2-stage Ileal Pouch-anal Anastomosis Research Articles

Risk factors and outcomes of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Retrospective study of 75 single center cases.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical gold standard in patients with ulcerative colitis (UC). Results are generally satisfactory but there is a significant rate of patients who experience postoperative complications. The aims of our study were to identify the pre- and intraoperative risk factors and their correlation with the reported outcomes. A retrospective study was conducted on the medical records of all consecutive patients undergoing restorative proctocolectomy with IPAA for UC in our center from 2010 to 2021. Pre- and intraoperative factors were examined and correlated with pouchitis, endoscopic pouchitis, pouch failure, anastomotic leak, postoperative complications classified according to Clavien-Dindo score and stoma outlet obstruction. A univariate and multivariate statistical analysis was performed. Out of 75 patients undergoing 3- or 2-stage IPAA surgery, the coexistence of extraintestinal clinical manifestations and preoperative topical rectal stump therapy for active proctitis were significantly associated with the occurrence of pouchitis (OR=4.4, p=0.03 and OR=7.6, p=0.01). Endoscopic pouchitis was found to be related to preoperative topical rectal therapy (OR=10.2, p=0.007), but not to extraintestinal manifestations of disease. Anastomotic leak was found to be significantly related to pouch failure (OR=22.7, p=0.007). Surgical indication for malignancy increased the risk for early complications (Clavien-Dindo >2) (OR=16.0, p=0.04). Young age was associated with the occurrence of outlet stoma obstruction in patients with recent IPAA surgery (OR=0.97, p=0.05). Based on observed results, an appropriate preoperative patient assessment aimed at detecting specific risk factors is crucial to identify early or prevent worse outcomes in patients undergoing IPAA surgery.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

OP13 Modified 2-stage vs. 3-stage ileal pouch-anal anastomosis result in equivalent long-term functional outcomes and pouch survival: A matched-pair analysis

Abstract Background Long-term outcomes data after modified 2-stage ileal pouch anal anastomosis (IPAA), defined as completion proctectomy (CP) and IPAA without loop ileostomy, is lacking. We aimed to describe long-term functional results, patient satisfaction, and pouch survival in a cohort of patients from a high-volume center. We hypothesized selective m2-stage can result in comparable long-term pouch survival relative to a 3-stage approach. Methods Our institutional ileal pouch database was retrospectively reviewed to identify patients who underwent index IPAA surgery from 1983–2019. Adults >18 years of age who underwent CP with IPAA were included. At our specialized institution, m2-stage is performed selectively based on surgeon judgement. Patients were stratified into 2 groups (3-stage vs m2-stage) and matched on a 1:1 basis based on age ±5, year of operation ±3, gender, preoperative diagnosis, double-stapled vs handsewn, and laparoscopy. Primary outcome was pouch survival, with pouch failure defined as permanent diversion, pouch excision, or conversion to a Kock pouch. Results In total, 2,433 patients were included, of whom 2,198 (90.3%) underwent 3-stage IPAA and 235 (9.7%) m2-stage IPAA. Matching resulted in 223 matched pairs, and long-term pouch survival (95.5% vs 93.2%, p=0.32) did not significantly differ (Figure 1). Short-term outcomes in the matched pairs revealed a shorter postoperative length of stay in the 3-stage patients (5 vs 8 days, p<0.001), but no significant difference in postoperative complications (12.1% vs 17%, p=0.09) was seen between the matched 3-stage and m2-stage patients, respectively. Functionally, there was no difference in the number of stools/24 hours (7 vs 7, p=0.33) or in proportion of patients requiring seepage protection at night (29.7% vs 24.6%, p=0.31). However, 3-stage patients required significantly more seepage protection during the day (25.1% vs 15.0%, p=0.02). Regarding pouchitis, there was no difference in the proportion of patients reporting recent symptoms (33.4% vs 33.3%, p=1.0), episodes in the last year (0 vs 0, p=0.51), or pouchitis requiring continuous medication (16.7% vs 10.1%, p=0.10). Patient satisfaction was similar as no difference in the proportion of those who would have surgery again (90.4% vs 93.7%, p=0.34), those who would recommend surgery (94% vs 95.5%, p=0.68), or overall patient satisfaction with surgery on a scale of 1 – 10 (highest) (3 vs 7, p=0.07) was reported. Figure 1: Kaplan-Meier curve for pouch survival (matched pairs) Conclusion Long-term outcomes were similar in patients who underwent modified 2-stage and 3-stage IPAA. Modified 2-stage IPAA is an alternative for selected patients with limited options if performed at high-volume centers in experienced hands.

