Small Volume Reservoir

The first type of reconstruction after total procto-colectomy was the straight ileo-anal anastomosis. The unsatisfactory results of such a procedure together with the studies of Nicholls [45], which demonstrated the presence of an inverse relation between evacuation frequency and reservoir capacity, determined the spread of the pelvic pouches. However, constructing a pouch so as to have satisfactory functional results is not sufficient, because an adequate volume of the reservoir is necessary for the functioning of the neo-rectum with a reduction of evacuation frequency. In fact, insufficient volume of the reservoir can be responsible for the elevated number of evacuations and urgency. The demonstration of the importance of an adequate volume is represented in the differences in the results that can be observed between the J and the W-pouch [46].

The pouch enema and above all the mano-vol-umetry along with the determination of the threshold volume (TV) and the maximum tolerated volume (MTV) can define the capacity and compliance of the reservoir exactly. Medical therapy (loperamide, codeine and mass-forming drugs), often is not able to improve the evacuation frequency, so therefore, an abdominal operation becomes necessary in order to enlarge the pouch. Herbst demonstrated a meaningful reduction of evacuation frequency using this method [38] and Fazio [11] used this method in 7 of 35 patients reoperated on for sepsis.

Klas [47] reported that in five cases of insufficient volume of the reservoir for which he carried out a conversion from a J to a W pouch, daily evacuation frequency had been reduced, with much satisfaction on behalf of the patients, from 13-8 to 5-8 and the nocturnal episodes from 3-0 to 0-3. However, such an increase of the pouch, which certainly represents a more conservative method than ex novo construction of the reservoir, is not always feasible. This technique consists of the addition of a small intestinal loop to the proximal part of the pouch without removing it from its site, or as an alternative, mobilisation of the reservoir, modification of the J-pouch in order to construct a W-reservoir and finally a reconstruction of the pouch-anal anastomosis. In the case of a J-pouch with a long blind stump, its integration with an L/L suture is sufficient for increasing the volume of the pouch.

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