Enteric continence and the ileal pouch-anal procedure.

The ileal pouch-anal procedure maintains enteric continence by preserving critical physiological mechanisms. The reservoir, although possessing somewhat different physiologic characteristics than the rectum, provides sufficient storage capacity to enable the patient to resume most daily activities. The intact anorectal angle continues to perform its pivotal role in the maintenance of gross fecal continence, while the functioning anal sphincter muscles fine-tune the system. The success of the procedure has shown that certain widely held "principles" of continence may be less important than previously believed. These include the requirement for a long rectal stump, the preservation of the rectosphincteric inhibitory reflex, and the maintenance of sensation to the upper half of the anal canal. Yet, results are not perfect, and it is possible that while these mechanisms are not required for gross fecal continence, their transgression results in a subtle reduction in function from that of the normal state. When one considers, however, that the only other curative procedure for patients with familial polyposis is total proctocolectomy with permanent ileostomy, the ileal pouch-anal operation represents an important advance. The disease is removed, yet reasonably effective control of enteric continence is restored such that quality of life appears to be enhanced when compared to that achieved after proctocolectomy and Brook ileostomy.