Gut 1994; 35: 1070-1075

The first 1 0 years' experience of restorativeproctocolectomy for ulcerative colitis

P Setti-Carraro, J K Ritchie, K H Wilkinson, R J Nicholls, P R Hawley

AbstractBetween 1976 and 1985, 110 patients hadrestorative proctocolectomy or proctec-tomy for ulcerative colitis and 103 werefoilowed up until death or February 1992.There was one postoperative and one latedeath related to surgery. The cumulativeprobability of pouch failure was 12% atfive years: half of the failures occurredwithin one year. The commonest reasonswere perianal/pelvic sepsis and probableCrohn's disease. The cumulative prob-ability of readmission, excluding thatfor ileostomy closure, was 68% at fiveyears. There were 152 operations carriedout during readmissions. These included44 laparotomies. Function was assessed in80 patients at a mean of 99*3 monthsafter ileostomy closure. For 66 patientswith spontaneous evacuation, averageminimum diurnal frequency was 3-8,maximum 4'9, with 35 evacuating atnight. One patient experienced majorcontinence problems, 30 had minor leaks,and 49 were completely continent.Postoperatively, five patients gave birth tonine babies, four had renal stones, twomyasthenia gravis, and two severeanaemia: seven had pre or postoperativethyroid dysfimction.(Gut 1994; 35: 1070-1075)

St Mark's Hospital,City Road, LondonP Setti-CarraroJ K RitchieK H WilkinsonR J NichollsP R Hawley

Correspondence to:Mr R J Nicholls, St Mark'sHospital, City Road, LondonEC1V 2PS.

Accepted for publication7 January 1994

The first restorative proctocolectomy in thishospital was carried out by Parks in 1976.Since that time it has become the mostcommonly used surgical procedure for ulcera-tive colitis as well as for selected patients withfamilial adenomatous polyposis and, more

recently, some patients with functional boweldisease. With an experience of the operation ofmore than 15 years, it was felt appropriate toreview the longterm outcome in patients withulcerative colitis. To allow for lengthy followup, the study has been confined to patientsoperated on before the end of 1985. It washoped that a minimum follow up of six yearswould permit an assessment of function in thelong term and show any possible delayedadverse effects of the operation.

Patients and methodsBetween July 1976 and December 1985, 1 10patients were treated at this hospital for ulcera-tive colitis by restorative proctocolectomy or

proctectomy. Review of the case notes was

supplemented by personal examination of 66patients by one clinician (PSC). Five patientswere contacted by letter or telephone and for

nine information was sought from the referringsurgeon using a standardised proforma.Patients were followed up until death orFebruary 1992, apart from seven (6-3%) whocould not be traced at that time.

Fifty six patients had all their surgeryperformed at this hospital: 40 had a restorativeproctocolectomy and 16 a restorative proc-tectomy. Fifty four patients were referred:42 had been treated by a colectomy andileostomy, four by a partial colectomy, andeight by colectomy and ileorectal anastomosis,which had proved unsuccessful (7) or in whomhigh grade dysplasia had developed in therectum (1). A temporary ileostomy wasconstructed in 104 cases.The indications for surgery in the 40

patients treated by a restorative proctocolec-tomy were chronic symptoms in 22, severerelapsing disease in seven, dysplasia in eight,and known or suspected carcinoma in two.One patient (the first in the series) had theoperation as an urgent procedure after failureof medical treatment for acute colitis.Of the 16 patients undergoing a restorative

proctectomy in this hospital, an original colec-tomy and ileostomy was carried out urgentlyin 10 and electively in four. In two patients,an ileorectal anastomosis was converted to apouch for diarrhoea in one and high graderectal dysplasia in the other.

There were 59 men and 51 women in theseries with a mean age at operation of 31-6years (median 30, range 14-60).