A Single-Center Comparative Study of Open Transabdominal and Laparoscopic Transanal Ileal Pouch-Anal Anastomosis with Total Mesorectal Excision. Has the Bar Been Raised?

BackgroundMost ulcerative colitis (UC) patients requiring surgery undergo transabdominal ileal pouch-anal anastomosis (IPAA) performed minimally invasively or open. Although one multicenter study demonstrated acceptably low morbidity after transanal pouch, our initial single-center experience with transanal IPAA (ta-IPAA) was associated with an unacceptably high rate of anastomotic leak. The aim of this study was to compare the short-term outcomes of ta-IPAA and transabdominal IPAA with growing experience of transanal proctectomy and determine whether one approach offered any advantage or benefit over the other. MethodsSingle-center series of consecutive ulcerative colitis patients underwent 3-stage IPAA, either ta-IPAA or transabdominal IPAA at a tertiary referral center. The primary outcome measure was overall complications until immediately prior to stoma closure. Secondary outcomes included postoperative clinical measures. ResultsThe study group consisted of 113 patients, which included 37 (33%) patients undergoing transabdominal or open IPAA and 76 (67%) patients undergoing ta-IPAA. The overall complication rate was numerically higher in the ta-IPAA group (56%) compared to the transabdominal group (38%) (p = 0.07) as was the incidence of anastomotic leak in the ta-IPAA group (12 vs. 5%) (p = 0.17). Mean length of hospital stay was significantly higher in the transanal IPAA group (p = 0.04). Operating time, opioid use and pain scores were similar between groups. ConclusionTransanal IPAA has a higher incidence of overall complications and anastomotic leak compared to transabdominal IPAA. Postoperative length of stay is significantly higher in patients undergoing ta-IPAA. Operating room time, opiate use and pain scores are comparable between the two surgical approaches. Transanal IPAA appears to offer little advantage over transabdominal IPAA.

Determinants of Pouch-Related Symptoms, a Common Outcome of Patients With Adenomatous Polyposis Undergoing Ileoanal Pouch Surgery.

INTRODUCTION:Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is performed in patients with adenomatous polyposis syndromes (APSs). Data regarding pouch outcomes in APS are scarce. The purposes of this study were to determine the prevalence of pouch-related symptoms in patients with APS and to identify the contributing factors.METHODS:This is a prospective cohort study. Demographic, surgical, and clinical data were collected. Endoscopy was performed, and biopsies from the terminal ileum, pouch, and cuff were obtained in all patients and reviewed by a dedicated pathologist.RESULTS:Fifty-one patients with APS after IPAA were followed. Twenty patients (39.2%) had pouch-related symptoms. Single-stage IPAA had better outcomes than 2-stage IPAA: fewer daily bowel movements (42.9% vs 13.8% with ≤5 daily bowel movement, P = 0.02), more solid consistency (52.4% vs 6.9%, P < 0.001), and less abdominal pain (19% vs 48.3%, P = 0.034). Younger age at IPAA (<20) was also associated with better outcomes: fewer daily bowel movement (58.3% vs 17.9% with ≤5 daily bowel movement, P = 0.011), less watery consistency (8.3% vs 53.8%, P = 0.005), and abdominal pain (8.3% vs 43.6%, P = 0.037). Eighteen patients (35.3%) had endoscopic signs of inflammation, and 22 patients (43.1%) had histologic signs of pouchitis. However, no correlation was found between symptoms and endoscopic or histologic findings. The median pouchitis disease activity index was low (2, interquartile range 1–4) and did not correlate with clinical symptoms.DISCUSSION:Pouch-related symptoms are common in patients with APS after IPAA. One-stage IPAA and younger age at surgery are associated with better clinical outcomes. However, symptoms do not correlate well with endoscopic or histologic findings or with pouchitis disease activity index and might be attributed to a functional pouch disorder.

