Handsewn ileal pouch-anal anastomosis on the dentate line after total proctectomy: technique to avoid incomplete mucosectomy and the need for long-term follow-up of the anal transition zone.

Abstract

During ileal pouch-anal anastomosis, both conservation of the anal transitional zone during the stapled technique and incomplete mucosectomy in the standard Park's procedure may expose the patient to disease recurrence. We propose here an technique whose aim is to solve both problems by performing handsewn ileal pouch-anal anastomosis on the dentate line after rectal eversion and total proctectomy. We reviewed the records of 172 consecutive patients who had undergone ileal pouch-anal anastomosis since 1984 for chronic ulcerative colitis (n = 80), familial adenomatous polyposis (n = 48), selected cases of Crohn's disease (n = 42), or other causes (n = 2). One patient (0.5 percent) died postoperatively. Operative morbidity was similar to that reported after the Park's and stapled procedures. Of our 128 patients with a five-year follow-up, anastomotic stricture occurred in 15 (12 percent), and 4 patients (3 percent) had to have pouch removal. Stool frequency per 24 hours was 4.8 +/- 1.6 (range, 1-11), continence was perfect in 104 patients (81 percent), and sexual activity was estimated to be unchanged in 120 (94 percent). No evidence of disease recurrence was noted in the patients with familial adenomatous polyposis or ulcerative colitis. During ileal pouch-anal anastomosis, Park's procedure carries the risk of incomplete mucosectomy and disease recurrence, and the stapled procedure requires a long-term follow-up of the anal transitional zone. Our alternative technique with total proctectomy avoids both problems and gives similar long-term functional results.