TECHNIQUEThirty five patients (31 8%) had a three looppouch (S), 34 (30.9%) a two loop (j), 38(34.5%) a four loop (W), and three had a Kockreservoir without the inverted nipple valve.Mucosectomy of the anorectal stump wasalways performed and the ileoanal anastomosiswas made endoanally to the dentate line.

PATHOLOGYThe pathological diagnosis was ulcerativecolitis in 103 specimens and indeterminatecolitis in three. In four patients there wasinsufficient rectum to permit a diagnosis to bemade. Crohn's disease was not diagnosed inany specimen.There were carcinomas in the specimen in

seven patients: four had a single Dukes's Alesion, one a Dukes's B, and two had multipletumours each with Dukes's C1 tumours as themost advanced. One patient had had twotumours (Dukes's A and B) in the colon beforereferral for restorative proctectomy.

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The first 10 years' experience of restorative proctocokctomy for ulcerative colitis

TABLE I Postoperative complications after restorativeproctocolectomy or proctectomy (60 complications in5I patients)

No complications 59Local complications 21

(pelvic sepsis 8, minor anastomotic breakdown 6,pouch-vaginal fistula 1, bleeding from drain 1,bleeding through anum 3, retraction of ileostomy 2)

General complications 33(small bowel obstruction 7 (laparotomy 2), chestinfection 2, deep venous thrombosis 2, septicaemia 1,subphrenic abscess 1, myocardial infarction 1,jaundice 2, raised ileostomy output 3,wound infection 9, urinary tract infection 5)

Other complications 5Death (bilateral pulmonary collapse and effusions) 1

POSTOPERATIVE COMPLICATIONSThere was one postoperative death: thepatient died on the evening of the operationfrom bilateral pulmonary collapse with massivepleural effusions. Fifty nine patients hadno complications. Table I shows the complica-tions in the remaining 50 patients. Significantpelvic sepsis occurred in eight (7-3%) patients:in no case was laparotomy required but infour a pelvic abscess needed drainage throughthe anum under anaesthetic. The meanpostoperative stay after the ileoanal procedurewas 17 days (median 14, range 7-65).

CLOSURE OF THE ILEOSTOMYThe ileostomy was closed in 101 of 104patients and the mean interval between thisand the ileoanal procedure was 96 days(median 71, range 21-399). Nine patientsdeveloped small bowel obstruction and fourrequired laparotomy. Wound infectionoccurred in nine patients, one patient hadupper gastrointestinal bleeding (coffee groundaspirate from nasogastric tube), and onedeveloped an ischiorectal abscess. Overallthere were 20 complications in 19 patients.The mean postoperative stay was 14 days(median 11, range 4-67).The ileostomy was not closed in three

patients. These were the patient who diedpostoperatively, a patient in whom a rectalcarcinoma was found in the specimen afterrestorative proctectomy and the pouch

TABLE II Failure of restorative proctocolectomy orproctectomy among 109 operation sur-vivors

Interval (months)Patient from ileostomyno Reasons forfailure closure Treatment

1* Recurrent pelvic and perianal sepsis ?CD - Excised2* Rectal cancer, inadequate clearance of margins - Excised3 Pouch-vaginal fistula 0 EI4 Recurrent pelvic sepsis 0 Excised5 Incontinence, frequency, pouchitis 1 Excised6 Perianal sepsis ?CD 5 Excised7 Pouch defect, small bowel, and anal fistulas ?CD 6 Excised8 Incontinence, perianal sepsis 11 Excised9 Recurrent pelvic and perianal fistula ?CD 12 Excised10 Perianal sepsis, probable pouch-vaginal fistula ?CD 13 KI**11 Malaise, frequency 25 Excised12 Malaise, failure to thrive 33 Excised13 Recurrent pouchitis, frequency 36 EI14 Recurrent pelvic sepsis and anal fistula ?CD 46 KI**15 Incontinence, frequency 80 KI16 Incontinence, frequency 83 EI

CD=Crohn's disease, EI=end ileostomy, KI=Kock ileostomy, *=ileostomy not closed beforepouch excision, **=Kock ileostomy subsequently excised.

removed two weeks later (case no 2, Table II),and a patient in whom the pouch wasultimately removed (case no 1, Table II).The mean duration of hospital stay for both

procedures combined was 30 days (median26, range 13-81).