S0719 The Use of Surgery in Ulcerative Colitis Has Decreased in the Past Decade, With a Proportional Increase in the Use of 3-Stage Ileal Pouch-Anal Anastomosis

S0719 The Use of Surgery in Ulcerative Colitis Has Decreased in the Past Decade, With a Proportional Increase in the Use of 3-Stage Ileal Pouch-Anal Anastomosis

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program.

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis(UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA(81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program.

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA (81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

De Novo Crohn's Disease of the Pouch in Children Undergoing Ileal Pouch‐Anal Anastomosis for Ulcerative Colitis

Approximately 10% of children with ulcerative colitis (UC) undergo colectomy with ileal pouch-anal anastomosis (IPAA). We aimed to describe the postoperative outcomes, with an emphasis on chronic pouch inflammation including de novo Crohn disease (CD) at a tertiary care inflammatory bowel disease center. Electronic medical records of all children who underwent colectomy ≤18 years between 2008 and 2017 were reviewed. Clinical and laboratory data were recorded. Primary outcome was frequency of chronic pouch inflammation including de novo CD. Secondary outcomes included early (≤30 days from index surgery) and late postoperative complications. Descriptive statistics (median and interquartile range) summarized the data and univariate analysis tested associations with outcomes. Fifty-eight children underwent colectomy and 56 completed IPAA. Median age at diagnosis was 14 years (12-16.2) and at colectomy 16.2 years (14.2-17.7) with median follow-up of 13 months (5-43). Sixty-six percent underwent 3-stage IPAA and 78% were biologic exposed. Eleven had chronic pouchitis, 73% antibiotic refractory and 25% met criteria for de novo CD by median of 19 months (9-41). A total of 21% and 50% experienced early and late surgical complications, most commonly ileus and recurrent IPAA stricture. The pouch failure rate was 3.6%. Chronic pouch inflammation was associated with a later diagnosis of de novo CD (P = 0.0025). In pediatric UC, CD is not uncommon after IPAA. Chronic pouch inflammation often precedes a diagnosis of de novo CD. Families should be informed of the short- and long-term outcomes in children before UC surgery.

Pouchitis in pediatric ulcerative colitis: A multicenter study on behalf of Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition

BackgroundData on the epidemiology and risk factors for pouchitis following restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) in pediatric patients with ulcerative colitis (UC) are scarce. AimsTo determine incidence, risk factors and clinical outcome of pouchitis following IPAA in children. MethodsThis multicenter, retrospective cohort study, included all pediatric UC patients who underwent colectomy and IPAA from January 2010 to December 2016. ResultsEighty-five patients were enrolled. During a median post-surgical period of 24.8 (range: 1.0–72.0) months following IPAA, 38 (44.7%) patients developed pouchitis, including 6 (15.8%) who developed chronic pouchitis. Kaplan–Meier survival estimates of the cumulative probability for pouchitis were 14.6% at 1 year and 27.3% and 51.5% at 2 and 5 years, respectively. Multiple Cox regression model showed that older age at colectomy (hazard ratio, HR: 0.89, p = 0.008) was a protective factor, whereas chronic active colitis as indication for surgery (HR: 4.45, p < 0.001), and a 3-stage IPAA (HR: 2.86, p = 0.028) increased the risk for pouchitis. ConclusionsLong-term risk for pouchitis is significantly high in pediatric-onset UC after IPAA. Younger age at colectomy, chronic active colitis as indication for surgery and 3-stage IPAA may increase the risk for pouchitis.

