Outcome of ileorectal anastomosis in an inflammatory bowel disease surgery experience of three decades.

OBJECTIVE: To reevaluate the role of ileorectal anastomosis (IRA) following total colectomy for inflammatory bowel disease in relation to the recent popularity of ileoanal reservoir anastomosis.

DESIGN: In a retrospective analysis of 255 patients who underwent colectomy for inflammatory bowel disease, we found that 144 patients had IRAs: 68 for ulcerative colitis and 76 for Crohn's disease. The follow-up ranged from 6 months to 30 years (mean, 22 years).

SETTING: A community teaching hospital. Patient compliance for close surveillance was sine qua non in selection.

PARTICIPANTS: Patients with ulcerative colitis or Crohn's disease who were selected for IRA if the anal sphincter apparatus was not severely compromised by perineal suppurative disease, if the conventional medical therapies had failed, if the rectum was relatively distensible, and if primary anastomosis was seen to be free of severe inflammatory disease.

INTERVENTIONS: Primary IRA was performed in 74 patients in whom the rectum was relatively healthy; in 63 patients, temporary end ileostomy with a mucus fistula was performed. The rectal stump was treated with topical steroids, and a secondary anastomosis was performed.

OUTCOME: The quality of life, rate of subsequent rectal excision, and development of carcinoma in the rectum were assessed to determine the validity of and appropriate recommendation for this procedure.

RESULTS: In a follow-up of 1 to 33 years, 129 patients had functioning IRAs. Four patients with functioning IRAs died of unrelated causes. Eight proctectomies (11.7%) were performed in patients with ulcerative colitis, seven (9.2%) in patients with intractable Crohn's disease, and two (1.4%) in patients with cancer.

CONCLUSIONS: An IRA following total colectomy for patients with ulcerative colitis or Crohn's disease is an acceptable alternative when the sphincter mechanism is intact and the rectum is distensible. Close surveillance is necessary.