Ileal Pouch-Anal Anastomosis
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The ileal pouch–anal anastomosis (IPAA) is a surgical procedure that is used to restore gastrointestinal continuity after surgical removal of the colon and rectum. Various conditions, including inflammatory states, cancer, or infection, may necessitate the complete surgical removal of the colon and rectum.
Also called a J pouch or an internal pouch, the procedure involves the creation of a pouch of small intestine to recreate the removed rectum. Two or more loops of intestine are sutured or stapled together to form a reservoir for stool. This reservoir is then attached to the anus for reestablishment of anal fecal flow. The IPAA is often protected by temporarily diverting the path of stool through the abdominal wall in the form of an upstream ileostomy. After a period of recovery, this ileostomy is reversed during a separate procedure.
The IPAA procedure is performed after the colon and rectum have been completely removed. Removal of the colon and rectum is termed proctocolectomy. When an IPAA follows, the procedure is called a restorative proctocolectomy. [1] Indications for restorative proctocolectomy include the following [2] :
Creation of a J pouch is contraindicated when the small bowel is involved in the disease process. Such involvement is most common when proctocolectomy is performed for Crohn disease, because the distal ileum is often affected. IPAA is also contraindicated when the distal rectum or anal canal is diseased, as with Crohn disease or rectal cancer.
Concerns have been expressed about the safety of IPAA in older patients. A systematic review by Ramage et al found that the procedure was safe in this population, provided that the increased risk of dehydration and electrolyte loss was kept in mind. [3] Older IPAA patients appeared to have worse postoperative function, but this impaired function seemed to level out over time, and there appeared to be no significant impact on overall quality of life and patient satisfaction.
Several standardized practices are followed to decrease the incidence of perioperative complications. Antibiotics are given within 1 hour of surgery to lower the rate of wound infection. Compression devices are placed on the legs to decrease the likelihood of blood clot formation. Patients are typically asked to stop taking any antiplatelet agents (eg, aspirin or clopidogrel) 1 week prior to surgery. This reduces bleeding complications.
Finally, before starting the surgical procedure, the surgeons, operating room staff, and anesthesia team should verify the correct patient and procedure in order to prevent errors.
Remzi FH, Lavryk OA, Ashburn JH, Hull TL, Lavery IC, Dietz DW, et al. Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care. Colorectal Dis. 2017 Nov. 19 (11):1003-1012. [Medline].
Tajika M, Niwa Y, Bhatia V, Tanaka T, Ishihara M, Yamao K. Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis. World J Gastroenterol. 2013 Oct 28. 19 (40):6774-83. [Medline]. [Full Text].
Ramage L, Qiu S, Georgiou P, Tekkis P, Tan E. Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review. Int J Colorectal Dis. 2016 Mar. 31 (3):481-92. [Medline]. [Full Text].
Um JW, M’Koma AE. Pouch-related dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Tech Coloproctol. 2011 Mar. 15 (1):7-16. [Medline].
Ianco O, Tulchinsky H, Lusthaus M, Ofer A, Santo E, Vaisman N, et al. Diet of patients after pouch surgery may affect pouch inflammation. World J Gastroenterol. 2013 Oct 14. 19 (38):6458-64. [Medline]. [Full Text].
Klos CL, Safar B, Jamal N, Hunt SR, Wise PE, Birnbaum EH, et al. Obesity increases risk for pouch-related complications following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). J Gastrointest Surg. 2014 Mar. 18 (3):573-9. [Medline].
Buckman SA, Heise CP. Nutrition considerations surrounding restorative proctocolectomy. Nutr Clin Pract. 2010 Jun. 25 (3):250-6. [Medline].
Joyce MR, Kiran RP, Remzi FH, Church J, Fazio VW. In a select group of patients meeting strict clinical criteria and undergoing ileal pouch-anal anastomosis, the omission of a diverting ileostomy offers cost savings to the hospital. Dis Colon Rectum. 2010 Jun. 53 (6):905-10. [Medline].
Jani K, Shah A. Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. J Minim Access Surg. 2015 Jul-Sep. 11 (3):177-83. [Medline].
Campos FG, Real Martinez CA, Monteiro de Camargo MG, Cesconetto DM, Nahas SC, Cecconello I. Laparoscopic Versus Open Restorative Proctocolectomy for Familial Adenomatous Polyposis. J Laparoendosc Adv Surg Tech A. 2017 Nov 10. [Medline].
Shimada N, Ohge H, Yano R, Murao N, Shigemoto N, Uegami S, et al. Hand-assisted laparoscopic restorative proctocolectomy for ulcerative colitis. World J Gastrointest Surg. 2016 Aug 27. 8 (8):578-82. [Medline]. [Full Text].
Morelli L, Guadagni S, Mariniello MD, Furbetta N, Pisano R, D’Isidoro C, et al. Hand-assisted hybrid laparoscopic-robotic total proctocolectomy with ileal pouch–anal anastomosis. Langenbecks Arch Surg. 2015 Aug. 400 (6):741-8. [Medline].
Kirat HT, Remzi FH, Kiran RP, Fazio VW. Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery. 2009 Oct. 146 (4):723-9; discussion 729-30. [Medline].
Zhuo C, Trencheva K, Maggiori L, Milsom JW, Sonoda T, Shukla PJ, et al. Experience of a specialist centre in the management of anastomotic sinus following leaks after low rectal or ileal pouch-anal anastomosis with diverting stoma. Colorectal Dis. 2013 Nov. 15 (11):1429-35. [Medline].
Navaneethan U, Shen B. Diagnosis and management of pouchitis and ileoanal pouch dysfunction. Curr Gastroenterol Rep. 2010 Dec. 12 (6):485-94. [Medline].
Holubar SD, Cima RR, Sandborn WJ, Pardi DS. Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst Rev. 2010 Jun 16. CD001176. [Medline].
Machiels K, Sabino J, Vandermosten L, Joossens M, Arijs I, de Bruyn M, et al. Specific members of the predominant gut microbiota predict pouchitis following colectomy and IPAA in UC. Gut. 2017 Jan. 66 (1):79-88. [Medline].
McKenna NP, Mathis KL, Khasawneh MA, Dozois EJ, Larson DW, Pemberton JH, et al. Obese Patients Undergoing Ileal Pouch-Anal Anastomosis: Short-and Long-term Surgical Outcomes. Inflamm Bowel Dis. 2017 Dec. 23 (12):2142-2146. [Medline].
Michael B Brewer, MD Resident Physician in General Surgery, Department of Surgery, University of Maryland Medical Center
Michael B Brewer, MD is a member of the following medical societies: American College of Physicians, American College of Surgeons, American Medical Association, Society for Vascular Surgery
Disclosure: Nothing to disclose.
Andrea C Bafford, MD Assistant Professor, Section of Colon and Rectal Surgery, Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center
Andrea C Bafford, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Ileal Pouch-Anal Anastomosis
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