RANDOMIZED PROSPECTIVE TRIAL COMPARING ILEAL POUCH-ANAL ANASTOMOSIS PERFORMED BY EXCISING THE ANAL MUCOSA TO ILEAL POUCH-ANAL ANASTOMOSIS PERFORMED BY PRESERVING THE ANAL MUCOSA

Objective The purpose of the study is to compare the results of ileal pouch-anal anastomosis (IPAA) in patients in whom the anal mucosa is e xcised by handsewn techniques to those in whom the mucosa is preserved using stapling techniques. Summary Background Data Ileal pouch-anal a nastomosis is the operation of choice for patients with chronic ulcera tive colitis requiring proctocolectomy. Controversy exists over whethe r preserving the transitional mucosa of the anal canal improves outcom es. Methods Forty-one patients (23 men, 18 women) were randomized to e ither endorectal mucosectomy and handsewn IPAA or to double-stapled IP AA, which spared the anal transition zone. All patients were diverted for 2 to 3 months. Nine patients were excluded. Preoperative functiona l status was assessed by questionnaire and anal manometry. Twenty-four patients underwent more extensive physiologic evaluation, including s cintigraphic anopouch angle studies and pudendal nerve terminal motor latency a mean of 6 months after surgery. Quality of life similarly wa s estimated before surgery and after surgery. Univariate analysis usin g Wilcoxon test was used to assess differences between groups. Results The two groups were identical demographically. Overall outcomes in bo th groups were good. Thirty-three percent of patients who underwent th e handsewn technique and 35% of patients who underwent the double-stap led technique experienced a postoperative complication. Resting anal c anal pressures were higher in the patients who underwent the stapled t echnique, but other physiologic parameters were similar between groups . Night time fecal incontinence occurred less frequently in the staple d group but not significantly. The number of stools per 24 hours decre ased from preoperative values in both groups. After IPAA, quality of l ife improved promptly in both groups. Conclusions Stapled IPAA, which preserves the mucosa of the anal transition zone, confers no apparent early advantage in terms of decreased steal frequency or fewer episode s of fecal incontinence compared to handsewn IPAA, which excises the m ucosa, Higher resting pressures in the stapled group coupled with a tr end toward less night-time incontinence, however, may portend better f unction in the stapled group over time. Both operations are safe and r esult in rapid and profound improvement in quality of life.