Ileal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: A ten-year experience

doi:10.1016/S0039-6060(96)80185-1

Surgery

Volume 119, Issue 6, June 1996, Pages 615-623

https://doi.org/10.1016/S0039-6060(96)80185-1 Get rights and content

Background. The choice between ileal pouch-anal anastomosis (IPAA) and ileorectal anastomosis (IRA) in the treatment of patients with familial adenomatous polyposis remains controversial. The aims of this study were to assess our 10-year experience with proctocolectomy, endoanal mucosectomy, construction of an ileal reservoir pouch, and IPAA in a series of 171 patients with familial adenomatous polyposis and to compare the functional results after IPAA with those after IRA.

Methods. Data from patients treated by IPAA at one institution were prospectively accumulated from October 1983 to October 1993. Medical records of 171 consecutive patients were studied regarding morbidity and functional results. These functional results were compared with those of a series of 23 patients who underwent IRA at the same institution.

Results. One patient (0.6%) died after operation. Sixty-two patients (36%) had concomitant colorectal carcinoma, 36 of which tumors were invasive (15 stage A, 13 stage B, and 8 stage C). Forty-six patients (27%) had at least one postoperative complication, with 14 patients requiring reoperation (8%). Twenty-six patients (15%) had obstruction. Seven patients (4%) had pelvic sepsis, and one had transient impotence (0.6%). Only two patients (1%) had a typical episode of pouchitis. The mean follow-up was 29 months (range, 3 to 100 months); 101 patients were monitored for more than 1 year. Little difference was noted between bowel function after IRA and that after IPAA. The mean daytime stool frequency after IPAA was 4.2 with 26% of patients having an average of 1 bowel movement at nighttime, compared with a stool frequency of 3.0 and 13% of patients having night evacuation after IRA. Daytime continence was normal for 98% of patients after IPAA and for all the patients after IRA. Nighttime continence was normal in 96% and 98% of patients, respectively.

Conclusions. Morbidity and functional results after IPAA for familial adenomatous polyposis do not differ from those reported after IRA. For this reason and because of the risk of rectal cancer after ileorectal anastomosis, IPAA with endoanal mucosectomy is our first choice in the treatment of patients with familial adenomatous polyposis. (Surgery 1996; 119:615–623.)

References (52)

TjandraJJ et al.
Similar functional results after restorative proctocolectomy in patients with familial adenomatous polyposis and mucosal ulcerative colitis
Am J Surg
(1993)
BusseyHJR
Familial polyposis coli
(1975)
LoygueJ et al.
Polyposes intestinales
(1977)
DozoisRR et al.
Surgical aspects of familial adenomatous polyposis
Int J Colorectal Dis
(1988)
MortensenNJMcC
Patient selection for restorative proctocolectomy
JagelmanDG
Choice of operation in familial adenomatous polyposis
World J Surg
(1991)
ArvanitisML et al.
Mortality in patients with familial adenomatous polyposis
Dis Colon Rectum
(1990)
BessMA et al.
Rectal cancer following colectomy for polyposis
Arch Surg
(1980)
BusseyHJR et al.
The rectum in adenomatous polyposis: the St-Mark's policy
Br J Surg
(1985)
SarreGR et al.
Colectomy with ileorectal anastomosis for familial adenomatous polyposis: the risk of rectal cancer
Surgery
(1987)

De CosseJJ et al.

Rectal cancer risk in patients treated for familial adenomatous polyposis

Br J Surg

(1992)

NugentKP et al.

Rectal cancer risk in older patients with familial adenomatous polyposis and an ileorectal anastomosis: a cause of concern

Br J Surg

(1992)

IwamaT et al.

The impact of familial adenomatous polyposis on the tumorigenesis and mortality at the several organs: its rational treatment

Ann Surg

(1993)

NugentKP et al.

Life expectancy after colectomy and ileorectal anastomosis for familial adenomatous polyposis

Dis Colon Rectum

(1993)

BeartRW et al.

The J-ileal pouchanal anastomosis: the Mayo Clinic experience

HealdRJ et al.

