It is now 25 years since the ileal pouch procedure was introduced for patients with ulcerative colitis and familial adenomatous polyposis, holding out the promise of life without a permanent ileostomy. As time has gone by the procedure has been modified, refined, and the indications widened until the present situation where most teams use an almost standard stapled pouch and pouch anal anastomosis. The technique has been simplified to such an extent that surgeons outside specialist centres are comfortable offering the operation. But problems remain. A tiny cuff of columnar epithelium is left behind1 which can potentially become inflamed or undergo malignant change.2 Also, however perfect a postoperative course, there is still a minority of patients who have poor function, whether unacceptable frequency, episodes of leakage, or of course pouchitis.

And now, along comes a new operation, which Andriesseet al have termed ileo neo-rectal anastomosis …