If our expectancies about IPAA seem quite confirmed by functional outcomes and long-term results, we must not ignore that the probability of developing septic complications and pouchitis increases over time  and therefore the risk of pouch loss over the long term . In relation to failed pouches, major revision surgery has a probability of being successful in 25-50% of cases, and, if objectively considered, functional outcomes after such major undertakings are often unsatisfactory [71, 72].
The most urgent issue in regard to IPAA in comparison with ileorectal anastomosis is, theoretically, rectal cancer risk that, even though substantially reduced, has not been completely eliminated [57,58]; therefore, regular endoscopic follow-up is strongly recommended . IPAA is a typical operation meant to improve quality of life and, despite various attempts to clarify this aspect, all studies conducted so far gave conflicting results .
If it is true that most patients are prompted to choose a procedure such as IPAA that preserves continence avoiding a stoma , it is also shown that a pelvic reservoir is advantageous in certain fields in comparison with a conventional ileostomy, but the differences seem less obvious in other respects , and reservoir malfunction may thwart the benefits of the preservation of body image .
Overall opinion regarding this operation is surely positive even if IPAA may not represent the ultimate panacea, as it was initially believed to be [46, 60]. If patients are suitably selected and the postoperative course is poor regarding complications, the result will generally be almost optimum with suitable preservation of continence and a good quality of life, as verified in most cases .
However, individual outcome after so complex an operation is sometimes unpredictable. Patients must be given detailed information about functional implications in the short and long term and the pros and cons of the different surgical options that, from time to time (conventional ileostomy in elderly patients and ileorectal anastomosis in young patients of child-bearing age as a bridge to a future IPAA) may represent reasonable alternatives [46, 67].
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