Operative Strategy, Risk Factors for Leak, and the Use of A Defunctioning Ileostomy with Ileal Pouch-Anal Anastomosis: Let’s Not Divert from Diversion and the Traditional 3-Stage Approach for Inflammatory Bowel Disease

Abstract

Operative strategy, risk factors for leak and the use of a defunctioning ileostomy with ileal pouch-anal anastomosis: let’s not divert from diversion and the traditional 3-stage approach for inflammatory bowel disease. Two articles are reviewed. The first paper, ‘Modified 2-stage ileal pouch-anal anastomosis results in lower rate of anastomotic leak compared to traditional 2-stage surgery for ulcerative colitis’, is an informative single-institution retrospective review of 2-stage ileal pouch-anal anastomosis [IPAA] procedures, the traditional versus the modified, over a 13-year period. The outcome of interest was anastomotic leak following pouch creation and was defined as ‘a clinical or radiographic leak originating from the ileo-anal anastomosis or the top of the J-pouch’. The authors report a significantly reduced and impressive leak rate in the modified 2-stage group, 4.6% vs 15.7%, along with a significantly reduced length of stay albeit at 9.5 days. The sequelae and morbidity of an ileal pouch-anal anastomotic leak are not necessarily comparable to those of a tip of the J-pouch leak, with or without a diverting ostomy. The exact sites of the 46 leaks across both groups are not reported here. We are told the ‘pouch failure’ rate in the study was 0.7%, that is three patients, but it is not readily apparent what this means. Furthermore, there are no data reported on the remaining 43 patients with leaks, i.e. pouch salvage, pouch excision, temporary or permanent pouch diversion. The predominant symptom following either site of leak is poor pouch function with a direct impact on the quality of life, and these data are often impossible to glean in the current retrospective setting. However, it would be widely agreed upon that pouch function following a leak is suboptimal in comparison with pouch function with no leak. We agree, as is clearly demonstrated here in terms of outcome, that … Both authors contributed equally to this work. Corresponding author: Dr F.H. Remzi, MD, FASCRS, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: 12164455020; fax: 12164458627; Email: remzif{at}ccf.org