Should ileal pouch-anal anastomosis include mucosectomy?
OBJECTIVE
Debate exists as to the benefits of performing mucosectomy as part of pouch surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Whilst mucosectomy results in a more complete removal of diseased mucosa, this benefit may be at the price of poorer function. We examined these issues.


METHODS
Using Medline, Embase, Ovid and Cochrane database searches papers were identified relating to the outcome following pouch surgery with and without mucosectomy. Potential reasons for functional problems were investigated, as were rates of 'cuffitis', dysplasia, polyposis and cancer in the ileal pouch and anal canal.


RESULTS
The available evidence suggests that performing a mucosectomy leads to a worse functional outcome. Meta-analysis suggested that nighttime seepage of stool and resting and squeeze pressure were worse after mucosectomy. The most likely reason for functional impairment following pouch surgery was the degree of anal manipulation. Mucosectomy does seem to confer benefit in terms of disease control but this benefit does not reach statistical significance.


CONCLUSIONS
Stapled anastomosis avoiding mucosectomy is the approach of choice for ileal pouch anal anastomosis because this leads to superior functional outcome. Performing mucosectomy results in some clinical benefits in terms of lower rates of inflammation and dysplasia in the retained mucosa in UC patients and lower rates of cuff polyposis in FAP patients. However, on the basis of available evidence mucosectomy is only indicated in those cases where the patient is at a high risk of disease in the retained rectal cuff.
Chambers
W M
WM
Department of Colorectal Surgery, John Radcliffe Hospital, Headington, Oxford, UK. wchambers@doctors.org.uk
McC Mortensen
N J
NJ
D000230:Adenocarcinoma / Q000517:prevention & control; D011125:Adenomatous Polyposis Coli / Q000601:surgery; D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods; D001005:Anus Neoplasms / Q000517:prevention & control; D001149:Arsenates; D003093:Colitis, Ulcerative / Q000601:surgery; D039021:Colonic Pouches / Q000009:adverse effects* / Q000473:pathology; D006801:Humans; D007078:Ileal Neoplasms / Q000517:prevention & control; D007413:Intestinal Mucosa / Q000601:surgery*; D016737:Proctocolectomy, Restorative / Q000009:adverse effects* / Q000379:methods; D016032:Randomized Controlled Trials as Topic
D001149:Arsenates; C025657:arsenic acid