Ileal pouch–anal anastomosis—a personal experience reevaluating complications, pouch survival, and quality of life

Background Ileal pouch–anal anastomosis (IPAA) is the gold standard for proctocolectomy. The present study evaluates surgical outcomes of the authors’ operations over a 30-year period, including pouch survival and quality of life (QOL). Methods Records of patients undergoing IPAA between 1986 and 2015 were retrospectively analyzed regarding early and late complications and pouch survival. An online survey assessed QOL. Results Of 119 patients, 84 had chronic inflammatory bowel disease (IBD) and 35 non-inflammatory bowel disease (non-IBD). Pouch construction was simultaneous with proctocolectomy in 69% and metachronous in 31%. Double-stapler anastomosis with purse string suture was performed in 100 patients. With temporary transanal decompression by catheter insertion in all patients, loop ileostomy (LIS) was selectively omitted in 68%. Three anastomotic insufficiencies occurred both without (4.4%) and with LIS (9.4%). Perioperative morbidity for LIS closure was substantial (33.3%). In the long-term course, 36 patients (30.5%) required revision (cumulative probability after 15 years: 59.1%). IPAA was discontinued in 16 patients (13.6%), reducing cumulative continence preservation to 72.9% after 15 years. By converting the pouch to a continent ileostomy (CI) in 6 patients with uncorrectable functional complications, cumulative pouch survival reached 81.8% after 27 years. The online survey revealed significant improvements in occupation, sports, and travel vs. before proctocolectomy, but no change in sexual life. Physical, psychological, and social scores were still below the age-matched norm values. Whereas >90% were satisfied with the surgical outcome, only 3/25 had no functional improvement requests. Conclusion IPAA in double-stapler technique is safe, even without protective LIS. However, short- and long-term morbidity is considerable, with a non-negligible risk of continence loss. Conversion to CI for purely functional complications can significantly reduce definite pouch failure. Despite patients’ high subjective satisfaction, QOL remains objectively compromised.