title: Ileal pouch anal anastomosis without ileal diversion.
abstract: OBJECTIVE
  To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion.
  
  
  BACKGROUND
  Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure.
  
  
  METHODS
  Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple 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 the patients who underwent the one-stage procedure, 178 had ulcerative 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 dentate 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 night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). 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%) patients 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.
authors.affiliation: General/Trauma Surgery Division, Department of Surgery, Medical College of Virginia of Virginia Commonwealth University, Richmond, Virginia, USA. hsugerma@hsc.vcu.edu
authors.forename: H J
authors.initials: HJ
authors.lastname: Sugerman
authors.forename: E L
authors.initials: EL
authors.lastname: Sugerman
authors.forename: J G
authors.initials: JG
authors.lastname: Meador
authors.forename: H H
authors.initials: HH
authors.lastname: Newsome
authors.forename: J M
authors.initials: JM
authors.lastname: Kellum
authors.forename: E J
authors.initials: EJ
authors.lastname: DeMaria
mesh_terms: D011125:Adenomatous Polyposis Coli / Q000601:surgery; D000328:Adult; D000368:Aged; D003093:Colitis, Ulcerative / Q000601:surgery; D003424:Crohn Disease / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D016737:Proctocolectomy, Restorative / Q000379:methods*; D017792:Surgical Stapling; D013997:Time Factors; D016896:Treatment Outcome