P048 Type and durability of antibiotic therapy among patients with chronic antibiotic dependent pouchitis

BACKGROUND: The management of chronic antibiotic dependent pouchitis (CADP) is associated with significant morbidity and burden to patients with an ileal pouch-anal anastomosis (IPAA). When individuals fail to respond to standard antibiotic therapy for pouchitis, little guidance is available in choosing subsequent antibiotic regimens. We performed a retrospective study to evaluate specific antimicrobials as well as duration of therapy among patients treated for CADP in our multidisciplinary IBD center. METHODS: We identified patients with CADP between January 1, 2009 and December 1, 2016. Patients diagnosed with Crohn’s disease of the pouch and acute antibiotic responsive pouchitis were excluded. For each individual with CADP, we analyzed the type and duration of up to 4 antibiotic regimens. Standard descriptive statistics are presented, including medians and interquartile ranges (IQR) for duration assessments and Wilcoxon-rank sum testing for comparisons of duration of antibiotic therapy. RESULTS: A total of 288 patients were evaluated for pouch related disorders during the study period. From the initial population, 90 (31%) were excluded due to a diagnosis of Crohn's disease of the pouch and 75 (26%) were excluded due to a diagnosis of acute antibiotic responsive pouchitis. In total, there were 123 patients (53% male, mean age at time of IPAA 40.9 years) who were diagnosed with CADP. Most patients underwent a 2-stage IPAA and had pancolitis prior to colectomy. In the majority of patients (93/123; 75%), the first antibiotic regimen consisted of a fluoroquinolone alone (43%) or a fluoroquinolone in combination with either metronidazole (30%) or another antibiotic (2%). Metronidazole was used in 15%, and other antibiotics in 10% of the patients. Of the 123 patients, 93%, 76%, and 59% needed a second, third, or fourth antibiotic regimen, respectively. The use of fluoroquinolones alone or in combination decreased to 54%, 48%, and 40% of patients for the second, third, and fourth regimen. In particular, amoxicillin/clavulanate, sulfamethoxazole/trimethoprim, rifaximin and doxycycline were increasingly used in the third and fourth antibiotic approach (31% and 42%, respectively). The duration of the different antibiotic regimens varied, but fluoroquinolones alone were given for a significantly longer duration during the first 4 consecutive regimens compared to other antibiotics indicating a better persistence of therapy (regimen 1 median fluoroquinolone duration 32 weeks vs others 7.5 weeks (IQR 4–36), P &lt; 0.001; regimen 2 median 20 weeks vs 8 weeks (IQR 4–28), P = 0.038; regimen 3 median 21 weeks vs 8 weeks (IQR 4–36), P = 0.005; regimen 4 median 20 weeks vs 10 weeks (IQR 4–20), P = 0.011). CONCLUSION(S): In a retrospective cohort of patients with CADP, we found that standard therapy with a fluoroquinolone alone or in combination was most common as the initial treatment for CADP. Although fluoroquinolones in particular demonstrated significant longevity, over time the proportion of the population treated with alternative antibiotic regimens such as amoxicillin/clavulanate, sulfamethoxazole/trimethoprim, doxycycline, and rifaximin increased presumably due to loss of response to standard therapy. Further studies are needed to individualize the therapeutic approach and determine the optimal antibiotic regimen with greatest durability and long-term response for this challenging patient population.

Obese Patients Undergoing Ileal Pouch-Anal Anastomosis: Short-and Long-term Surgical Outcomes.

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with chronic ulcerative colitis. Little is known about the impact of obesity on operative characteristics, short-term postoperative complications and long-term functional outcomes after IPAA. A retrospective review of all patients undergoing IPAA for chronic ulcerative colitis at a single tertiary referral center between January 2002 and August 2013 was performed. Thirty-day postoperative complications and long-term functional outcomes were analyzed according to body mass index. Nine hundred nine IPAAs (154 obese [body mass index ≥ 30] and 755 not obese [body mass index < 30]) were performed during the study period. For 2-stage IPAA, obese patients were less likely to undergo laparoscopic IPAA (P < 0.0001), had greater estimated blood loss (P = 0.005), and longer operative times (P = 0.02). For 3-stage IPAA, obese patients were less likely to undergo a laparoscopic procedure (P = 0.03), had greater estimated blood loss (P < 0.0001), and longer operative times (P = 0.0002). Postoperatively, obese patients had a longer length of stay after a 2-stage procedure (P = 0.009), an increased rate of superficial surgical site infections (P = 0.003), and an increased rate of urinary tract infections (P = 0.03). Of the 61% (n = 546) of patients with IPAA with long-term (median 5.0 years) follow-up, there were no significant differences in functional outcomes including incontinence, frequency of bowel movements, pad usage, and pouchitis between the groups. Obesity impacts intraoperative complexity and 30-day postoperative outcomes. Long-term functional outcomes are not affected. These findings underscore the need to counsel patients on preoperative weight loss before undergoing elective IPAA.

