Transanal ileal pouch-anal anastomosis: A systematic review and meta-analysis of technical approaches and clinical outcomes

Abstract

Purpose: Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.

Methods: Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.

Results: Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.

Conclusions: Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.

Keywords: Ileoanal; Meta-analysis; Systematic Review; Transanal; Ulcerative Colitis.

Fig. 1

Prisma flowchart of search strategy

Fig. 2

Overlap Analysis. Venn diagrams demonstrating (A) Patient overlap for transanal patients between studies, (B) Patient overlap for transabdominal patients. 179 patients overlapped in the Ta-IPAA group, and 70 in the abd-IPAA cohorts, leaving a total of 404 unique Ta-IPAA patients, and 563 abd-IPAA patients across the studies

Fig. 3

Non-comparative outcomes forest plots. Proportion of events as fraction of total population is plotted for each variable. I² describes study heterogeneity, and p values relate to significance of heterogeneity

Fig. 4

Meta-analysis of Ta-IPAA compared to abd-IPAA. Left side of plot favours Ta-IPAA, right side favours abd-IPAA. Risk difference is reported for dichotomous variables, and mean difference for continuous variables. I² describes study heterogeneity, and p values relates to the significance of heterogeneity

Fig. 5

Meta-analysis of post operative co-morbidity of Ta-IPAA compared to abd-IPAA. Left side of plot favours Ta-IPAA, right side favours abd-IPAA. I² describes study heterogeneity, and p values relates to the significance of heterogeneity