Ileal Pouch Anal Anastomosis and Pouchitis

The surgical treatment of choice for patients requiring colectomy for ulcerative colitis or familial adenomatous polyposis (FAP) is restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The “pouch” is an ileal reservoir that acts as a neorectum to store fecal material and to avoid constant output from the ileostomy. Anastomosis of the ileal-to-rectal mucosa is controversial, but most surgeons prefer mucosectomy, bringing the ileal mucosa to the anal skin line. This is best accomplished with suturing, but some prefer stapling.

There are three types of pouches—J, S, and W—but the J pouch has become the most popular ( Fig. 93.1 ). Unfortunately, as many as 40% of patients who undergo this procedure develop at least one episode of pouchitis, and 60% of these patients may have recurrent disease. Only 15% of patients with pouchitis have chronic disease that requires maintenance therapy.

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Ileal Pouch Anal Anastomosis and Pouchitis.

Patients with IPAA to manage FAP rarely experience pouchitis. Furthermore, pouchitis appears to occur more frequently in patients with extraintestinal manifestations of colitis. Patients with primary sclerosing cholangitis have the highest prevalence of pouchitis.