title: Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP)--a critical issue.
abstract: BACKGROUND
  Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis.
  
  
  METHODS
  One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed.
  
  
  RESULTS
  Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) (P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02).
  
  
  CONCLUSIONS
  Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120, Heidelberg, Germany.
authors.forename: Petra
authors.initials: P
authors.lastname: Ganschow
authors.forename: Irmgard
authors.initials: I
authors.lastname: Treiber
authors.forename: Ulf
authors.initials: U
authors.lastname: Hinz
authors.forename: Christine
authors.initials: C
authors.lastname: Leowardi
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
authors.forename: Martina
authors.initials: M
authors.lastname: Kadmon
mesh_terms: D011125:Adenomatous Polyposis Coli / Q000473:pathology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D001707:Biopsy, Needle; D016009:Chi-Square Distribution; D015331:Cohort Studies; D039021:Colonic Pouches; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D007413:Intestinal Mucosa / Q000473:pathology* / Q000601:surgery; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D018365:Neoplasm, Residual / Q000473:pathology* / Q000601:surgery; D016737:Proctocolectomy, Restorative / Q000009:adverse effects / Q000379:methods*; D011351:Proctoscopy / Q000009:adverse effects / Q000379:methods; D011379:Prognosis; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D017792:Surgical Stapling; D013537:Sutures; D016896:Treatment Outcome; D055815:Young Adult