Long Efferent Limb

Parks and Nicholls's S-pouch [35] or Fonkalsrud's H-pouch [22] can determine the formation of an efferent limb of the terminal ileum, which constitutes the proximal side of ileo-anal anastomosis. A long efferent limb (LEL), >8 cm of length, fashioned in the first "debut" cases of the S-reservoir, needed catheterisa-tion of the pouch to achieve evacuation in more than 50% of the patients [36].

Fonkalsrud [22], in his study of 601 PRs, reports an OO rate of 27.3%, with a success rate after surgical review in 93% of cases. In this experience, however, 221 patients had an H-reservoir and 4 had an S-reser-voir constructed in the early 1980s. Those made at that time were abandoned because of an elevated incidence of emptying with the necessity of catheter-isation.

The removal of the LEL is possible through a transanal approach, but it is technically feasible in less than 30% of patients [22,37]. The technique consists of mobilisation of the pouch and separation of the ileo-anal anastomosis. The efferent limb is removed and a new manual anastomosis is fashioned between the pouch and the anal canal.

Sagar [10], in a study of 1 770 ileal pouches, evidenced 9 LELs (5-11 cm), all of which were in patients with an S-pouch, and 3 blind handle torsions in patients with J-pouches. After surgical treatment of the nine patients with LEL, five demanded construction of a new reservoir, which was successful in seven cases (78%). In the three patients with blind handle torsions, he did not fashion a new reservoir and only one patient benefited from the surgical treatment. Of a total of 26 patients who underwent this treatment, failure of the surgical procedure was recorded in 5, while 18 showed improvement which included a change from needing catheterisation to spontaneous evacuation [9,10, 37, 38].

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