PURPOSE: This study was designed to define the different types of strictures, the factors favoring their occurrence, and their treatment after ileal pouch-anal anastomosis. METHODS: Between January 1981 and June 1996, 1,884 ileal pouch-anal anastomoses were constructed at the Mayo Clinic in Rochester, Minnesota. Data were collected prospectively and included age, gender, type of underlying diseases (chronic ulcerative colitis vs. familial adenomatous polyposis), proctologic antecedents, technique of anastomosis, intraoperative difficulties, and postsurgical complications. Strictures were categorized as nonfibrotic and fibrotic on the basis of the presence or absence of a fibrotic segment at the anal canal anastomosis that was responsible for pouch-outlet obstruction requiring at least one dilation. RESULTS: Strictures occurred in 213 patients (11.2 percent; 11 percent for chronic ulcerative colitis and 12 percent for familial adenomatous polyposis; P = not significant). Strictures were nonfibrotic in 86.4 percent of patients and fibrotic in 13.6 percent. A greater number of strictures were observed after a handsewn anastomosis (12 percent) than after a stapled anastomosis (4 percent; P = 0.03). Intraoperative technical difficulties were associated with 13 percent of all strictures regardless of the type of stricture (fibrotic, 7.5 percent; nonfibrotic, 14 percent; P = 0.4). Postoperative complications such as abscess, fistula, and pouch retraction were found in 13 percent of cases and were primarily associated with fibrotic strictures. Treatment included dilation, which was successful in 95 percent of nonfibrotic strictures but in only 45 percent of fibrotic strictures ( P = 0.0001). Surgical treatment was required in 25 strictures (12 percent), including excision of the strictured segment with mucosal advancement flap (5 patients), excision of the pouch with permanent ileostomy (9 patients), or redo pouch (3 patients). With one exception, all excised pouches were associated with other perianastomotic complications, such as abscess, fistula, and pouch retraction. The remaining eight patients had other surgical procedures because of abscess (n = 3), division of an obstructive bridge (n = 2), and débridement and curettage of a fistula (n = 3) with dilation for associated strictures. CONCLUSIONS: Strictures were observed in 11.2 percent of the patients in this study. Nonfibrotic strictures responded well to anal dilation, whereas fibrotic strictures were more commonly associated with intraoperative or postoperative complications, often necessitated surgical therapy to salvage pouch function, and were eventually responsible for pouch failure in nine patients.

: The role of a temporary defunctioning stoma in patients undergoing coloanal anastomosis remains controversial. Previous experimental studies have shown that the defunctioned colon is more resistant to neoplasia. The aim of this study was to investigate whether a defunctioning stoma was able to decrease complication rates and, also, to evaluate whether it had any impact on recurrence and survival rates in patients who underwent coloanal anastomosis. The records of 173 patients, 54 with benign rectal disease and 119 patients with cancer, operated on between 1980 and 1996, were retrospectively reviewed. Eighty-nine patients had a defunctioning stoma, 34 in the benign rectal disease and 55 in the cancer group. Mean age was 57.2 years (range 17–88). There were 126 men and 47 women. Follow-up was 57.2 month (range 17–88). There were 126 men and 47 women. Follow-up was done by clinical examination, telephone or mailed questionnaire. Mean time of follow-up was 3.8 years (range 0–13 years). There was no operative mortality. Non-stoma patients tended to have more early complications (pelvic sepsis and obstruction) and more probability of having a permanent stoma than the stoma group, but no significant differences could be found between the two groups ( P > 0.05). The probability of being free of stricture was greater in the non-stoma group (stoma 62.6%; non-stoma 78.5%; P < 0.05). Probability of disease-free survival, at 5 years, for rectal cancer patients, was 73.7% for the stoma group and 53.6% for non-stoma group ( P = 0.02). After coloanal anastomosis, defunctioning stomas may decrease postoperative complications, increase the likelihood of anastomosis structure and allow a greater disease-free survival.

Surgery is the only treatment that can cure most patients with colorectal cancer. Radiation therapy (pre or postoperative) has been shown to improve results by decreasing local recurrence and improving survival. Our aim was to analyze whether postoperative radiation influenced long-term functional outcomes and the probability of stricture of anastomosis in patients who underwent coloanal anastomosis for rectal cancer. Methods: The records of 84 patients with coloanal anastomosis for rectal cancer were studied between 1980 and 1996. There were 82 males and 28 females. Mean age was 57.8 years (range 24 to 78 years). Mean distal resection margin was 2.6 cm (range 0 to 14cm). Twenty-three patients received postoperative irradiation therapy. Patients who received chemotherapy were not included in the study. Results were analysed by examination , telephone or questionnaire. Mean follow-up was 3.8 years (range 0 to 13 years). Results: There was no operative mortality. Functional variables were much better in non-irradiated patients. The irradiated group had more number of stools/day (p>0.05), more number of stools/ night (p>0.05), more incontinence/day (p<0.05) and more incontinence/night (p<0.05). Irradiated patients also wore more pads (p<0.05) than non-irradiated patients. The probability of remaining free of stricture at 5 years was slightly better in non-irradiated (72 percent) than in irradiated patients (65 percent, p>0.05). Conclusion: Postoperative irradiation after colo-anal anastomosis for rectal cancer is safe, but may increase the risk of stricture of anastomosis and does affect functional results adversely.

Coloanal anastomosis is a well-established technique for resecting very low rectal cancer The aim of this study is to determine whether the addition of a colonic pouch improves functional outcomes.Methods: The records of 104 patients with rectal cancer, in whom a coloanal anastomosis was performed between 1980 and 1993, were reviewed.A colonic pouch was constructed in 14%.Functional results were measured by determining patients' satisfaction.Follow-up was done by exam, telephone and/or questionnaire.Results: There was no operative mortality.Minor complications were present in 20%, and major complications in 47% of the patients who had a pouch.This difference was not statistically significant when compared with the group of patients without a pouch (p>0.05).Stool frequency was greater than three movements per day in only 11% of the patients with a pouch and in 52% of those with a straight coloanal anastomosis.This difference was statistically significant (p<0.05).Satisfactory continence was achieved by all the patients with a colonic pouch and by 85% without a pouch (p>0.05).Conclusion: Pouch coloanal anastomosis appears to improve defecatory function, without increased operative mortality and/or morbidity.