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31
escalated on medications for different reasons that do not concern
the primary site? So, the question is whether they were on medical
therapy more frequently than the surgical group, perhaps because
they have disease at a different site.
MD
Is this study changing your practice signicantly? If you have a
patient that comes in with mild inammatory disease would you
strongly recommend surgery over medical management?
LS
Well, no. I mean, not strongly. This is currently more of a theo-
retical scenario rather than a practical scenario given the realistic
disease presentations we are faced with, as we mentioned before.
Given the circumstances, I feel I would not recommend surgery
strongly, but I would openly talk about the natural history of dis-
ease and quality of life, especially in young patients. It is reassur-
ing to know that there are data which can help me in that
discussion. The other practical issue in this conversation is that
oftentimes patients come in with a preset opinion about surgery,
which can be favorable or unfavorable. I oftentimes feel that we
are a sort of a product located on a shelf and we are picked up
based on the patient’s own preference. Some of these precon-
ceived ideas can be prejudicial against surgery. It is not common
that the patient just comes in asking us for advice given our exper-
tise in the treatment of their disease. In those circumstances, there
is no point in presenting, explaining, or defending the literature. If
requested, I could certainly quote the LIR!C trial as evidence sup-
porting surgery, but I have to confess that I tend to go with the
ow. I present my opinion understanding that mine is just one
opinion among many.
Discussion
32
AM
Yes, again, I think it is symbolic of how gastroenterologists
remain the gatekeepers of the disease. We are partners, I think,
perhaps unfortunately, lesser partners sometimes in the treatment
decisions. To answer your question, for me, maybe I push it a little
bit harder, but I think this paper has given us at least a platform to
present more robust data that say that patients can do equally as
well as those on medications. Also, to some patients, the side
effects of medications are concerning enough to proceed with sur-
gery. Or maybe it is for the younger patients who are looking at
medical treatment over a much longer period of time. Maybe sur-
gery can give them a number of years prior to even initiating a
biologic, or maybe it is just immunomodulator therapy to save
exposure to the biologic for a later date.
LS
Dorin, did the LIR!C study change your practice?
DC
Not much. I think probably because I already had a similar bias.
Before we look at the study itself, there is an important question
of how the disease phenotype is determined to be stricturing vs.
non-stricturing. They try to describe it, but essentially, what they
say is that patients are excluded if they had previously ileocecal
resection or obstructive Crohn’s at the terminal ileum that would
probably require surgery. So, when you take that into account, the
fact that this was a multi-institutional study, both in the Netherlands
and in the UK, and you take into account a number of radiologists
and endoscopists that are assessing whether this is inammatory
or not, then we have to take that with a grain of salt. We add to that
the fact that even though roughly about 70 patients were assigned
in each group at the beginning, we actually end up with more
4 Is Early Surgery for Crohn’s Disease Preferable to Continued…
33
patients having surgery, 13 individuals who failed medical man-
agement, and so even though the groups didn’t change a lot with
the intention-to-treat design, what actually ended up happening is
still that 13 patients failed iniximab treatment and required sur-
gery. So, I think that all this points out to the fact that earlier sur-
gery is not detrimental, and it is probably going to help the patient.
That was the impression I had before but that was based on the
fact that at least in my mind, inammation and stricturing disease
are not at all separate processes, but separate points along a con-
tinuum of disease progression; we just frequently do not know
where we are on that continuum despite MRI, endoscopic assess-
ment, with the exception of obvious stricturing disease. We do not
know if it is just inammation or if there is some stricturing as
well. That is a long-winded way of saying that it did not change
my practice and that probably I favor surgery earlier.
Discussion
35
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Colibaseanu et al., Essential Articles in Colorectal Surgery,
https://doi.org/10.1007/978-3-031-77745-5_5
5
Stapled vs. Handsewn Ileal
Pouch-Anal Anastomosis
forUlcerative Colitis
Ziv Y, Fazio VW, Church JM, Lavery IC, King TM, Ambrosetti
P.Stapled ileal pouch anal anastomoses are safer than handsewn
anastomoses in patients with ulcerative colitis. Am J Surg.
1996;171(3):320–3.
Abstract
Background: One of the theoretic advantages of using a stapled
versus handsewn ileal pouch-anal anastomosis (IPAA) in restor-
ative proctocolectomy is a reduction in septic complications. We
performed this study to compare the incidence of early septic
complications in patients undergoing restorative proctocolectomy
with stapled or handsewn IPAA.
Patients and Methods: A chart review of 692 patients under-
going restorative proctocolectomy for treatment of ulcerative
colitis was performed. The incidence of early septic complica-
tions in patients having stapled IPAA was compared to that in
patients having handsewn IPAA. Follow-up studies included an
annual questionnaire and physical examination.
