Secondary Logo

Institutional members access full text with Ovid®

Share this article on:

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

Lovegrove, Richard E. MRCS*; Constantinides, Vasilis A. MB, BS*; Heriot, Alexander G. MD*‡; Athanasiou, Thanos MD*; Darzi, Ara MD*; Remzi, Feza H. MD; Nicholls, R John MD; Fazio, Victor W. MD; Tekkis, Paris P. MD*†‡

doi: 10.1097/01.sla.0000225031.15405.a3

Objective: 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.

Background: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

The present meta-analysis compared hand-sewn versus stapled ileal pouch-anal anastomosis among 21 studies between 1988 and 2003, comprising 4183 patients. Stapled anastomosis (n = 1484) had significantly improved nocturnal continence with higher anal resting and peak squeeze pressures than those with hand-sewn (n = 2699) anastomosis. The stapled group reported higher incidence of dysplasia in the anal transition zone.

From the *Imperial College London, Department of Biosurgery and Surgical Technology, St. Mary's Hospital, London, United Kingdom; †Department of Colorectal Surgery, St. Mark's Hospital, Harrow, United Kingdom; and ‡Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH.

Reprints: Paris P. Tekkis, MD, FRCS, Department of Biosurgery and Surgical Technology, St. Mary's Hospital, 10th Floor, QEQM Building, Praed Street, London W2 1NY, United Kingdom. E-mail:

© 2006 Lippincott Williams & Wilkins, Inc.