S100 Long-Term Outcomes of S-Pouch Configured Ileal Pouch-Anal Anastomosis

Abstract

Background: The ileal pouch-anal anastomosis (IPAA) is the gold standard for restoration of intestinal continuity after a total proctocolectomy, with the J-pouch most commonly used. S-pouches are more recently infrequently performed, and often in the setting of mesenteric length problems. We analyzed the indications and outcomes of S-pouches in the prior to and since the 21st century. Methods: A prospectively maintained pouch database (1983 - 2015) was queried to identify patients with an S-pouch with underlying inflammatory bowel disease. The cohort was stratified into groups based on the time of operation: before 2000 (group 1) and after 2000 (group 2). Patients’ demographics, postoperative complications, cumulative Kaplan – Meier pouch survival, function, and quality of life (QoL) were analyzed. Results: A total of 349 patients were identified: group 1 – 314 patients and group 2 – 35 patients. The median follow-up in group 1 was 12 years (16-24) vs 4 (2-10) years in group 2 (P < 0.001). Patients were comparable in terms of age, gender, BMI, and ASA scores (all p>0.05). The histopathological diagnoses were also similar in group 1 (UC 77%, CD 10%, IC 13%) vs group 2 (UC 65%, CD 6%, IC 29%), P = 0.07. The median preoperative duration of IBD was significantly longer in group 2: 11(4 - 18) years vs group 1: 7 (3-11), P < 0.001. Group 1 was treated with steroids more (62% vs 25%, P < 0.001). The majority underwent colectomy for medically refractory disease; however, dysplasia was present more in group 2 (28% vs 14%), P < 0.001. After 2000, the 3-stage approach was utilized more frequently: 18.5% vs 31%; P = 0.01. Single-stage IPAA were more common in group 1 (5% vs 0%), while handsewn anastomoses were more common in group 2: 69% vs 36%, P = 0.003. The majority had challenges reaching the pelvis leading to S-pouch creation with 37% patients in group 2 sighting bulky and short mesentery due to obesity and had proximal stoma creation. The median hospital length of stay was significantly longer in the group 1: 9 (8-11) days compared to group 2: 5 (4-6.5) days, P < 0.001. The overall morbidity was similar between the groups (group 1 vs group 2, 85% vs 74%, P = 0.12). There were significantly more anastomotic separations in group 2: 25% compared to group 1 (5%), P = 0. 001. The rates of anastomotic stricture and fistula were comparable. The estimated Kaplan-Meier pouch survival was better in group 1 compared to group 2: at 1-year (99% vs 90%), 5-years (96% vs 85%), and at 10-years (94% vs 85.3%), respectively, P = 0.001. The number of stools were also comparable between the groups, group 1 vs 2: 6 (4-9) vs 6 (5-9), P = 0.81. The quality of life did not differ in group 2 vs 1: 0.7 (0.6 – 0.9) vs 0.8 (0.7 – 0.9), P = 0.18. Conclusion(s): S-pouches are less frequently used since 2000, with more recent S-pouch construction showing higher rates of leak and pelvic sepsis yet allowing adequate reach to allow pouch construction in most patients.