The ileal pouch-anal anastomosis procedure has become the procedure of choice for many patients with chronic ulcerative colitis and with familial adenomatous polyposis. The results in several thousand patients from many institutions are excellent. In an attempt to reduce the number of bowel movements and to improve continence, a modification of the original hand-sewn anastomosis has been proposed in which and ileal pouch distal rectal anastomosis is performed which, in turn, leaves from 1 to 3 cm of diseased rectal mucosa above the anal canal. Advocates of this modification state that resting pressure is higher and that continence, particularly nighttime continence, is significantly improved. Despite some apparent advantage, with less of a decrease in resting pressure and an advantage in ease of operation, no advantage over hand-sewn ileal pouch-anal anastomosis has been shown to-date in two prospective randomized trials in functional results or in complication rate. In addition, it is uncertain what the significance is of the small strip of diseased mucosa that i retained as far a recurrent disease, continuation of extra-intestinal manifestations of inflammatory bowel disease, and with risk of carcinoma. We believe that the stapled ileal pouch distal rectal anastomosis should be avoided in patients who have severe chronic ulcerative colitis low in the rectum or if there is proximal chronic ulcerative colitis with dysplasia or carcinoma. We also feel that this procedure should be avoided in patients with familial adenomatous polyposis and in patients who have extra-intestinal manifestations of inflammatory bowel disease.(ABSTRACT TRUNCATED AT 250 WORDS)