The History of the Ileoanal Pouch

  • John Nicholls
  • Guy Worley


This chapter summarises roughly 100 years of innovation in colorectal surgery. Colectomy was introduced as a treatment for ulcerative colitis in the 1940s, dramatically lowering mortality. Quality of life improved markedly with the introduction in the early 1950s of the spout everted ileostomy. By the 1960s there was general consensus that proctocolectomy with permanent ileostomy was the procedure of choice for ulcerative colitis when surgery was indicated.

In parallel, there had been focus on the avoidance of the permanent ileostomy through procedures such as colectomy with ileorectal anastomosis and to a lesser extent proctocolectomy with ‘straight’ ileoanal anastomosis. With the introduction in the late 1960s of the continent ileostomy which included a small intestinal reservoir and the simultaneous development of endoanal anastomotic technique, the essential elements of restorative proctocolectomy or the ‘pouch operation’ were in place. The operation was first carried out in the late 1970s and included a mucosal proctectomy with manual anastomosis. The initial ‘S’ reservoir was modified to a ‘J’ in the early 1980s and later to a ‘W’ to increase capacity. The ‘J’ configuration has proved most used over time. There have been important technical developments of restorative proctocolectomy in the subsequent decades regarding design, the method of construction of the anastomosis, whether a de-functioning ileostomy is routinely necessary and the use of minimally invasive surgery.


Restorative proctocolectomy Ileoanal pouch Development Innovation Ulcerative colitis Familial adenomatous polyposis 


  1. 1.
    Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978;2:85–8.CrossRefGoogle Scholar
  2. 2.
    Wilks S, Moxon W. Lectures on pathological anatomy. 2nd ed. London: J&A Churchill; 1875.Google Scholar
  3. 3.
    White H. On simple ulcerative colitis and other rare intestinal tumours. Lancet. 1888;131:1130–1.CrossRefGoogle Scholar
  4. 4.
    Cammeron H, Rippman CH. Statistics of ulcerative colitis from London hospitals. Proc R Soc Med. 1909;2:100.Google Scholar
  5. 5.
    Brown J. The value of complete physiological rest of the large bowel in the treatment of certain ulcerative and obstructive lesions of this organ. Surg Gynecol Obstet. 1913;16:610.Google Scholar
  6. 6.
    Corbett CR. A review of the surgical treatment of chronic ulcerative colitis. Proc R Soc Med. 1945;38:277.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Cattell R. New type of ileostomy for chronic ulcerative colitis. Surg Clin North Am. 1939;19:629–35.Google Scholar
  8. 8.
    Miller CG, Ripstein CB, Tabah EG. The surgical management of ulcerative colitis surgery. Gynecol Obstet. 1949;88:351–8.Google Scholar
  9. 9.
    Cattell R. Discussion on the surgery of ulcerative colitis. Proc R Soc Med. 1953;46:1021.Google Scholar
  10. 10.
    Brooke BN. The management of an ileostomy. Lancet. 1952;260:102–4.CrossRefGoogle Scholar
  11. 11.
    Warner E, Taylor S. Meeting of the Section of Proctology of the Royal Society of Medicine with the American Proctological Society. London June 29-July 1. Proc R Soc Med. 1959;52(Suppl. 3):31.Google Scholar
  12. 12.
    Devine H. Method of colectomy for desperate cases of ulcerative colitis. Surg Gynecol Obstet. 1943;76:136.Google Scholar
  13. 13.
    Aylett SO. Three hundred cases of diffuse ulcerative colitis treated by total colectomy and Ileo-rectal anastomosis. Brit med J. 1966;1:1001–5.CrossRefGoogle Scholar
  14. 14.
    Newton CR, Baker WN. Comparison of bowel function after ileorectal anastomosis for ulcerative colitis and colonic polyposis. Gut. 1975;16:785–91.CrossRefGoogle Scholar
  15. 15.
    Hawley PR. Ileorectal anastomosis. Br J Surg. 1985;72(S1):s75–6.CrossRefGoogle Scholar
  16. 16.
    Nissen R. Sitzungsberichte aus Chirurgischen Gesellschaften Berliner Gesellschaft für Chirurgie. Zentralbl Chir. 1933;60:888.Google Scholar
  17. 17.
    Ravitch MM, Sabiston DC. Anal ileostomy with sphincter preservation in patients requiring total colectomy for benign conditions. Surgery. 1948;24:170–87.PubMedGoogle Scholar
  18. 18.
