Ileal-anal pouches: A review of its history, indications, and complications.

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but "early" and "late" complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis: historical development and current status.

In summary, the history and development of the proctocolectomy and ileal pouch-anal anastomosis has involved innovative animal and clinical research by several surgical investigators. This evolution followed the classic process of academic surgical progress: a clinical problem is identified; solutions are studied in the laboratory; and these solutions are applied back to the clinical situation with success. Dr. Sabiston's disappointment with clinical results in ulcerative colitis and familial polyposis patients led to laboratory experiments in which a new technique was shown safe in dogs. The further work of his collaborator Dr. Ravitch as well as that of Sir Alan Parks and Dr. Utsunoimya proved small-scale clinical application of the new technique. Finally, large-scale outcomes work by Dr. Fazio at the Cleveland Clinic Foundation and others has allowed further refinements to occur and has highlighted other areas to study. The work of these investigators and other has allowed lack of a permanent ostomy with satisfactory functional results in more than 95% of patients. Continued experience with these procedures has and will lead to further improvements in operative times, morbidity rates, and functional results. Although research in this area will continue, the evolution of this operation has allowed it to become the gold standard for the treatment of ulcerative colitis and familial adenomatous polyposis.

Surgical management of total ulcerative colitis and familial adenomatous polyposis.

Total ulcerative colitis (UC) and familial adenomatous polyposis (FAP) are two major diseases that require total removal of the colorectal mucosa. To provide a high quality of postoperative life, various surgical techniques have been used. However, results were far from ideal. Since 1978, we have worked on the ileoanal anastomosis (IAA) technique to achieve both radical removal of the mucosa and preservation of natural anal function. From 1979 to 1991, a total of 155 patients were treated by IAA. To evaluate the surgical results, these patients were divided into three groups: the Tokyo series (49 cases, 1979-1983), Hyogo I series (49 cases 1983-1988) and Hyogo II series (57 cases, 1989-1991). The success rates in terms of preservation of anal continence were: 58% (UC) and 78% (FAP) in the Tokyo series, 84% (UC) and 96% (FAP) in the Hyogo I series and 92% (UC) and 100% (FAP) in the Hyogo II series. The surgical time and blood loss were significantly reduced in the later series. Of the 82 patients followed up for 6 mo in the two Hyogo series, anal continence was normal or nearly normal in 54 patients, with only minor leakage at night in 22 patients. Septic complications in the pelvic caused the majority of surgical failures. We conclude that improved IAA techniques can achieve total removal of the colorectal mucosa and preserve anal function in more than 90% of patients with UC or FAP. However, the skill of an experienced surgeon is still required to achieve this goal. The long-term outcome of anal function after such procedures needs further evaluation.