MORTALITYIn addition to the one postoperative death,there was a further death related to surgery.This patient died of septicaemia 17 monthsafter restorative proctectomy. Four patientsdied of carcinoma at intervals between 24 and61 months after surgery. Three patients diedof unrelated causes (road traffic accident,carcinoma of the stomach, and grand malseizures) at intervals of 30, 89, and 151 monthsrespectively from the operation.

FAILUREFailure was defined either as the need toremove the reservoir, to defunction by anileostomy not closed at the time of thisassessment or to convert to a Kock abdominalreservoir. There were 16 such cases giving anoverall crude failure rate of 15% (Table II).The cumulative probability of failure from thetime of ileostomy closure (based on the last14 patients in Table II) was 12% (95% CI7% to 20%) at five years and 15% (95% CI90/O to 24%) at seven years (Figure). Amongthe patients in whom the pouch failed, Crohn'sdisease was suspected in seven: in two biopsyof an anal lesion supported this diagnosis.Perianal pelvic sepsis, or both, were thecommonest reasons for failure. The result wassatisfactory in one of the three patientsconverted to a Kock continent ileostomy: inthe other two the abdominal reservoir wasexcised. There was no statistically significantdifference in the failure rate in the two periods1976-80 (4 of 19: 21%) and 1981-85 (12 of90:13%), p=0.47.

ReadmissionsDuring the period of follow up before or afterileostomy closure 74 (68%) patients werereadmitted on 188 occasions here or elsewhereexcluding the admission for closure of theileostomy. These figures are up to February1992 or up to and including the admission atwhich the pouch failed. Thirty three patientswere readmitted once, 15 twice, and 26 onthree or more occasions. Surgical treatment wasdone during 127 of these readmissions. Theoperations were abdominal in 63 (including44 laparotomies) and confined to the pouch oranal region in 89. The risk of readmission fromthe time of formation of the pouch was 68% atfive years (95% CI 59% to 77%).

POUCHrIISPouchitis was diagnosed by the presence offrequency of defecation associated withendoscopic appearances of inflammation andhistological evidence of inflammation in a

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Setti-Carraro, Ritchie, Wilkinson, Nicholls, Hawley

-00.

0._

CD

E

Q

10 20 30 40 50 60 70 80 90 100 110 120

Time after ileostomy closure (mth)

Cumulative probability ofpouch failure after ileostomy closure.

biopsy specimen from the reservoir. Completeinformation was available for 60 of 66 patientsseen in the clinic. Of these, 30 had never hadany evidence of pouchitis, 21 patients had hadat least one attack, and nine had chronicpersistent pouchitis.

FUNCTIONAt the time of the study there were 80 patientswith an intact pouch available for a review offunction. The mean follow up from closure ofthe ileostomy was 99 3 months (range63-173). There were 24 patients with. an

S pouch, 24 with a J, 31 with a W, and one

with a pelvic Kock pouch.Sixty six patients did not use a catheter.

Average diurnal minimum frequency among

these was 3-8 (range 1-10) and maximum of4-9 (range 1-12).Of the 66 patients with spontaneous

evacuation, 31 (47%) never had a bowel actionat night. In 21, bowel movements occurredsometimes during the night and in 14 everynight. Of the 35 patients, 24 had at most one

bowel action, eight had two, two had three,and one patient had four.

Overall, the average minimum 24 hourfrequency in these 66 patients was 4 1 and themaximum 5-7.

Forty nine patients were completelycontinent but one wore a pad as a precaution.Of the remaining 31, 30 had minor mucous or

faecal leaks. One patient had more severe

faecal leaks, particularly at night. Of thesepatients, 23 needed to wear a pad. Twentyseven patients took constipating agents.