Variant Two-Stage Ileal Pouch-Anal Anastomosis: An Innovative and Effective Alternative to Standard Resection in Ulcerative Colitis

Ulcerative colitis patients have been historically treated with standard single, 2-, and 3-stage operative approaches. We perform a variant 2-stage procedure beginning with total abdominal colectomy and end ileostomy followed by completion proctectomy and ileal pouch-anal anastomosis (IPAA) without a diverting loop ileostomy. This study evaluates the effectiveness of this innovative alternative. Patients with ulcerative colitis, admitted to the University of North Carolina Hospital between 2003 and 2010 for IPAA, were eligible for inclusion. The 3-year cumulative incidence of pouch leaks among patients undergoing variant 2-stage were compared with those undergoing classic 2-stage, using inverse probability-of-treatment weighted Kaplan- Meier survival curves, and 95% CIs were estimated using nonparametric bootstrapping. There were 248 patients who underwent IPAA; 139 (56.1%) underwent classic 2-stage and 109 (43.9%) underwent variant 2-stage. After standardization, there was no significant difference in the 3-year cumulative incidence of pouch leaks between patients undergoing variant 2-stage, compared with the standard single- or 2-stage procedure (risk difference 0.01; 95% CI -0.08, 0.15). At the time of the first surgical procedure, patients undergoing a variant 2-stage were more likely to have lower BMIs (median 22.5 kg/m2 vs 26.7 kg/m2; p<0.0001), an urgent/emergent procedure (56.9% vs 0.0%; p < 0.0001), biologic use within 2 weeks of surgery (32.1% vs 17.5%; p= 0.003), and high dose steroid use (60.4% vs 16.7%; p ≤ 0.0001). Variant 2-stage IPAA is a safe and effective operative approach with comparable outcomes in a more acute population based on BMI, steroid use, and urgency of operation.

DOP042 Omentectomy is not necessary during laparoscopic total coloproctectomy and ileal pouch-anal anastomosis for inflammatory bowel disease. A comparative study in 247 consecutive patients from 4 expert centres

Background: Today, there is no consensus about the indication of associated omentectomy during the (sub)total colectomy. Data about its impact on later small bowel obstruction are conflicting. The objective was thus to evaluate possible impact of omentectomy during total coloproctectomy and ileal pouch-anal anastomosis (IPAA) for inflammatory bowel disease. Methods: All the patients who underwent laparoscopic 2-stage IPAA for inflammatory bowel disease from 2005 to 2015 in 4 expert European centres were included and divided into 2 groups: omentectomy (Group A) and no omentectomy (Group B). Comparisons were performed between groups for the following findings: demographic features, inflammatory bowel disease characteristics, preoperative treatment in the three last months, intraoperative features, postoperative outcomes and long-term results. Results: During the study period, 247 patients (148 males, median age =45 [14–78] years) were divided into Groups A (n=109) and B (n=138). Patients in Gr. A were more frequently under steroids before IPAA (63% vs 50%, p=0.04), and required more frequently conversion into laparotomy (6% vs 1%, p=0.02). Surgical morbidity rate (31% vs 33%, p=0.78), Dindo ≥3 morbidity (35 vs 39%; p=0.84) and unplanned reoperation (12 vs 16%; p=0.46) rates were similar in both groups. Median length of stay was longer in Gr. A than B (12 vs 10 days; p<0.0001). At the end of follow up, small bowel obstruction rate was higher in Gr. A than Gr. B (10 vs 1%; p=0.003). Conclusions: This study suggests that omentectomy during laparoscopic IPAA do not modify operative results but seems to increase conversion rate, length of stay and long-term small bowel obstruction rates. Thus, omentectomy is probably not necessary during laparoscopic IPAA.

