The effect on morbidity of mesentery lengthening techniques and the use of a covering stoma after ileoanal pouch surgery.
OBJECTIVE
A tension-free anastomosis in a restorative proctocolectomy requires sufficient length of small-bowel mesentery. To ensure adequate length, it has been proposed that the superior mesenteric artery be divided and the right colon marginal vascular arcade be preserved. This study was designed to evaluate the influence of mesenteric lengthening techniques on the need for a stoma and on early outcomes after restorative proctocolectomy.


METHODS
Records of patients who had a restorative proctocolectomy between January 1998 and October 2003 were reviewed. Patient and disease characteristics, operative techniques and findings, the need for a stoma, and postoperative complications were recorded.


RESULTS
In one patient a restorative proctocolectomy was not possible. The remaining 220 patients were divided into two groups: Group A (inflammatory bowel disease; n = 123) and Group B (noninflammatory bowel disease; n = 97). Sixty-nine patients (31.4 percent) had major comorbidities. A lengthening technique was performed in 120 patients (54.5 percent) by dividing the ileocecal artery (n = 37) or the superior mesenteric artery (n = 88); 5 patients had only the marginal vascular arcade preserved. An ileostomy was not required in 116 patients (52.7 percent). In multivariate analysis, in Group B the only surgical variable influencing the need for an ileostomy was preservation of the marginal vascular arcade (50 vs. 14.7 percent; P < 0.0005). Complications occurred in 41 patients (18.6 percent), more frequently for those in Group A and for patients receiving steroids (23.6 vs. 12.4 percent, P = 0.012; 10.4 vs. 6.8 percent, P = 0.0172).


CONCLUSIONS
The use of mesentery lengthening techniques allows a restorative proctocolectomy to be performed in almost all patients without increasing morbidity and may reduce the number of covering stomas. Because division of the ileocecal and/or superior mesenteric arteries may be required, preservation of the marginal vascular arcade is essential whenever possible.
Department of Digestive Surgery, Hôpital Saint-Antoine AP-HP, University Paris VI (Pierre and Marie Curie), Paris, France.
Toshimitsu
T
Araki
Yann
Y
Parc
Jérémie
J
Lefevre
Nidal
N
Dehni
Emmanuel
E
Tiret
Rolland
R
Parc
D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000009:adverse effects; D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D002648:Child; D015897:Comorbidity; D005260:Female; D006801:Humans; D007081:Ileostomy; D015212:Inflammatory Bowel Diseases / Q000601:surgery; D016015:Logistic Models; D008297:Male; D017538:Mesenteric Artery, Superior / Q000601:surgery*; D008875:Middle Aged; D015999:Multivariate Analysis; D016737:Proctocolectomy, Restorative / Q000009:adverse effects / Q000379:methods*; D011446:Prospective Studies; D012737:Sex Factors; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones