Review Article

Current Controversies in Pouch Surgery

Authors: Jules E. Garbus, MD, Fabio Potenti, MD, Steven D. Wexner, MD

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.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. BMJ 1978; 2: 85–88.
 
2. Lavery IC, Fazio VW, Oakley JR, et al. Pouch surgery: The importance of the transitional zone. Can J Gastroenterol 1990; 7: 428–431.
 
3. Becker JM, Lamonte WS, Marie G, et al. Extent of smooth muscle resection during mucosectomy and ileal pouch anal anastomosis affects anorectal physiology and functional outcome. Dis Colon Rectum 1997; 40: 653–660.
 
4. Garcia Armengol J, Solona Bueno A, Roig Vila JV, et al. The mucosal electrosensitivity of the anal canal following restorative proctocolectomy for ulcerative colitis [in Spanish]. Gastroenterol Hepatol 1997; 20: 339–343.
 
5. Johnston D, Holdsworth PJ, Nasmyth DG, et al. Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: A pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis. Br J Surg 1987; 74: 940–944.
 
6. Miller R, Bartolo DC, Orrom WJ, et al. Improvement of anal sensation with preservation of the anal transition zone after ileoanal anastomosis for ulcerative colitis. Dis Colon Rectum 1990; 33: 414–418.
 
7. Sagar PM, Holdsworth PJ, Johnston D. Correlation between laboratory findings and clinical outcome after restorative proctocolectomy: Serial studies in 20 patients with end-to-end pouch-anal anastomosis. Br J Surg 1991; 78: 67–70.
 
8. Knight CD, Griffen FD. An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery 1980; 88: 710–714.
 
9. Wexner SD, Jagelman DG. The double stapled ileal reservoir and ileoanal anastomosis. Perspect Colorect Surg 1990; 3: 132–144.
 
10. Cohen Z, McLeod RS, Stephen W, et al. Continuing evolution of the pelvic pouch procedure. Ann Surg 1992; 216: 506–512.
 
11. Reissman P, Piccirillo M, Ulrich A, et al. Functional results of the double-stapled ileoanal reservoir. J Am Coll Surg 1995; 181: 444–450.
 
12. Tuckson W, Lavery I, Fazio V, et al. Manometric and functional comparison of ileal pouch anal anastomosis with and without anal manipulation. Am J Surg 1991; 161: 90–96.
 
13. Wexner SD, James K, Jagelman DG. The double-stapled ileal reservoir and ileoanal anastomosis: A prospective review of sphincter function and clinical outcome. Dis Colon Rectum 1991; 34: 487–494.
 
14. Sugerman HJ, Newsome HH. Stapled ileoanal anastomosis without a temporary ileostomy. Am J Surg 1994; 167: 58–66.
 
15. Choen S, Tsunoda A, Nicholls RJ. Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy. Br J Surg 1991; 78: 430–434.
 
16. Reilly WT, Pemberton JH, Wolff BG, et al. Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa. Ann Surg 1997; 225: 666–677.
 
17. MacRae HM, McLeod RS, Cohen Z, O'Connor BI, Ton EN. Risk factors for pelvic pouch failure. Dis Colon Rectum 1997; 40: 257–262.
 
18. Ziv Y, Fazio VW, Church JM, et al. Stapled ileal pouch anal anastomoses are safer than handsewn anastomoses in patients with ulcerative colitis. Am J Surg 1996; 171: 320–323.
 
19. Puthu D, Rajan N, Rao R, Rao L, Venugopal P. Carcinoma of the rectal pouch following restorative proctocolectomy: Report of a case. Dis Colon Rectum 1992; 35: 257–260.
 
20. Rodriguez-Sanjuan JC, Polavieja MG, Naranjo A, Castillo J. Adenocarcinoma in an ileal pouch for ulcerative colitis. Dis Colon Rectum 1995; 38: 779–780 (letter).
 
21. Stern H, Walfisch S, Mullen B, McLeod R, Cohen Z. Cancer in an ileoanal reservoir: A new late complication? Gut 1990; 31: 473–475.
 
22. Senagore AJ, Billingham RP, Luchtefeld MA, Isler JT, Adkins TA. The single-stapled ileo pouch anal anastomosis: A reasonable compromise. Am Surg 1996; 62: 535–539.
 
23. Pricolo VE, Potenti FM, Luks FI. Selective preservation of the anal transition zone in ileoanal pouch procedures. Dis Colon Rectum 1996; 39: 871–877.
 
24. Metcalf AM, Dozois RR, Kelly KA, Wolff BG. Ileal pouch-anal anastomosis without temporary, diverting ileostomy. Dis Colon Rectum 1986; 29: 33–35.
 
25. Del Gaudio A. Ileal J pouch anastomosis without diverting ileostomy. Coloproctology 1993; 1: 31–34.
 
26. Jarvinen HJ, Luukkonen P. Comparison of restorative proctocolectomy with and without covering ileostomy in ulcerative colitis. Br J Surg 1991; 78: 199–201.
 
27. Matikainen M, Santavirta J, Hiltunen KM. Ileoanal anastomosis without covering ileostomy. Dis Colon Rectum 1990; 33: 384–388.
 
28. Mowschenson PM, Critchlow JF, Rosenberg SJ, Peppercorn MA. Factors favoring continence, the avoidance of a diverting ileostomy and small intestinal conservation in the ileoanal pouch operation. Surg Gynecol Obstet 1993; 177: 17–26.
 
29. Gorfine SR, Gelernt IM, Bauer JJ, Harris MT, Kreel I. Restorative proctocolectomy without diverting ileostomy. Dis Colon Rectum 1995; 38: 188–194.
 
30. Hainsworth PJ, Bartolo DC. Selective omission of loop ileostomy in restorative proctocolectomy. Int J Colorectal Dis 1998; 13: 119–123.
 
31. Mowschenson PM, Critchlow JF. Outcome of early surgical complications following ileoanal pouch operation without diverting ileostomy. Am J Surg 1995; 169: 143–146.
 
32. Weiss EG, Reiver D, Reissman P, et al. Septic complications of ileal pouch anal anastomosis. South Med J 1994; 87: 519(abstr).
 
33. Williamson ME, Lewis WG, Sagar PM, Holdsworth PJ, Johnston D. One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis: A note of caution. Dis Colon Rectum 1997; 40: 1019–1022.
 
34. Sagar PM, Lewis W, Holdsworth PJ, Johnston D. One-stage restorative proctocolectomy without temporary defunctioning ileostomy. Dis Colon Rectum 1992; 35: 582–588.
 
35. Galandiuk S, Wolff BG, Dozois RR, Beart RW Jr. Ileal pouch-anal anastomosis without ileostomy. Dis Colon Rectum 1991; 34: 870–873.
 
36. Tjandra JJ, Fazio VW, Milsom JW, et al. Omission of temporary diversion in restorative proctocolectomy: Is it safe? Dis Colon Rectum 1993; 36: 1007–1014.
 
37. Pezim ME, Pemberton JH, Beart RW Jr, et al. Outcome of “indeterminate” colitis following ileal pouch-anal anastomosis. Dis Colon Rectum 1989; 32: 653–658.
 
38. Wells AD, McMillan I, Price AB, Ritchie JK, Nicholls RJ. Natural history of indeterminate colitis. Br J Surg 1991; 78: 179–181.
 
39. Meucci G, Bortoli A, Riccioli FA, et al. Frequency and clinical evolution of indeterminate colitis: A retrospective multi-center study in northern Italy—GSMII (Gruppo di Studio per le Malattie Infiammatorie Intestinali). Eur J Gastroenterol Hepatol 1999; 11: 909–913.
 
40. Riegler G, Arimoli A, Esposito P, Iorio R, Carratu R. Clinical evolution in an outpatient series with indeterminate colitis. Dis Colon Rectum 1997; 40: 437–439.
 
41. McIntyre PB, Pemberton JH, Wolff BG, Dozois RR, Beart RW Jr. Indeterminate colitis: Long-term outcome in patients after ileal pouch-anal anastomosis. Dis Colon Rectum 1995; 38: 51–54.
 
42. Marcello PW, Schoetz DJ Jr, Roberts PL, et al. Evolutionary changes in the pathologic diagnosis after the ileoanal pouch procedure. Dis Colon Rectum 1997; 40: 263–269.
 
43. Breen EM, Schoetz DJ Jr, Marcello PW, et al. Functional results after perineal complications of ileal pouch-anal anastomosis. Dis Colon Rectum 1998; 41: 691–695.
 
44. Foley EF, Schoetz DJ Jr, Roberts PL, et al. Rediversion after ileal pouch-anal anastomosis: Causes of failures and predictors of subsequent pouch salvage. Dis Colon Rectum 1995; 38: 793–798.
 
45. Koltun WA, Schoetz DJ Jr, Roberts PL, et al. Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis. Dis Colon Rectum 1991; 34: 857–860.
 
46. Belliveau P, Trudel J, Vasilevsky CA, Stein B, Gordon PH. Ileoanal anastomosis with reservoirs: Complications and long-term results. Can J Surg 1999; 42: 345–352.
 
47. Atkinson KG, Owen DA, Wankling G. Restorative proctocolectomy and indeterminate colitis. Am J Surg 1994; 167: 516–518.
 
48. Peters WR. Laparoscopic total proctocolectomy with creation of ileostomy for ulcerative colitis: Report of two cases. J Laparoendosc Surg 1992; 2: 175–178.
 
49. Reissman P, Salky BA, Pfeifer J, et al. Laparoscopic surgery in the management of inflammatory bowel disease. Am J Surg 1996; 171: 47–51.
 
50. Wexner SD, Johansen OB, Nogueras JJ, Jagelman DG. Laparoscopic total abdominal colectomy: A prospective trial. Dis Colon Rectum 1992; 35: 651–655.
 
51. Schmitt SL, Cohen SM, Wexner SD, Nogueras JJ, Jagelman DG. Does laparoscopic-assisted ileal pouch anal anastomosis reduce the length of hospitalization? Int J Colorectal Dis 1994; 9: 134–137.
 
52. Thibault C, Poulin EC. Total laparoscopic proctocolectomy and laparoscopy-assisted proctocolectomy for inflammatory bowel disease: Operative technique and preliminary report. Surg Laparosc Endosc 1995; 5: 472–476.
 
53. Tucker JG, Ambroze WL, Orangio GR, et al. Laparoscopically assisted bowel surgery: Analysis of 114 cases. Surg Endosc 1995; 9: 297–300.
 
54. Liu CD, Rolandelli R, Ashley SW, et al. Laparoscopic surgery for inflammatory bowel disease. Am Surg 1995; 61: 1054–1056.
 
55. Rhodes M, Stitz RW. Laparoscopic subtotal colectomy. Semin Colon Rectal Surg 1994; 5: 267–270.
 
56. Hildebrandt U, Lindemann W, Kreissler-Haag D, Feifel G, Ecker KW. Laparoscopically assisted proctocolectomy with ileoanal pouch in ulcerative colitis [in German]. Zentralbl Chir 1998; 123: 403–405.
 
57. Santoro E, Carlini M, Carboni F, Feroce A. Laparoscopic total proctocolectomy with ileal J pouch-anal anastomosis. Hepatogastroenterology 1999; 46: 894–899.
 
58. Jorge JM, Wexner SD, James K, Nogueras JJ, Jagelman DG. Recovery of anal sphincter function after the ileoanal reservoir procedure in patients over the age of fifty. Dis Colon Rectum 1994; 37: 1002–1005.
 
59. Lewis WG, Sagar PM, Holdsworth PJ, Axon AT, Johnston D. Restorative proctocolectomy with end to end pouch-anal anastomosis in patients over the age of fifty. Gut 1993; 34: 948–952.
 
60. Reissman P, Teoh TA, Weiss EG, Nogueras JJ, Wexner SD. Functional outcome of the double stapled ileoanal reservoir in patients more than 60 years of age. Am Surg 1996; 62: 178–183.
 
61. Keighley MR, Ogunbiyi OA, Korsgen S. Pitfalls and outcome in ileo-anal pouch surgery for ulcerative colitis. Neth J Med 1997; 50: S23–S27.
 
62. Bauer JJ, Gorfine SR, Gelernt IM, Harris MT, Kreel I. Restorative proctocolectomy in patients older than fifty years. Dis Colon Rectum 1997; 40: 562–565.
 
63. Tan HT, Connolly AB, Morton D, Keighley MR. Results of restorative proctocolectomy in the elderly. Int J Colorectal Dis 1997; 12: 319–322.
 
64. Takao Y, Gilliland R, Nogueras JJ, Weiss EG, Wexner SD. Is age relevant to functional outcome after restorative proctocolectomy for ulcerative colitis? Prospective assessment of 122 cases. Ann Surg 1998; 227: 187–194.
 
65. Dayton MT, Larsen KR. Should older patients undergo ileal pouch-anal anastomosis? Am J Surg 1996; 172: 444–448.
 
66. Schwandner O, Schiedeck TH, Bruch HP. Advanced age: Indication or contraindication for laparoscopic colorectal surgery? Dis Colon Rectum 1999; 42: 356–362.