Do not despair. Even in the most difficult circumstance, do not give up and excise the anal canal. I have frequently seen this done, and know from personal experience, that even in the most awful case when one thinks that all is lost, when one fears that there will be leaks and problems with healing, the anastomosis can still heal primarily and the patient obtain a satisfactory functional result. Even when the ileal J-pouch tears when it is brought down to the anal canal due to a large amount of tension on the anastomosis, it may still heal. One must, however, realize that the more tension there is on an anastomosis, the more likely the patient is to have a stricture postoperatively. It is therefore extremely impor tant to check for this prior to loop ileostomy closure. If this is not treated with dilation prior to loop ileostomy closure, there is a much higher risk of dehiscence of the loop ileostomy closure site. There is also a higher rate of pouchitis and chronic pouchitis associated with untreated strictures. Such strictures may only require digital dilation or dilatation under anesthesia . When performing a hand-sewn anastomosis, it is very useful to first place quadrant sutures to fix the pouch to the anal canal before making a pouch enterotomy at the apex of the pouch for the anastomosis. A hand-sewn anastomosis with a complete mucosectomy should be performed in cases in which there is a distal rectal cancer, for example a distal rectal cancer in ulcerative colitis or FAP which does not permit a stapler to be placed below it due to its very distal location.
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