Laparoscopic Restorative Proctocolectomy in Adenomatus Patients

I read with great interest the series presented by Bananzadeh et al. (1). This series includes a group of 19 patients who underwent laparoscopic restorative proctocolectomy (RPC) without ileostomy, performed by the same surgeon, to treat Familial Adenomatous Polyposis (FAP) between October 2008 and May 2011. Ileal pouch-anal anastomosis (IPAA) is currently the standard surgical alternative for the majority of ulcerative colitis (UC) and FAP patients. Despite the complexity of the operation, IPAA is safe (mortality: 0.5–1%) and carries an acceptable risk of non-life-threatening complications (10–25%), achieving good long-term functional outcomes with excellent patient satisfaction (over 95%). During the last decade, the surgical technique has evolved significantly, mainly due to the growing incorporation of laparoscopic approaches. Because it is a complex technical procedure, a temporary ileostomy proximal to the ileal pouch has typically been performed (2). Thus, the most controversial aspect of the study discussed here being the omission of ileostomy in a series of laparoscopic surgeries. A protective ileostomy may reduce anastomosis leakage, prevent pelvic sepsis and fistulization, thus preserving pouch function. Consequently, it should also prevent the need for re-laparotomy and most importantly, pouch failure. The rationale for this decision is based on the fact that a protective ileostomy may limit the severity of septic complications, as the prevalence of pouch-related septic complications varies between 6% and 37% (2). Furthermore, most patients are able to accept this temporary stoma well, although it may be a source of complications after its construction or closure. These complications may include dehydration and metabolic disorders, peristomal irritation, anastomotic fistula, intestinal obstruction, and others (3). Although a protective ileostomy is still performed in the vast majority of series, its omission is associated with a similar rate of septic complications and may also provide economic advantages for select patients. By avoiding an ileostomy, the surgeon should prevent potential associated problems such as high output and complications of the stoma and its closure. Selection criteria for this choice should exclude clinical factors (high doses of steroids, malnutrition, toxicity or anemia) and technical factors (difficult procedures with intraoperative complications). Furthermore, surgeons must be sure that the ileoanal anastomosis is tension-free, that it is supplied with adequate blood flow, that the tissue rings are intact and that there are no air leaks (3, 4). Within this context, a German group studied 706 consecutive patients (494 UC, 212 FAP) in an attempt to identify subgroups of patients who were at high risk for pouch-relat* Corresponding author: Fabio Guilherme Campos, Gastroenterology Department, Colorectal Unit, Hospital das Clinicas, Medical School, University of Sao Paulo, Sao Paulo, Brazil. E-mail: fgmcampos@terra.com.br