarcoma and the OES5 breast carcinoma
injected by the intracardiac route (so that tumour
cells reach normal and healing tissues in approximately equal numbers) we have shown that tumour
growth is enhanced in healing wounds but not in
the surrounding normal tissues when cells reach a
healing colonic anastomosis or laparotomy wound
within 2 h of its formation. Furthermore, by studying the distribution of radiolabelled tumour cells
after intracardiac injection, we have calculated that
the probability of a tumour cell leading to a deposit
in a healing anastomosis or laparotomy wound is
increased 1,000 fold compared to normal tissue. No
previous studies have combined the data for intracardiac, intraluminal and intraperitoneal injection
of tumour cells using the same animal model. We
conclude that the same phenomenon of tumour
growth enhancement in colonic anastomoses and
laparotomy wounds reported after intracardiac injection of tumour cells may well be enhancing tumour growth after intraperitoneal and intraluminal
injection. If these results can be extrapolated to
man, then tumour cells spilled at surgery for colorectal cancer (or indeed any other cancer) may
well encounter an environment which favours their

growth and so the healing process itself may contribute to the genesis of local recurrence of malignant disease.
Local recurrence of colorectal cancer after curative

resection is a common problem with most series
reporting rates of 10-20% [1, 2], although some
series are much higher [3] while others much lower
[4]. Cells giving rise to local recurrence may be
derived from a number of sources. Incomplete resection of the primary tumour [5, 6] is a major
contributing factor. For many years, cells exfolialed into the lumen of the bowel have been held to
be one of the causes of local recurrence of colorectal cancer. Recent studies have shown these
cells to be viable [7] and to have the capacity for in
vivo [8] and in vitro [9] growth. The mesorectum is
a richly lymphovascular structure draining the
rectum. Incomplete resection of the mesorectum
[6, 10] is claimed to be a further source of tumour
cells which may give rise to local recurrence, and
tumour cells derived from the mesorectum have
been shown to have a capacity for in vitro growth
[9].
For many years, trauma to a tissue has been
known to enhance the growth of tumour cells either
implanted into the peritoneal cavity [11] or delivered to the tissues via the circulation [/2-14]. Using the hooded Lister rat, we have found that
bloodborne MC28 sarcoma and OES5 breast carcinoma cells developed into tumour deposits much
more readily when arrested at the site of a healing
colonic anastomosis than when trapped in the capillaries of the normal colon. Based on calculations
using radiolabelled tumour cells, the probability
that a single tumour cell will grow into a macro-
173
scopic lesion in this situation was increased more

than 1,000 times by trauma. Similarly, bloodborne
tumour cells will grow preferentially in a recently
fashioned laparotomy wound [15] as opposed to
normal skeletal muscle.
The aim of this study was to determine whether
syngeneic MC28 sarcoma and OES5 breast carcinoma cells instilled into the peritoneal cavity or
into the lumen of the bowel would grow preferentially at the site of a healing colonic anastomosis.
Table 1. Growth of MC28 sarcoma cells at colonic anastomoses

after intraperitoneal and intraluminal injection
No. MC28
cells injected
Intraperitoneal
injection
lntraluminal
injection
106
4/4
6/9
105
4/4
104
103
M a t e r i a l s and m e t h o d s
No. of animals with

tumour at anastomosis
3/3 j
0/3 a
2/2
0/3"
22 with Yates correction= 11; p<0.001
Animals
These were syngeneic hooded Lister rats, obtained initially from
the Chester Beatty Institute and then maintained as an inbred
line in Southampton. Both males (weight 200 300 g) and females (weight 150-250 g) were used.
Tumours
Two tumours syngeneic for the hooded Lister rat were used.
These were the MC28 sarcoma used for the majority of the
experiments, and the OES5 breast carcinoma. MC28 is a
methylcholanthrene induced sarcoma and OES5 is an oestrogen
induced breast carcinoma [16]. Both were maintained by subcutaneous passage, the MC28 every 14 21 days and the OES5
every 2 1 - 2 8 days. Growth of OES5 is oestrogen dependent and
so all animals used with this tumour were females given oestrogen implants. The implant was made by heating and fusing
together 80% Oestrone Gold Label (Aldrich Chemical Co) and
20% cholesterol (Aldrich Chemical Co) in a crucible. These
particular tumours were used since previous studies [15] have
shown them to act in an identical fashion to adenocarcinomas
and are much easier to maintain in passage with high viability.
Preparation of tumour cell suspensions

Tumours were removed from the flanks of passage animals,
chopped finely with scissors, washed in Hank's balanced salt
solution (Hank's BSS; Gibco) and then mechanically and enzymatically disaggregated using protease 0.5 mg/ml (Sigma No
P5647) and deoxyribonuclease 0.005 mg/ml (Sigma No D4638)
in Hank's BSS and a magnetic stirrer for 45 min. After allowing
large lumps to settle, the cell rich supernatant was pipetted oil,
spun down and washed twice with Hank's BSS. Viability counts
were performed using trypan blue exclusion [17], and dilutions
were made to give 103, 104, 105 or 106 viable cells in 1 ml.
Colonic anastomoses
Under ether anaesthesia, the anterior abdominal wall was
shaved and the abdomen opened through a midline incision.
The left colon was delivered and transected with scissors, taking
care not to injure the mesenteric arterial arcade. Any faeces in
the immediate vicinity were removed but no formal attempt was
made to prepare the bowel, no antibiotics were used and no

dietary restrictions were imposed either pre or post operatively.
The bowel was anastomosed using one layer of interrupted 6/0
silk sutures (Ethicon). The abdomen was closed with one layer
of continuous 2/0 silk (Ethicon) to muscle and continuous 2/0
silk to skin. Animals were then allowed to recover.
lntraperitoneal tumour cell injections

Under ether anaesthesia, a colonic anastomosis was performed,
if appropriate, and the abdomen closed. A suspension of 103 to
10 ~" tumour cells in 1 ml of Hank's BSS was injected into the
abdominal cavity through a 25 gauge needle inserted into the left
upper quadrant. (For numbers of animals in each group see
Table 1 ~) The animal was then allowed to recover. If no anastomosis was to be performed, the abdomen was not opened. Tumour cell injection was performed immediately after anastomosis and no other timing of tumour injection relative to
anastomosis was investigated.
Intraluminal tumour cell injections

Under ether anaesthesia, the abdomen was opened through a
midline incision and, if appropriate, a left colonic anastomosis
was performed at this stage. The large bowel was pierced 2 cm
proximal to the anastomosis with a 25 gauge needle and 1 ml of
air injected to distend the colon and check for leakage at the
anastomosis. A suspension of 103 to 10 6 tumour cells in 1 ml
Hank's BSS was then injected through the same needle (for
number in each group see Table 1). The needle was withdrawn,
the abdomen closed and the animal allowed to recover. Tumour
cell injection was performed immediately after the anastomosis
and no other timing of injection relative to surgery was investigated. Injection of cells via a rectal tube passed across the anastomosis was tried. This method avoided the danger of contaminating the peritoneal cavity with the cell suspension but was
abandoned due to the difficulty of passing the tube in an unprepared bowel and the attendant risk of disrupting the anastomosis with faecal debris carried proximally.
Post mortem examinations

Animals were killed 16 days after intraperitoneal injection of
MC28 sarcoma and either 17 or 22 days after intraluminal injec-
174
tion. Where OES5 was injected by the intraperitoneal or intraluminal routes, animals were killed between days + 35 and +45.
The abdomen was opened by excising a standard
3 cm x 2 cm area of the abdominal wall bearing the laparotomy
scar. The 1.5 cm of colon bearing the anastomosis and the adjacent proximal 1.5 cm of normal colon were removed separately,
opened and faecal debris removed. The specimens of bowel
(normal and anastomosed) and abdominal wall were mounted
on blotting card and fixed in 10% formalin.
Paraffin sections were made ( 3 - 5 longitudinal blocks for
the anastomosis, 2 - 4 longitudinal blocks for the normal bowel
and 10-12 transverse blocks for the abdominal wall). These
were then stained with haematoxylin and eosin and examined
for tumour.
Results
Growth of MC28 following intraperitoneal injection

Three animals received intraperitoneal injection of
10 6 MC28 sarcoma cells but no laparotomy or
colonic anastomosis. Large quantities of tumour
grew on the omentum and scattered deposits occurred on the serosal surface of the abdominal wall,
the serosal surface of the liver, and the small bowel
mesentery. A few, small scattered deposits occurred
on the serosal surface of the large bowel.
Colonic anastomoses were performed and animals received 103 (n=2), 104 (n=3), 105 ( n = 4 ) or
10 6 (n=4) MC28 sarcoma cells injected intraperitoneally immediately after closure of the abdomen.
By day 16, extensive tumour growth had occurred
around the anastomosis (Fig. 1) and on the serosal
surface of the laparotomy wound in all animals
(Table 1), in addition to deposits growing in the
same sites as in the non-operated animals. The tumour growth on the colon was confined to the area
of the anastomosis and similarly the tumour
growth on the abdominal wound was confined to
the laparotomy wound.
Growth of MC28 Jollowing intraluminal injection

Colonic anastomoses were performed and animals
received 10 a (n=3), 104 (n=2), 105 o r 1 0 6 ( n = 9 )
MC28 sarcoma cells injected into the lumen of the
bowel. This was achieved in one animal by injecting
via a rectal catheter, and in the others by needle
puncture of the colon 2 cm proximal to the anastomosis, No tumour growth occurred if animals received less than 1 0 6 cells. There was a small needle
track tumour in the bowel in each animal receiving
10 6 cells. Of those animals receiving l06 cells, tumour grew at the anastomosis in two out of four
animals killed 17 days following injection but de-
Fig. 1. View of the peritoneal surface of the anterior abdominal

wall. Animal had received an intraperitoneal injection of 10 6
MC28 sarcoma cells 16 days prior to killing but no laparotomy
wound. Note the presence of three small, scattered tumour deposits
posits were small. However in four out of five animals receiving 10 6 cells where killing was delayed
until day 22, large deposits grew at the anastomosis
(Fig. 2). These deposits did not grow as exophytic
growths into the lumen of the bowel, but grew
through the bowel wall, disrupting the entire thickness of the bowel wall and protruding from the
serosal surface so that, in macroscopic and microscopic appearance, no difference could be seen between those turnouts arising from intraperitoneal
cells and those arising from intraluminal cell innoculation. In two of the animals, killed at + 22 days,
tumour deposits were seen on the serosal surface of
the abdominal wound and scattered on the omentum. Cells must either have spread from the lumen
through the anastomosis at the time of the tumour
innoculation to form these deposits, or the cells
leading to the deposits must have broken away
from tumour established at the anastomosis.
Growth of OES5 carcinoma at colonic anastomoses

following intraperitoneal and intraluminal injection
Two animals received 10 6 0 E S 5 breast carcinoma
cells intraperitoneally and an oestrogen implant
immediately following formation of a left colonic
anastomosis. Large tumour deposits grew at the
anastomoses and laparotomy wounds, appearing
similar to the deposits occurring after MC28 sar-
175
Figs. 2. Colon taken from four animals which

22 days earlier had each received a colonic
anastomosis followed immediately by an intraluminal injection of 106 MC28 sarcoma cells.
Note the large deposits of tumour confined to
the area of the anastomosis. Note the similarity
of this appearance to that of turnout deposits
occurring after intraperitoneal injection
coma injection shown in Fig. 1. A few small scattered deposits of tumour occurred on the serosal
surface of the large and small bowel.
Three animals received 106 OES5 breast carcinoma cells intraluminally and an oestrogen implant immediately following formation of a left
colonic anastomosis. Tumour growth occurred at
the anastomosis in all animals. Histologically, turnout grew through the full thickness of the bowel
wall. As well as growing out from the serosal surface, in a manner similar to MC28 sarcoma, tumour also grew into the lumen of the bowel, causing obstruction in two animals.
MC28 sarcoma did not lead to bowel obstruction, possibly because the tumour has little stroma
and would be constantly broken away by the passage of faeces. OES5 has much more stroma and
this may allow it to grow into the lumen and obstruct the bowel.
Discussion
From the results of this study, it is clear that both
MC28 sarcoma and OES5 breast carcinoma cells
grow preferentially at healing colonic anastomoses
and laparotomy wounds after intraperitoneal injection and at healing colonic anastomoses after intraluminal injection. MC28 sarcoma grew at the
colonic anastomosis after intraperitoneal injection
of as few as 103 cells, but no growth occurred after
intraluminal injection of less than 106 cells. This is
probably because the lumen of the bowel is a hostile environment [18] in which tumour cells would
be unlikely to survive for long. Hence tumour
growth occurred only with the higher numbers of
injected cells. OES5 carcinoma grew preferentially

at colonic anastomoses and laparotomy wounds
after intraperitoneal injection and at colonic anastomoses after intraluminal injection, showing that
the phenomenon is not confined to the MC28 sarcoma. However, no injection of less than 10 6 cells
was performed with the OES5 carcinoma and so
the tumour dose/tumour growth relationship seen
with MC28 (Table 1) was not demonstrated with
OES5. Regardless of whether tumour cells reached
the anastomosis from the serosal aspect (intraperitoneal injection) or the mucosal aspect (intraluminal injection) tumour was shown macroscopically
and histologically to have grown through all layers
of the bowel wall. Turnout growth leads to intestinal obstruction following intraluminal injection of
OES5 but not MC28. This is probably because
MC28 contains little stroma and so would tend to
be sheared off by the passage of faeces. OES5, on
the other hand, has much stroma and its deposits
would easily encroach upon the lumen of the
bowel.
These results confirm and expand the observations of Vink [18] and Cohn [19] who found that
Brown Pearce tumour cells grew at a colonic anastomosis in the rabbit following intraluminal injection. Neither of these previous studies provided a
direct answer as to whether the presence of an
anstomosis merely allows tumour cells to gain access to the tissues or whether turnout growth is
actually enhanced at a healing colonic anastomosis,
and indeed, the present study on its own still does
not answer this question.
We have previously described [20] studies of the
growth of MC28 sarcoma and OES5 breast carcinoma at colonic anastomoses after intracardiac
176
injection of tumour cells. This method allowed delivery of tumour cells to the healing colonic anastomosis and to the adjacent normal colon. Using 12sI
labelled MC28 sarcoma cells it was found that trapping of tumour cells was increased 1.5- 1.6 times in
a 1.5 cm segment of colon bearing a recently fashioned anastomosis, when compared to the adjacent
1.5 cm of un-operated colon. Tumour grew only at
the anastomotic line and never in normal colon,
and the enhancement of tumour growth at the
anastomosis was calculated to be more than 1,000
fold. Furthermore the effect of varying the timing
of the anastomosis with respect to the timing of the
tumour injection showed that the enhancement of
tumour growth varied at different stages of the
healing process. Growth of tumour was maximally
enhanced if intracardiac injection of tumour cells
was performed when the healing process had been
in progress between 2 and 8 days. However, there
was also a minor peak of enhancement if tumour
cells arrived at the colonic anastomosis within 2 h
of its formation. It may be the counterpart of this
early peak of enhancement which is responsible for
the tumour growth seen at the colonic anastomosis
in the present study after intraperitoneal or intraluminal injection of tumour cells.
Murphy et al. [15] studied tumour growth in
laparotomy wounds following intracardiac injection of MC28 sarcoma cells and OES5 carcinoma
cells and found that tumours grew in the laparotomy wound although, unlike the situation with the
colon, there was a small amount of background
tumour growth in normal skeletal muscle. By
studying the distribution of 125I labelled MC28
cells, it was calculated that there was a 1,000 fold
enhancement of tumour growth in the healing laparotomy wound. In the present study, tumour
grew at the laparotomy wound and it is reasonable
to assume that the enhanced soil effect observed by
Murphy et al. [15] was contributing to the tumour
growth observed in this study.
Hence we have shown that tumour cells reaching a recently formed colonic anastomosis or la-~.
parotomy wound by direct contact (intraperitoneal
or intraluminal injection) will grow in the healing
tissues. Furthermore, from previous studies of intracardiac injection of MC28 sarcoma and OES5
carcinoma, we know that there is approximately a
1,000 fold enhancement of growth of these tumours
in healing colonic anastomoses and laparotomy
wounds.
If these observations of enhanced tumour
growth can be extrapolated to man, then a healing
colonic anastomosis or laparotomy wound provides a favourable soil for the growth of colorectal
cancer cells spilled during surgery and thus may

