State of the Art: Pouch Surgery in the 21st Century.

BACKGROUND: An ileoanal pouch with ileal pouch-anal anastomosis is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations.

OBJECTIVE: To review the main changes in pouch surgery during the last two decades, with focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration.

RESULTS: The decision on the number of stages depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open in the hostile pelvis. The J pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications.

CONCLUSIONS: Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each individual patient. See video from symposium.