The colon and rectum are completely resected with RP and IPAA, ensuring the intestinal continuity of the patients and defecation via the anus (1). Park et al. first described this procedure in 1978 as the anastomosis of the S-shaped pouch manually to the dentate line level after mucosectomy was performed in the remaining rectum (5). Over the years, J, W, and K-shaped pouch designs have also been defined. Since the 1980s, J pouch and stapler anastomosis have become the most common techniques with the development of surgical stapler technology. It has a simple design, the construction with the linear stapler is easier compared to the other techniques, and the application time is shorter (6). IPAA procedure has various complications such as the postoperative anastomotic leak, stricture, fistula, pelvic abscess, obstruction, and pouchitis. In addition, there are consequences that negatively affect daily life activities, social life, and quality of life, such as an increase in the number of defecations during the day and at night, the urgent need to urinate, excessive weight loss, fecal and gas incontinence problems, which are defined as the functional outcomes of this surgery after the procedure.
In the present study, we evaluated the postoperative functional outcomes, complications, approaches to complications, and quality of life in patients, who underwent IPAA in our clinic. The results of this procedure have been discussed since the day Park et al. presented their IPAA results in 1978. According to the previous studies, morbidity rates after IPAA varied between 30–60% (7–10). The surgical technique is constantly changing and improving to reduce these morbidity rates. We used total mesorectal excision and J pouch stapler anastomosis technique in all our patients. In many studies, the J pouch has been reported as the most common pouch type due to its ease of application and good long-term functional outcomes (11–13). The studies comparing stapled anastomosis with hand-sewn anastomosis concluded that the functional outcomes were observed to be better. (11, 14). Considering the functional outcomes of the patients, we avoided mucosectomy in patients with no suspicion of dysplasia and neoplasia in the anal canal (15).
The most common complications we encountered in our study were wound infection, pouchitis, anastomotic stenosis, pelvic abscess, and pouch dysfunction. Fazio et al. demonstrated that such complications affected functional outcomes and the quality of life (16, 17). Tiainen & Matikainen (18) mentioned that pouchitis was the most common complication after IPAA. Similar to our study, certain studies reported that small bowel obstruction was one of the most common complications of restorative proctocolectomy and is encountered in 12–17% of all patients (19–21). When we compared the patients with UC and FAP, the development of ileus and pelvic abscess in patients with UC was significantly higher compared to the patients with FAP. In a study, Fazio et al. reported the increase of many complications in patients with UC (22).
Kıran et al. mentioned that the protective ileostomy would not prevent pelvic sepsis; (23) and some other studies indicated that protective ileostomy did not prevent anastomotic leaks (24, 25). However, we performed protective ileostomy in all patients and closed the ileostomies after controlling with endoscopy and pouch radiography in an average of 4.2 months. When we identified problems such as pouch fistula and pouchitis on endoscopy and pouch radiography, we postponed the ileostomy closure process and started treatment, where necessary.
We performed the 2-stage RP surgery in all patients diagnosed with FAP and the patients with UC, who underwent elective surgery. 3-stage surgery is recommended for patients with acute severe colitis, who received steroid therapy or anti-TNF therapy for a long time (11, 26). We performed the 3-stage surgery to 3 patients diagnosed with UC.
Patients, who undergo IPAA, are expected to have defecations 4–6 times during the day and 0–1 times at night, with complete continence (27, 28). In our study, it was observed that the number of day and night defecations were compatible with the literature, 27.3% of the patients, 2 of whom used pads, had fecal incontinence; and these results were found to be acceptable (29). Half of the patients stated that they suffered from sexual dysfunction; and one of our patients got pregnant after the operation.
We saw that our patients were satisfied with the IPAA operation and the quality of life score was similar to the study conducted by Özdemir et al. (1).
When we compared the patients with UC and FAP, it was seen that the results of patients with FAP were better in terms of complications, functional outcomes, and quality of life score. It is believed that the patients with UC required emergency surgery, which was caused by the preoperative treatments received by the patients and malnutrition during the preoperative period.
It was observed that the IPAA procedure had a certain complication rate as well as functional outcomes and results affecting the quality of life; however, these were at an acceptable level when compared to the preoperative period. In a study by Lichtenstein et al., 10 clinical studies investigating the quality of life after IPAA were examined. The quality of life was found to have increased in 8 of the studies, remained the same in one of the studies, and was worse than the general population in the other study.
The insufficient number of patients and the retrospective nature of the study have been the limitations. However, the postoperative complication rates, functional outcomes, and quality of life of the patients were similar when compared with the literature. This procedure could be applied safely with low comorbidity and good functional outcomes in experienced health centers with high caseloads.