Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients

In restorative proctocolectomy the use of a stapling technique to construct an ileal pouch with anal anastomosis offers an alternative to the hand-sewn technique following mucosectomy; a temporary defunctioning loop ileostomy may reduce the consequences of an anastomotic leakage, however it may entail discomfort for the patient, an additional operation, possible complications, and longer total hospital stay. This prospective study evaluated the peri- and postoperative courses in 86 consecutive, referred patients receiving ileal pouch-anal anastomosis using the stapling technique to construct the ileal pouch and ileoanal anastomosis, omitting the defunctioning loop ileostomy except in cases of increased risk of ileoanal anastomotic insufficiency according to defined criteria. Follow-up time was 36-96 months. Patients undergoing primary loop ileostomy stayed a median of 19 days in hospital, as opposed to a median of 9 days in those who did not. Eight patients developed pelvic sepsis that demanded a secondary defunctioning loop ileostomy, and five showed symptoms arising from relapsing inflammation in residual rectal mucosa; in three of these, a secondary transanal mucosectomy covered by a loop ileostomy was necessary. During the follow-up period ten patients had bowel obstructions that demanded surgery; two developed late pouch-vaginal fistulas, and one a fistula from the J-limb to the abdominal scar. There was one case of pouch procidentia. At 12-month follow-up the median evacuation frequency was 6 per 24 h, the incidence of minor incontinence was about 10%, and urgency to evacuate occurred in about 10%. None of the patients experienced any major incontinence. The stapling technique and omission of the defunctioning loop ileostomy in restorative proctocolectomy were thus a comparatively reliable and time-saving method with short total hospital stay. In patients at increased risk of anastomotic complications, however, a defunctioning loop ileostomy is recommended. We believe it is important to perform an exact dissection into the anal canal to avoid a residual rectal mucosa that may be inflamed or even become dysplastic.