Ileal pouch anal anastomosis without ileal diversion

Objective To evaluate continued experience with a one-stage stapled ileoana l pouch procedure without temporary ileostomy diversion. Summary Background Data Most centers perform colectomy, proctectomy, and il eal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedur es for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the ne ed for temporary ileal diversion, with its complications and need for subse quent surgical closure. Methods Two hundred one patients underwent a stapled IPAA since May 1989, 1 92 as a one-stage procedure without ileostomy, and 1 with a concurrent Whip ple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery. Results Among patients who underwent the one-stage procedure, 178 had ulcer ative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7-70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the denta te line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2. 4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3 , of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and nig ht-time control was 90%. Only 2.3% needed to wear a perineal pad. Average l ength of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmissi on for complications. Abscesses or enteric leaks occurred in 23 patients; I PAA function was excellent in 19 of these patients (2 have permanent ileost omies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) pa tients died (myocardial infarction, mesenteric infarction). Conclusions The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction , provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.