The ileoanal pull-through procedure, also referred as restorative proctocolectomy, is rarely performed in urgent cases. This procedure can be potentially offered to patients in good clinical condition, namely, young patients with normal anal sphincter function and/or rectal adenocarcinoma or uncontrollable hemorrhage (Figs. 7, 8). The real advantages of the IPAA are avoidance of permanent stoma and maintenance of the anal route of evacuation, along with the inherent eradication of the disease and discontinua-
tion of anti-inflammatory therapy. Disadvantages include length and complexity of the procedure, possibility of pelvic nerve injuries, pouchitis, septic complications and frequent evacuations. The most significant complications of IPAA include anastomotic and pouch suture-line leak that can lead to pelvic infection, fibrosis and poor functional outcome. Another major complication is pouch vaginal fistula that can require pouch resection. Pouchitis is an inflammatory disease with an aetiologic mechanism not yet clarified. Increasing bowel movements, fever, abdominal cramps and tenderness usually respond to rehydration and metronidazole. Repeated episodes of pouchitis may have deleterious functional effects. The two main technical controversies of the IPAA procedure regard choice of anastomosis and need for diverting ileostomy. The double-stapled pouch-anal anastomosis, 1.5-2.0 cm proximal to the dentate line, is currently considered easier to perform than a mucosectomy with hand-sewn anastomosis . There is no significant difference between the two techniques with respect to functional outcome although patients with mechanical anastomosis tend to experience higher resting sphincter pressure and less nocturnal incontinence [51-53].
Opponents of the stapled procedure without mucosectomy are concerned about leaving in place columnar epithelium with the potential risk of cancer in the transitional area. However, there is evidence of an island of residual mucosa even after mucosectomy with hand-sewn anastomosis [54, 55]. Proponents of the one-stage procedure, without diverting ileosto-my, believe that a single operation lowers risk of postoperative small-bowel obstruction and reduces hospital stay and total costs. Supporters of the double-stapling technique suggest that septic complications related to pouch leakage might be more severe in patients without a diverting ileostomy . A one-stage procedure, without temporary loop ileostomy, should be offered only to select patients in order to avoid ileostomy takedown and ileostomy-associated morbidity higher than 20% [57-59]. However, in patients with portal hypertension due to primary sclerosing cholangitis, an ileostomy should be discouraged to avoid peristomal varices . Ileostomy closure should be delayed after 6 weeks of primary surgery. After stoma mobilisation, the ileostomy can be closed with a hand-sewn, end-to-end anastomosis, a stapled side-to-side anastomosis or a mechanical end-to-end functional anastomosis.
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