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The role of protective ileostomy for restorative proctocolectomy
has been debated. Although anastomotic complications
can be minimized with protective stoma (1),
several authors have reported good outcomes in patients
who have undergone restorative proctocolectomy without
ileostomy (2-5). A previous report has suggested the
possibility of rectal cancer development from the rectal
mucosa remnants resulting from ileal pouch–anal anastomosis
(IPAA) performed using the stapling technique (6).
Therefore, some authors have suggested the selective use
of this technique, particularly in patients with familial adenomatous
polyposis with rectal sparing; while in other
cases, rectal mucosectomy and hand-sewn IPAA have been
recommended (7), because the functional or manometric
outcome of staple and hand-sewn IPAA is not significantly
different (7, 8). However, lifelong surveillance of the IPAA is
essential in all patients.
The key factor to a successful operation is tension-free
anastomosis with good blood supply to the ileal pouch.
Therefore, ileal pouch elongation is a crucial step, particularly
in patients with hand-sewn IPAA, where an additional
ileal length of 3–4 cm may be required. Several techniques
for ileal pouch elongation have been reported, e.g., selective
division of branches of the superior mesenteric artery or division
of the ileocolic artery. Some authors have advocated
preserving the middle colic artery as an additional blood
supply route (9). We have proposed the technique of dividing
the submesenteric arcades and preserving 3 or 4 of the
innermost arcades of the distal ileum as well as both the

     

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