    Valiente MA, Rey H, Rico P, Bacon HE. Construction of pouch using ‘pantaloon’ technic for pull-through of ileum following total colectomy. Am J Surg. 1955;90:742–50.CrossRefGoogle Scholar
  19. 19.
    Kock NG. Intra-abdominal ‘reservoir’ in patients with permanent ileostomy. Arch Surg. 1969;99(2):223–31.CrossRefGoogle Scholar
  20. 20.
    Devine J, Webb R. Resection of the rectal mucosa, colectomy, and anal ileostomy with normal continence. Surg Gynecol Obstet. 1951;92:437–42.PubMedGoogle Scholar
  21. 21.
    Peck DA, German JD, Jackson FC. Rectal resection for benign disease: a new technic. Dis Colon Rectum. 1966;9:363–6.CrossRefGoogle Scholar
  22. 22.
    Beart RWJ, Fleming CR, Banks PM. Tubulovillous adenomas in a continent ileostomy after proctocolectomy for familial polyposis. Dig Dis Sci United States. 1982;27(6):553–6.CrossRefGoogle Scholar
  23. 23.
    Wu JS, McGannon EA, Church JM. Incidence of neoplastic polyps in the ileal pouch of patients with familial adenomatous polyposis after restorative proctocolectomy. Dis Colon Rectum United States. 1998;41(5):552–7.CrossRefGoogle Scholar
  24. 24.
    Parc YR, Olschwang S, Desaint B, Schmitt G, Parc RG, Tiret E. Familial adenomatous polyposis: prevalence of adenomas in the ileal pouch after restorative proctocolectomy. Ann Surg. 2001;233(3):360–4.CrossRefGoogle Scholar
  25. 25.
    Dozois RR, Goldberg SM, Rothenberger DA, Utsunomiya J, Nicholls RJ, Cohen Z, Hulten L, Moskowitz RL, Williams NS. Symposium restorative proctocolectomy with ileal reservoir. Int J Colorectal Dis. 1986;1:2–19.CrossRefGoogle Scholar
  26. 26.
    Setti-Carraro P, Ritchie JK, Wilkinson KH, Nicholls RJ, Hawley PR. The first 10 years’ experience of restorative proctocolectomy for ulcerative colitis. Gut. 1994;35:1070–5.CrossRefGoogle Scholar
  27. 27.
    Pemberton JN, Kelly KA, Beart RW, Dozois RR, Wolff BG, Ilstrup DM. Ileal pouch-anal anastomosis for chronic ulcerative colitis: long term results. Ann Surg. 1987;206:504–13.CrossRefGoogle Scholar
  28. 28.
    Fazio VW, O’Riordain MG, Lavery IC, Church JM, Lau P, Strong SA, et al. Long-term functional outcome and quality of life after stapled restorative proctocolectomy. Ann Surg. 1999;230:575.CrossRefGoogle Scholar
  29. 29.
    Tiret E, Kartheuser A, Legrand M, Penna C, Parc R. Ileo-anal pouch anastomosis: results in ulcero-hemorrhagic rectocolitis and in familial adenomatous polyposis. Acta Gastroenterol Belg Belgium. 1990;53(4):423–9.Google Scholar
  30. 30.
    Oresland T, Fasth S, Nordgren S, Hulten L. The clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients. Int J Colorectal Dis. 1989;4:50–6.CrossRefGoogle Scholar
  31. 31.
    Cohen Z, McLeod RS, Stern H, Grant D, Nordgren S. The pelvic pouch and ileoanal anastomosis procedure. Surgical technique and initial results. Am J Surg. 1985;150:601–7.CrossRefGoogle Scholar
  32. 32.
    Philipson B, Brandberg A, Jagenburg R, Kock NG, Lager I, Ahren C. Mucosal morphology, bacteriology, and absorption in intra-abdominal ileostomy reservoir. Scand J Gastroenterol. 1975;10:145–53.PubMedGoogle Scholar
  33. 33.
    Moskowitz RL, Shepherd NA, Nicholls RJ. An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal ileal reservoir. Int J Colorectal Dis. 1986;1:167–74.CrossRefGoogle Scholar
  34. 34.
    Madden MV, Farthing MJ, Nicholls RJ. Inflammation in ileal reservoirs: ‘pouchitis. Gut. 1990;31:247–9.CrossRefGoogle Scholar
  35. 35.
    Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF. Pouchitis after ileal pouch-anal anastomosis: a pouchitis disease activity index. Mayo Clin Proc. 1994;69:409–15.CrossRefGoogle Scholar
  36. 36.
    Gionchetti P, Rizzello F, Helwig U, Venturi A, Lammers KM, Brigidi P, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology. 2003;124:1202–9.CrossRefGoogle Scholar
  37. 37.
    Heuschen UA, Autschbach F, Allemeyer EH, Zollinger AM, Heuschen G, Uehlein T, et al. Long-term follow-up after ileoanal pouch procedure: algorithm for diagnosis, classification, and management of pouchitis. Dis Colon Rectum United States. 2001;44:487–99.CrossRefGoogle Scholar
  38. 38.
    Olsen KO, Joelsson M, Laurberg S, Oresland T. Fertility after ileal pouch-anal anastomosis in women with ulcerative colitis. Br J Surg. 1999;86:493–5.CrossRefGoogle Scholar
  39. 39.
    Olsen KO, Juul S, Bulow S, Jarvinen HJ, Bakka A, Bjork J, et al. Female fecundity before and after operation for familial adenomatous polyposis. Br J Surg. 2003;90:227–31.CrossRefGoogle Scholar
  40. 40.
    Bartels SAL, D’Hoore A, Cuesta MA, Bensdorp AJ, Lucas C, Bemelman WA. Significantly increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional study. Ann Surg. 2012;256:1045–8.CrossRefGoogle Scholar
  41. 41.
    Beyer-Berjot L, Maggiori LL, Birnbaum D, Lefevre JHJH, Berdah SS, Panis Y. A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study. Ann Surg. 2013;258:275–82.CrossRefGoogle Scholar
  42. 42.
    Utsunomiya J, Iwama T, Imago M, Matsuo S, Sawai S, Yaegashi K, Hirayama R. Total colectomy, mucosal proctectomy and ileo-anal anastomosis. Dis Colon Rectum. 1980;23:459–66.CrossRefGoogle Scholar
  43. 43.
    Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs. Br J Surg. 1985;72:470–4.CrossRefGoogle Scholar
  44. 44.
    Heppell J, Kelly KA, Phillips SF, Beart RW Jr, Telander RL, Perrault J. Physiologic aspects of continence after colectomy, mucosal proctectomy, and endorectal ileo-anal anastomosis. Ann Surg. 1982;195:435–43.CrossRefGoogle Scholar
  45. 45.
    Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg. 1987;74:564–6.CrossRefGoogle Scholar
  46. 46.
    Fonkalsrud EW. Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy. Ann Surg. 1984;199:151–7.CrossRefGoogle Scholar
  47. 47.
    Lovegrove RE, Heriot AG, Constantinides V, Tilney HS, Darzi AW, Fazio VW, Nicholls RJ, Tekkis PP. Meta-analysis of short-term and long-term outcomes of J, W and S ileal reservoirs for restorative proctocolectomy. Colorectal Dis. 2007;9:310–20.CrossRefGoogle Scholar
  48. 48.
    McCormick PH, Guest GD, Clark AJ, Petersen D, Clark DD, Stevenson AR, Stitz R. The ideal ileal-pouch design: a long-term randomized control trial of J- vs W-pouch construction. Dis Colon Rectum. 2012;55:1251–7.CrossRefGoogle Scholar
  49. 49.
    Heald RJ, Allen DR. Stapled ileo-anal anastomosis: a technique to avoid mucosal proctectomy in the ileal pouch operation. Br J Surg. 1986;73:571–2.CrossRefGoogle Scholar
  50. 50.
    Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH, Nicholls RJ, Fazio VW, Tekkis PP. A comparison of hand-sewn versus stapled Ileal Pouch Anal Anastomosis (IPAA) following proctocolectomy. Ann Surg. 2006;244:18–26.CrossRefGoogle Scholar
  51. 51.
    Wong NY, Eu KW. A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum. 2005;48(11):2076–9.CrossRefGoogle Scholar
  52. 52.
    Weston-Petrides GK, Lovegrove RE, Tilney HS, Heriot AG, Nicholls RJ, Mortensen NJ, Fazio VW, Tekkis PP. Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg. 2008;143:406–12.CrossRefGoogle Scholar
  53. 53.