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

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

Ileal pouch anal anastomosis in pediatric familial adenomatous polyposis: A 24-year review of operative technique and patient outcomes

BackgroundTotal proctocolectomy with ileal pouch anal anastomosis (IPAA) is the operative procedure of choice for familial adenomatous polyposis (FAP) patients. We review 24years of operative experience and outcomes in pediatric patients with FAP. MethodsPatients with FAP, age<20years, presenting to a single institution between 1987 and 2011 were included. Operative technique and outcomes were reviewed retrospectively. Primary outcomes included postoperative complications (30days), long-term bowel function, and polyp recurrence at the anal anastomosis. Results95 patients with FAP underwent IPAA. Mean age at IPAA was 15.5years with a mean follow-up of 7.6years. 29 patients underwent 1-stage IPAA, 65 patients had a two-stage IPAA, and 1 patient underwent a 3-stage procedure. 67 patients had an open procedure, 25 underwent a laparoscopic approach, and more recently 3 patients underwent single incision laparoscopic IPAA. Patients with 1-stage IPAA demonstrate better long term bowel control vs. 2-stage IPAA patients (10.7% vs. 36.0% occasional incontinence, p=0.018). However, 1-stage IPAA patients suffered increased short-term complications, such as anastomotic leak (17.2% vs. 0%, p=0.002) and reoperation (20.7% vs. 4.6%, p=0.02) compared to 2-stage IPAA. Anal anastomosis polyp recurrence occurred in 22.7% of 1-stage patients and 10.0% of 2-stage patients. Short-term complications, polyp recurrence, or long-term continence were equivalent between open and laparoscopic cases. ConclusionSingle-stage IPAA in children with FAP is associated with better bowel control but increased anastomotic leak, reoperative rate, and polyp recurrence. In experienced hands, laparoscopic IPAA is equivocal to open IPAA.

Possible Overuse of 3-Stage Procedures for Active Ulcerative Colitis

There is an assumption that patients treated with 3-stage procedures for active ulcerative colitis are undergoing a safer surgical approach and thus spared the complications associated with a 2-stage procedure. However, there is a paucity of data addressing the validity of this assumption, and the optimal staging approach for patients traditionally considered at high risk for anastomotic leak remains unclear. To identify factors associated with 3- vs 2-stage procedures and to determine their impact on surgical outcomes. Retrospective analysis of patients who underwent 2-stage or 3-stage ileal pouch-anal anastomosis (IPAA) surgery for active ulcerative colitis due to failure of medical management over a 10.5-year period (September 1, 2000, to March 30, 2011). The mean (SEM) follow-up was 5.15 (0.24) years (range, 0.26-11.09 years). Single large academic medical center. One hundred forty-four patients treated with 3- or 2-stage IPAA surgery for active ulcerative colitis. Among these patients, 77 were male and 67 were female. The mean (SEM) age was 34.6 (1.0) years (range, 11-67 years). Of the 144 patients, 116 (80.6%) had a 2-stage procedure and 28 (19.4%) had a 3-stage procedure. Two-stage vs 3-stage IPAA procedures for active ulcerative colitis. Factors leading to decision for 3-stage procedure, postoperative outcomes with 3-stage vs 2-stage procedures, and risks for complications in patients undergoing 3-stage vs 2-stage procedures. RESULTS Of 144 patients, only 19.4% had a 3-stage procedure. Decision to perform a 3-stage vs 2-stage procedure was affected by emergent status (P < .001) and hemodynamic instability (P = .04) but not by age, sex, body mass index, use of steroids, or use of anti-tumor necrosis factor agents. For patients with 2-stage procedures, multivariate regression revealed that the number of perioperative complications was affected by surgeon experience (P = .02) but not by emergent status, use of steroids, or use of anti-tumor necrosis factor agents. Two-stage procedures were associated with more perioperative complications on univariate analysis (P = .05), but multivariate regression suggested that this difference was due to surgeon experience (P = .02) rather than to creation of an IPAA at the first operation (P = .55). Importantly, 2-stage procedures did not change the risk of anastomotic leak when all operations were taken into account (odds ratio = 1.09; P = .94). In the long term (mean [SEM], 5.2 [0.2] years), patients who underwent 2-stage surgery had a lower risk of anal stricture (odds ratio = 8.21; P = .01) and no differences in fistula or abscess formation or in pouch failure. In patients with active ulcerative colitis, use of steroids and anti-tumor necrosis factor agents alone do not appear to justify the decision to avoid IPAA creation at the first operation provided that it is performed by a high-volume inflammatory bowel disease surgeon.