Urgency was a rare complaint: of the sixpatients who could not defer evacuation for 15minutes, three had active pouchitis at the time.

Fourteen of 24 patients with an S pouchneeded to use a catheter. None of the other56 patients with an S or other type of pouchneeded to use a catheter.

SEXUAL FUNCTION

Two of 42 men had complained of some

impairment of sexual function. In one man of

30 years this was temporary and had resolvedcompletely a year after closure of theileostomy. In the other patient, aged 60 yearsat the time of restorative proctocolectomy for arectal carcinoma complicating ulcerativecolitis, lack of complete erection was thoughtto result from Peyronie's disease and wastreated by a penile implant.

Five of 37 women became pregnant after theoperation and gave birth to nine babies: all buttwo deliveries (in the same patient) were bycaesarean section.

GENERAL HEALTHLongterm morbidity in these patients seemedto fall into four categories, two probablyrelated to the surgery and two apparentlyunrelated.Anaemia with an iron deficiency picture was

sufficiently severe in three patients to requiretransfusion; in two there had been significantblood loss as a result of pouchitis.

Renal calculi were recorded in four patients.One patient passed a stone about six weeksafter restorative proctocolectomy and anotherpatient had a left renal calculus some sevenyears after a restorative proctectomy. Onepatient was found to have a 2 cm calculus inthe left renal pelvis while an inpatient afterexcision of the pouch and was treatedmedically with a diagnosis of hyperuricaemia.The fourth patient had passed a stone twoyears before restorative proctectomy and sixyears after the pouch operation, a largeright sided renal calculus was treated bylithotripsy.

Seven patients had various thyroiddisorders, three before the pouch operation.One was said to have been hypothyroid inthe past, one had had a thyroidectomyand was receiving thyroxine, and one hadacute thyrotoxicosis treated medically andby radioactive iodine and five years afterthe pouch was receiving thryoxine forhypothyroidism. At the time of restorativeproctectomy, one patient was found to have asymptomless bilateral multinodular goitreand another had a nodule in the left lobe ofthe thyroid with normal thyroid functiontests.Two patients developed thyroid disorders

after the restorative procedure, one hyperand one hypothyroidism at intervals ofsix years and six months respectively. Bothhad other diseases: the first renal sarcoidsome three months after a restorative procto-colectomy having had pulmonary involve-ment eight years earlier. The second whohad had two colonic carcinomas at theoriginal colectomy elsewhere, developed thefirst signs of myasthenia gravis while aninpatient at this hospital after the pouchoperation. Thymectomy was carried out sixmonths later.One other patient also developed myasthe-

nia gravis just over three years after restorativeproctocolectomy. Treatment with azathioprineand prednisolone was continuing four yearslater when he was last seen.

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The first 10 years' experience of restorative proctocolectomy for ulcerative colitis

LIFE EXPECTANCYExcluding all patients with carcinoma, the fiveyear survival probability after the restorativeoperation was 98% (95% CI 90 5 to 99%) andthe 10 year figure was 95 5% (95% CI 88X3 to98-3%).The number of observed deaths was four

(one related late death resulting from sepsisand three resulting from unrelated causes) orfive if the postoperative death is included. Thenumber of expected deaths was 1-09 giving aratio of 3-7 for observed to expected deathswith 95% CI of 1-0 to 9 4, p=005.

DiscussionAny elective operation for ulcerative colitisshould be associated with a nil or very lowpostoperative mortality, the initial andlongterm complication rate should be accept-able, and the disease eradicated in total or neartotal with the carcinoma risk eliminated or verymuch reduced. Restorative proctocolectomyretaining the normal faecal pathway comesnearest to the ideal and has the advantage overcolectomy and ileorectal anastomosis in that itcan be used in patients with severe rectaldisease. Over the past 15 to 20 years at thishospital, it has become the most commonoperation in the elective situation or, as a twostage procedure, for patients operated onurgently.

