Tech Coloproctol (1999) 3:145-151 © Springer-Verlag 1999 S. Ascanelli • D.C.C. Bartolo Functional outcome after restorative proctocolectomy Received: 28 May 1998 / Accepted in revised form: 22 September 1999 REVIEW S. Ascanelli () Department of General Surgery, University of Ferrara, Corso Giovecca 203, I-44100 Ferrara, Italy D.C.C. Bartolo Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK Abstract Incontinence and pouchitis are complications that affect most patients who have undergone restorative proctocolectomy. Incontinence, with particular regard to night leakage, is related to the combination of poorly func- tioning ileal reservoir and poor anal sphincter function. Pouchitis, the major late complication of restorative procto- colectomy, is quite similar to the previous inflammatory bowel disease. Pouchitis has an important impact on func- tional results after restorative proctocolectomy, causing a significant increase in defecation frequency, pain on evacu- ation, urgency, watery bowel movements, bloody diarrhea, anal irritation and stool leakage. In particular, chronic pou- chitis can cause distress, anxiety and disappointment for patients needing continuous treatment. The influence of anal sphincter and ileal pouch function on clinical outcome after ileal pouch-anal anastomosis (IPAA) is reviewed, together with the correlation between ileal pouch function and pouchitis. The possible correlation between pouchitis and long-term functional outcome after restorative proctocolectomy is examined. Key words Ulcerative colitis • Restorative proctocolecto- my • Anorectal physiology • Fecal incontinence • Pouchitis Introduction The operation of mucosal proctectomy and pelvic ileal pouch formation has rapidly become an established tech- nique for the surgical treatment of ulcerative colitis and familial adenomatous polyposis (FAP), as an alternative to total proctocolectomy and end-ileostomy. By the use of mucosal proctectomy and pelvic pouch formation, a per- manent ileostomy is avoided, the disease is eradicated, and gastrointestinal continuity and continence are restored. Despite the success of the procedure and the reduction of morbidity as expertise increases [1-3], postoperative functional results are not still completely satisfactory. Although most patients who undergo this procedure are usually pleased with their quality of life and remain conti- nent for most of the time, many patients leak both mucus and feces intermittently and particularly at night [4-7]. The average number of bowel movements gradually decreases over time, but in most series six per 24 hours is the norm and many patients need to empty the pouch once or twice during the night [8]. Some patients also complain of urgency of defecation similar to that experienced when they had their disease (Table 1). Much interest has been focused on two complications that affect most patients having undergone restorative proctocolectomy: incontinence and pouchitis. The impact of pouchitis on functional results has been little studied previously [9]. From the literature, there is a significant overlap in pouch function or dysfunction between inflamed and normal pouches; it seems that there is no correlation between pouchitis and alterations in pouch mobility or between the degree of mucosal inflammation and the fre- quency of defecation. In the following pages, the functional aspects of ileoanal pouch and the principal factors implicated in the generation of pouchitis are reviewed, to understand if there is a correlation between pouchitis and alterations in pouch motility.