Results: Of the 692 patients, 238 had handsewn IPAA and 454
had stapled IPAA; these two groups were similar in sex, duration
of disease, age at surgery, and type of surgical procedure per-
formed. In the handsewn IPAA group, 25 patients (10.5%) had 32
septic complications, and 24 required 89 reparations. In 7 patients,
the pouch was excised. In the stapled IPAA group, 21 patients
36
(4.6%) had 23 septic complications, and 14 required 40 repara-
tions. One patient needed pouch excision. There were more
patients (P=0.0001) with early septic complications, and more
(P<0.0001) pouch excisions because of these complications, in
patients with handsewn IPAA than in patients with stapled
IPAA.The sepsis-related reoperation rates did not differ signi-
cantly.
Conclusions: The stapled technique for IPAA has fewer septic
complications and results in fewer sepsis-related pouch excisions,
in our hands, than the handsewn technique, for treating patients
with ulcerative colitis.
LS
This is a study which did not have the strongest methodological
design but was convincing in that it came from a unit with exten-
sive experience in ileal pouch-anal anastomosis. A stapled tech-
nique is intuitively easier than a handsewn technique, and the
results of this study were not surprising. The other recognized
advantage of stapled ileal pouch-anal anastomosis not specically
addressed by this study is in its functional outcomes. An earlier
prospective randomized study with a smaller number of patients
failed to detect a signicant difference between mucosectomy and
handsewn anastomosis versus stapled anastomosis [1]. However,
subsequent experiences have corroborated the functional advan-
tages associated with the stapled approach which has established
itself as the preferred ileal pouch-anal anastomotic technique. In a
metanalysis on 8872 patients (4871 patients in the stapled group
and 4038in the handsewn group) included in 31 studies, the sta-
pled group had a lower rate of anastomotic stricture, small bowel
obstruction, and ileal pouch failure. Operative times, anastomotic
leak, pelvic sepsis, pouchitis rates, and hospital stays were simi-
lar. With respect to functional outcomes, the stapled group was
associated with reduced rates of seepage, both during day and
night times, pad use, and night incontinence [2]. One of the puta-
tive reasons to perform a mucosectomy would be the complete
removal of the inamed tissue to prevent the subsequent onset of
5 Stapled vs. Handsewn Ileal Pouch-Anal Anastomosis…
37
cancer. However, older studies have indicated that even after
mucosectomy, small islets of rectal mucosa and anal glands can
remain [3], and therefore, it is not surprising that a considerable
proportion of patients who develop cancer of the ileal pouch-anal
anastomosis had indeed undergone mucosectomy which therefore
should not be considered as protective for the onset of cancer. On
the other hand, a retained anorectal cuff can allow more effective
detection of abnormalities including dysplasia during long-term
surveillance after ileal pouch-anal anastomosis. The above-
mentioned metanalysis indicated no difference between the two
groups in terms of dysplasia and neoplasia. Stapled anastomosis
can undergo surveillance safely, and dysplasia in the anal transi-
tional zone does not automatically require mucosectomy or pouch
excision [4]. An elective indication for mucosectomy and hand-
sewn ileal pouch-anal anastomosis is cancer of the rectum in the
background of ulcerative colitis, especially if located in the distal
third of the viscus. Colorectal dysplasia without cancer or cancer
in the more proximal rectum is a more controversial indication.
Otherwise, most surgeons treating ulcerative colitis in this day
and age perform stapled ileal pouch-anal anastomosis.
References
1. Reilly WT, Pemberton JH, Wolff BG, Nivatvongs S, Devine
RM, Litchy WJ, McIntyre PB.Randomized prospective trial
comparing ileal pouch-anal anastomosis performed by excis-
ing the anal mucosa to ileal pouch-anal anastomosis performed
by preserving the anal mucosa. Ann Surg. 1997;225(6):666–76;
discussion 676–7.
2. Chaouch MA, Hussain MI, Gouader A, Krimi B, Mazzotta A,
Costa ACD, Petrucciani N, Bouassida M, Khan J, Noomen F,
Oweira H.Stapled anastomosis versus hand-sewn anastomosis
with mucosectomy for ileal pouch-anal anastomosis: a sys-
tematic review and meta-analysis of postoperative outcomes,
functional outcomes, and oncological safety. Cancer Control.
2024;31:10732748241236338.
References
38
3. O’Connell PR, Pemberton JH, Weiland LH, Beart RW Jr,
Dozois RR, Wolff BG, Telander RL. Does rectal mucosa
regenerate after ileoanal anastomosis? Dis Colon Rectum.
1987;30(1):1–5.
4. Silva-Velazco J, Stocchi L, Wu XR, Shen B, Remzi
FH. Twenty-year-old stapled pouches for ulcerative colitis
without evidence of rectal cancer: implications for surveil-
lance strategy? Dis Colon Rectum. 2014;57(11):1275–81.
Discussion
DC
Excellent study; it is almost 30years old, with almost 700 patients.
Excellent question, especially at the time, and I think they
answered reasonably well, especially being able to now in retro-
spect see that most pouches today by far are stapled. Fundamentally,
a handsewn anastomosis is going to be lower, will take longer, and
will be more difcult. There are certainly circumstances where it
is warranted, but for me, stapled is the way to go.
