The critical factor in ileal pouch pull-through operations is the length of the superior mesenteric artery. The pouch must reach the dentate line and have adequate blood supply. A series of cadaver and morgue studies were performed to evaluate the two most popular pouches of the "J" and "S" configurations. The "S" pouch generally reaches 2 to 4 cm more caudad than the "J" pouch. If necessary, however, the "J" pouch can be lengthened 2 to 4 cm by cutting the branch vessel under tension to the pouch, sparing vessels to either side and the marginal arcade. The "S" pouch procedure always sacrifices the ileocecal artery, but the "J" pouch procedure does not necessarily do so. The greatest caudad reach is available when the ileum is cut flush with the cecum. To verify a rule of thumb for reaching the dentate line with the pouch, the length of the superior mesenteric artery (SMA) origin to the inferior margin of the symphysis pubis and the SMA to dentate line were compared. If the tip of the pouch or conduit reached 6 cm below the symphysis pubis, all pouches reached the dentate line.
Some of the initial problems associated with the ileonal reservoir have been solved. In their place, other complications have been recognized. Among these, the ileal pouch vaginal fistula stands out as a recently recognized difficult management problem. This multicenter study was undertaken to gain insight into the causes for, and treatment of, pouch vaginal fistulas. Cases were gathered from 11 surgical practices, throughout North America, in which the ileoanal reservoir procedure is frequently performed. Overall, 304 females had undergone ileoanal reservoir procedures by these surgical groups. Twenty-one patients developed 22 pouch vaginal fistulas for an overall incidence of 6.9 percent. Five additional patients with pouch vaginal fistulas, whose restorative proctocolectomies were done elsewhere, were referred to these surgeons for treatment. The courses of these 26 patients form the basis of this report. This study details the risk factors which predispose to the development of a pouch vaginal fistula, as well as the various treatment options available.
From January 1988 to December 1993, we identified six men with minimally invasive (stage I) squamous cell carcinoma of the anus and 10 men with anal carcinoma in situ (CIS). Of the six patients with invasive carcinoma, four were infected with human immunodeficiency virus (HIV), including one with AIDS. Of the 10 patients with CIS, eight were infected with HIV, including four with AIDS. Anal pain and bleeding were the most common symptoms of minimally invasive anal cancer and anal CIS. Anal irritation, burning, or pruritus occurred more frequently in patients with CIS, whereas anal ulcers, masses, or abscesses were more frequent in patients with minimally invasive cancer. Several patients with CIS had a discrete area of leukoplakia in the anal canal or a pigmented plaque of the anus and anal canal. These lesions were not observed in patients with minimally invasive anal cancer. The symptoms and signs of early-stage anal cancer in men at risk for developing HIV infection or men infected with HIV often resemble those of other common anorectal diseases in homosexual men. Anal cancer in HIV-infected men is not limited to those individuals with AIDS.
Over a period of 16 months, three-fourths of the proctologic surgery performed by our clinic was done on an outpatient basis. By doing so, 1,200 patient visits and approximately 300 histories, physicals, and discahrge summaries were eliminated, while obviously benefiting patients and reducing health care costs. Thus, we can conclude that hospitalization is not necessary for the majority of proctologic surgery patients.