Stapled ileo-anal anastomosis: a technique to avoid mucosal proctectomy in ileal pouch operations

Br J Surg

(1986)

JohnstonD et al.

Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection, with mucosal proctectomy and endo-anal anastomosis

Br J Surg

(1987)

WilliamsNS et al.

Function after ileal pouch and stapled pouch-anal anastomosis for ulcerative colitis

Br J Surg

(1989)

PennaCP et al.

Intérêt du dépistage dans la prévention du cancer colorectal de la polypose adénomateuse familiale

Gastroenterol Clin Biol

(1992)

PennaC et al.

Comparaison des résultats fonctionnels des anastomoses ilèo-rectales et iléo-anales dans la polypose adénomateuse familiale: les transformations d'anastomoses iléo-rectales en anastomoses iléo-anales

Gastroenterol Clin Biol

(1992)

PennaC et al.

Function of ileal J pouch-anal anastomosis in patients with familial adenomatous polyposis

Br J Surg

(1993)

PennaC et al.

Secondary protectomy and ileal pouch-anal anastomosis after ileorectal anastomosis for familial adenomatous polyposis

Br J Surg

(1993)

UtsunomiyaJ et al.

Total colectomy, mucosal proctectomy and ileoanal anastomosis

Dis Colon Rectum

(1980)

AstlerV et al.

The prognostic significance of direct extension of carcinoma of colon and rectum

Ann Surg

(1954)

MaddenMV et al.

Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis

Br J Surg

(1991)

PembertonJH

Complications, management, failure and revisions

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^*: Presented in part at the Ileal Pouch-Anal Anastomosis International Symposium, Versailles, France, Sept. 18–19, 1992.

View full text

Ileal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: A ten-year experience*

Am J Surg

Familial polyposis coli

Polyposes intestinales

Surgical aspects of familial adenomatous polyposis

Int J Colorectal Dis

Patient selection for restorative proctocolectomy

Choice of operation in familial adenomatous polyposis

World J Surg

Mortality in patients with familial adenomatous polyposis

Dis Colon Rectum

Rectal cancer following colectomy for polyposis

Arch Surg

The rectum in adenomatous polyposis: the St-Mark's policy

Br J Surg

Colectomy with ileorectal anastomosis for familial adenomatous polyposis: the risk of rectal cancer

Surgery

Rectal cancer risk in patients treated for familial adenomatous polyposis

Br J Surg

Rectal cancer risk in older patients with familial adenomatous polyposis and an ileorectal anastomosis: a cause of concern

Br J Surg

The impact of familial adenomatous polyposis on the tumorigenesis and mortality at the several organs: its rational treatment

Ann Surg

Life expectancy after colectomy and ileorectal anastomosis for familial adenomatous polyposis

Dis Colon Rectum

The J-ileal pouchanal anastomosis: the Mayo Clinic experience

Stapled ileo-anal anastomosis: a technique to avoid mucosal proctectomy in ileal pouch operations

Br J Surg

Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection, with mucosal proctectomy and endo-anal anastomosis

Br J Surg

Function after ileal pouch and stapled pouch-anal anastomosis for ulcerative colitis

Br J Surg

Intérêt du dépistage dans la prévention du cancer colorectal de la polypose adénomateuse familiale

Gastroenterol Clin Biol

Comparaison des résultats fonctionnels des anastomoses ilèo-rectales et iléo-anales dans la polypose adénomateuse familiale: les transformations d'anastomoses iléo-rectales en anastomoses iléo-anales

Gastroenterol Clin Biol

Function of ileal J pouch-anal anastomosis in patients with familial adenomatous polyposis

Br J Surg

Secondary protectomy and ileal pouch-anal anastomosis after ileorectal anastomosis for familial adenomatous polyposis

Br J Surg

Total colectomy, mucosal proctectomy and ileoanal anastomosis

Dis Colon Rectum

The prognostic significance of direct extension of carcinoma of colon and rectum

Ann Surg

Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis

Br J Surg

Complications, management, failure and revisions