Gains and losses with stapling and omission of loop ileostomy in pelvic pouch surgery: a matched control study

After 10 years experience of pelvic pouch surgery with handsewn pouch and ileoanal anastomosis, mucosectomy, and covering loop ileostomy, the surgical technique was altered. Twenty patients were operated on with staple technique in pouch and ileoanal anastomosis but without mucosal proctectomy and loop ileostomy. This study group was compared with a matched control group of patients from our previous series with respect to duration of surgery, blood loss, hospital stay, complications, and functional outcome after 2 months, 12 months, and 60 months. It was found that staple technique significantly reduced the duration of surgery and the need of blood transfusions. Length of hospital stay after pouch surgery did not differ between the two groups, but omitting loop ileostomy reduced total hospital stay by about 2 weeks. Ileoanal anastomotic insufficiency occurred in two patients in the study group. Treatment by establishment of a defunctioning loop ileostomy, local saline perfusion, and administration of antibiotics was successful; the anastomosis healed within 2 weeks, and the longterm functional outcome did not differ from the average. Increased temperature persisted postoperatively in seven patients in the study group. Transient peroneal paresis occurred in three patients in the control group. Only in the control group was there stenosis in the ileoanal anastomosis requiring dilatation and fibrosis at the levator plane demanding emptying by a catheter. Concerning functional outcome, nighttime continence was significantly better in the study group than in the control group. The evacuation rate per 24 h was significantly higher in the study group after 2 and 12 months but not after 60 months. The outcome concerning other functional parameters such as urgency to evacuate, capacity to discriminate between gas and stool, deferral time, and perianal symptoms, did not differ significantly. Staple technique without mucosal proctectomy and loop ileostomy thus results in shorter duration of surgery and shorter hospital stay. In patients with increased risk of insufficiency of the anastomosis, however, covering loop ileostomy may be justified because of the risk for more serious consequences if anastomotic leakage occurs.