AllpatientsundergoingIRParemanagedsimilartothoseundergoing standardcolorectalprocedures—includingLARorAPR.Allpatientsare preoperativelycounseledonourinstitution’smultimodalityenhanced recoveryprotocol.Patientsarestartedonlow-residuedietimmediately postoperatively.Narcoticopioidanalgesiaisminimizedwithapreference fororalandintravenousnonsteroidalanti-inflammatorydrugs(NSAIDs). Itiscurrentlynottheauthor’sroutinetoutilizecentralneuraxial blockade(i.e.,intrathecalorspinalepidurals)ortransversusabdominis planeblocks,thoughthelatterhasbeeneffectivelyutilizedinother centers.Thepresacraldrainplacedatthetimeofoperationisalso removedonceoutputisserosanguineousandlessthan100ml/day.Once stomafunctionisappropriate(generally<1,300ml/day),patientsare dischargedwithfollow-upappointmentswiththeostomynursein2 weeks.Patientsaregenerallyadvisedtowearpadsorgauzeperianallyto captureanymucusorsanguineousdischargeintheimmediate postoperativeperiod.Mostpatientsareabletobedischargedonoral NSAIDswithminimal,ifany,narcoticopioids.Atapproximately2–6 weekspostoperatively,patientsmayundergoawater-solublecontrast enemaand/orphysicalexaminationwithflexiblesigmoidoscopyto evaluateforpatencyoftheanastomosisandalsotoexcludean anastomoticleak.Ifaleakisfound,thesegenerallyresolvespontaneously duringtheintervalinwhichpatientsareonadjuvantchemotherapy. Nevertheless,ifaleakisobserved,reversalisnotperformeduntilaleakis excludedorself-containedandminimal.Managementofanastomotic leaksarecoveredseparatelyinthistext.

Therewassomethoughtthatduetoabetterbloodsupplyinpatients undergoingpouchprocedures,theiranastomosismayhealbetterwitha resultantdecreaseintherateofclinicallysignificantanastomoticleaks. Thistheoryseemedtobesupportedbyinitialreportsindicatingthat therewasaclinicallysignificantlowerincidenceofanastomoticleaks followingcolonicpouchanastomosis(2%)comparedwiththoseincaseof non-pouchCAA(15%).

LaterstudiesrevealedthedifferenceinleakratesbetweenCPAand CAAtobeduetoaconfoundingvariable.Inthisstudy,fecaldiversion wasperformedinonly59%ofpatientswithCAAandin71%withCPA.A follow-upstudybythesamegroupwithaprotectiveileostomyinall patientsshowednosignificantdifferences.Theseresultshavesincethen beenconfirmedbyotherstudies.Later,randomizedstudieslookingat leakratesbetweenTCPandCJPandaside-to-endanastomosisalso revealednoclinicallysignificantdifference.