title: A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients.
abstract: OBJECTIVE
  Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy.
  
  
  BACKGROUND
  The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes.
  
  
  METHODS
  Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone.
  
  
  RESULTS
  Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080).
  
  
  CONCLUSIONS
  Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.
authors.affiliation: Imperial College London, Department of Biosurgery and Surgical Technology, St. Mary's Hospital, London, United Kingdom.
authors.forename: Richard E
authors.initials: RE
authors.lastname: Lovegrove
authors.forename: Vasilis A
authors.initials: VA
authors.lastname: Constantinides
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Heriot
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: R John
authors.initials: RJ
authors.lastname: Nicholls
authors.forename: Victor W
authors.initials: VW
authors.lastname: Fazio
authors.forename: Paris P
authors.initials: PP
authors.lastname: Tekkis
mesh_terms: D000714:Anastomosis, Surgical; D039021:Colonic Pouches / Q000009:adverse effects; D006801:Humans; D011183:Postoperative Complications; D016737:Proctocolectomy, Restorative; D011788:Quality of Life; D017792:Surgical Stapling; D013537:Sutures; D016896:Treatment Outcome