Restorative proctocolectomy at this hospitalis generally restricted to younger patients.The mean (variance) age at operation of thefirst 110 patients treated here between 1976and 1985 is identical to that of 390 cases fromthe Mayo clinic operated on from 1981-85(31 (9 years)),2 82 from Toronto,3 and 114from Minneapolis4 although the last two seriescontained patients with familial adenomatouspolyposis. The average age at operation ofpatients treated by excisional surgery at thishospital was 40 7 years5 but, since the adventof restorative proctocolectomy, has risen to 49years for elective total proctocolectomy.6

All operations for ulcerative colitis are

major undertakings even when elective andthe one postoperative death (0 9%) in thisseries compares with one such death in 390patients (0 3%) in the largest single series2although there has been no such mortalityin many others.3 7-9 Both elective totalproctocolectomy and colectomy and ileorectalanastomosis also carry a postoperativemortality.1 10

Postoperative complications can be dividedinto those of any operation and those relatingto the specific procedure. In this series, thecomplication rate was high: 51 of 1 10 patientshad complications. Complication rates fromother series range from 13%7 upwards with thelargest series having a combined postoperativecomplication rate from the initial operationand ileostomy closure of 290/o.2 The generalcomplications were those associated with anyabdominal operation with the most frequent(apart from wound infection) being smallbowel obstruction in seven patients requiringlaparotomy in two. This obstruction rate

of 6% and needing surgery in 2% is low incomparison with some reports.2 8 Of the localcomplications pelvic sepsis in eight patients(7%) was the most frequent with four needingdrainage of an abscess, but without laparo-tomy. The figure of 7% falls well withinthe range reported from elsewhere.28 1 Theoverall complication rate of 45% is not dis-similar to that of 39% for elective total procto-colectomy over almost exactly the same timeperiod at this hospital.6 Furthermore themedian postoperative stay for the restorativeoperation was 14 days compared with 16 forthe excisional surgery: patients in the secondgroup were, however, considerably older.

This is, of course, a misleading comparison,as, in most patients, a second operation wasrequired for closure of a temporary ileostomywith a median postoperative stay of 11 daysand a complication rate of 19%. The smallbowel obstruction rate after this second opera-tion was 9% with a reoperation rate of 4%:these figures are almost identical with thosefrom elsewhere.2

Reported series do not give detailed figuresfor readmissions during the follow up periodand, as far as we are aware, there had been nocalculation of the cumulative probability ofreadmission previously. In addition, the meanduration of follow up in the largest series2 wasonly 2-3 years compared with 6-6 years in thisreport. Thus the probability of readmission of68% at five years, which seems high cannot becompared with that from elsewhere. Perhapsthe fairest comparison is with that for electivetotal proctocolectomy at this hospital over avery similar time period, which was 45% at sixyears.6 The longterm course of patients afterrestorative proctocolectomy should be viewedagainst that for total proctocolectomy andnever in isolation.The overall failure rate of the operation

(including three patients with a disconnectedpouch) was 15%, which was disappointingbut perhaps not entirely surprising as weare reporting here the first 1 10 patientswith ulcerative colitis in an experience at thishospital that now encompasses over 400 cases.Failure rates in other series range from 0-14%:an overall rate in nine series was 5%. 12 These,however, were mainly early and the failure rateclearly increases with the duration of follow up.The reasons for early failure in our patientswere similar to those reported elsewhere - thatis, pelvic sepsis, incontinence, intractablepouchitis, and possible Crohn's disease. Thelast, suspected in seven of our cases, wasnever diagnosed in any specimen and onlythe subsequent clinical course suggested thediagnosis. Most of the failures occurredfairly soon after ileostomy closure as reportedby others.2 9 11 In the long term, however, fail-ures occurred for various reasons includingpoor function, malaise, and fistulation fromthe reservoir. Pouch-vaginal or perineal fistulais often delayed several months after ileostomyclosure and accounts for some late failures.13These have not been included in most reportsof the outcome of restorative proctocolectomy.

