Ileal pouch anal anastomosis and the problem of pouchitis

Ileal pouch-anal anastomosis (IPAA) has emerged as the procedure of choice for patients with ulcerative colitis and most patients with familial adenomatous polyposis. Patients over 60 appear to tolerate IPAA well 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 adenomatous polyposis, IPAA is safe and provides functional results comparable to those achieved with ileorectostomy. The double-stapled IPAA technique 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 resection, are discussed. A large series of IPAA patients confirms the safety and efficacy of IPAA. Pouch failure appears to be primarily the result of uncontrolled fistula and poor function, Nonspecific inflammation of the pouch (pouchitis) is the most frequent long-term complication of abdominal colectomy with ileal pouch-anal anastomosis for ulcerative colitis. The 10-year cumulative risk of pouchitis in patients with ulcerative colitis with and without associated primary sclerosing cholangitis is 45% and 79%, respectively. Smoking protects against pouchitis. The preoperative extent of ulcerative colitis does not predict pouchitis. In contrast to previous reports, recent studies show no association between pouchitis and perinuclear antineutrophil cytoplasmic antibodies. Similar to patients with ulcerative colitis, patients with pouchitis 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 acids and bacteria do not predict pouchitis. Most patients with pouchitis 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.