Trends and Distribution of Ileal Pouch Anal Anastomosis (IPAA) in the United States; Becoming Harder to Find in Colon and Rectal Surgery Residency Training?

Abstract

BACKGROUND: There has been concern among colon and rectal surgery residency training programs in the United States that ileal pouch anal anastomosis procedures have been decreasing, however evidence is limited. OBJECTIVE: To evaluate the number of ileal pouch anal anastomosis performed by colon and rectal surgery residents in the United States and examine the distribution of these cases on a national level. DESIGN: Retrospective. SETTINGS: The Accreditation Council for Graduate Medical Education Case Log National Data Reports were used to examine the number of ileal pouch anal anastomosis performed by residents from 2005 to 2021. The Nationwide Inpatient Sample database was used to identify all patients undergoing these procedures from 2005 to 2019. PATIENTS: All ileal pouch anal anastomosis procedures regardless of indication. MAIN OUTCOME MEASURE: Primary outcome is the number of ileal pouch anal anastomosis performed by residents yearly. Secondary outcome is the national distribution of these procedures. RESULTS: Among colon and rectal surgery residents, case log data revealed an increase in mean and total number of ileal pouch anal anastomosis from 2005 to 2013, followed by a decline in both metrics after 2013. Despite the decrease, the mean number of cases per resident remained >6 between 2011 and 2021. A weighted national estimate of 48,532 ileal pouch anal anastomosis patients were identified in the Nationwide Inpatient Sample database. A significant decrease was noted in the number of ileal pouch anal anastomosis after 2015 that persisted through 2019. There was a significant decrease in rural and urban non-teaching hospitals (from 2.1% to 1.6% and 25.6% to 4.3% respectively, p < 0.001) and an increase in urban teaching hospitals (from 72.4% to 94.1%, p < 0.001). LIMITATIONS: Nonrandomized retrospective study. CONCLUSION: Despite the recent increase in the percentage of ileal pouch anal anastomosis performed at urban academic centers, there has been a decrease in cases performed by colon and rectal surgery residents. This can have significant implications for residents who graduate without adequate experience in performing this complex procedure independently, as well as training programs that may face challenges with maintaining accreditation. See Video Abstract.