contribute to the genesis of local recurrence of this
disease. It is difficult in humans to investigate directly the effect of the healing process in promoting
tumour growth but circumstantial evidence of the
effect exists, at least for malignant melanoma [21].
Viable malignant cells [7] with potential for in vivo
[8] and in vitro [9] growth are present in the lumen
of the bowel in patients with colorectal cancer; and
malignant cells with potential for in vitro growth
have recently been demonstrated in the mesorectum, in washings of the serosal surface of the bowel
and in washings of the tumour bed after resection
and anastomosis [9]. If these viable malignant cells
are left behind at surgery, they will encounter an
environment made favourable for their growth by
the very surgery which was designed to eradicate
them. The advice of Umpleby and Williamson [22]
to wash out the lumen of the bowel with cytotoxic
agents should be followed and should probably be
extended to washout of the tumour bed after resection.
Acknowledgements. We would like to thank Mr. R. Lee of the
University Histology Department for his meticulous care in
preparing the slides. Thanks are also due to Mr. T. Richards and
his technical staff. The work was supported by a generous grant
from the Cancer Research Campaign. DS is a Cancer Research
Campaign Fellow.
References
1. Phillips RKS, Hittinger R, Blesovsky L, Fry JS, Fielding LP
(1984) Local recurrence following "curative" surgery for
large bowel cancer: I. The overall picture. Br J Surg 71:12-16
2. McDermott FT, Hughes ESR, Pihl E, Johnson WR, Price
AB (1985) Local recurrence after potentially curative resection for rectal cancer in 1,008 patients. Br J Surg 72:34-37
3. Hurst PA, Prout WG, Kelly JM, Bannister JJ, Walker RT
(1982) Local recurrence after low anterior resection using
the staple gun. Br J Surg 69:275-276
4. Heald R J, Ryall RDH (1986) Recurrence and survival after
total mesorectal excision for rectal cancer. Lancet i: 1479
1482
5. Williams NS (1984) The rationale for preservation of the
anal sphincter in patients with low rectal cancer. Br J Surg
71:575-581
6. Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local
recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour
spread and surgical excision. Lancet ii:996-999
7. Umpleby HC, Fermor B, Symes MO, Williamson RCN
(1984) Viability of exfoliated colorectal carcinoma cells. Br
J Surg 71:659-663
8. Fermor B, Umpleby HC, Lever JV, Symes MO, Williamson
RCN (1986) Proliferative and metastatic potential of exfoliated colorectal cancer cells. J Natl Cancer Inst 76:347-349
9. Skipper D, Cooper AJ, Marston JE, Taylor I (1987) Exfoliated cells and in vitro growth in colorectal cancer. Br J Surg
74:1049-1052
177
10. Heald RJ, Husband EM, Ryall RDH (1982) The mesorecturn in rectal cancer surgery the clue to pelvic recurrence?
Br J Surg 69:613-616
11. Jones FS, Rous P (1914) On the cause of the localisation of
secondary turnouts at points of injury. J Exp Med 20:404412
12. Robinson KP, Hoppe E (1962) The development of bloodborne metastases. Effect of local trauma and ischaemia.
Arch Surg 85:720-724
13. Alexander JW, Altemeier WA (1964) Susceptibility of injured tissues to haematogenous metastases; an experimental
study. Ann Surg 159:933-944
14. Fisher ER, Fisher B (1965) Experimental study of factors
influencing development of hepatic metastases from circulating turnout cells. Acta Cytol 9:146-158
15. Murphy P, Alexander P, Senior PV, Fleming J, Kirkham N,
Taylor I (1988) Mechanisms of organ selective tumour
growth by bloodborne cancer cells. Br J Cancer 57:19-31
16. Senior PV, Murphy P, Alexander P (1985) Oestrogen dependent rat mammary carcinoma as a model for dormant
metastases. In: Hellman K, Eccles SA (eds) Treatment of
metastasis: problems and prospects. Taylor and Francis,
London, pp 113-116
17. Tennant JR (1964) Evaluation of the trypan blue technique
for determination of cell viability. Transplantation 2:685
694
18. Vink M (1954) Local recurrence of cancer in the large

bowel: the role of implantation metastases and bowel disinfection. Br J Surg 41:431 433
19. Cohn I (1967) Implantation in cancer of the colon. Surg
Gynecol Obstet 124:501 508
20. Skipper D, Jeffrey M J, Cooper AJ, Taylor I, Alexander P
(1988) Preferential growth of bloodborne cancer cells in
colonic anastomoses. Br J Cancer 57:564-568
21. Flook D, Horgan K, Taylor BA, Hughes LE (1986) Surgery
for malignant melanoma: from which limb should the graft
be taken? Br J Surg 73:793-795
22. Umpleby HC, Williamson RCN (1984) The efficacy of
agents employed to prevent anastomotic recurrence in colorectal carcinoma. Ann R Coll Surg Engl 66:192-194
Accepted: 20 March 1989
Mr. D. Skipper
Department of Cardiothoracic Surgery
St. George's Hospital
Tooting
London SW17 0QT
Announcements
1 8 - 2 0 September 1989 - Bologna/Italy
International Symposium on New Trends in Pelvic Pouch Procedures
For further information contact: R.M. Societa di Congressi, Via Ciro Menotti II,
1-20129 Milano, Italy. Telephone: 02/7 42 63 08 or 7 42 67 72, fax: 73 82 610, telex:
3 50 538 IBC I. Organisers: Prof. G. Gozzetti, Prof. L. Barbara
1 5 - 1 7 February 1990 - Ft. Lauderdale/
Florida/USA
Colorectal Disease in 1990:

An International Exchange of Medical and Surgical Concepts
For further information contact: The Cleveland Clinic Foundation, Department of

Continuing Education, 9500 Euclid Avenue, TT31, Cleveland, OH 44195-5241, USA.
Telephone: 444-56 96 (local), 800-7 62-81 72 (Ohio), 800-7 62-81 73 (outside Ohio)
177
10. Heald RJ, Husband EM, Ryall RDH (1982) The mesorecturn in rectal cancer surgery the clue to pelvic recurrence?
Br J Surg 69:613-616
11. Jones FS, Rous P (1914) On the cause of the localisation of
secondary turnouts at points of injury. J Exp Med 20:404412
12. Robinson KP, Hoppe E (1962) The development of bloodborne metastases. Effect of local trauma and ischaemia.
Arch Surg 85:720-724
13. Alexander JW, Altemeier WA (1964) Susceptibility of injured tissues to haematogenous metastases; an experimental
study. Ann Surg 159:933-944
14. Fisher ER, Fisher B (1965) Experimental study of factors
influencing development of hepatic metastases from circulating turnout cells. Acta Cytol 9:146-158
15. Murphy P, Alexander P, Senior PV, Fleming J, Kirkham N,
Taylor I (1988) Mechanisms of organ selective tumour
growth by bloodborne cancer cells. Br J Cancer 57:19-31
16. Senior PV, Murphy P, Alexander P (1985) Oestrogen dependent rat mammary carcinoma as a model for dormant
metastases. In: Hellman K, Eccles SA (eds) Treatment of
metastasis: problems and prospects. Taylor and Francis,
London, pp 113-116
17. Tennant JR (1964) Evaluation of the trypan blue technique
for determination of cell viability. Transplantation 2:685
694
18. Vink M (1954) Local recurrence of cancer in the large

bowel: the role of implantation metastases and bowel disinfection. Br J Surg 41:431 433
19. Cohn I (1967) Implantation in cancer of the colon. Surg
Gynecol Obstet 124:501 508
20. Skipper D, Jeffrey M J, Cooper AJ, Taylor I, Alexander P
(1988) Preferential growth of bloodborne cancer cells in
colonic anastomoses. Br J Cancer 57:564-568
21. Flook D, Horgan K, Taylor BA, Hughes LE (1986) Surgery
for malignant melanoma: from which limb should the graft
be taken? Br J Surg 73:793-795
22. Umpleby HC, Williamson RCN (1984) The efficacy of
agents employed to prevent anastomotic recurrence in colorectal carcinoma. Ann R Coll Surg Engl 66:192-194
Mr. D. Skipper
Department of Cardiothoracic Surgery
St. George's Hospital
Tooting
London SW17 0QT
Announcements
1 8 - 2 0 September 1989 - Bologna/Italy
International Symposium on New Trends in Pelvic Pouch Procedures
For further information contact: R.M. Societa di Congressi, Via Ciro Menotti II,
1-20129 Milano, Italy. Telephone: 02/7 42 63 08 or 7 42 67 72, fax: 73 82 610, telex:
3 50 538 IBC I. Organisers: Prof. G. Gozzetti, Prof. L. Barbara
1 5 - 1 7 February 1990 - Ft. Lauderdale/
Florida/USA
Colorectal Disease in 1990:

An International Exchange of Medical and Surgical Concepts
For further information contact: The Cleveland Clinic Foundation, Department of

Continuing Education, 9500 Euclid Avenue, TT31, Cleveland, OH 44195-5241, USA.
Telephone: 444-56 96 (local), 800-7 62-81 72 (Ohio), 800-7 62-81 73 (outside Ohio)
Col6i'ee/al
Disease
Ileal pouch-anal anastomosis without rectal muscular cuff

J. E M. Slors, C.W. Taat and W.H. Brummelkamp
Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
Abstract. T w e n t y patients u n d e r w e n t p r o c t o c o l e c t o m y f o l l o w e d b y an ileal p o u c h - a n a l a n a s t o m o s i s .

T h e r e c t u m was m o b i l i z e d in the i n t e r s p h i n c t e r i c
p l a n e a n d t r a n s e c t e d at the level o f the d e n t a t e line.
A s a c o n s e q u e n c e , a rectal cuff, w h i c h is c o n s i d e r e d
b y s o m e to be i m p o r t a n t f o r the m a i n t e n a n c e o f
a n a l c o n t i n e n c e , was n o t left behind. All p a t i e n t s
were c o n t i n e n t . M a n o m e t r i c d a t a d e m o n s t r a t e d n o
difference c o m p a r e d to a g r o u p o f 21 p a t i e n t s with
a c o n v e n t i o n a l m u c o s e c t o m y . N e a r l y h a l f o f the
p a t i e n t s in b o t h g r o u p s h a d a positive r e c t o - a n a l
i n h i b i t o r y reflex. A s a rectal c u f f is n o t essential f o r
m a i n t a i n i n g c o n t i n e n c e , the r e c e p t o r s o f the rectoanal i n h i b i t o r y reflex are p r o b a b l y l o c a t e d o u t s i d e
the rectal wall.
P a t i e n t s with familial a d e n o m a t o u s p o l y p o s i s
( F A P ) a n d ulcerative colitis are c u r e d o f c o l o r e c t a l
disease after p r o c t o c o l e c t o m y . T h e ileal p o u c h - a n a l
a n a s t o m o s i s has b e c o m e a feasible alternative to
the c o n v e n t i o n a l ileostomy. S a t i s f a c t o r y results
h a v e been r e p o r t e d , a l t h o u g h the p r o c e d u r e is associated with c o n s i d e r a b l e m o r b i d i t y [ 1 - 5 ] .
T h e d i s c u s s i o n a r o u n d this p r o c e d u r e is m a i n l y
f o c u s e d o n the t y p e o f reservoir a n d the length o f
the rectal cuff. T h e o p t i m a l m e t h o d f o r reservoir
c o n s t r u c t i o n has still to be d e t e r m i n e d . E x c i s i o n o f
all the affected m u c o s a is an essential p a r t o f the
p r o c e d u r e . R e t a i n e d m u c o s a l cells m a y leave c o n siderable risk o f r e c u r r e n c e o f the disease with subs e q u e n t c o m p l i c a t i o n s f o r the o p e r a t i o n a n d p o t e n tial m a l i g n a n t d e g e n e r a t i o n [ 6 - 8 ] . I n 1986 H e a l d
[9] a n d B r u m m e l k a m p [10] i n d e p e n d e n t l y develo p e d a t e c h n i q u e o f radical excision o f the m u c o s a
t o g e t h e r with the rectal wall. This m e t h o d a v o i d s
s t r i p p i n g o f the rectal m u c o s a and, as a conseq u e n c e , n o rectal c u f f is left.
O u r experience with the ileal p o u c h - a n a l anast o m o s i s w i t h o u t m u c o s e c t o m y is r e p o r t e d .

