Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care

Background Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analyzed the effect of changes in practice on the technique of IPAA and its outcomes. Methods Patients undergoing primary IPAA at this institution were divided into three groups by date of IPAA: those operated from 1983-1993, 1994-2004, and 2005 – 2015. Demographics, patient comorbidity, surgical techniques, post-operative outcomes, pouch function and quality of life were analyzed. Results 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I=8, II=16, III=31), patients tended to be sicker (higher ASA score) and 3-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. Laparoscopic technique blossomed in the last decade. 90 day postoperative morbidity by decade was 38.3% vs. 50% vs. 48% (p<0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (p<0.0001). Functional results improved, but Quality of Life scores did not. Pouch survival rate at 10 years was maintained (94% vs. 95.2% vs. 95.2% (p=0.06). Conclusions IPAA is still evolving. Despite new generations of surgeons, more accurate diagnosis, appropriate staging, and laparoscopic technique have made IPAA a safer, more effective and enduring operation. This article is protected by copyright. All rights reserved.