THE PULL-THROUGH PROCEDURE - TECHNICAL FACTORS IN INFLUENCING OUTCOME, WITH EMPHASIS ON POUCHITIS

Background The purpose of the study was to review those features that we believed to be critical to the successful performance of the ileal pouch-anal anastomosis, or pull-through, procedure, and specifically t he complication of pouchitis. Methods. The charts of 205 patients who successfully underwent ileal pouch-anal anastomosis procedure were rev iewed. No follow-up was available in five patients; therefore the basi s of this report and its analysis was based on 200 consecutive procedu res in which at least two of the three surgeons participated. Particul ar emphasis was placed on continence, particularly nighttime continenc e. The incidence of pouchitis, either a single episode or intermittent episodes, was surveyed. Particular attention was paid to the level of rectal mucosectomy and anastomosis at the top of the columns of Morga gni, thus retaining the transitional zone. Results. Only 5% of patient s were incontinent in the absence of pouchitis. Twenty-five patients ( 13%) wore a pad at night, but only nine (5%) wore a pad during the day . Of those patients with pouchitis, 6% (12) have had a single episode and 12% (23) were intermittently on medication. Therapy of pouchitis w as usually carried out with ciprofloxacin 500 mg by mouth everyday or twice a day. Conclusions. Ileal pouch-anal anastomosis is an excellent procedure, provided technical details are adhered to. Satisfactory ou tcome with respect to nighttime continence can be achieved with rectal mucosectomy with minimal manipulation and retaining the transitional epithelium, performing the pouch anastomosis at the top of the columns of Morgagni. The incidence of pouchitis is disappointing but need not be inhibiting of either patients or carrying out this life-saving pro cedure in patients with ulcerative colitis and familial polyposis.