Can bedside criteria predict complications after Ileal Pouch-Anal Anastomosis for chronic Ulcerative Colitis?

Truelove and Witts' criteria remains the gold standard for assessment of disease severity in ulcerative colitis, but it's clinical use is not ideal given its reliance on the combination of clinical, laboratory, and radiographic variables. In a recent study reporting the feasibility of minimally invasive subtotal colectomy and ileal pouch-anal anastomosis (IPAA) for fulminant colitis, we described surgical selection criteria which can be assessed at the bedside, including 1) recent (prior 6 weeks) hospitalization, 2) recent transfusion, 3) malnutrition (weight loss, hypoalbuminemia, or need for parenteral nutrition), or 4) immunosuppression (corticosteroids or infliximab). We aimed to determine if these criteria were associated with overall or infectious complications when present in a cohort of patients who underwent 2-stage IPAA. We identified all adult patients with CUC who underwent hand-assisted laparoscopic total proctocolectomy TPC-IPAA (stage 1 of 2) at our institution from 2004 - 2009 using a prospectively maintained database. Disease extent and severity was assessed according to the Montreal classification. Univariate analysis was performed to assess associations with overall or infectious complications after IPAA. Multivariate logistic regression analysis was performed to assess associations with overall 30-day complications. Data are frequency (proportion), median (interquartile range). Over 5-years, 212 patients underwent HALS-IPAA. Overall age was 35 (26 - 46) years, 88 (41%) women, BMI 25.3 (21.3 - 28.4) kg/m2. According to the Montreal classification of extent, 172 (80%) had pancolitis (E3), 34 (16%) had left-sided colitis (E2), and 8 (3.7%) had ulcerative proctitis (E1), and severity was classified as follows: 7 (3.2%) had severe colitis (S3), 84 (39%) moderate colitis (S2), 100 (48%) mild colitis (S1), and 23 (11%) asymptomatic (S0). A total of 169 (79%) were receiving steroids or infliximab, 49 (23%) had been recently hospitalized, 27 (13%) had evidence of malnourishment, and 16 (7.4%) had recent transfusion. Median operative time was 290 (241 - 354) minutes, 16 (7.4%) were converted to laparotomy, and the median post-operative length of stay was 5 (4 - 7) days. Overall 81 (38%) of patients developed a complication of any grade; 29 of these (13.5% overall) were infectious complications. On univariate analysis, neither Montreal classification extent or severity, nor any of the 4 clinical criteria were associated with overall complications; recent hospitalization (p= 0.5), transfusions (p= 0.82), immunosuppression (p= 0.96) were not associated with infectious complications, while malnutrition was associated with post-operative infections (p= 0.04). When stratified by the number of selection criteria present (2 or more, 3 or more) no statistically significant associations were noted with either overall or infectious complications on univariate analysis. On multivariate analysis of predictors for overall complications, including adjustment for disease severity, no statistically significant associations were noted; multivariate analysis of infectious complications was limited by the absolute number of events. In patients undergoing 2-stage ileal pouch-anal anastomosis, malnutrition appears to be a risk factor for post-operative infectious complications. Further study in a larger cohort is needed to determine if this association is independent of disease severity, extent, or other clinically important variables.