Techniques of ileoanal anastomosis: historical evolution, refinements, and current approaches

Abstract

Restorative proctocolectomy with ileal pouchanal anastomosis is the surgical option favoured by most in the definitive treatment of mucosal ulcerative colitis and familial adenomatous polyposis. Throughout this century, the operation has evolved from a concept to a very refined procedure which cures the underlying colorectal disease, restores bowel function and promises a quality of life superior to that of other surgical options. Each component of the operation whether it be the design of the reservoir or the necessity for a temporary ileostomy has been the subject of some degree of controversy, but the most debated aspect remains whether a transanal mucosectomy is detrimental and what type of ileoanal anastomosis is preferable, i.e. hand sewn to dentate line area or stapled at the level of proctectomy. This debate has arisen in part to simplify the operation, and in part to try to minimize complications and improve function, especially nighttime incontinence. The advantages and disadvantages of each current approach are reviewed and conclusions drawn from our own experience and that of others. Further research will be needed to improve continence and clarify the nature of pouchitis, which may in turn lead to the discovery of the cause of ulcerative colitis.

Predictors of surgical outcomes

“…Several studies have demonstrated superior quality of life for patients following IPAA compared with the Brooke ileostomy or Kock pouch 2 . Indeed, many of the ongoing technical refinements of the procedure are focused on maximizing function 3 . Whether or not a mucosectomy and hand‐sewn anastomosis should be performed to complete the resection of at‐risk mucosa is debated against the preference for the double‐stapled anastomosis, which theoretically offers improved continence 4 .…”