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Risks and benefits of ileal pouch–anal anastomosis for ulcerative colitis

Udayakumar Navaneethan, Preethi GK Venkatesh and Bo Shen

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia, and for the majority of patients with familial adenomatous polyposis. Colectomy substantially reduces the risk for UC-associated colonic neoplasia and for the long-term need of immunosuppressive medications. The pouch procedure is a safe operation, with a low postoperative mortality rate at 0–1%, which significantly improves patients’ quality of life. However, patients with IPAA are susceptible to a number of surgical/mechanical, inflammatory and functional complications, such as anastomotic leaks, pelvic sepsis, pouchitis, Crohn’s disease of the pouch, cuffitis and irritable pouch syndrome. IPAA may also impact the patient’s sex life and fertility. There is also a small risk for the development of neoplasia of the anal transitional zone. These complications adversely affect the outcome and compromise the improvement in the patient’s quality of life gained initially from the restorative proctocolectomy. Recognition and discussion of the advantages and disadvantages of IPAA will be helpful for patients and clinicians in decision-making regarding pursuing further medical therapy versus surgical intervention when their UC becomes refractory to conventional medical therapy.