Patients
From October 1984 to July 1988, 41 patients underwent the
pelvic pouch and ileoanal anastomotic procedure.
A conventional mucosectomy was carried out in 21 patients
leaving a rectal cuff of approximately 5 7 cm. In 20 patients the
rectum was divided at the level of the dentate line, thus leaving
no rectal cuff. The group of 20 patients, who did not undergo a
mucosectomy consisted of 4 women and 16 men with a mean
age of 33 years (range 19 70 years). Three patients had FAP and
17 ulcerative colitis. Three patients had previously undergone
colectomy and ileorectal anastomosis, two a colectomy and
ileostomy and one a Hartmann procedure. Six patients had
undergone emergency operation because of a toxic megacolon
or severe haemorrhage.
Methods
After routine colectomy, the rectum with its mesorectum was
mobilized via the presacral avascular plane. This plane was
followed down to the pelvic floor. Sharp dissection of the lateral
ligaments, close to the rectal wall, and freeing of the anterior
wall completed the mobilization of the rectum. The rectum was
stretched and a right angled clamp was placed on the rectum just
above the pelvic floor. Strong traction was applied while the
intersphincteric plane was entered (Fig. l). Endo-anal proctoscopic inspection from below demonstrated when the level of the
dentate line was reached. Then the rectum was divided at that
level. An ileal pouch was constructed (a modified J-pouch with
two or three anastomoses, Fig. 2) and anastomosed full thickness to the dentate line, by means of interrupted 2/0 polyglactin (Vicryl| sutures (n= 17) or by an EEA stapler (Autosuture | in three patients. In the group of patients with a rectal
muscular cuff (n = 21) the ileoanal anastomosis was performed
with the stapler in two patients. A temporary loop ileostomy
completed the procedure in all cases. For anal manometry an
open tip rapid pull-through technique was used.
179
Fig. 2. Modified J-pouch with 2 - 3 interrupted anastomoses

(B-pouch I-II)
Fig. 1. Schematic drawing of the intersphincteric freeing of the

rectum and transection of the dentate line. 1, traction; 2, intersphincteric route; 3, endoanal inspection; 4, transection dentate
line
Results
Complications
There was no postoperative mortality. The
ileostomy has been closed in 15 patients. The mean
follow-up of these 15 patients is 13 months (range
1 - 2 4 months). Five patients, all with an uneventful
postoperative course, are waiting for closure of
their stomas.
One 24-year old patient had obstruction of the
small bowel which required laparotomy. Another
developed a pelvic abscess; laparotomy showed an
infected haematoma and dehiscence of the ileo-anal
anastomosis. The abscess was drained and the ileoanal anastomosis refashioned. This patient is doing
well; the ileo-anal anastomosis healed without

stenosis. Another patient, a 70 year old man, underwent acute colectomy and ileal pouch-anal procedure for toxic megacolon. Histological examination showed severe inflammation of the colon with
a carcinoma in the distal part. After closure of the
ileostomy he was continent, with 6 - 8 bowel movements per 24 h. After one year he became incontinent and resection of the pouch was necessary. A
few months thereafter he died of distant metastasis.
His late incontinence was probably due to a combination of advanced age and diabetic neuropathy.
One patient had a stenosis of the distal part of the
pouch due to leakage from the pouch. The pouch
and stricture had to be removed and a new ileal
pouch-anal anastomosis was constructed. Finally,
two patients developed pouchitis with severe diarrhoea and ulceration of the mucosa at endoscopy.
Sphincter Junction
The ileostomy could be closed in 15 of the 20 patients who underwent transection of the rectum at
the dentate line. These 15 patients are continent
and able to evacuate their reservoirs spontaneously. One patient complained of major nocturnal soiling once a week during the first year and one
patient uses pads because of regular soiling. The
mean frequency of bowel movements is 5.7+2.3
per 24 h. The pre- and postoperative manometric
180
Table 1. Manometry data (mean + standard deviation)
Rectal cuff
n=21
No rectal
cuff
n=20
- pressure
-rest
Preoperative
Postoperative
69_+27*
184+30
21+ 4
27 11
60_+ 29"
192 _+38
20_+ 6
29 + 12
-sphincter
length
(ram)
-rest
-squeeze
109_+24
186_+41
22+ 2
35 10
- pressure
(cm H20)
- sphincter
length
-rest
-squeeze
-rest
-squeeze
98 Jr 34
203 _+37
25_+ 9
35 + ! 3
(cm H20 ) -squeeze
(ram)
Manometry data indicating no difference between patients with
or without a rectal cuff, except a significant decrease in pre- and
postoperative resting pressures in both groups (*p <0.01)
data of patients both with and without a rectal

muscular cuff are summarized in Table 1.
No differences were found between pre- and
postoperative results in either group except for a
significant decrease in the resting pressure in patients in both groups (p<0.01 Student's t-test).
In nearly half of the patients of both groups the
recto-anal inhibitory reflex ( > 3 4 cm H 2 0 ) was
present. Fourteen of the 15 patients with transection of the rectum at the dentate line are able to
differentiate between flatus and faeces.
frequency of developing a carcinoma in such limited mucosal sleeve will be low. Moreover, this
short sleeve can easily be monitored by regular and
simple proctoscopy. Our clinical results and those
of Heald and Allen [9] demonstrate that intersphincteric freeing of the rectum with transection at
the dentate line is a feasible technique. Although
the pelvis is in general less accessible in men with
this technique, no differences were encountered between men and women. It is evident that transection at the dentate line with a "radical" mucosectomy is compatible with continence. This approach
avoids the often difficult and time-consuming conventional mucosectomy. The limited number of patients does not allow any conclusion on the relation
between pelvic sepsis and the absence of a rectal
muscular cuff. Furthermore, our patients represent
a negative selection with regard to age (three patients were older than 50 years) and the number of
acute interventions (n=6). The fact that a rectoanal inhibitory reflex was present in nearly half the
patients with no rectal cuff is interesting. Various
studies in patients with a rectal muscular cuff are
demonstrating conflicting results. Absence of this
reflex has been reported in all cases [15, 17] while
others found an adequate reflex in a varying percentage of patients [18, 19]. It is evident that the
absence of this reflex does not interfere with continence. Our data suggest that the receptors of this
reflex are located outside the most distal part of the
rectum.
Acknowledgement. The authors wish to thank R. van Gameren,
Discussion
Originally, a long rectal cuff with a length of at

least 10 cm was generally considered to be essential
for maintaining continence [11-14]. More recent
publications showed similar results with regard to
anal continence in patients with a much shorter
rectal cuff [4, 15, 16]. Long rectal cuffs are associated with a higher incidence of cuff abscesses and
pelvic sepsis and failure of the ileo-anal anastomosis [15, 16]. More recently a lower transection of the
rectum at the level of the anorectal junction has
been reported [4]. It remains to be seen whether the
pouch should be anastomosed at the dentate line or
at the top of the anal canal. Rectal division at the
anorectal junction without mucosectomy has the
advantage that anastomotic retraction occurs less
frequently. Anastomotic dehiscence, due to the limited length of the mesentery in some cases, is a
serious condition resulting in failure of the procedure. The risk inherent in retaining rectal mucosa is
not yet known although it is to be expected that the
M.D. for his assistance in the preparation of the manometric

data.
References
1. Taylor BA, Dozois R R (1987) The J ileal pouch-anal anastomosis. World J Surg 11:727 734
2. Schoetz DJ, Coller JA, Veidenheimer MC (1986) Ileoanal
reservoir for ulcerative colitis and familial polyposis. Arch
Surg 121:404 409
3. Fonkalsrud EW (1987) Update on clinical experience with
different surgical techniques of the endorectal pullthrough
operation for colitis and polyposis. Surg Gynecol Obstet
165:309-316
4. Nicholls RJ (1987) Restorative proctocolectomy with various types of reservoir. World J Surg 11:751-762
5. Williams NS, Johnston D (1985) The current status of mucosal proctectomy and ileo-anal anastomosis in the surgical
treatment of ulcerative colitis and adenomatous polyposis.
Br J Surg 72:159-168
6. Hepell J, Weiland LH, Perrault J, Pemberton JH, Telander
RL, Beart RW (1983) Fate of the rectal mucosa after rectal
mucosectomy and ileoanal anastomosis. Dis Colon Rectum
26:768-771
181
7. Heimann TM, Bolnick K, Aufses AH (1986) Results of
surgical treatment in familial polyposis coli. Am J Surg
152:276-278
8. Wolfstein IH, Bat L, Neumann G (1982) Regeneration of
rectal mucosa and recurrent polyposis coli after total colectomy and ileoanal anastomosis. Arch Surg 117:1241 - 1242
9. Heald RJ, Allen DR (1986) Stapled ileo-anal anastomosis:
a technique to avoid mucosal proctectomy in the ileal pouch
operation. Br J Surg 73:571-572
10. Brummelkamp WH, Slors JFM (1986) Ileal pouches. Br J
Surg 73:940
11. Utsunomiya L Iwama T, Imajo M, Matsuo S, Sawai S,
proctectomy and ileoanal anastomosis. Dis Col Rectum
23:459-466
12. Martin LW, LeCoultre C, Schubert WK (1977) Total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis. Ann Surg 186:477 480
3: 294- 303
15. Grant D, Cohen Z, McHugh S, McLeod R, Stern H (1986)
Clinical results and manometric findings with long and
short rectal cuffs. Dis Col Rectum 29:27-32
16. Pescatori M, Mattana C, Castagneto M (1988) Clinical and

functional results after restorative proctocolectomy. Br J
Surg 75:321-324
17. Heppell J, Kelly KA, Philips SF, Beart RW Jr, Telander RL,
Perrault J (1982) Physiologic aspects of continence after
colectomy, mucosal proctectomy and ileo-anal anastomosis. Ann Surg 195:435 443
18. Pescatori M, Parks AG (1984) The sphincteric and sensory
components of preserved continence after ileoanal reservoir.
Surg Gynecol Obstet 158:517-521
mucosal proctectomy, and endorectal ileoanal pullthrough.
Arch Surg 119:526-531
Dr. J. F. M. Slors
Academic Medical Center
Meibergdreef 9
NL-1105 AZ Amsterdam
The Netherlands
Erratum
Jass JR, Mukawa K, Richman PI, Hall PA: Do

aggressive subclones within primary colorectal cancer give rise to liver metastases? Int J Colorect
Dis (1989) 4:109-117
Figure 2B and 2C (page 112) were incorrectly

labelled. The photographs themselves are in the
correct positions but "C" should be "B" and vice
versa. The legend is correct.
181
7. Heimann TM, Bolnick K, Aufses AH (1986) Results of
surgical treatment in familial polyposis coli. Am J Surg
152:276-278
8. Wolfstein IH, Bat L, Neumann G (1982) Regeneration of
rectal mucosa and recurrent polyposis coli after total colectomy and ileoanal anastomosis. Arch Surg 117:1241 - 1242
9. Heald RJ, Allen DR (1986) Stapled ileo-anal anastomosis:
a technique to avoid mucosal proctectomy in the ileal pouch
operation. Br J Surg 73:571-572
10. Brummelkamp WH, Slors JFM (1986) Ileal pouches. Br J
Surg 73:940
11. Utsunomiya L Iwama T, Imajo M, Matsuo S, Sawai S,
proctectomy and ileoanal anastomosis. Dis Col Rectum
23:459-466
12. Martin LW, LeCoultre C, Schubert WK (1977) Total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis. Ann Surg 186:477 480
3: 294- 303
15. Grant D, Cohen Z, McHugh S, McLeod R, Stern H (1986)
Clinical results and manometric findings with long and
short rectal cuffs. Dis Col Rectum 29:27-32
16. Pescatori M, Mattana C, Castagneto M (1988) Clinical and

functional results after restorative proctocolectomy. Br J
Surg 75:321-324
17. Heppell J, Kelly KA, Philips SF, Beart RW Jr, Telander RL,
Perrault J (1982) Physiologic aspects of continence after
colectomy, mucosal proctectomy and ileo-anal anastomosis. Ann Surg 195:435 443
18. Pescatori M, Parks AG (1984) The sphincteric and sensory
components of preserved continence after ileoanal reservoir.
Surg Gynecol Obstet 158:517-521
mucosal proctectomy, and endorectal ileoanal pullthrough.
Arch Surg 119:526-531
Dr. J. F. M. Slors
Academic Medical Center
Meibergdreef 9
NL-1105 AZ Amsterdam
The Netherlands
Erratum
Jass JR, Mukawa K, Richman PI, Hall PA: Do

aggressive subclones within primary colorectal cancer give rise to liver metastases? Int J Colorect
Dis (1989) 4:109-117
Figure 2B and 2C (page 112) were incorrectly

labelled. The photographs themselves are in the
correct positions but "C" should be "B" and vice
versa. The legend is correct.
Coloi'eclal
Disease
Preoperative prediction of late cancer-specific deaths in patients

with rectal and rectosigmoid carcinoma
E. Sthhle 1, B. Glimelius 2, R. Bergstriim 3 and L. Phhlman 1
i Department of Surgery and 2 Department of Oncology, University of Uppsala, Akademiska sjukhuset, Uppsala and
3 Department of Statistics, University of Uppsala, Uppsala, Sweden
Abstract. The possibility of predicting late cancerspecific deaths from (a) the preoperative serum levels of three tumour markers, carcinoembryonic
antigen (CEA), tissue polyptide antigen (TPA) and
an antigen defined by the C-50 antibody (CA-50),
from (b) one clinical factor of independent prognostic relevance, polypoid tumour growth, and
from (c) Dukes' stage was evaluated in 276 patients
with rectal carcinoma operated upon with curative
intent ("potentially curable"), and in the 251 of
those patients who were considered to be "potentially cured" after surgery. Using the Cox regression model, the preoperative serum levels of the
tumour markers strongly predicted the cancerspecific mortality within the first year after surgery.
This ability of S-CEA and S-CA-50 diminished for
the mortality during the second year after surgery,
and virtually disappeared thereafter. The ability of
S-TPA to predict cancer-specific deaths did not
change as dramatically with time as that of the
other two markers, particularly in the group of
"potentially cured" patients. Patients with polypoid
tumour growth had a good prognosis which did not
appear to change with time. Similarly, the prognostic information provided by Dukes' staging system
was valid at all studied time intervals after surgery,
although it declined after the second year. The importance of these results in relation to the selection
of patients for adjuvant treatment is discussed.
The principal aim of therapy additional to surgery

in colorectal cancer is not solely to increase the
disease-free survival time, but to increase the proportion of cured patients. In all adjuvant settings
this is a question of treating subclinical disease. The
number of tumour cells present in patients "potentially cured by surgery" may, however, vary between
0 and about 109. The extent to which the chemo-
therapeutic agents available today may reduce this

tumour cell burden in colorectal cancer is limited,
though it is not yet properly established. Even if it
is postulated that micrometastases are more sensitive to cytotoxic drugs than macroscopic disease,
findings in studies in advanced disease indicate that
these drugs may reduce the cell population no more
than 100-10,000 fold [1]. Hence, the patients with
colorectal disease who are of special interest for
adjuvant chemotherapy with curative intent are
those with a truly minimal tumour burden. Even
though the tumour growth rate varies both interand intraindividually, the patients with such a minimal tumour cell burden are most likely those who
will have a long disease-free period, i.e. those represented by late cancer-specific deaths. This group of
patients must, at present, be the group to be specially considered for additional therapy.
We have recently shown that the best set of
preoperatively available prognostic predictors consists in the preoperative serum levels of the three
tumour markers carcinoembryonic antigen (CEA)
[2], tissue polypeptide antigen (TPA) [3] and an
antigen defined by the C-50 antibody (CA-50) [4] in
combination with one easily available preoperative
clinical variable, namely polyploid growth of the
tumour [5]. Postoperatively, Dukes' stage (or any
modification thereof) has long been recognized as
the best predictor [6, 7].
The aim of this study was to determine to what
extent the preoperative serum levels of CEA, TPA
and CA-50, polypoid tumour growth, and Dukes'
stage give prognostic information about late
cancer-specific deaths.
Material and methods
Patients
Between March 1981 and December1985, 327 consecutivepatients with a histological diagnosis of adenocarcinomaof the
183
rectum and rectosigmoid (lesion within 20 cm from the anal
verge) attended the Department of Surgery of the University
Hospital, Uppsala, Sweden. There were 140 women (mean age
70 years, range 40 87) and 176 men (mean age 70 years, range
40-93). Eleven patients did not undergo surgery because of a
poor general and/or mental condition.
Of the remaining 316 patients, 276 (87%) were considered
to be "potentially curable" by surgery, i.e. they had a locally
resectable turnout and no signs of distant metastases at the time
of the clinical evaluation (see below). These 276 patients formed
the basis of the present study.
Seventy-five (27%) patients proved to have a tumour in
Dukes ' stage A, 95 (34%) in stage B, 81 (29%) in stage C and
25 (10%) had advanced disease (stage 'D'). All but the 25 patients in stage 'D' were considered "potentially cured".
length of follow-up was 49 months (range 20-80) and the median length 47 months. Causes of death were obtained from the
hospital records and death certificates. Death in any patient not
cured by surgery or with known relapse of disease was considered to be cancer-specific irrespective of the actual cause. No
patient has been lost to follow-up.
Tumour markers
CEA, TPA and CA-50 determinations were performed as described earlier [12].
Preoperative serum values of all three tumour markers were
available for 251 of the 276 patients (90%). CEA values were
missing for 5 patients, TPA for 13 patients and CA-50 for 17
patients.
Clinical evaluation
Clinical evaluation of the resectability of the tumour was made
either by digital examination or by rigid sigmoidoscopy, or both
[8]. In 28 patients the tumour protruded into the lumen with a
"stalk-like" base and was classified as polypoid.
In all patients a chest X-ray and routine blood tests, including liver function tests, were performed. If liver metastases were
suspected on a clinical basis, computed tomography (CT) or
ultrasonography of the liver was carried out.
Treatment and pathological stage

