Ulcerative colitis (UC) is an inflammatory condition characterized by continuous inflammation throughout the colon and significantly increases the risk of developing colorectal cancer, with up to 1 in 5 patients developing cancer after 30 years of diagnosis [1]. A substantial proportion of patients (up to 30 %) will require colectomy in their lifetime for either intractable inflammation or dysplasia/cancer development [2], [3]. Patients have two broad options after colectomy, one is an end ileostomy and the other is to attempt to re-establish intestinal continuity. Restorative surgery in UC has been performed for over 60 years, with the first procedures dating back to 1953 by Stanley Aylett and colleagues [4]. Restorative surgery has essentially-two main approaches, one is ileorectal anastomosis (IRA), and the other, is ileal pouch-anal anastomosis (IPAA). Both have unique characteristics in terms of bowel function, success, complications, and longevity.

From the outset, IRA mainly aims to rid the patient of a permanent ileostomy, allowing for the return to normal activities and by extension improvement of the patient’s quality of Life (QoL). However, IRA has its own set of problems despite this laudable aim, both in terms of early postoperative complications, including anastomotic leak, prolonged ileus [5], increased stool frequency [6], recurrent proctitis [7], and the impact on long-term fertility particularly in female patients [8]. Furthermore, the risk of developing cancer in the remnant rectum persists [9] although a recent cohort study reported that the absolute risk of cancer development in the rectal remnant was only 1.6 % at 10 years [10]. Patients with IRA will require continuous surveillance and monitoring for dysplasia/cancer development because a portion of the rectum is in place. Additionally, a proportion of patients may require further surgery in the form of a permanent stoma or conversion to IPAA due to IRA failure.

Therefore, IRA has been largely superseded by IPAA over the last few decades. First described by Sir Alan Parks in 1978 [11], IPAA has gained popularity largely because IPAA permits better control over bowel movements and less urgency and obviates the need for intensive cancer surveillance of the rectal remnant. However, IRA is still performed in current practice in patients who want to avoid more extensive pelvic surgery and thereby avoid the risk of reduced fecundity and erectile dysfunction. While much has been published with regards to surgical outcomes between IRA and IPAA in terms of surgical outcomes and function, there remains little in the literature with regards to the quality of life and symptom experienced post-IRA surgery. This systematic review aims to assess short- and long-term outcomes after IRA for UC, including leak rates, IRA failure (as defined by conversion to pouch or end stoma), dysplasia/cancer risk in the rectal remnant, and QoL post-IRA surgery.