    Gignoux BM, Dehni N, Parc R, Tiret E. Ileal pouch anal-anastomosis without covering ileostomy. Gastroenterol Clin Biol. 2002;26:671–4.PubMedGoogle Scholar
  54. 54.
    Santoro E, Carlini M, Carboni F, Feroce A. Laparoscopic total proctocolectomy with ileal J pouch-anal anastomosis. Hepatogastroenterology Greece. 1999;46(26):894–9.Google Scholar
  55. 55.
    Dunker MS, Bemelman WA, Slors JF, van Duijvendijk P, Gouma DJ. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum. 2001;44:1800–7.CrossRefGoogle Scholar
  56. 56.
    Leo CA, Samaranayake S, Perry-Woodford ZL, Vitone L, Faiz O, Hodgkinson JD, et al. Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery. Colorectal Dis. 2016;18:1162–6.CrossRefGoogle Scholar
  57. 57.
    Borstlap WAA, Harran N, Tanis PJ, Bemelman WA. Feasibility of the TAMIS technique for redo pelvic surgery. Surg Endosc. 2016;30:5364–71.CrossRefGoogle Scholar
  58. 58.
    Singh P, Bhangu A, Nicholls RJ, Tekkis P. A systematic review and meta-analysis of laparoscopic vs open restorative proctocolectomy. Colorectal Dis. 2013;15:e340–51.CrossRefGoogle Scholar
  59. 59.
    Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg. 2003;238(2):229–34.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Hahnloser D, Pemberton JH, Wolff BG, Larson DR, Crownhart BS, Dozois RR. Results at up to 20 years after ileal pouch–anal anastomosis for chronic ulcerative colitis. Br J Surg. 2007;94(3):333–40.CrossRefGoogle Scholar
  61. 61.
    Tekkis PP, Lovegrove RE, Tilney HS, Smith JJ, Sagar PM, Shorthouse AJ, Mortensen NJ, Nicholls RJ. Long-term failure and function after restorative proctocolectomy – a multi-centre study of patients from the UK National Ileal Pouch Registry. Colorectal Dis. 2010;12:433–41.CrossRefGoogle Scholar
  62. 62.
    Tekkis PP, Fazio VW, Lavery IC, Remzi FH, Senagore AJ, Wu JS, Strong SA, Poloneicki JD, Hull TL, Church JM. Evaluation of the learning curve in ileal pouch-anal anastomosis surgery. Ann Surg. 2005;241:262–8.CrossRefGoogle Scholar
  63. 63.
    Galandiuk S, Scott NA, Dozois RR, Kelly KA, Ilstrup DM, Beart RW Jr, Wolff BG, Pemberton JH, Nivatvongs S, Devine RM. Ileal pouch-anal anastomosis. Reoperation for pouch-related complications. Ann Surg. 1990;212:446–52.CrossRefGoogle Scholar
  64. 64.
    Fazio VW, Wu JS, Lavery IC. Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment. Ann Surg. 1998;228:588–97.CrossRefGoogle Scholar
  65. 65.
    Meagher A P, Farouk R, Dozois RR, Kelly KA, Pemberton JH. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg. 1998;85:800–3.CrossRefGoogle Scholar
  66. 66.
    MacLean AR, O’Connor B, Parkes R, Cohen Z, McLeod RS. Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results. Dis Colon Rectum. 2002;45:880–6.CrossRefGoogle Scholar
  67. 67.
    Tulchinsky H, McCourtney JS, Rao KV, Chambers W, Williams J, Wilkinson KH, Nicholls RJ. Salvage abdominal surgery in patients with a retained rectal stump after restorative proctocolectomy and stapled anastomosis. Br J Surg. 2001;88:1602–6.CrossRefGoogle Scholar
  68. 68.
    Dehni N, Remacle G, Dozois RR, Banchini F, Tiret E, Parc R. Salvage reoperation for complications after ileal pouch-anal anastomosis. Br J Surg. 2005;92:748–53.CrossRefGoogle Scholar
  69. 69.
    Tekkis PP, Heriot AG, Smith JJ, Das P, Canero A, Nicholls RJ. Long-term results of abdominal salvage surgery following restorative proctocolectomy. Br J Surg. 2006;93:231–7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • John Nicholls
    • 1
  • Guy Worley
    • 1
  1. 1.St. Mark’s HospitalHarrowUK

Personalised recommendations