The ileal pouch anal anastomosis (IPAA) procedure, also known as ileoanal anastomosis or restorative proctocolectomy, was developed in the 1970s by Sir Alan Parks in London. It was offered as an alternative to performing a Brooke end ileostomy for patients who underwent total colectomies for a variety of diagnoses, most commonly inflammatory bowel disease.1,2 The Parks’ procedure offered important advantages over the previously used ileoanal end-to-end anastomosis (without a pouch reservoir), which resulted in poor functional outcomes, including higher fecal frequency, urgency, and incontinence rates.3-5 With the addition of a pouch that serves as a lower pressure reservoir, patients are offered the quality-of-life advantage of restoring the continuity of their intestinal tracts, which obviates the need for permanent abdominal wall stomas (and ostomy appliances). When performed on properly selected patients, high rates of fecal continence and patient satisfaction can be expected.6,7
Over the past several decades minor modifications in the IPAA procedure have been suggested; however, the basic principles of the surgery have been maintained. Parks’ original reservoir was created as an S-shaped (or 3-limbed) ileal pouch.2 Alternatives to the 3-limbed S-pouch are the 4-limbed W-pouch and the 2-limbed J-pouch (Figure 15-1). Because fecal continence rates are equal in all the pouch designs, and the 2-limbed approach offers the greatest amount of surgical ease and a lower complication rate, the J-pouch ileoanal anastomosis is most commonly used and is our preferred technique. Other modifications have included the addition of an anorectal mucosectomy (important for primary colonic disorders such as colon cancer, polyposis, or inflammatory bowel disease) and the use of hand-sewn versus stapled techniques.8-10 We believe that the most appropriate technique for patients who undergo an IPAA following radical pelvic resections for gynecologic cancers is a stapled ileal J-pouch anal anastomosis. It is a complex procedure that should be performed by experienced surgeons.
Pouch design options. The 2-limbed J-pouch, 3-limbed S-pouch, and 4-limbed W-pouch are depicted.
INDICATIONS AND CLININCAL APPLICATIONS
The IPAA is most commonly performed after total colectomy for patients with ulcerative colitis or familial adenomatous polyposis.6,11,12 Although Crohn disease is a relative contraindication to performing this procedure due to concerns for the development of Crohn enteritis and higher risks for pouch complications, patients with Crohn disease can be cautiously offered this option if total colectomy is required.13-15 Toxic megacolon is another indication for colectomy and IPAA.16 Patients with colon cancer may also be offered this restorative procedure following colectomy if appropriate counseling with regard to the potential risk of recurrent cancer to the remaining bowel is provided.17-19
There is very little published data with respect to the use of the IPAA in patients who undergo radical surgical procedures for gynecologic cancers....