Patients with a primarily resectable turnour were randomly allocated to one of two groups, one of which received preoperative
(25.5 Gy in one week) and the other postoperative (60 Gy in 7 8
weeks) irradiation. Thirty-seven patients, randomised to receive
postoperative radiotherapy but who were found to have Dukes'
Stage A tumours at examination of the operative specimen, were
not irradiated [9]. An interim analysis of this randomized study
indicates that the survival is identical in the two treatment categories (unpublished data). Standard surgical procedures were
used and the operations were performed by a number of
surgeons. Local surgery was not considered curative.
Throughout this study, Dukes' staging was applied [10]. All
patients "not cured by surgery" are referred to here as being at
stage 'D'. Patients who were considered initially to have an
unresectable tumour or who underwent a locally non-curative
resection without any metastatic disease being discovered were
considered as stage 'D~oca~. The postoperative pathological examination of the specimen was performed according to routine,
but all the histopathological material was re-evaluated by one of
the authors (BG).
Follow-up
All patients were followed up clinically every third month during
the first postoperative year, every fourth month in the second
year and twice a year until the fifth year. Routine CT of the
pelvic region was performed at certain intervals in patients
who entered the study within the first two years. As this was
found to be of limited value [11], CT was carried out only if there
was any clinical suspicion of recurrence, either locally or elsewhere. If local recurrence was suspected, a fine-needle and/or
a truecut biopsy was performed. Once or twice a year chest
x-ray, liver function tests and CEA were carried out. The mean
Statistical analyses
For this investigation of the effects of different variables on
survival, Cox's proportional hazards model [13] was used:
h (tl x) = h o (t) exp (/31 x~ + . . . / 3 k Xk)
where h (tlx) denotes the hazard function, the definition of
which implies that the risk of dying in the interval (t, t + dt) is
h (tlx) dt, provided that an individual is alive at time t. h o (t) may
be looked upon as a baseline hazard function for an individual
with all explanatory variables x 1 ... x k equal to zero. The parameter/3i represents the change in the logarithm of the hazard
function as the variable x i increases by one unit, given that the
other variables are unchanged. The effect on the hazard function
associated with the variable xl is exp (/3i)- A positive value of fl~
indicates an increased "immediate death risk" (poorer survival
prospects). The standard Cox model assumes that the relative
hazards are constant over time. In order to determine whether
this was true, a generalized version of the model was estimated
in which the effects of variables were allowed to change with
time. Rather than modelling the changing effects and assuming
time-dependent variables, an approach that is very computerintensive and requires choice of the functional form of the time
dependence, models were estimated in which relative effects
were assumed to be constant in the time intervals 0 - 1 , 1 - 2 and
> 2 years, but were allowed to change between the intervals [14].
Results
Clinical presen ta tion

T h e o v e r a l l m o r t a l i t y in p a t i e n t s " p o t e n t i a l l y c u r able" by surgery was 49% (136/276) and the
cancer-specific mortality 37% (101/276). During
the first year, the cancer-specific mortality was 9%
(25/276) and the crude mortality 14% (38/276). No
other patient was censored in this interval. During
the second year, 16% (39/238) died of causes
r e l a t e d t o t h e r e c t a l c a n c e r a n d a f u r t h e r 4 % (8
patients) of other causes. Five additional patients
w e r e c e n s o r e d d u r i n g t h e i n t e r v a l a n d t h u s 186 p a tients remained at risk of dying at the beginning of
the third year. The cancer-specific mortality rate in
184
Table 1. Description of "potentially curable" patients at risk of dying during different time intervals
Dukes' tumour stage
(number (%))
At risk from
the start
At risk after
one year
At risk after
two years
Polypoid
tumour
yes/no
'D'
75 (27)
96 (35)
80 (29)
25 (10)
72 (30)
87 (37)
67 (28)
68 (36)
70 (38)
46 (25)
Preoperative serum level of

(range; median)
CEA (gg/1)
TPA (U/l)
CA-50 (U/ml)
28/248
1.0-500.0; 5.3
21-825; 71
0-138; 12
12 (5)
25/213
1.0-500.0; 5.0
21-245; 71
0-100; 12
2 (1)
24/162
1.0-332.0; 4.1
21-245; 67
0-100; 11
Table 2. Comparison of regression coefficients from different time intervals in patients "potentially curable" by surgery
Year at risk
Total
First
S-CEA
S-TPA
S-CA-50
Polypoid tumour
growth
Dukes'
A
B
C
'D'
Second
/~
sE (/~) p
0.481
2.127
0.954
0.125
0.371
0.254
-
ref
1.627
2.330
3.179
***
***
***
0.489
0.0497 ***
0.0574
/~
More than two

SE (/~) p
SE (/~) p
/~
SE (/~) p
0.360
1.443
0.602
1.491
0.072
0.228
0.142
0.586
0.431
1.173
0.508
- 0.966
0.113
0.375
0.201
0.725
***
**
*
ns
0.123
0.923
0.341
- 1.616
0.150
0.460
0.261
1.016
ns
*
ns
ns
2.492
3.237
4.521
1.037
1.024
1.063
***
1.211
1.878
-
0.572
0.563
***
1.800
2.459
3.773
***
***
***
**
0.481
0.473
0.504
*p<O.05; **p<O.Ol; ***p<O.O01

patients surviving the first 2 years is at present 19%
(35/186) and the crude m o r t a l i t y 2 7 % (51/186). The
clinical characteristics o f the " p o t e n t i a l l y c u r a b l e "
patients w h o were at risk o f dying at the beginning
o f each interval are given in Table 1. O f the 25
patients initially in stage ' D ' , 13 died during the first
year a n d 10 during the second year. Two o f the
patients with a p o l y p o i d t u m o u r h a d distant m e t a s tases at surgery, one o f w h o m died during the seco n d year.
Prediction of cancer-specific survival

by the preoperative serum level of S-CEA, S-TPA
and S-CA-50
Patients "potentially curable" by surgery (Table 2).
The p r e o p e r a t i v e s e r u m level o f each t u r n o u t
m a r k e r was closely associated with the risk o f dying
o f rectal cancer during the first year after surgery
( p < 0 . 0 0 1 ) . D u r i n g the second year after surgery,
the p r o g n o s t i c i n f o r m a t i o n given by the p r e o p e r a tive s e r u m level o f each o f the t u m o u r m a r k e r s was
reduced (particularly for T P A and CA-50) as can be
seen f r o m the fl estimates. The i n f o r m a t i o n provided was still statistically significant for all three
t u r n o u t markers. A f t e r the second year, there was
a considerable decrease in the i n f o r m a t i o n given by
S - C E A and S-CA-50, whereas the decrease in the
fl estimate for S - T P A was less p r o n o u n c e d . The
i n f o r m a t i o n b e y o n d the second y e a r was statistically significant only for S-TPA.
Patients "potentially cured" among those ''potentially curable" by surgery (Table 3). The close association between the p r e o p e r a t i v e serum level o f
each t u m o u r m a r k e r a n d the risk o f dying o f rectal
cancer during the first year after surgery also applied to patients considered " p o t e n t i a l l y c u r e d "
a m o n g those " p o t e n t i a l l y c u r a b l e " by surgery.
D u r i n g the second year after surgery, the p r o g n o s tic i n f o r m a t i o n was reduced for S-CA-50, but not
for S - C E A and S-TPA. This i n f o r m a t i o n was further reduced after the second y e a r for S-CA-50 and
also for S-CEA, b u t n o t for S-TPA, which still gave
statistically significant i n f o r m a t i o n even concerning the late cancer-specific deaths.
185
Prediction of" outcome by clinico-pathological

variables (Table 2)
The regression coefficient could not be established
for the variable polypoid tumour, as no patient
with a polypoid tumour died of rectal cancer during
the first year after surgery. Based on the fi estimates,
patients with a polypoid tumour also seemed to
have a good prognosis beyond both the first and
the second year after diagnosis. However, as few
patients had this type of tumour, the power of statistical tests was low, which may explain why statistical significance (p<0.05) was not reached even
though a difference was apparent.
The/3 estimates for the Dukes stages are given
in Table 2. The prognostic value of the tumour
stage was virtually unchanged from the first to the
second year of follow-up, but then seemed to diminish somewhat, although the statistical significance was still high after the second year.
Discussion
The standard Cox model assumes that the relative

hazards are constant over time [13]. Using this standard mode, many investigators, ourselves included,
have shown that prognostic information in rectal
cancer is provided by a number of variables, including, for example, S-CEA and Dukes' stage [8, 12,
14, 15, 16]. However, it is not likely that the capacity of these factors as predictors will be unchanged
with time, i.e. that their ability to predict early
relapses (early deaths) will be equal to their ability
to predict relapses several years after surgery (late
deaths).
Using the standard Cox regression model, we
have found that it is possible to make a fairly good
prognostic classification of patients "potentially
curable" by surgery before operation by using the
preoperative serum CEA, TPA and CA-50 combined with the knowledge of whether the tumour is
polypoid or not [5]. In order to further evaluate the
possibilities of selecting patients suitable for neoadjuvant therapy with curative intent, we used a
generalized version of the standard Cox regression
model which allowed the effects of the variables to
change with time. In this way we have shown that
two serum markers, S-CEA and S-CA-50, tended
to predict only early cancer-specific mortality (i.e
within 2 years from surgery). In contrast, the third
serum marker S-TPA and Dukes' stage still provided information concerning deaths after the second year. Regarding S-TPA, this was particularly
evident when the patients found to have metastatic
disease at surgery were excluded from analyses
(compare the /3 estimates in Tables 2 and 3). Patients with a polypoid tumour seemed to have a
good prognosis even after two years from surgery.
We have previously proposed that S-TPA is
related both to the local tumour burden and to the
presence of metastatic disease [17]. Patients with
low preoperative serum levels of TPA were, for
example, found most likely to have a small and
localized tumour (Dukes' stage A). In contrast, the
other two markers, especially CA-50, reflected
more or less only generalized disease. Thus, the
capability of predicting "late" cancer-specific
deaths seemed to be related to that of predicting the
extent of the local tumour burden.
When some other clinico-pathological variables
which have also been found previously to be of
prognostic value, although not independently [5],
i.e. tumour size, tumour stricture and ulceration,
were tested in a similar way, their ability to predict
the outcome likewise did not decline dramatically
with time (data not illustrated), although the prognostic information was limited during all time periods. Thus, the prognostic information provided by
the clinico-pathological variables appeared to be of
Table 3. C o m p a r i s o n o f regression coefficients from different time intervals in patients "potentially cured" a m o n g "potentially
curable" patients
Year at risk
Total
First
S-CEA
S-TPA
S-CA-50
Polypoid t u m o u r
growth
*p<O.05;
Second
fl
SE (fi)
0.414
1.366
0.714
-
0.189
0.681
0.364
-
*
*
*
**p<O.01;
***p<O.O01
/3
0.428
1.283
0.563
--0.731
M o r e than two
SE (/3)
0.125
0.440
0.236
0.729
***
**
*
ns
/3
0.147
1.277
0.346
-- 1.565
SE (/3)
0.153
0.541
0.261
1.016
ns
*
ns
ns
/3
0.321
1.296
0.517
-- 1.257
SE (fl)
0.085
0.228
0.156
0.586
186
a different kind from that provided by two of the
serum markers. A clinico-pathological variable can
only reflect the probability of residual disease, either local or general. Since the tested clinicopathological variables contain prognostic information concerning the first post-surgical year and retain this information beyond the second year it
would seem that, at least theoretically, they are able
to predict both "minimal" and "more extensive" though subclinical - residual disease provided there
is at least some correlation between the time of
death after curative surgery and the extent of subclinical disease. This latter assumption has never
been proven, although it is likely to be true in spite
of the fact that the malignant cell population
doubling time in colorectal carcinoma can vary
considerably. In contrast, the serum markers can
reflect not only the risk of, but also the extent of,
residual disease. The fact that much of the prognostic information provided by two of the serum
markers had disappeared after the first 2 years indicates that it is the extent of disease (i.e. the total
tumour burden) rather than the risk of residual
disease (i.e. the local tumour burden and/or any
specific biological property of the tumour) that is
predicted. Since the serum test is made prior to
surgery, the marker level must reflect both the extent of local disease and possible metastatic disease.
As previously shown and mentioned above there is
virtually no correlation between the extent of the
local disease (Dukes' A - ' D ~ o c a l ) and the level of
S-CEA or S-CA-50 [17]. The local tumour burden
can vary substantially, at least one hundred-fold in
tumour volume, between patients. This large variation is only reflected by S-TPA, and here only to a
limited extent. It thus appears that the serum level
of the markers, particularly S-CEA and S-CA-50,
does not indicate the size of the primary tumour to
a major extent but rather is a reflection of disease
at other sites.
A previous analysis of follow-up data in patients with rectal cancer revealed an excess mortality from rectal cancer that continued for up to ten
years after surgery, although the majority of the
patients died within the first 5 years [18, 19]. In the
present study we have defined "late" cancerspecific deaths as those that occur more than two
years after surgery. This early point in time was
chosen mainly for practical reasons - the number of
events after, for example, the third and fourth year
would have been too few to allow any statistical
analysis. However, in the light of the present finding of a pronounced decline in the prognostic ability of the serum markers as early as during the first
2 years in the group of "potentially curable" pa-
tients, it is unlikely that the "optimized prognostic

