A Comparison of Hand-Sewn Versus Stapled Ileal Pouch Anal Anastomosis (IPAA) Following Proctocolectomy A Meta-Analysis of 4183 Patients

• Published in: Annals of surgery Vol. 244; no. 1; pp. 18 - 26
• Main Authors: Lovegrove, Richard E., Constantinides, Vasilis A., Heriot, Alexander G., Athanasiou, Thanos, Darzi, Ara, Remzi, Feza H., Nicholls, R John, Fazio, Victor W., Tekkis, Paris P.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott 01.07.2006
• Subjects: Anastomosis, Surgical; Biological and medical sciences; Colonic Pouches - adverse effects; General aspects; Humans; Medical sciences; Postoperative Complications; Proctocolectomy, Restorative; Quality of Life; Review; Stomach, duodenum, intestine, rectum, anus; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Surgical Stapling; Sutures; Treatment Outcome; Human; Medicine; Treatment; Surgery; Rectum; Patient; Proctocolectomy; Colon; Hand; Comparative study; Ileal pouch-anal anastomosis; Metaanalysis
• ISSN: 0003-4932; 1528-1140
• DOI: 10.1097/01.sla.0000225031.15405.a3

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. 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. 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. 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). 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.