STRAIGHT ILEOANAL ANASTOMOSIS WITH MULTIPLE ILEAL MYOTOMIES AS AN ALTERNATIVE TO PELVIC POUCH

An alternative technique of restorative proctocolectomy, by means of s traight ileoanal anastomosis with multiple myotomies (SIAM) of the ter minal ileum in 15 patients, nine with familial adenomatous polyposis ( FAP) and six with ulcerative colitis (UC) is reported. Surgical techni que: eight to ten longditudinal myotomies (3-4 cm long, on three diffe rent circumferential sites) were performed on the terminal ileum for a total length of 12-14 cm. Clinical results: at a mean follow up of 44 months (range 3-84 months) from the closure of the ileostomy, daytime continence was achieved in all the patients; stool frequency per 24 h ours (+/-SD) was 4.1+/-1.8 for FAP patients and 5.8+/-1.7 for UC patie nts; nocturnal defecation was 1.0+/-0.5 and 1.2+/-0.8 for FAP and UC p atients respectively; frequent nocturnal soiling was present in 2/5 of UC patients, and in 3/9 of FAP patients. SIAM failed in one UC patien t that was converted to an ileoanal reservoir because of poor function al result. Signs of ileal mucosal inflammation were never observed at endoscopic examination. Histopathological assessment showed no evidenc e of acute terminal ileitis. Manometric findings: a significant postop erative reduction in anal resting pressure was observed after SIAM. Ne ither the absence of anal inhibitory reflex nor the presence of high p ressure waves generated in the terminal ileum during air insufflation were related to the presence of soiling. The closure of the loop ileos tomy was followed by an increased capacity and distensibility of the t erminal ileum. Values of neorectal compliance were similar in FAP and UC patients although FAP patients were able to reach higher values of maximum tolerated volume and pressure. Conclusions: 1) SIAM can be an alternative to pelvic pouch in patients who have undergone restorative proctocolectomy when the construction of the pouch is not feasible. 2 ) The functional result observed after SIAM has been shown to be simil ar to that observed after pouch construction.