model" based only on preoperatively known parameters will be able to predict cancer-specific
deaths beyond the third or fourth year. These
deaths will most likely be referable to those patients
with a minimal tumour burden that can be eradicated by presently available cytotoxic drugs.
The information provided by the tumour stage,
though not available preoperatively, is the most
valuable prognostic variable in colorectal cancer
today. Taking into account the fact that other authors have also reported the relevance of the local
tumour burden, this highlights the need for carefully assessing the extent of tumour growth through
the bowel wall and any local lymph node metastases prior to surgery, provided that the aim is to
select patients for additional therapy pre- or peroperatively.
In summary, even though the preoperative serum concentrations of the three tumour markers
provided statistically highly significant prognostic
information, only one of them (S-TPA) gave information concerning cancer-specific deaths beyond
the second year. This fact must be taken into account when using tumour markers to select patients
for adjuvant therapy. Dukes' staging system is still
the most informative prognostic predictor, and also
provides prognostic information for patients who
have survived 2 years after surgery.
Acknowledgements. Supported by grants from the Swedish Cancer Society (Project No 1921-B87-04XA), the Swedish Society of
Medical Sciences and the Medical Research Council of the
Swedish Life Insurance Companies.
References
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3. Bj6rklund B, Bj6rklund V (1957) Antigenicity of pooled
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4. Lindholm L, Holmgren J, Svennerholm L, Fredman P,
Nilsson O, Persson B, Myrvold H, Lagerg~rd T (1983)
Monoclonal antibodies against gastrointestinal tumourassociated antigens isolated as monosialogangliosides. Int
Archs Allergy 71:178 181
5. Stable E, Glimelius B, Bergstr6m R, Pgthlman L (in press)
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6. Chapuis PH, Dent OF, Fisher R, Newland RC, Pheils MT,
Smyth E, Colquhoun K (1985) A multivariate analysis of
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7. Jass JR, Atkin WS, Cuzick J, Bussey HJR, Morson BC,
Northover JMA, Todd IP (1986) The grading of rectal
cancer: historical perspectives and a multivariate analysis of
447 cases. Histopathology 10:437-459
8. Stfihle E, Glimelius B, Bergstr6m R, Pfihlman L (1988)
Preoperative clinical and pathological variables in prognostic evaluation of patients with rectal cancer. A prospective
study of 327 consecutive patients. Acta Chir Scand 154:
231-239
9. Pahlman L, Glimelius B, Graffman S (1985) Pre- versus
postoperative radiotherapy in rectal carcinoma: an Interim
report from a randomized multicentre trial. Br J Surg
72:961-966
10. Dukes CE, Bussey H JR (1958) The spread of rectal cancer
and its effect on prognosis. Br J Cancer 12:309-320
11. Adalsteinsson B, Glimelius B, Graffman S, Hemmingsson
A, Pfihlman L (1985) Computed tomography in staging of
rectal carcinoma. Acta Radiol Diagn 26:45 55
Preoperative serum markers in carcinoma of the rectum and
rectosigmoid. II. Prediction of prognosis. Eur J Surg Oncol
14:287 296
13. Lawless JF (1982) Statistical models and methods for lifetime data. Wiley, New York
14. Gore SM, Pococh SJ, Kerr GR (1984) Regression models

and non-proportional hazards in the analyses of breast cancer survival. App in Statistics 33:176 195
15. Steinberg S, Barkin JS, Kaplan RS, Stablein DM (1986)
Prognostic indicators of colon tumours. The Gastrointestinal Tumor Study Group of Experience. Cancer
57:1866-1870
16. Moertel CG, O'Fallon JR, Go VLW, O'Conell MJ, Thynne
GS (1986) The preoperative carcinoembryonic antigen test
in the diagnosis, staging, and prognosis ofcolorectal cancer.
Cancer 58:603-610
Preoperative serum markers in carcinoma of the rectum and
rectosigmoid. I. Prediction of tumour stage. Eur J Surg
Oncol 14:277 286
18. Berge T, Ekelund G, Mellner C, Phil B, Wenckert A (1973)
Carcinoma of the colon and rectum in a defined population.
Acta Chir Scan [Suppl 438]
19. Enblad P, Adami H-O, Bergstr6m R, Glimelius B, Krusemo
UB, Pfihlman L (1988) Improved survival of patients with
cancers of the colon and rectum? JNCI 80:586 591
Accepted: 21 December 1988
Dr. Elisabeth Stfihle
Akademiska sjukhuset
S-751 85 Uppsala
Sweden
Colbi'ee/al
Disease
Anorectal function in normal human subjects:

effect of gender
Wei Ming Sun and N.W. Read
Sub-Department of Human Gastrointestinal Physiology and Nutrition, Royal Hallamshire Hospital, Sheffield, UK
Abstract. Multiport anorectal manometry and external anal sphincter (EAS) and internal anal
sphincter (IAS) electromyography were conducted
in 15 males (41 + 3 years) and 20 females (43-+
2 years; 5 nulliparous) during rest, maximum conscious sphincter contraction, rectal distension and
increases in intra-abdominal pressure. The basal
pressure declined within 15 minutes of insertion of
the manometric probe to a stable plateau, 55 + 4%
of the initial value. The maximum basal (91 + 5 vs
61 -+6 cm water; mean_+ SEM), minimum basal
(43-+7 vs 27_+3 cm water) and the maximum
squeeze pressures (257-+20 vs 107___13 cm water)
were higher (p < 0.05) in males than females. Distension of a rectal balloon caused a reduction in
pressure in all anal channels, that increased in
depth and duration as the distending volume was
increased. These anal relaxations were associated
with rectal contractions and transient increases in
the electrical activity of the EAS. U p o n deflating
the balloon, the anal pressure increased to values
that exceeded the pre-inflation values. The pre-inflation ( 8 9 + 4 vs 49-+4cm water), post-inflation
(104 _+9 vs 62-+-7 cm water) and residual (47 + 4 vs
30-+ 2 cm water) pressures during rectal distension
were significantly higher in males than in females
(p<0.05). The higher residual pressure in males
was associated with a higher EAS index during
rectal distension (0.94-+0.10 vs 0.65_+0.10 mvs;
p<0.05). The lowest volume required to cause a
desire to defaecate was significantly higher in males
than in females (76 + 7 vs 48 -+ 6 ml; p < 0.05) and
only 13% of males compared with 55% females
(p<0.01) felt pain during rectal distension with
100 ml. During increases in intra-abdominal pressure, all subjects showed increases in pressures in
the outermost anal channels, that were associated
with increases in the electrical activity of the EAS
and were significantly higher in males compared
with females (188 _+ 17 vs 98 + 9 cm water; p < 0.05).

In conclusion, the data suggest that males have
stronger internal and external anal sphincters than
females, while females have greater rectal sensitivity.
Continence to faeces is achieved by the resistance of

the anal canal to the passage of rectal contents.
This resistance is made up of two overlapping muscular components; an inner ring of smooth muscle,
the internal anal sphincter (IAS); and an outer ring
of striated muscle, the external anal sphincter
(EAS). The two muscular sleeves appear to function independently of each other and often in a
reciprocal fashion. For example, rectal distension
causes a relaxation of the IAS and a contraction of
the EAS [1], while micturition is associated with a
contraction of the IAS and a relaxation of the EAS
[2]. Exactly how these two muscles collaborate to
maintain continence is unclear. In this study, we
have used multiport anorectal manometry and
sphincter electromyography in order to document
the contribution that each muscle makes to sphincter resistance under resting conditions, during conscious contraction of the sphincter and during
threats to continence provided by rectal distension
and increases in intra-abdominal pressure.
This study has also created the opportunity to
compare the effect of gender on the detailed function of the anal sphincter. Although it is known
that sphincter pressures tend to be lower in females
than males [3, 4], and incontinence is commoner in
females [5, 6], there is no detailed information on
the influence of gender on the responses of the
sphincter to rectal distension or increases in intraabdominal pressure.
189
Subjects and methods
Channel cmHaO
160]
Subjects
0J
160]
Studies were carried out on 35 normal volunteers, all of whom

were healthy members of hospital staff or students. These included 15 males, aged between 20 and 63 years (mean = 4 l ) and
20 females, aged between 21 and 55 years (mean=43). Five of
the females were nulliparous.
Each subject gave written informed consent for the study to
be carried out and the protocol was approved by the Ethical
Committee of the Sheffield Area Health Authority.
0j
160 ]
O"
16~1
0'
160]
0j
Methods
With the subjects lying in the left lateral position with the hips
flexed to 90 ~ a manometric probe, consisting of a polyvinyl
7-lumen tube with an external diameter of 4 mm and bearing a
terminal inflatable balloon (Durex Dry, LRC Products Ltd.),
was inserted into the rectum. When correctly positioned, manometric side holes were situated in the anal canal at approximately 0.5, 1.0, 1.5, 2.0 and 2.5 cm from the anal verge and in
the rectum at 4.5 cm from the anal verge and the anal pole of the
balloon was 8 cm from the anal margin. The side holes were
perfused with water at a rate of 0.4 ml per minute by a low
compliance pressurised perfusion system (Mui, PIP 2, Mississauga, Ontario, Canada), and pressures were measured by
means of pressure transducers (Statham 23ID, California,
USA), which were situated in each perfusion line and connected
via amplifiers to a multichannel chart recorder (Hewlett Packard, 7758A, Mass. USA).
The electrical activity of the sphincter was recorded using a
bipolar electrode, consisting of two trimel coated wires (diameter=0.025 mm) with their ends bared, hooked and offset to
avoid electrical contact [7, 8]. The wires were inserted either into
the superficial EAS or into the groove between the EAS and IAS
inside a fine gauge hypodermic needle, which was subsequently
withdrawn, leaving the hooked ends of the wires in situ. The free
ends of the wires were bared and attached to an amplifier (Differential type 21C01 URO-DISA), which was connected via an
integrator (AC to RMS convertor: Analog Devices AD536) to
the chart recorder. Both raw and integrated records (170 ms
time constant) were displayed on the chart recorder. The activity
of the IAS was represented on the raw E M G record as a regular
oscillation (Fig. 1), which occurred at a frequency of between 16
and 24 per minute and increased in amplitude as the activity of
the muscle increased [9]. The activity of the EAS appeared on
the raw EMG record as successive spikes that increased in amplitude and frequency as the activity of the muscle increased,
and on the integrated record as an elevation above the baseline.
The index of the EAS during any particular manoeuvre was the
product of the voltage and the duration of activity. The electrical activity of the EAS recorded during rectal distension, straining and inflating a balloon were expressed as a percentage of
that recorded during conscious contraction of the sphincter.
6
0
I nlecJrated
Wi'-nd F;It
I
60ml
lOOml
=.
1 min
Fig. 1. Recordings of anorectal pressure at ports situated 0.5,

1.0, 1.5, 2.0, 2.5 and 4.5 cm from the anal margin (channels 1 to
6) and the electrical activity of the sphincter complex during
distension of a rectal balloon with 60 and 100 ml of air. Note
that rectal distension induces a relaxation in sphincter pressure
associated with abolition of the IAS slow wave activity and an
increase in the activity of the EAS. Deflation of the balloon
produces a rebound increase in pressure which is associated with
an increase in the amplitude of the IAS slow wave oscillation
and a transient increase in EAS electrical activity. DD = desire
to defaecate
inflated with 10, 20, 40, 60 and 100 ml of air. Each inflation was
maintained for one minute and a gap of at least 1 min was
allowed before the next inflation. Subjects were asked to report
their subjective sensations during each inflation and to indicate
the duration of the sensation on the chart using a remote event
marker. The lowest distending volumes, at which the balloon
was perceived, and sensations of gas in the rectum (wind), a
desire to defaecate and pain were experienced, were noted on the
chart, and the pre-inflation, post-inflation and residual pressures
during inflation in each channel were noted. After a further rest
period of at least 10 min, the subject was instructed to increase
the intra-abdominal pressure by blowing up a balloon (Sainsbury's Partytime Round Balloons, 747/350, J. Sainsbury plc.,
London) and by straining as if to defaecate. Both manoeuvres
were repeated three times and a gap of at least one minute was
allowed between inflations. The presence or absence of an external sphincter response was noted and the difference between
highest anal and rectal pressures was measured.
Protocol
Statistical analysis
Anorectal motility was recorded under resting conditions for

30 rain. Spontaneous episodes of sphincter relaxation were identified during this time as decreases in anal pressure of at least
20 cm water, occurring in each anal channel and lasting at least
15 seconds before returning to the original baseline. After the
resting period, the subject was instructed to contract his anal
sphincter as hard as he could for a period of one minute. This
was repeated two more times with gaps of at least a minute
between the contractions. Then the rectal balloon was serially
The statistical significance of the differences in the pressures at

different sites or the responses to different volumes of distension
between males and females was assessed using analysis of variance. If this indicated that the results were significant then the
levels of significance were determined by Student's t-test or
Mann-Whitney U-test (for sensory data). Chi-square test was
used to determine the differences between the percentages of
males and females who showed a certain phenomenon.
190
Minimum Basal Pressure
Maximum Basal Pressure
Maximum Squeeze Pressure
300
112
E 200-
100
8
Ay "j
4.5
2.5 2 1.5 1 0.5
4.5
//)/
,
2.5 2 1.5 1 0.5
1.5
Fig. 2. Anorectalpressure profiles

in males (e.
e.) and females
(o---o) just after insertion of the
probe (maximumbasal pressure),
under steady state resting conditions (minimumbasal pressure)
and during a maximumconscious
contraction (maximumsqueeze
pressure). Results are shown as
Mean_+SEM. Asterisks indicate
significantdifferencesbetween
males and females (p < 0.05)
2.521.510.5
Distance from anal verge (cm)
Results
Resting pressures
The resting anal pressure profiles were asymmetrical; the highest pressures occurred in the outermost
channels (Fig. 2). After insertion of the manometric
probe, the anal pressures slowly fell over a period
of 15 minutes to reach a stable baseline. This decline was greater in the outermost anal channels
and was associated with a reduction in the electrical
activity of the EAS. The pressures recorded by the
innermost port, situated 4.5 cm from the anal margin, were always lower than 20 cm of water, and
exhibited no relaxations; these features suggested
that this port was situated in the rectum. The pressures recorded 2.5 cm from the anal verge in females were very similar to those recorded at 4.5 cm,
but in males they were significantly higher
(p < 0.05), suggesting that the high pressure zone of
the anal sphincter is longer in males than in females.
During the basal record, 2 males and 4 females
showed transient reductions in anal pressure of between 24 and 100 cm water (median=45), lasting
between 18 and 20 seconds (median = 30) (Fig. 3).
These spontaneous relaxations were recorded in all
the anal channels and were associated with increases in rectal pressure in 5 subjects, increases in
the electrical activity of the EAS in 4 subjects and
suppression of the IAS slow wave activity (Fig. 3).
Transient sphincter relaxations were not associated
with reductions in the electrical activity of the EAS
in any subject.
The maximum basal pressures all along the anal
canal and the minimum basal pressures in the outermost two channels were higher in males than
females (/)<0.05; Fig. 2), but the percentage difference between the maximum and minimum
basal pressures (maximum - minimum/maximum
x 100%) in males and females were very similar
[ M ' F ; 55_+7 vs 55-t-4% (Mean+SEM)].
Conscious sphincter contraction

