A Single-Center Comparative Study of Open Transabdominal and Laparoscopic Transanal Ileal Pouch-Anal Anastomosis with Total Mesorectal Excision. Has the Bar Been Raised?

Background Most ulcerative colitis (UC) patients requiring surgery undergo transabdominal ileal pouch-anal anastomosis (IPAA) performed minimally invasively or open. Although one multicenter study demonstrated acceptably low morbidity after transanal pouch, our initial single-center experience with transanal IPAA (ta-IPAA) was associated with an unacceptably high rate of anastomotic leak. The aim of this study was to compare the short-term outcomes of ta-IPAA and transabdominal IPAA with growing experience of transanal proctectomy and determine whether one approach offered any advantage or benefit over the other. Methods Single-center series of consecutive ulcerative colitis patients underwent 3-stage IPAA, either ta-IPAA or transabdominal IPAA at a tertiary referral center. The primary outcome measure was overall complications until immediately prior to stoma closure. Secondary outcomes included postoperative clinical measures. Results The study group consisted of 113 patients, which included 37 (33%) patients undergoing transabdominal or open IPAA and 76 (67%) patients undergoing ta-IPAA. The overall complication rate was numerically higher in the ta-IPAA group (56%) compared to the transabdominal group (38%) (p = 0.07) as was the incidence of anastomotic leak in the ta-IPAA group (12 vs. 5%) (p = 0.17). Mean length of hospital stay was significantly higher in the transanal IPAA group (p = 0.04). Operating time, opioid use and pain scores were similar between groups. Conclusion Transanal IPAA has a higher incidence of overall complications and anastomotic leak compared to transabdominal IPAA. Postoperative length of stay is significantly higher in patients undergoing ta-IPAA. Operating room time, opiate use and pain scores are comparable between the two surgical approaches. Transanal IPAA appears to offer little advantage over transabdominal IPAA.