From Stillwater-Ponca City (OK) Ostomy Outlook May 1996:

Pelvic Pouch Issues

Editor's note: The "Pelvic Pouch" procedure (also known as Ileoanal Reservoir, Ileoanal Pull-Through, J-Pouch, as well as various other names) is now probably the dominant alternative to conventional ileostomy for ulcerative colitis and familial polyposis.

I present this material in two parts. Part I originated from Dr. Zane Cohen of Mount Sinai Hospital, Toronto. It appeared in their "Pelvic Pouch Newsletter," and I received it in "Metro Halifax News" from the Halifax (Nova Scotia) UOA Chapter.

However, some aspects of Dr. Cohen's procedure are controversial. Therefore, Part II is a response from Dr. Russell Postier of University Hospital in Oklahoma City, who is the leading practitioner of the Ileoanal procedure in this part of the country.

Part I - Pelvic Pouch Questions & Answers

Q: I had my surgery in 1982 and I was told I have a rectal cuff. What is the difference now in surgical technique?
A: The difference presently is that the rectum is dissected down to the pelvic floor thus leaving virtually no rectal cuff. Whereas previously there was a rectal cuff left of approximately 10 cm, the entire rectum is now removed and only an anal cuff is left. This has been found to be an easier operation to perform and the results have been the same with a lesser risk of leaving any mucosa behind in the rectal cuff.

Q: If you are leaving mucosa behind, is there not a risk of cancer?
A: At the present time we are using a staple technique which does in fact leave 1 to 2 cm of diseased mucosa behind. We have used this technique as the functional results appear to be better when this amount of tissue is left behind. There is only a theoretical risk of cancer. In the world literature on Ulcerative Colitis, the risk of developing cancer in the anal canal is extremely remote. If an individual has any evidence of malignant transformation or dysplasia or if there are extraintestinal manifestations of the disease or if the patient has polyposis as opposed to Ulcerative Colitis, then a proctomucosectomy would be performed leaving no mucosa behind. In removing these higher risk groups we do not feel that we are placing the patient at a significantly increased risk of developing cancer.

Part II - Response

I think it is important to point out that surgeons are not uniform in their acceptance of Dr. Cohen's technique which leaves behind usually more than 1 or 2 cm of anal and rectal mucosa and oftentimes as much as 3 to 4 cm. While this is a technically easier operation to perform, it does leave mucosa behind which can all be removed if a mucosal proctectomy is done. There are a number of surgeons and I suspect the majority of surgeons who do this operation who still feel that is the preferred technique. There are no studies which have compared these two techniques in a prospective and randomized way which would be the only way to determine definitively which is better. This study which will be required, will take a large number of years and a large number of patients to determine not only the functional results but also the cancer risk. Older data dating back to the 1960s with a somewhat larger segment of rectum being left in place showed that a significant number of those patients long term would develop cancer.