Maximum conscious contraction of the anal
sphincter increased the pressure all along the length
of the anal canal, but the largest pressure increments were observed in the two outermost channels. Thus external sphincter contraction accentuated the asymmetric profile of the sphincter, and
caused the pressure in the innermost anal port
(2.5 cm from the anal verge) to rise above the rectal
pressure, even in females, thus lengthening the high
pressure zone.
Male subjects generated higher anal pressures
during maximum conscious contraction of the
sphincter than females (p<0.01; Fig. 2) and exhibited a different pressure profile; the highest pressure was recorded 1.0 cm from the anal margin in
males and 0.5 cm from the anal margin in females.
The higher anal pressures in males were associated
with higher EAS E M G indices (Table 1). Two male
subjects and 2 female subjects exhibited transient
( < 6 s) post-squeeze relaxations of the sphincter to
pressures at least 5 cm water below the pressure
recorded immediately before maximum conscious
contraction (Fig. 4). These 4 subjects also demonstrated transient sphincter relaxations under basal
conditions. Post-squeeze relaxations were not associated with reductions in the electrical activity of
the EAS to levels below basal values, but were associated instead with suppression in IAS electrical
oscillations (Fig. 4).
191
Channel cmH=O
Channel cmH=O
320 ]
32O
__
0J
0 J
320]
320
2
0l
320 ]
320
3
0J
]
0
0J
320]
320 ]
4
0a
320
'
0]
320 ]
0j
320
0J
EMG 140pV]
J
EMG 140pV]
I nteg rated
I ntegrated
,,_._ [~ _ __
EMR
EMG
t
I min
1.0, 1.5, 2.0, 2.5 and 4.5 cm from the anal margin (channels I to
6) and the electrical activity of the sphincter complex during a
transient anal relaxation. Note that the pressure drop is associated with a disappearance of the IAS slow wave, but an increase
in the electrical activity of the EAS
1 min
1.0, 1.5, 2.0, 2.5 and 4.5 cm from the anal margin (channels l to
6) and the electrical activity of the sphincter complex during a
maximum conscious sphincter contraction. Note the post
squeeze relaxation, which is associated with suppression of the
IAS slow wave and the electrical activity of the EAS
Table 1. The electrical activity of the EAS recorded during

rectal distension, straining, and inflating a balloon, compared
with that obtained during maximum contraction of the sphincter
Anorectal responses to rectal distension
Male
Female
Maximum contraction
7.1 0.1
3.9 0.4
< 0.05
Rectal distension
10 ml
%
20 ml
%
40 ml
%
60 ml
%
100 ml
%
1.0
19
2.4
38
2.8
48
3.0-t-0.4
48
3.7
58
1.0
24
1.8_+0.3
47
2.1
53
2.4
60
2.5
67
NS
Straining
%
5.1 1.0
72
2.1 +0.3
56
<0.02
Inflating balloon
%
5.3_+1.0
62
1.9_+0.2
53
<0.02
Results are expressed as Mean SEM
NS
<0.05
<0.05
<0.05
Distension of the rectal balloon caused a transient

increase in anal pressure, seen most clearly in the
outermost anal channels and associated with an
increase in the electrical activity of the external
sphincter (Fig. 1). This was followed by a reduction
in pressure, which was usually observed in all anal
channels and was associated with suppression of
IAS electrical oscillations and increases in rectal
pressure, comprising in most instances an initial
peak followed by a plateau (Fig. 1). Two female
subjects did not show anal relaxation at low volumes of rectal distension (10 and 20 ml), though the
rectal pressure profile and the external sphincter
E M G changes were quite similar to the others. The
minimum basal anal pressures in these two subjects
were less than 10 cm water above the rectal pressure; much lower than in the other female subjects
(Fig. 5).
As the rectal volume increased, the electrical
activity of the EAS increased in amplitude and duration (Fig. 6), the pre-inflation pressures increased
192
in amplitude (Fig. 7), while the residual pressures
declined in amplitude and increased in duration
(Fig. 7). Rectal contractile activity also increased in
amplitude and duration as the rectal volume increased (Fig. 8). One female volunteer showed repetitive rectal contractions through out the period
of distension.
U p o n deflating the balloon, the anal pressure
often increased to values that were higher than the
pre-inflation pressures. The rebound increases in
pressure lasted at least a minute when rectal volumes exceeded 60 ml and were always associated
with increases in the amplitude of the IAS slow
wave (Fig. 1), but only transient (3 s) increases in
the activity of the EAS. The magnitude of the post
inflation pressure increased as the distending volumes increased (Fig. 7). The rectal volumes required to evoke an EAS response on deflation (off
response) were higher than those required to evoke
an EAS response upon inflation (on response)
(Table 2; p<0.01).
The rectal volume required to cause an anal
relaxation was higher in females than in males
(Table 2), but despite this, greater degrees of relaxation were obtained at lower volumes in females
than males (Fig. 7); thus the rectal volume that
induced 50% of maximal relaxation was significantly lower in females (Table 2). There was no
significant gender difference in the rectal volumes
that prevented recovery of the sphincter pressure
during the period of rectal distension. Pre-inflation,
rebound and residual pressures were higher in male
subjects than female subjects at all volumes of distension and particularly in the outermost anal ports
(Fig. 9), and the rebound pressures obtained after
rectal distension with 100 ml air were more prolonged in males than females ( 8 3 + 7 vs 6 2 + 4 s ,
p<0.05). The rectal volumes required to evoke a
rectal contraction or to evoke 'on' or 'off' EAS
responses were not influenced by the gender of the
subjects (Table 2), but the EAS indices during
rectal distension were higher in the male subjects
(Table 1), and this difference was accentuated as the
distending volume increased. When EAS indices
during rectal distension were expressed as a percentage of EAS activity during a maximum conscious contraction, however, females showed a
higher proportional activity than males (Table 1).
Serial distension of the rectum with increasing
volumes of air induced a feeling of wind, followed
by a desire to defaecate and eventually pain. There
were no significant differences between male and
female subjects for the volumes at which the rectal
balloon was first perceived and subjects experienced a sensation of 'wind' (Table 2). The volumes
60
E
=o
<
i15 i 0.5
Fig. 5. Profiles of minimum basal pressure in the anal canal in

female subjects who exhibited no sphincter relaxation during
rectal distension (A- A), and the remainder of the female subjects (o-----o). Results are shown as the Mean _+SEM. Asterisks
indicate significant differences between the two groups
2
5;
160
Distension volume (ml)

Fig. 6. The EMG index during inflation of a rectal balloon
with increasing volumes of air in males (o
o) and females
(oo). Results are shown as Mean -t- SEM. Asterisks indicate
significant differences between the sexes
Table 2. Lowest rectal distending volumes (ml) required to induce IAS and EAS responses and rectal sensations in normal
subjects
Anal relaxation
50% maximal relaxation
Sustained relaxation
'On' EAS response
'Off' EAS response
Perception of balloon
Wind
Desire to defaecate
Male
Female
11_+1
47_+8
69 4- 9
25-+ 6
39-+7
13_+2
32_+5
76_+7
19_+ 4
26_+ 4
77 8
23 5
51 _+11
12_+ 1
29_+ 5
48-+ 6
<0.05
<0.05
NS
NS
NS
NS
NS
<0.05
Results are expressed as Mean 4-SEM
required to induce a desire to defaecate, however,

were significantly higher in males than females
(Table 2), and only 13 % of males experienced pain
at 100 ml distension, compared with 55% of females (p < 0.01).
193
d'
Pre-inflati0n
150
150
~100
E
.... I .......... ]
% 150
Residual
-1-
50
,<
50
100
i0
100
Fig. 7. The highest pre-inflation (o) residual (A) and rebound

(e) pressures, recorded in the anal canal during distension of a
rectal balloon with increasing volumes of air in male ( - - ) and
female @ - - ) volunteers. Note that as the balloon volume
increases, the pre-inflation and rebound pressures increase and
the residual pressures drop. Results are shown as Mean_+ SEM
=o
150
Rebound
,t~ /
415
2.5 2 1.5 1 0.5
"
01
50
100
the EAS; EAS responses did not take place unless

balloon distension was perceived, and the length of
the EAS response was strongly correlated with the
duration of sensation (r=0.8, p < 0 . 0 0 1 ) (Fig. 10).
~o
8
Fig. 9. Pre-inflation, residual and rebound pressures recorded

0.5, l.O, 1.5, 2.0, 2.5 and 4.5 cm from the anal verge in male
( - - ) and female ( o - - o ) normal volunteers during distension
of the rectal balloon with 100 ml of air. Results are shown as
Mean + SEM. Asterisks indicate significant differences between
males and females (p < 0.05)
50
100
Fig. 8. Rectal pressures and the duration of peak rectal contraction during inflation of a rectal balloon with increasing volumes
of air in male (e
e) and female ( o - - - o ) volunteers. Results
are displayed as Mean_+ SEM
The perception of rectal sensation was related

to the contractile activity of the rectum and the anal
sphincter. Rectal sensation was not perceived if
rectal distension did not elicit a phasic rectal contraction, and there was a highly significant direct
correlation (r = 0.8, p < 0.001) between the duration
of sensation and the duration of the rectal contraction, with the values matching in most instances
(Fig. 10). There was a similar close relationship between rectal sensation and the electrical activity of
Anorectal responses to increases in

intra-abdominal pressure
When subjects increased their intra-abdominal

pressures by straining (as if to defaecate) or inflating a balloon, the increase in pressure recorded in
the rectum was associated with an increase in the
electrical activity of the EAS and a rise in anal
pressures, particularly in the outermost anal channels, to values that were higher than those recorded
in the rectum (Figs. 11 and 12). There were no obvious changes in the electrical activity of the IAS
during these manoeuvres. The anal and rectal pressures, and values for the electrical activity of the
EAS during straining and during attempts to blow
up a balloon were significantly higher in male
subjects than female subjects (p<0.02) (Fig. 12,
194
60-
"2
._o
9l
-~ 30.
.~
Ill
~176
.i:,
~
9m : l
~ l
i
.
9 -II
" ~
Fig. 10. The correlation between the duration of rectal sensation and (a) the duration of the initial rectal contraction (left)
and (b) the duration of the increase in electrical activity of the
EAS (right) during rectal distension with 10 to 100 ml air
cm H20
320 ]
0J
320
0J
320
0d
320
.,.li,JI.
--
II
9
J . .
. . .
J.
llf
Duration of rectal contractions (sec.)
Channel
9176
A__
320,
0
160
0
EMG 140 ~V ]
30
60
Duration of initial EAS activity (sec.)
Table 1). The percentage of maximum EAS activity

recorded during increases in intra-abdominal pressure was also higher in males than females.
Females, but not males, achieved higher anal
pressures when they inflated a balloon than when
they strained (Fig. 12), though the EAS electrical
responses to the two tests were similar (Table 1).
Rectal pressures were significantly higher during
straining than blowing up a balloon in both males
and females (Fig. 12).
One male subject showed an 8 second poststrain reduction in anal pressure to a value of 40 cm
water below basal values. This reduction was accompanied by an abolition of IAS electrical oscillations, and an increase in the electrical activity of the
EAS. The same subject also showed transient
sphincter relaxations under basal conditions and
after maximal sphincter contraction. Three female
subjects showed no increase in the electrical activity
of the EAS during straining. Another showed an
appropriate increase in the electrical activity of the
EAS, followed by a decrease in activity, while two
more showed an initial decrease in activity followed
by an increase. Even when the EAS was inhibited,
however, the anal pressures remained higher than
the rectal pressure during this manoeuvre. All subjects showed increases in EAS activity when they
inflated a balloon.
I nteg rated
EMG
t
1 rain
Fig. 11. Anorectal pressures at 0.5, 1.0, 1.5, 2.0, 2.5 and 4.5 cm
from the anal verge (channels I to 6) and the electrical activity
of the EAS during increases in intra-abdominal pressure induced by straining as if to defaecate in a typical volunteer subject. When the intra-abdominal pressure increases, the electrical
activity of the EAS also increases with rises in sphincter pressure
that exceed those recorded in the rectum
Discussion
Simultaneous recordings of pressure from multiple

ports within the anal canal and sphincter myoelectrical activity provide a means of assessing the relative contributions to the anal pressure profile made
by the internal and external anal sphincters. Under
resting conditions, the anal sphincter exhibits an
195
Strain
Blow up balloon
300
200
~ 100-
L.......... ~-_z.-5'''J'''~
4.5
2.52 1o5 10.5
415
2.52 1.5 1 0.5
Fig. 12. Anorectal pressure profiles in male (~----~) and female

(o- -o) subjects during increases in intra-abdominal pressure
induced by inflating a rectal balloon and by straining as if to
defaecate. Results are expressed as Mean _+SEM. Asterisks indicate gender differences (p < 0.02)
asymmetric profile with the highest pressures being