In this series, postoperative obstruction

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1074 Setti-Carraro, Ritchie, Wilkinson, Nicholls, Hawley

requiring surgery was similar to that afterexcisional surgery but the rate (18%) duringfollow up may be higher. Now that small bowelobstruction is a well recognised complicationof all operations for ulcerative colitis both inthe short and the long term, it is to be hopedthat it will no longer be a cause of late death aspreviously.'0 14

Anastomotic stenosis has become a wellknown long term complication in pouchpatients. Seven patients in this series (with 14admissions) required dilation under generalanaesthetic for this complication. Otherreports give similar incidences ranging from5-18% with an overall incidence with nineseries of 14-7%.2 1112 Stenosis, however, wasnot a factor leading to pouch excision in ourpatients as in the Birmingham report. I I

At this hospital, pouchitis has beendiagnosed by clinical, endoscopic, andpathological criteria. Frequency of defecationalone is insufficient to justify the diagnosisbut must be accompanied by the presence ofacute inflammation on biopsy examination.15Only 60 of our patients were thus fully assessedand, of these, half had never had evidence ofpouchitis. Of the 21 with one episode,this had resolved with treatment (usuallymetronidazole) and had not recurred. Ninepatients with persistent pouchitis had avariety of treatments including low doselongterm metronidazole and conventionalanti-inflammatory treatment. In only two(12-5%) of 16 patients who failed wasintractable pouchitis the major reason.The details of function reported here relate

to patients after at least five years from closureof the ileostomy. It is known that function canimprove for several years after operation and soour figures must represent the optimum thathas been achieved. Comparison with otherseries may not be valid because of differentlengths of follow up and varying pouch design.Our results include four types of pouch andoverall figures are given. A minimum diurnalstool frequency of 3-6 (range 1-10) and a max-imum of 4-7 (range of 1-12), however, com-pares well with other series, for example, 6 (3)at three years in the Mayo series,2 5 (1 5) at sixmonths,3 and 5A4 (2 5) at mean follow up offive years.4 Almost half of the patients (47%)in this series never had a bowel action atnight: this compares with a figure of 73%from elsewhere.3 Other reports do not give acomparable figure.Minor mucous or faecal leakage occurred in

some 40% of patients but only a third of these(around 16% of the total) needed to wear apad. This is in noticeable contrast with anotherseries where 62% usually used a pad by dayand 68% at night.4

Perhaps the most important aspects of thisfollow up are the enquiry into general healthand the life expectancy figures, which have notbeen mentioned previously.Minor degrees of anaemia are sometimes

seen in patients with pouches and the pictureis usually one of iron deficiency that can becorrected with oral iron. A low serum B-12resulting possibly from changes in the terminal

ileum because of the pouch may also needappropriate treatment. Severe degrees ofanaemia with haemoglobin as low as 5-0 g/dlin two of our patients are more worryingparticularly as it was recurrent in one patientand the cause never adequately established.A tendency to urolithiasis, perhaps greater

than that of the general population has beenshown in patients after total proctocolectomy516 and the occurrence of stones in four patientsmay relate to the previous ileostomy in two anda high output from a defunctioning ileostomyin one.

Although seven patients had thyroid disor-ders before or after the establishment of thepouch, these were of various types and prob-ably unrelated to the operation. Thyrotoxicosisin a patient with ulcerative colitis has beendescribed17 and there seems no reason whythese two disorders should not, on occasion,occur in the same patient.Two cases of myasthenia gravis among 109

patients who left hospital after the pouch does,however, seem strange as myasthenia is anuncommon disease. No conclusions can bedrawn from two cases: a longer follow up mayclarify the position.With certain provisos, it is known that

