Ileostomy or ileal pouch for the surgical treatment of ulcerative colitis?

Until recently, the elective surgical treatment of patients with ulcerative colitis has been either proctocolectomy with a permanent ileostomy or colectomy and ileorectal anastomosis (IRA). The former technique has many disadvantages, not least being the psychological readjustment necessary to face life with an incontinent orifice on the abdominal wall. IRA appears on face value to be more acceptable, but unfortunately disease is left behind in the rectum, which not only may cause persistent gastrointestinal symptoms, but exposes the patient to the considerable risk of developing carcinoma. For these reasons surgeons have striven for a technique which can eradicate the disease entirely, yet restore gastrointestinal continuity and continence. In the past decade, such a procedure has been developed. This operation, known as mucosal proctectomy and pouch anal anastomosis or restorative proctocolectomy, consists of colectomy, removal of the rectal mucosa, and the creation of a pouch from the terminal ileum. The latter is then pulled through the rectal muscular cuff and is anastomosed to the anal canal via the transanal route.1 The procedure is based on several tenets. First, that ulcerative colitis is a mucosal disease, and thus removal of the colon and rectal mucosa results in its eradication; second, that continence is preserved because the receptors necessary for its maintenance