recorded in the outermost channels. This profile is
accentuated by activity occurring in the EAS either
shortly after insertion of the manometric probe or
during an increase in intra-abdominal pressure and
it is exaggerated durating a voluntary contraction
of the sphincter. This suggests that the asymmetry
is largely caused by contraction of the EAS, which
is tonically active under basal conditions and surrounds predominantly the outermost aspect of the
anal canal. The puborectalis muscle, which loops
around the posterior aspect of the inner sphincter,
does not appear to make any contribution to the
sphincter pressure, presumably because contraction of this muscle pulls the sphincter forward instead of closing it. The observation that the basal
pressure declines over a period of 15 min after insertion of the probe suggests that the 'basal' pressures recorded by probes that are pulled through
the sphincter may be much higher than the true
basal sphincter pressure. The decline in basal pressure is associated with a corresponding decline in
the electrical activity of the EAS.
Rectal distension reduces the pressure in a symmetrical manner throughout the sphincter. The observation that the reduction in anal pressure is associated with an attenuation of electrical slow wave
activity but an increase in the electrical activity of
the EAS confirm that it is caused by relaxation of
the IAS. The reduction in anal pressure is directly
related to the distending volume and is greatest at
60 ml. Since the IAS slow waves are absent at this
volume, we assume that the residual pressure profile, obtained during rectal distension with 60 ml or
above, reflects the residual activity in the EAS.
The electrical activity of the EAS, induced by
rectal distension, increases in amplitude and duration as the distending volume increases. Presumably, this activity prevents the incontinence
that becomes more likely, the greater the relaxation
of the IAS. Although rectal distension can cause a
reflex increase in EAS activity in paraplegic patients [10], the EAS response to rectal distension in
normal subjects is heavily modulated by conscious
mechanisms. It is absent, for example, in subjects
who are deeply asleep or anaesthetised [11, 12] and
it can be altered by biofeedback training [13]. The
data from this study support the concept of conscious modulation, through the demonstration that
the EAS response is absent if the subject does not
perceive rectal distension, and that the duration of
the EAS response matches very closely the duration
of the sensation. Analysis of rectal pressure profile
during rectal distension indicates that rectal sensation and EAS responses are strongly correlated
with the duration of the rectal pressure peak, suggesting that both are induced by stimulation of
rapidly adapting rectal tension receptors.
Previous studies have shown that very high levels of rectal distension can be associated with an
abolition of external sphincter activity causing a
profound reduction in anal pressure [14]. We did
not observe this during inflation of a rectal balloon
with up to 200 ml air, although we have seen it at
these volumes in patients with faecal incontinence
(unpublished observations).
U p o n deflating the rectal balloon, there is always a rebound increase in pressure to levels higher
than the pre-inflation level. This rebound lasts sufficiently long to increase the pressure level immediately before the next inflation. Thus both the preinflation and the post-inflation pressures tend to
rise as the rectal volume increases while the residual
pressures tend to fall. Two female subjects did not
initially show any reduction in anal pressure upon
rectal distension because their anal tone was so low.
The rebound increase in IAS activity, seen after
deflation of a rectal balloon, however, produced
sufficient anal tone to cause relaxations at higher
distending volumes. Although deflation is associated with a brief increase in EAS activity, the peak
rebound pressure often occurs when the EAS activity has returned to basal values and is associated
with an increase in the amplitude of the IAS slow
waves. These features indicate that the post inflation rebound is caused by an increased activity in
the IAS.
196
A n increase in i n t r a - a b d o m i n a l pressure,
caused either by blowing up a balloon or straining
as if to defaecate, induced a c o m p e n s a t o r y increase
in the electrical activity o f the external sphincter.
This was associated with an increase in anal pressure, which remained a b o v e the rectal pressure, creating a pressure barrier that w o u l d preserve continence. The rectal pressures recorded during
straining were higher than during inflation o f a
balloon.
O u r results show some obvious differences in
anal function between male and female subjects.
The pressures exerted by the c o n t r a c t i o n o f the
EAS were m u c h higher in males than females and
were associated with enhanced electrical activity.
Thus the m a x i m u m basal pressures, the squeeze
pressures and squeeze increments, the residual pressures during rectal distension and the increases in
anal pressure associated with increases in intra-abd o m i n a l pressure, all o f which p r e d o m i n a n t l y deflect activity in the EAS, were all higher in males
t h a n females (Table 2). However, the differences
between residual pressures and either pre- or postinflation pressures, which reflect activity in the internal anal sphincter, were also higher in males
than females. Thus the d a t a suggest that the activities o f both the internal and the external sphincters
in males were greater t h a n in females, a l t h o u g h the
percentage contributions that each sphincter makes
to the overall sphincter pressure were similar in
each group. The enhanced E A S activity in males
m a y be explained by differences in the n u m b e r and
the properties o f the somatic neurones innervating
the pelvic organs [15]. Sex steroids can bind to
O n u f ' s nucleus, which contains m o t o n e u r o n e s innervating perineal striated muscles and m a y therefore m o d u l a t e c o n t r a c t i o n o f the EAS [16].
The observation that females utilise a higher
percentage o f m a x i m u m E A S activity during rectal
distension than males, despite the fact that rectal
pressures were similar, can be explained by the
higher m a x i m u m EAS activity in males. Males,
however, generate a greater percentage o f maxim u m EAS activity during increases in intra-abd o m i n a l pressure, p r e s u m a b l y as c o m p e n s a t i o n for
the greater i n t r a - a b d o m i n a l pressures that can be
generated by males.
The other i m p o r t a n t gender difference was that
female subjects experienced a desire to defaecate
and pain at lower rectal volumes than male subjects. Perhaps the m o r e acute rectal sensation helps
to c o m p e n s a t e the female for a weaker sphincter,
by allowing her to m o u n t a quicker EAS response
to rectal distension. The enhanced sensitivity o f the
rectum m a y also explain the p r e p o n d e r a n c e o f fe-
males, w h o suffer from the irritable bowel synd r o m e [17].
References
1. Duthie HL, Bennett RC (1963) The relationship of sensation in the anal canal to the functional anal sphincter; a
possible Factor in anal incontinence. Gut 4:179-182
2. SalducciJ, Planche D, Naudy B (1982) Physiologicalrole of
the Internal Anal Sphincter and the External Anal Sphincter
during Miction. In: Weinbeck M (ed) Motility of the Digestive Tract. Raven Press, New York, pp 513-522
3. Loening-Bauke V, Anuras S (1985) Effects of age and sex on
anorectal manometry. Am J Gastroenterol 80:50-53
4. McHugh SM, Diamant NE (1987) Effects of age, gender
and parity on anal canal pressures. Contribution of impaired anal sphincter function to faecal incontinence. Dig
Dis Sci 32:726-736
5. Read NW, Harford WV, Schmulen AC, Read MG, Santa
Ana CA, Fordtran JS (1979) A clinical study of patients
with faecal incontinence and diarrhoea. Gastroenterology
76:747- 756
6. Bartolo DCC, Read NW, Jarrett JA, Read MG, Donnelly
TC, Johnson AG (1983) Differences in anal sphincter function and clinical presentation in patients with pelvic floor
descent. Gastroenterology 85:68-75
7. Basmajian JV, Stecko G (1962) A new bipolar electrode for
electromyography. J Appl Physiol 17:849
8. Haynes WV, Read NW (1982) Anorectal activity in man
during rectal infusion of saline. A dynamic assessment of the
anal continence mechanism. J Physiol 330:45 56
9. Monges H, Salducci J, Naudy B, Raniere F, Gonella J,
Bouvier M (1980) The electrical activity of the internal anal
sphincter: a comparative study in man and cat. In: Christenson J (ed) Gastrointestinal motility. Raven Press, New
York, pp 495-501
10. Freckner B (1975) Function of the anal sphincters in spinal
man. Gut 16:638-644
11. Whitehead WE, Orr WC, Engel BT, Schuster MM (1982)
External anal sphincter response to rectal distension:
learned response or reflex. Psychophysiology 19:57 72
12. Freckner B, Ihre Y (1976) Influence of autonomic nerves on
the internal anal sphincter in man. Gut 17:306-312
13. Whitehead WE, Schuster MM (1980) Therapeutic applications of biofeedback in gastrointestinal disorder. In: Berk
LE (ed) Developments in digestive disease, vol 3. Lea and
Febiger, Philadelphia; pp 165-177
14. Porter NH (1962) Physiological study of the pelvic floor in
rectal prolapse. Ann R Coll Surg 31:379-404
15. Greenwood D, Coggeshall RE, Hulsebosch CE (1985) Sexual dimorphism in the numbers of neurones in the pelvic
ganglia of adult rats. Brain Res 14:23-48
16. Breedlove SM, Arnold AP (1980) Hormone accumulation
in a sexually oligomorphic nucleus of the rat spinal cord.
Science 210:564- 566
17. Fielding JF (1977) The irritable bowel syndrome. Clin Gastroenterol 6:607-622
Prof. N. W Read
Sub-Department of Human Gastrointestinal
Physiology and Nutrition
K Floor
Royal Hallamshire Hospital
Sheffield SI0 2JF
UK
Int J Colorect Dis (1989) 4:197
Coloi'ectai
Disea, se
199
The histology of anal skin tags in Crohn's disease:

an aid to confirmation of the diagnosis *
B.A. Taylor, G.T. Williams, L.E. Hughes and J. Rhodes
University Departments of Surgery, Gastroenterology and Pathology, University of Wales College of Medicine, Cardiff, U K
Abstract. We have investigated excision biopsy of

anal skin tags as an adjunct to rectal biopsy in the
diagnosis of Crohn's disease. Twenty-six patients
with proven Crohn's disease of the large and/or
small bowel were studied. All had perianal skin tags
removed under local anaesthesia as outpatients,
when rectal biopsies were also obtained. Three sections from each skin tag and three from each rectal
biopsy were examined for granulomas. The rectal
biopsies were also examined for changes 'suggestive' of Crohn's disease. Anal skin tags from 26
patients without Crohn's disease acted as controls.
Of the patients with Crohn's disease, granulomas
were found in both anal skin tags and rectal biopsies in five patients, in anal skin tags only in four,
and in rectal biopsies only in three. When present,
granulomas were more plentiful in anal skin tags
than in rectal biopsies, being seen in all 3 sections
in 7 of 9 'positive' tags (i.e.: in 31% of 78 sections),
compared to only 1 of 8 'positive' rectal biopsies
(i.e.: in 13% of 78 sections). No granulomas were
seen in control anal skin tags. The procedure provides a simple technique which is complementary to
rectal biopsy, by which histological confirmation of
Crohn's disease may be obtained.
Crohn's disease is a chronic granulomatous condition of the intestine, in which granulomas are frequently not found [1, 2]. Most patients in whom the
diagnosis is considered will therefore undergo rigid
sigmoidoscopy with rectal biopsy in an attempt to
obtain histological confirmation. However, granulomas will be found in less than 20% of rectal biop* This work was presented in part to the International Surgical
Scientific Conference at the Bicentenary Meeting of the Royal
College of Surgeons in Ireland, 1984
sies from cases of Crohn's disease, although 'suggestive' changes will be present rather more
frequently [3, 4]. Even after exhaustive serial sectioning, granulomas will still only be found in 30%
of rectal biopsies [5].
Crohn's disease is known to be associated both
with primary anal lesions, including oedematous
skin tags, chronic fissures and cavitating or fissuring ulcers, and secondary suppurative lesions including abscesses and fistulae [6]. It is also well
known that typical non-caseating granulomas may
be found in the secondary anal lesions of Crohn's
disease [7], although the incidence of granulomas in
simple oedematous skin tags, which are the most
common anal manifestation of the condition, has
not been studied. The aim of the present study was
to assess the usefulness of anal skin tag biopsy as a
complementary investigation to rectal biopsy in the
histological confirmation of Crohn's disease.

There was a female preponderance (62%) in the group of 26
patients with Crohn's disease, with a mean age of 37 years. In 9
patients the disease was diagnosed radiologically (6 ileal; 9 ileocolonic), while in 12 patients the diagnosis was made on the
basis of classical histological changes in resected bowel (9 ileal;
3 ileo-colonic). The remaining five patients had Crohn's disease
confirmed histologically on rectal biopsies. All patients were
seen in a combined inflammatory bowel disease clinic, and evaluation of activity of anal disease was based upon criteria previously described [6].
The study was explained to each patient and informed consent obtained. Anal skin tags were removed easily in outpatients
after infiltrating the base of the tag with local anaesthetic (1%
lignocaine and 1 : 200,000 adrenaline). The procedure was well
tolerated and without complication. Rectal biopsies were obtained from the most abnormal looking area of the rectum, at
the same time as the anal skin tag biopsy or within 2 months. All
specimens were processed routinely into paraffin blocks. Random sections from three levels in each biopsy were stained with
198
Table 1. Histological assessment of rectal biopsies and anal skin tags in 26 patients with Crohn's disease
Rectal biopsy
Normal or non-specific
Anal skin tags
Number of
patients (%)
Number of
sections (%)
Number of
patients (%)
Number of
sections (%)
17
(65)
54
(69)
15
(58)
60
(78)
Suggestive
(11)
(9)
Diagnostic (granulomas)
(31)
10
(13)
(35)
24
(31)
26
(100)
78
(100)
26
(100)
78
(100)
Totals
Table 2. Correlation between patients with or without granulomas from rectal biopsies and anal skin tags
Anal skin tags
Granulomas
Granulomas
tags. Six of the 9 patients with granulomas in skin tags had large
bowel involvement, as did 5 of the 17 patients without granulomas in skin tags. In the control group, no granulomas were
seen in any of the 114 sections examined.
No granulomas
3
Rectal
biopsy
Discussion
No granutomas
4"
14
" Includes 1 patient whose rectal biopsy was 'suggestive' of

Crohn's disease
haematoxylin and eosin. All sections were examined by a single
histopathologist (GTW) who was unaware of the clinical findings. Rectal biopsies were reported as 'normal', 'non-specific',
'suggestive' of Crohn's disease (i.e.: focal crypt disruption but no
granulomas [8]), or 'diagnostic' (with typical non-caseating
granulomas). Anal skin tags were examined for the presence or
absence of granulomas only.
Anal skin tags were excised from a control group of 26
patients who had a male preponderance (54%), with a mean age
of 52 years. A total of 114 sections were examined from these
specimens. Thirteen of these patients had a variety of perianal
problems including pruritus ani, fissure and fistula, 7 had skin
tags removed immediately prior to haemorrhoidectomy and a
further 6 had ulcerative colitis.
Results (Tables 1 and 2)

Granulomas were detected in anal skin tags taken from 9 of 26
patients with Crohn's disease (35%), and were seen in all 3
sections in 7 patients. Of 78 sections examined, granulomas were
found in 24 (31%). Granulomas were detected in rectal biopsies
in 8 of the 26 patients with Crohn's disease (31%), but were
present in all 3 sections in a single case only. Of the 78 sections
examined, granulomas were found in 10 (13%). Eight sections
from rectal biopsies in three patients were 'suggestive' of
Crohn's disease, and one of these three patients had granulomas
within an anal skin tag. Granulomas were present in both anal
skin tags and rectal biopsies in five patients. Four patients had
granulomas in skin tags but not in rectal biopsies, and three had
granulomas in rectal biopsies but not in anal skin tags. Eight of
the 9 patients with granulomas in anal skin tags had 'active' anal
disease, as did 2 of the 17 patients without granulomas in skin
The finding of a granuloma within a rectal biopsy

is usually taken as diagnostic of Crohn's disease,
assuming a consistent clinical picture [2, 9]. However, there are some patients in whom granulomas
cannot be found, even after intestinal resection,
and in these patients an additional means of confirming the diagnosis would be useful. We have
therefore investigated the usefulness of anal skin
tag biopsy as an adjunct to rectal biopsy in the
histological confirmation of Crohn's disease. The
results indicate that the procedure may well be useful in this situation, although we have not yet investigated its place in the initial assessment of a patient
presenting de novo.
The frequency with which anal lesions are
found in Crohn's disease varies with the site and the
extent of involvement, although Fielding [10] described anal lesions in 76% of all cases. Goligher
[11] reported anal lesions in 20% of patients with
disease confined to the small bowel, increasing to
55% and 68% of those with isolated large bowel
and rectal involvement respectively. The anal lesions of Crohn's disease are a particularly useful
diagnostic feature, although they may appear in
isolation, and pre-date intestinal involvement by
months or years [7, 12]. However, anal skin tags are
a common finding among normal individuals with
non-specific perianal conditions, and histological
examination must be the definitive investigation in
this situation. The procedure can be undertaken in
outpatients under local anaesthesia, without causing the patient any undue inconvenience or risk.
199
The rates at which granulomas were found by

the two techniques were similar in this study (31%
for rectal biopsies; 35% for anal skin tag biopsies).
Obviously, had granulomas always been found in
both sites in all positive patients, the possible complementary value of anal skin tag biopsy would be
lost. However, the results from rectal and anal skin
tag biopsy define different patient populations, in
that there were four patients with granulomas in
anal skin tags only and three with granulomas in
rectal biopsies only. Furthermore, granulomas are
less likely to be missed during the cursory examination of a single section from an anal skin tag rather
than from a rectal biopsy, since they were present
in all three sections in seven of nine 'positive' anal
skin tags, compared to only one of nine 'positive'
rectal biopsies. This finding alone makes the procedure potentially useful in the histological confirmation of Crohn's disease. The fact that no granulomas were found in 114 sections from anal skin tags
taken from 26 control patients also suggests that
granulomas within anal skin tags are of diagnostic
importance.
Granulomas in anal skin tags appear to be associated with distal, rather than proximal, disease,
and also with active anal disease. The reason for
this is not known, although it has been suggested
that granulomas become more frequent distally,
and that they may be a feature of early disease,
which tend to disappear as the disease progresses
[13]. Perianal disease might be expected to present
to the clinician early, perhaps considerably earlier
than more proximal disease.
In conclusion, it appears from this small study
that anal skin tag biopsy may provide a useful test
which is complementary to rectal biopsy in the histological confirmation of Crohn's disease. Granulomas seem to be more widespread when present in
anal skin tags than in rectal biopsies, and are therefore less likely to be missed by limited sectioning.
Finally, locally active distal disease is more likely to
be associated with granulomas in anal skin tags
than is isolated proximal disease.
References
1. Morson BC, Dawson IMP (1979) Gastrointestinal Pathology, 2nd edn. Blackwell Scientific Publications, Oxford,
pp 293-312
2. Lennard-Jones JE, Lockhart-Mummery HE, Morson BC
(1968) Clinical and pathological differentiation of Crohn's
disease and proctocolitis. Gastroenterology 54:1162-1170
3. Korelitz BI, Sommers SC (1977) Rectal biopsy in patients
with Crohn's disease: normal mucosa on sigmoidoscopic
examination. J A M A 237:2742 2744
4. Hill RB, Kent TH, Hansen R N (1979) Clinical usefulness of
rectal biopsy in Crohn's disease. Gastroenterology 77:938
944
5. Petri M, Poulsen SS, Christensen K, Jarnum S (1982) The
incidence of granulomas in serial sections of rectal biopsies
from patients with Crohn's disease. Acta Pathol Microbiol
Immunol Scand (a) 90:145-147
6. Hughes LE (1978) Surgical pathology and management of
anorectal Crohn's disease. J R Soc Med 71:644-651
7. Morson BC, Lockhart-Mummery HE (1959) Anal lesions in
Crohn's disease. Lancet ii: 1122-1123
8. Morson BC (1974) The technique and interpretation of
rectal biopsies in inflammatory bowel disease. In: Somers
SC (ed) Pathology Annual Prentice-Hall Englewood Cliffs,
NJ, pp 209-230
9. Hadfield G (1939) The primary histological lesion of regional ileitis. Lancet ii: 773 - 775
10. Fielding JF (1972) Perianal lesions in Crohn's disease. J R
Coll Surg Edinb 17:32-37
11. Goligher JC (1984) Surgery of the anus, rectum and colon.
5th edn. Balli~re Tindall, London, p 979
12. Gray BK, Lockhart-Mummery HE, Morson BC (1965)
Crohn's disease of the anal region. Gut 6:515-524
13. Chambers TJ, Morson BC (1980) The relationship between
course of Crohn's disease and the number of granulomas in
involved bowel. In: Jones Williams W, Davies B (eds) Eighth
International Conference on Sarcoidosis and other granulomatous disease. Alpha Omega Publishing, Cardiff, pp 750757
Prof. L. E Hughes
University of Wales
College of Medicine
Heath Park
Cardiff CF4 4XN
UK
Col6i'eetal
D.sease
9 Springer-Verlag1989
How I do It
Emergency colectomy in colitis