life expectancy is normal in patients afterexcisional surgery for colitis.5 For colectomyand ileorectal anastomosis the number ofobserved deaths was over twice the expectedwith 12 deaths resulting from rectal carci-noma.10 With strict follow up and routine useof rectal biopsies, it is to be hoped that betterfigures could be obtained nowadays.The findings after restorative proctocolec-

tomy are encouraging. Patients with carcinomain the specimen were excluded and thus theonly related late death was from sepsis. Thefigure of 3-7 of observed/expected death lieswithin the 95% confidence intervals. Thissuggests that the operation is compatiblewith a normal life expectancy in the short termbut much longer follow up is necessary beforethis can be said with certainty for the longterm.

1 Melville DM, Ritchie JK, Nicholls RJ, Hawley PR. Surgeryfor ulcerative colitis in the era of the pouch: the St Mark'sHospital experience. Gut 1994; 35: 1076-80.

2 Pemberton JH, Kelly KA, Beart RW, Dozois RR, WolffBG,Ilstrup DM. Ileal pouch-anal anastomosis for chroniculcerative colitis. Ann Surg 1987; 206: 504-12.

3 Cohen Z, McLeod RS, Stern H, Grant D, Nordgren S. Thepelvic pouch and ileoanal anastomosis procedure.Surgical technique and initial results. Am Jf Surg 1985;150: 601-7.

4 Wexner SD, Jensen L. Rothenberger DA, Wong WD,Goldberg SM. Long-term functional analysis of theileoanal reservoir. Dis Colon Rectum 1989; 32: 275-81.

5 Ritchie JK. Ulcerative colitis treated by ileostomy and exci-sional surgery. Fifteen years' experience at St Mark's hos-pital. BrJSurg 1972; 59: 345-51.

6 Phillips RKS, Ritchie JK, Hawley PR. Proctocolectomy andileostomy for ulcerative colitis: the longer term story. Jf RSoc Med 1989; 82: 386-7.

7 Becker JM, Raymond JL. Ileal pouch-anal anastomosis. Asingle surgeon's experience wvith 100 consecutive cases.Ann Surg 1986; 204: 375-81.

8 Pescatori M, Mattana C, Castagneto M. Clinical and func-tional results after restorative proctocolectomy. BrJ Surg1988; 75: 321-4.

9 Wexner SD, Wong WD, Rothenberger DA, Goldberg SM.The ileoanal reservoir. AmJSurg 1990; 159: 178-83.

10 Baker WNW, Glass RE, Ritchie JK, Aylett SO. Cancer ofthe rectum following colectomy and ileorectal anastomo-sis for ulcerative colitis. BrJ Surg 1978; 65: 862-8.

11 Keighley MRB, Winslet MC, Flinn R, Kmiot W.

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Multivariate analysis of factors influencing the results ofrestorative proctocolectomy. Br j Surg 1989; 76: 740-4.

12 Williams NS, Johnston D. The current status of mucosalproctectomy and ileo-anal anastomosis in the surgicaltreatment of ulcerative colitis and adenomatous polyposis.BrJ Surg 1985; 72: 159-68.

13 Groom JS, Nicholls RJ, Hawley PR, Phillips RKS. Pouch-vaginal fistula. BrJ3Surg 1993; 80: 936-40.

14 Ritchie JK. The cause of late mortality in ileostomists. ProcR Soc Med 1972; 65: 73.

15 Madden MV, Farthing MJG, Nicholls RJ. Inflammation inileal reservoirs: 'pouchitis'. Gut 1990; 31: 247-9.

16 Ritchie JK. Ileostomy and excisional surgery for chronicinflammatory disease of the colon: a survey of one hospi-tal region. Part II The health of ileostomists. Gut 1971;12: 536-40.

17 Triantafillidis JK, Manoussakis CA, Tsafaras Ch,Koutsorizof A. Coexistence of thyrotoxicosis and exacer-bation of ulcerative colitis. Am Jf Gastroenterol 1990; 85:908-10.

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