Hand-sewn or stapled ileal-pouch-anal anastomosis after proctocolectomy?

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Abstract

BACKGROUND

Whether hand-sewn ileal-pouch-anal anastomosis (IPAA) or stapled IPAA provides better functional outcome following restorative proctocolectomy in patients with IBD, familial adenomatous polyposis (FAP) or cancer is unclear.

OBJECTIVE

To evaluate and compare outcomes in patients who received hand-sewn IPAA or stapled IPAA following restorative proctocolectomy.

DESIGN AND INTERVENTION

This meta-analysis included studies that compared hand-sewn IPAA versus stapled IPAA. Databases that included EMBASE, Medline, Ovid and the Cochrane database were searched for suitable articles. Eligible studies were those that were comparative, published between 1998 and 2003 and contained at least one of the following end points: adverse outcomes, functional outcomes and anorectal physiologic measures. Adverse outcome measures included anastomotic leak, pouch failure, wound infection and postoperative mortality and neoplastic transformation of the anal transition zone (ATZ). Functional outcome measures included frequency of defecation per 24 h, incontinence, use of incontinence pads, use of antidiarrheal medication, stool seepage and quality of life. Anorectal physiologic measures included measurement of resting and squeeze pressure of the sphincter complex. Studies were reviewed and data extracted by two independent investigators who followed a planned protocol. A number of statistical analyses were performed.

OUTCOME MEASURES

The main outcome measures were postoperative complications, functional outcomes, anorectal physiology, quality of life and neoplastic transformation.

RESULTS

In total, the meta-analysis included 21 studies that contained 4,183 patients (2,699 patients had hand-sewn IPAA and 1,484 had stapled IPAA). Mean follow-up was 26.8 months and 19.6 months in the hand-sewn IPAA group and stapled IPAA group, respectively. Mean age at surgery was 32.5 years and 34.1 years in the hand-sewn IPAA group and stapled IPAA group, respectively. Postoperative complication rates, use of antidiarrheal medication and frequency of defecation were similar between groups. Patients in the stapled IPAA group had significantly less nocturnal seepage and incontinence pad use than patients in the hand-sewn IPAA group: odds ratio (OR) 2.78 (95% CI 1.70-4.56), P<0.001 and OR 4.12 (95% CI 1.48-11.44), P = 0.007, respectively. The resting and squeeze pressure in the hand-sewn IPAA group was significantly reduced compared with the stapled IPAA group by 13.36 mmHg and 14.43 mmHg, P<0.018, respectively. Meta-analysis revealed a trend towards a higher rate of ATZ dysplasia in the stapled IPAA group compared with the hand-sewn IPAA group, OR 0.42 (95% CI 0.16-1.10). Postoperative quality of life was similar between the stapled IPAA group and the hand-sewn IPAA group.

CONCLUSION

Stapled IPAA gives significantly better nocturnal continence compared with hand-sewn IPAA following proctocolectomy; other postoperative outcomes are similar between groups.

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