Surgery of ulcerative colitis. Restorative proctocolectomy: manual or mechanical anastomosis?

Background: One of the controversial aspects in surgery of the UC is related to the opportunity to perform or not the mucosectomy of the last 1-2 cm of the rectal ampulla in the course of restorative proctocolectomy or IPAA (ileal pouch-anal anastomosis) and therefore the necessity or otherwise of resort to a manual anastomosis. The introduction and dissemination of the staplers have led to their greater use in packaging ileal pouch and ileo\uac-anal anastomosis for their presumed ease of execution. This implies left in place the last 1-2 cm of the rectal mucosa; the innervation of the transition anal zone is preserved and sphincter damage would be reduced to a minimum; also the anastomosis would be subjected to less stress. Methods: A review of the literature of the last two decades was conducted to analyze the current role of surgery in the management of UC. Results: A meta-analysis of 4183 patients (2699 underwent total proctocolectomy with mucosectomy and manual ileo-anal anastomosis and 1484 underwent IPAA with stapler but without mucosectomy) has not point out significant differences in the incidence of postoperative complications. The incidence of nocturnal seepage and the need for antidiarrhoeal drugs argue in favor of the staplers. Manometric surveys show that pressures at rest and under stress are reduced in the group of manual anastomosis. Against the use of staplers were given the higher incidence of cuffite and the consequent increased risk of carcinogenesis. However in a recent review of the literature are reported only 17 cases of cancer; in 12 cases, dysplasia or cancer were in the resected specimen; all 17 patients had a diagnosis of UC by at least 10 years. Conclusions: With increasing experience it has been observed that the mucosectomy is burdened by alterations in innervation and in sphincter function, and furthermore introduces minimal benefits as regards the control of the disease. Shows the importance of a careful follow-up: monitoring should be initiated in all cases after 10 years of disease onset; in patients undergoing IPAA with the use of staplers has recommended a more intense and careful monitoring, with multiple biopsies in those cases where it is documented the presence of dysplasia or cancer in the surgical resected specimen