ILEAL POUCH-ANAL ANASTOMOSIS AND THE PROBLEM OF POUCHITIS

Ileal pouch-anal anastomosis (IPAA) has emerged as the procedure of ch oice for patients with ulcerative colitis and most patients with famil ial adenomatous polyposis. Patients over 60 appear to tolerate IPAA we ll and have functional results comparable to those achieved in younger patients. The distribution of disease in the colon does not appear to affect outcomes after IPAA. For most patients with familial adenomato us polyposis, IPAA is safe and provides functional results comparable to those achieved with ileorectostomy. The double-stapled IPAA techniq ue now appears to be safe and to provide better functional results in terms of incontinence than the hand-sewn technique. Variations of IPAA technique, including anorectal eversion and anal transition zone rese ction, are discussed. A large series of IPAA patients confirms the saf ety and efficacy of IPAA. Pouch failure appears to be primarily the re sult of uncontrolled fistula and poor function, Nonspecific inflammati on of the pouch (pouchitis) is the most frequent long-term complicatio n of abdominal colectomy with ileal pouch-anal anastomosis for ulcerat ive colitis. The 10-year cumulative risk of pouchitis in patients with ulcerative colitis with and without associated primary sclerosing cho langitis is 45% and 79%, respectively. Smoking protects against pouchi tis. The preoperative extent of ulcerative colitis does not predict po uchitis. In contrast to previous reports, recent studies show no assoc iation between pouchitis and perinuclear antineutrophil cytoplasmic an tibodies. Similar to patients with ulcerative colitis, patients with p ouchitis have increased pouch mucosal concentrations of leukotriene B- 4 and cytokines, increased serum concentrations of adhesion molecules, and increased intestinal permeability. Fecal concentrations of bile a cids and bacteria do not predict pouchitis. Most patients with pouchit is will respond to metronidazole or ciprofloxacin. Dysplasia occurred in 3% of 87 patients undergoing surveillance endoscopy of the ileoanal pouch after a mean of 6 years of follow-up.