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.