R.S. McLeod
University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
Despite the use of steroids and other medical
modalities, many patients require urgent or emergency surgery for acute episodes of ulcerative colitis. From a technical standpoint, surgery may be
hazardous because the colon is often friable and
dilated. Free or sealed perforations may be present
or, because of the friability of the colonic wall,
perforations may occur iatrogenically. Besides the
technical difficulties, other factors contribute to an
increased morbidity and mortality in this group of
patients. Patients tend to be malnourished and immunosuppressed both from the disease as well as
from high doses of steroids. They may be hemodynamically unstable due to sepsis or hemorrhage.
Consequently, special precautions may be necessary when operating on these patients. This article
will discuss the surgical management of patients
with acute colitis, with special emphasis on the
technical aspects of surgery.
Indications for surgery

The usual indication for urgent or emergency
surgery is toxic megacolon. Some patients have
episodes of acute colitis without evidence of colonic
dilatation, but in other respects mimic toxic megacolon and these too may require urgent surgery.
Colonic perforations and massive hemorrhage
rarely occur except as complications of toxic megacolon but when they do, emergency surgery is often
indicated.
Patients with toxic megacolon may require
surgery at the time of presentation or at any time
subsequently. Some surgeons have argued that the
diagnosis of toxic megacolon in itself constitutes an
indication for surgery, but it has been our policy to
initially treat patients with nasogastric suction, intravenous fluids, steroids and antibiotics for a limited period of 24-72 h. If the patient deteriorates at
any time during this period, surgery is performed

immediately. No significant improvement after this
period of treatment also constitutes an indication
for surgery. Complications such as free perforation
manifesting radiologically as pneumoperitoneum
or clinically as generalized peritonitis; localized tenderness suggesting impending perforation, septic
shock, or major hemorrhage are other indications
for immediate operation.
Surgical options
The three procedures which have been advocated
for fulminant colitis are (1) proctocolectomy and
ileostomy, (2) abdominal colectomy and ileostomy
or (3) "blowhole" colostomy and ileostomy.
Proctocolectomy has been advocated for patients who are considered good operative risks and
in whom there are no colonic perforations. It is
claimed that in experienced hands the procedure
can be performed safely, that it avoids bleeding and
perforation of the rectal stump and it eliminates the
need for a second operation. However, virtually all
of these patients are acutely ill, and there is a higher
risk of complications including the development of
pelvic sepsis. Following abdominal colectomy, major bleeding from the rectal stump is unusual and
the risk of perforation can be eliminated if the rectum is exteriorized. Additionally, with the introduction of the ileal reservoir and ileoanal anastomosis procedure, the advantage of this operation
eliminating the need for further surgery is no longer
an issue, but instead an argument against it.
The only role for proctocolectomy is in the patient in whom the indication for surgery is massive
hemorrhage. However, even in these patients, we
have tended to do a colectomy and leave a very
short rectal stump. In most situations bleeding does
not continue since it is usually diffuse rather than
201
from one site. It also leaves the option for reconstructive surgery.
Our operation of choice is subtotal colectomy
and ileostomy. Despite preserving the diseased rectum, the general health of most patients improves
and they can be weaned off steroids. Some patients
may continue to complain of rectal bleeding but
rarely does it necessitate surgical intervention. Frequently no treatment is required, but a small proportion may require 5-aminosalicylic acid or
steroid enemas to control the disease. The advantages of this operation are that it has a lower complication rate than emergency proctocolectomy.
Secondly, the rectum is preserved so the patient has
the option of reconstructive surgery in the future.
For patients with a perforation, this is the procedure of choice.
Blow hole colostomy and ileostomy has been
advocated by Turnbull and others from the Cleveland Clinic. Rather than resecting the colon, it is
decompressed with a colostomy made from the
transverse colon and the intestinal contents are diverted through a loop ileostomy. Turnbull advocated this procedure because of the increased mortality in patients in whom there is a perforation of
the colon. He believed that many perforations are
iatrogenic or that sealed perforations are disrupted
at the time of surgery. The Cleveland Clinic group
has shown that the procedure is successful in detoxifying most patients and that it can be performed
with a low operative morbidity and mortality. Despite this, the procedure has not gained popularity.
At our institution we have performed it occasionally in patients who have grossly dilated colons and
in whom performing a colectomy would be quite
difficult. It should also be considered by the surgeon who is inexperienced in operating on patients
with toxic megacolon, or who does not have
adequate assistance to take down a high splenic
flexure. One might also consider this option if the
diagnosis is in doubt and the etiology of the toxic
megacolon might be an infectious cause. It is contraindicated in the patient with a free perforation.
A final option is construction of an ileal reservoir and ileoanal anastomosis. This should be
strongly discouraged in the emergency setting since
patients are not in optimal condition and therefore
are at high risk for septic and non-healing complications.
midline incision is made, extending it as far cephalad as necessary to ensure optimal exposure of the
splenic flexure. It is essential that one has adequate
surgical assistance. A self-retaining retractor such
as the Buckwalter can provide excellent exposure.
The colon is mobilized using cautery to minimize
bleeding. The splenic flexure is mobilized in this
way rather than attempting to clamp and tie vessels, as this is often very difficult if the colon is
markedly dilated. If one encounters adhesions either to an adjacent organ or the retroperitoneum,
one should be suspicious that there is a sealed
colonic perforation. In such a case, one can attempt
to prevent opening into the bowel by removing a
disc of tissue with the colon. Usually, however, the
bowel is entered so precautions should be taken to
minimize fecal contamination prior to mobilizing
that area. Quarantining the area with sponges and
having the abdominal sucker close at hand are two
useful measures. This is also the situation where
Turnbull has advocated doing a blow hole
colostomy and ileostomy.
The mesenteric vessels are divided close to the
margin of the bowel. The terminal ileum is divided
at the ileocecal valve using a linear stapler (Fig. 1).
It is essential to preserve the small bowel if construction of an ileal reservoir is contemplated in the
future. The ileum is then brought out through the
abdominal wall and matured as an end ileostomy.
Surgical technique
Fig. 1. The terminal ileum is divided close to the ileocecal valve.

The ileocolic vessels are divided close to the superior mesenteric
vessels. There is an avascular space between the superior mesenteric and ileocecal vessels. The triangular segment of mesentery
can be removed, and in doing so the terminal ileum can be
brought out through the stomal aperture easily
Subtotal colectomy and ileostomy

Prior to undertaking surgery, a stoma site is
marked in the right lower quadrant. A generous
202
method to performing a Hartmann procedure or

leaving a mucus fistula. With the Hartmann procedure, there is a risk of the rectal suture line leaking,
and causing a pelvic abscess or even generalized
peritonitis. If this should occur when the colon is
buried in the subcutaneous tissue, the discharge
drains extrafascially rather than intra-abdominally.
In most patients, however, the colon heals and the
inconvenience of a mucus fistula is avoided. Despite leaving more rectum in situ than if a Hartmann type procedure were performed, the disease
activity settles and the general health of most patients improves. Another advantage of this method
is that at the second operation it is easier to take
down the colon from the abdominal wall, compared with mobilizing the rectal remnant from the
pelvis. Consequently, the risk of pelvic nerve injury
is lower.
Diverting loop ileostomy and blow-hole colostomy
"rv7
I},
--,.
b
Fig. 2 a, b. The rectal remnant is oversewn and brought through
an opening in the left lower quadrant
Distally, the sigmoid colon is divided at a level

where it can be brought out easily through a left
lower quadrant incision (Fig. 2). The bowel is divided and a two layer suture closure is performed.
We prefer to divide the colon and suture it since the
colon wall tends to be inflamed and staples may
fracture the bowel wall. Then the bowel is brought
through the fascia so it lies just below the skin.
sutures are inserted between the fascia and bowel to
maintain it in this position. The overlying skin is
closed with sutures or staples. We prefer this
An ileostomy site is marked pre-operatively in the

right lower quadrant. The abdomen is opened
through a small lower midline incision. The abdominal cavity is inspected to ensure there is not a
free perforation. Adhesions are not taken down
since they may indicate a walled off perforation.
Following the laparotomy, an ileostomy aperture is made at the previously marked site in the
right lower quadrant. A loop of ileum proximal to
the ileocecal valve is brought out as a loop
ileostomy through the stoma site and a rod is
placed through the mesentery at skin level.
The blow hole colostomy is constructed by first
making an incision directly over the dilated transverse colon (Fig. 3). The transverse colon is usually
grossly distended and its position is easily localized.
An incision of approximately 5 cm through all layers of the abdominal wall is usually adequate. Once
the colostomy incision is made the midline incision
is closed. The loop ileostomy is matured by incising
the small bowel at skin level on the distal loop for
approximately three quarters of its circumference.
The ileum is everted and sutured with interrupted
absorbable sutures. The blow-hole colostomy is
constructed by dividing the omentum over the colon, and suturing it to the peritonum with interrupted sutures. This prevents any of the colonic
contents from entering the peritoneal cavity. Then
the transverse colon is sutured to the rectus sheath
with interrupted absorbable sutures. The colon is
decompressed by inserting a large bore needle attached to a suction into it. Following this, the
transverse colon is incised and the wall of the colon
203
Fig. 3. To construct the blow hole colostomy, an incision is

made over the dilated transverse colon. Then the abdominal
incision is closed and the loop ileostomy is matured
Fig. 4. The transverse colon is sutured to the abdominal wall.

No attempt is made to evert the colonic wall as is done with the
usual colostomy
is sutured to the skin or fascia with interrupted

sutures (Fig. 4).
Appliances are applied over both stomas. There
may be considerable discharge from the colostomy
initially, but as the disease activity diminishes, so
does the discharge.
surgeon. To optimize results, patients require careful and frequent assessment, and vigorous preoperative resuscitation. Surgery must be performed
carefully with the goal of improving the patient's
overall well-being. In most instances, this means
that a definitive surgical procedure is not performed.
Conclusion
While the overall morbidity and mortality of ulcerative colitis is low, toxic megacolon poses a challenge to even the most experienced gastrointestinal
Dr. Robin S. McLeod

EN-9-242 Toronto General Hospital
200 Elizabeth Street
Toronto, Ontario M 5 G 2C4
Canada
Answer: Ulcerative colitis. The mucosa is thrown

into folds by muscular shortening (and thickening).
The polyps, seen to the right of B, are inflammatory, with granulation tissue and slough at their
tips. (Similar polyps, when inflammatory features

have subsided would be described as "post-inflammatory" and the condition could be termed "colitis
polyposa".)
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Col6i'eeial Disease: Original Articles

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Col6i'eeial

Int J Colorect Dis (1989) 4:141-143

postoperative pain. Nine days following operation, while she

A 70-year-old man was admitted to the hospital because of

were operated on. Hartmann's operation was the

Table 1. Acute postoperative diverticulitis series published in the last 10 years

Our series 1988

a No data on treatment; b no data on presentation

6. Schwartz SI, Shires GT, Spencer FC, Storer EH (1984)

Int J Colorect Dis (1989) 4:144 149

Abstract. The effects of epidural anaesthesia (EDA,

Anastomotic break-down is a significant cause of

evade unwanted cholinergic effects, but whether

Patients and methods

Anaesthesia and operative procedure

Motility recordings. Intestinal motility was observed during the

Fig. 1. Schematic illustration of the motility recording technique

In six patients the effect of atropine/neostigmine on left

Basic motility pattern

Left colon. During EDA, forceful segmental tonic

EDA and reached a maximum after 5 15 min. In

Fig. 4. Colonic motor response to EDA. Upper

Fig. 5. The effect of EDA followed by atropine on

Fig. 6. Typical record of the effect of atropine and neostigmine

In experiments with two synchronous recording

Rectum. At direct inspection a tonic contraction

tained throughout the recording period. The rectal

Fig. 7. Diagrammatic representation of the effect of atropine/

The results of the present study show that EDA of

intraluminal volumetric recording technique used

Acknowledgements. This investigation was supported by grants

8. Pflug AE, Halter JB (1981) Effect of spinal anesthesia on

Int J Colorect Dis (1989) 4:150-155

Evaluation of ileal W pouch-anal anastomosis for

Restorative p r o c t o c o l e c t o m y with ileal reservoir

The examination was performed with patients in the left lateral

cerative colitis and familial a d e n o m a t o u s polyposis

Patients and methods

F i g . 2. Pouchogram by barium sulphate (anterior-posterior

diameter of the pelvic cavity. Dilatation r a t l o = ~ x 100 (per

Table 1. Derivation of clinical score in neorectal function

Mean daily stool frequency

Postoperative complications (Table 2)

There was one patient with a partial dehiscence of

Table 2. Postoperative complications in 16 patients

Table 3. Changeover time in mean daily frequency after ileostomy closure

3.8_+1.2 3.6_+0.8 3.3_+1.0

Mean maximal reservoir resting pressure was

Months after i[eostomy closure

Fig. 5. Relationship between mean daily stool frequency and

Maximal tolerated reservoir volume

Dilatation ratio of ileal reservoir

" Not significant as compared with normal controls

had been 200 to 250 ml, all reservoir volumes rose

There was an inverse linear relationship between

daily stool frequency and horizontal diameter of

operative procedure resulting in better defaecatory

closure. Impaired internal anal sphincter function

10. Keighley MRB, Yoshioka K, Kmiot W, Heyen F (1988)

10. Keighley MRB, Yoshioka K, Kmiot W, Heyen F (1988)

Int J Colorect Dis (1989) 4:156-160

Manovolumetric characteristics and functional results