LS
I think what was impressive to me in this study is that it was pub-
lished during a period where there was a debate on the best anas-
tomotic technique, and this study is denitely in favor of stapled
anastomosis, while a prospective randomized trial that was done
at the same time was inconclusive. Besides the individual charac-
teristics of each study, this is a situation where in retrospect, it
feels as if a study with a worse methodological design ultimately
advocates for something that becomes the preferred standard of
care, which is the stapled ileal pouch-anal anastomosis and par-
ticularly with the recognized advantages in anal function com-
pared to the handsewn anastomosis. I think that there are very few
advocates of systematic handsewn anastomosis for this indication
in general whereas, clearly, the original technique description
5 Stapled vs. Handsewn Ileal Pouch-Anal Anastomosis…
39
included handsewn technique, and there used to be a time when
stapled anastomosis was introduced when there was a lot of
debate. The other hypothesis which, I think, is widely considered
as debunked today is the idea that with a mucosectomy, we can
completely remove the diseased mucosa. Instead, we can see that
in those rare but possible cancers which can occur at the ileal
pouch-anal anastomosis, mucosectomy is not protective, and
there are cells that could lead to cancer which are left in place
even after handsewn anastomosis which was also demonstrated
by specic studies examining pathologic specimen of removed
ileal pouches.
DC
Luca, do you think that this might be one of those “lost arts”?
Could it be that the technique is lost, so to speak? Just like we do
not do anymore “S” pouches. I have learned how to do it, but I do
not do them anymore.
LS
We do so much less handsewn anastomoses in general, so I think
that you might be right, but I think the reason stapled anastomosis
is preferable is that functional results are better, and there’s pretty
strong evidence indicating that it is basically safe for the risk of
cancer in the retained cuff. It might seem counterintuitive that
patients do better while retaining disease in place in the anal tran-
sitional zone, so I understand the argument in the abstract, but
now, there are thousands of patients that have had stapled anasto-
mosis providing compelling data on postoperative outcomes, risk
of dysplasia, cancer, and long-term functional results. I think
there is no point in doing a study indicating, for example, how
many of the handsewn anastomoses develop anastomotic struc-
ture. My impression is that I have seen in the ofce over the years
a lot of patients with 30-year-old pouches who have symptomatic
strictures, and I do not feel that I see as many patients who have
Discussion
40
strictures after stapled anastomosis. So, to me, the verdict is
clearly in favor of stapled technique. Of course, there are situa-
tions where handsewn can be preferable, I am thinking of dyspla-
sia in the anal transitional zone or perhaps cancer in the low
rectum. However, these are not common situations.
MD
I agree with all the comments. I think this was a very impressive
paper by sheer numbers alone. And that, yes, I think that there’s
really no further controversy with regard to handsewn vs. stapled.
I think that the one nice thing or the one thing that handsewn
offers is that you do not have the concern about retained rectum. I
think with regard to stapled pouches, some rectal cuffs are left too
long, which can ultimately lead to problems with the pouch or
ongoing proctitis, even after the pouch operation due to retained
rectal cuff. In some cases, the surgeon may feel certain that they
are low enough, and they think they are about 2cm, but in fact,
they are anywhere between 4 and 6cm from the anal verge. So
that would be, I would say, the only advantage at this point, short
of the specic scenarios that Luca, you were talking about.
5 Stapled vs. Handsewn Ileal Pouch-Anal Anastomosis…
41
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Colibaseanu et al., Essential Articles in Colorectal Surgery,
https://doi.org/10.1007/978-3-031-77745-5_6
6
Intentional Ileal Pouch-Anal
Anastomosis forCrohn’s
Disease
Melton GB, Fazio VW, Kiran RP, He J, Lavery IC, Shen B, Achkar
JP, Church JM, Remzi FH.Long-term outcomes with ileal pouch-
anal anastomosis and Crohn’s disease: pouch retention and impli-
cations of delayed diagnosis. Ann Surg. 2008;248(4):608–16.
Abstract
Objective: To assess long-term outcomes after ileal pouch-anal
anastomosis (IPAA) in Crohn’s disease (CD).
Summary of Background Data: While considered the proce-
dure of choice for ulcerative colitis, performance of ileal pouch-
anal anastomosis (IPAA) is controversial in CD.
Methods: CD patients were identied from a prospectively
maintained IPAA database. Time-to-diagnosis and pouch reten-
tion rates were analyzed using Kaplan–Meier curves. Demo-
graphic, clinical, and pathologic factors associated with pouch
retention were evaluated with log-rank test and Cox proportional
hazards model.
Results: Two hundred and four CD patients (108 female,
median age 33 years, and median follow-up 7.4 years) with pri-
mary IPAA were included. CD diagnosis was before IPAA (inten-
tional) in 20 (10%), from postoperative histopathology (incidental)
in 97 (47%) or made in a delayed fashion at median 36 months