Current Controversies in Pouch Surgery

Abstract

Restorative proctocolectomy with ileal pouch anal anastomosis has become the most commonly used procedure for elective treatment of patients with mucosal ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in an attempt to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. These modifications of the technique are discussed in this review, limited to the current points of controversy. We reviewed the current literature describing restorative proctocolectomy with ileal pouch anal anastomosis. The current "hot topics" for debate are transanal mucosectomy with hand-sewn anastomosis versus the double-stapled technique, the use of diverting ileostomy, indeterminate colitis, the role of laparoscopy, and indications for pouch surgery in the elderly. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with active prospective evaluation of the procedure are required to settle these issues. Patients must be fully informed to understand inherent risks of each choice.

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians

“…Although restorative proctocolectomy (RP) with ileal J pouch anal anastomosis (IPAA) is considered the operation of choice for patients with mucosal ulcerative colitis (MUC), it is as a complex surgery with higher risks of morbidity and poorer functional outcome when compared to proctocolectomy with end Brooke ileostomy. Furthermore, RP with mucosectomy and a handsewn ileal pouch anal anastomosis (IPAA) has been associated with poor postoperative continence [1]. As such, this procedure was rarely offered to elderly patients.…”

Laparoscopic Management of Inflammatory Bowel Disease

“…The surgical approach to the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP) has dramatically evolved; restorative proctocolectomy with the construction of an ileal reservoir emerged as the treatment of choice to manage these conditions [11,12] . In the case of MUC, procedures like appendicostomy and ileostomy, aimed to decompress the colon, were followed by safe treatment options like subtotal colectomy and completion proctectomy [11] .…”

“…In the original technique, a transanal mucosectomy followed by a pouch-anal hand-sewn anastomosis was performed [12,15] . Alternatively, closure of the rectum with a stapler and completion of the anastomosis with a circular stapler placed through the staple line -the so-called double-stapling techniquewas described by Knight and Griffen [22] and was intended to preserve the anal transition zone, hence achieving better functional results [11][12][13] . Temporary diverting loop ileostomy has been routinely used as a protective measure.…”

“…In 1976, Parks and Nicholls [15] described the technique of ileal reservoir-anal anastomosis after total proctocolectomy in 8 patients with MUC, obtaining satisfactory results in 4 out of 5 patients available to follow-up by the time of publication. During the last 30 years, restorative proctocolectomy with ileal pouchanal anastomosis (IPAA) has become the standard surgical treatment for patients with MUC and FAP [11][12][13][16][17][18][19][20][21] and several modifications to the original technique have been advocated including changes to the shape of the pouch itself [12,13] . In the original technique, a transanal mucosectomy followed by a pouch-anal hand-sewn anastomosis was performed [12,15] .…”

“…During the last 30 years, restorative proctocolectomy with ileal pouchanal anastomosis (IPAA) has become the standard surgical treatment for patients with MUC and FAP [11][12][13][16][17][18][19][20][21] and several modifications to the original technique have been advocated including changes to the shape of the pouch itself [12,13] . In the original technique, a transanal mucosectomy followed by a pouch-anal hand-sewn anastomosis was performed [12,15] . Alternatively, closure of the rectum with a stapler and completion of the anastomosis with a circular stapler placed through the staple line -the so-called double-stapling techniquewas described by Knight and Griffen [22] and was intended to preserve the anal transition zone, hence achieving better functional results [11][12][13] .…”