From Stillwater-Ponca City (OK) Ostomy Outlook May 1996:
Pelvic Pouch Issues
Editor's note: The "Pelvic Pouch" procedure (also known as
Ileoanal Reservoir, Ileoanal Pull-Through, J-Pouch, as well as various
other names) is now probably the dominant alternative to conventional
ileostomy for ulcerative colitis and familial polyposis.
I present this material in two parts. Part I originated from Dr. Zane
Cohen of Mount Sinai Hospital, Toronto. It appeared in their "Pelvic
Pouch Newsletter," and I received it in "Metro Halifax
News" from the Halifax (Nova Scotia) UOA Chapter.
However, some aspects of Dr. Cohen's procedure are controversial.
Therefore, Part II is a response from Dr. Russell Postier of University
Hospital in Oklahoma City, who is the leading practitioner of the
Ileoanal procedure in this part of the country.
Part I - Pelvic Pouch Questions & Answers
by Dr. Zane Cohen, Mount Sinai Hospital, Toronto
Q: I had my surgery in 1982 and I was told I have a rectal
cuff. What is the difference now in surgical technique?
A: The difference presently is that the rectum is dissected down to
the pelvic floor thus leaving virtually no rectal cuff. Whereas previously
there was a rectal cuff left of approximately 10 cm, the
entire rectum is now removed and only an anal cuff is left. This has been
found to be an easier operation to perform and the results have been the
same with a lesser risk of leaving any mucosa behind in the rectal cuff.
Q: If you are leaving mucosa behind, is there not a risk of
A: At the present time we are using a staple technique which does
in fact leave 1 to 2 cm of diseased mucosa behind. We have
used this technique as the functional results appear to be better when
this amount of tissue is left behind. There is only a theoretical risk
of cancer. In the world literature on Ulcerative Colitis, the risk of
developing cancer in the anal canal is extremely remote. If an
individual has any evidence of malignant transformation or dysplasia or
if there are extraintestinal manifestations of the disease or if the
patient has polyposis as opposed to Ulcerative Colitis, then a
proctomucosectomy would be performed leaving no mucosa behind. In
removing these higher risk groups we do not feel that we are placing the
patient at a significantly increased risk of developing cancer.
Part II - Response
by Dr. Russell G. Postier, University Hospital, Oklahoma City
April 8, 1996
I think it is important to point out that surgeons are not uniform in
their acceptance of Dr. Cohen's technique which leaves behind usually
more than 1 or 2 cm of anal and rectal mucosa and
oftentimes as much as 3 to 4 cm. While this is a
technically easier operation to perform, it does leave mucosa behind
which can all be removed if a mucosal proctectomy is done. There are a
number of surgeons and I suspect the majority of surgeons who do this
operation who still feel that is the preferred technique. There are no
studies which have compared these two techniques in a prospective and
randomized way which would be the only way to determine definitively
which is better. This study which will be required, will take a large
number of years and a large number of patients to determine not only the
functional results but also the cancer risk. Older data dating back to
the 1960s with a somewhat larger segment of rectum being left in place
showed that a significant number of those patients long term would
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