Ileal Pouch-anal Anastomosis Procedures Research Articles

Trends and Distribution of IPAAs in the United States: Becoming Harder to Find in Colon and Rectal Surgery Residency Training?

There has been concern among colon and rectal surgery residency programs in the United States that IPAA procedures have been decreasing, but evidence is limited. The study aimed to evaluate the number of IPAAs performed by colon and rectal surgery residents in the United States and analyze the distribution of these cases on a national level. Retrospective. The Accreditation Council for Graduate Medical Education Case Log National Data Reports were used to evaluate the number of IPAAs 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. All IPAA procedures regardless of indication. The primary outcome was the number of IPAAs performed by residents yearly. The secondary outcome was the national distribution of these procedures. Among colon and rectal surgery residents, case log data revealed an increase in mean and total number of IPAAs from 2005 to 2013, followed by a decline in both metrics after 2013. Despite the decrease, the mean number of cases per resident remained fewer than 6 between 2011 and 2021. A weighted national estimate of 48,532 IPAA patients were identified in the Nationwide Inpatient Sample database. A significant decrease was noted in the number of IPAAs after 2015 that persisted through 2019. There was a significant decrease in rural and urban nonteaching hospitals (from 2.1% to 1.6% and 25.6% to 4.3%, respectively; p < 0.001) and an increase in urbanteaching hospitals (from 72.4% to 94.1%; p < 0.001). Nonrandomized retrospective study design. Despite the recent increase in the percentage of IPAAs 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. ANTECEDENTES:Ha habido preocupación entre los programas de capacitación de residencia en cirugía de colon y recto en los Estados Unidos porque los procedimientos de anastomosis anal con bolsa ileal han estado disminuyendo; sin embargo, la evidencia es limitada.OBJETIVO:Evaluar el número de anastomosis anales con bolsa ileal realizadas por residentes de cirugía de colon y recto en los Estados Unidos y examinar la distribución de estos casos a nivel nacional.DISEÑO:Retrospectivo.AJUSTES:Se utilizaron los informes de datos nacionales del registro de casos de educación médica de posgrado del Consejo de Acreditación para examinar el número de anastomosis anales con bolsa ileal realizadas por residentes de 2005 a 2021. Se utilizó la base de datos de muestra nacional de pacientes hospitalizados para identificar a todos los pacientes sometidos a estos procedimientos de 2005 a 2019.PACIENTES:Todos los procedimientos de anastomosis anal con bolsa ileal independientemente de la indicación.MEDIDA DE RESULTADO PRINCIPAL:El resultado primario es el número de anastomosis anales con bolsa ileal realizadas por los residentes anualmente. El resultado secundario es la distribución nacional de estos procedimientos.RESULTADOS:Entre los residentes de cirugía de colon y recto, los datos de los registros de casos revelaron un aumento en el número medio y total de anastomosis anal con bolsa ileal de 2005 a 2013, seguido de una disminución en ambas métricas después de 2013. A pesar de la disminución, el número medio de casos por El residente permaneció >6 entre 2011 y 2021. Se identificó una estimación nacional ponderada de 48 532 pacientes con anastomosis anal con bolsa ileal en la base de datos de la Muestra Nacional de Pacientes Hospitalizados. Se observó una disminución significativa en el número de anastomosis anales con bolsa ileal después de 2015 que persistió hasta 2019. Hubo una disminución significativa en los hospitales no docentes rurales y urbanos (del 2,1% al 1,6% y del 25,6% al 4,3% respectivamente, p < 0,001) y un aumento en los hospitales universitarios urbanos (del 72,4% al 94,1%, p < 0,001).LIMITACIONES:Estudio retrospectivo no aleatorizado.CONCLUSIÓN:A pesar del reciente aumento en el porcentaje de anastomosis anal con bolsa ileal realizadas en centros académicos urbanos, ha habido una disminución en los casos realizados por residentes de cirugía de colon y recto. Esto puede tener implicaciones significativas para los residentes que se gradúan sin la experiencia adecuada en la realización de este complejo procedimiento de forma independiente, así como para los programas de capacitación que pueden enfrentar desafíos para mantener la acreditación. (Traduccion-AI-generated).

Diagnosis and treatment of primary ileal pouch leaks: a 27-year experience at a referral center

Ileal pouch-anal anastomosis (IPAA) is considered the preferred restorative surgical procedure for patients with ulcerative colitis and familial adenomatous polyposis requiring proctocolectomy. Unfortunately, postoperative leaks remain a complication with potentially significant ramifications. This study aimed to provide a comprehensive description of the evaluation, management, and outcomes of leaks after primary IPAA procedures. Between 1995 and 2022, a total of 4058 primary IPAA procedures were performed at Cleveland Clinic. From a prospectively maintained pouch registry, we retrospectively reviewed the data of 237 patients who presented to the pouch center for management. Of these, 114 (3%) had undergone the index IPAA procedure at our clinic (de novo cases), whereas 123 patients had their index IPAA performed elsewhere. Data were missing for 43 patients, resulting in a final cohort of 194 patients. Our cohort had an average age of 41 years (range, 16-76) at the time of leak diagnosis. Overall, 55.2% were males, average body mass index was 24.4kg/m2, and pain was the most prevalent presenting symptom (61.8%), followed by fever (34%). Leaks were confirmed through diagnostic testing in 141 cases, whereas 27.3% were detected intraoperatively. The most common initial diagnoses were pelvic abscess (47.4%) and enteric fistulas (26.8%), including cutaneous (9.8%), vaginal (7.2%), and bladder fistulas (3.1%). By location, leaks occurred at the tip of the "J" (52.6%), at the pouch-anal anastomotic site (35%), and in the body of the pouch (12.4%). A nonoperative management approach was initially attempted in 49.5% of cases, including antibiotic therapy, drainage, endoclip, and endo-sponge, with a success rate of 18.5%. Surgery was eventually required in 81.4% of patients, including (1) sutured or stapled pouch repair (52.5%), with diversion performed in 87.9% of these cases either before or during the salvage surgery; (2) pouch excision with neo-IPAA (22.7%), including 9 patients from the first group; and (3) pouch disconnection, repair, and reanastomosis (9.3%). Pouch failure occurred in 8.4%, with either pouch excision (11.1%) or permanent diversion (4.5%). Ultimately, 12.4% of patients (24 of 194) required permanent diversion, with all necessitating pouch excision. In the 30-day follow-up after salvage surgery, short-term complications arose in 38.7% of patients. The most common complications observed were ileus, pelvic abscess/sepsis, and fever. Leaks after primary IPAA procedures represent an infrequent, yet challenging, complication. Despite attempts at nonoperative management, the success rate is limited. Salvage surgery is associated with a high pouch retention rate, underscoring its importance in the management of post-IPAA leaks.

Third Time's the Charm? Indications and Outcomes for Redo-Redo IPAA.

Up to 20% to 40% cases of redo IPAA procedures will result in pouch failure. Whether to offer a second redo procedure to maintain intestinal continuity remains a controversial decision. To report our institutional experience of second redo IPAA procedures. This was a retrospective review. Patient-reported outcomes were compared between patients undergoing second redo procedures and those undergoing first redo procedures using propensity score matching to balance the 2 cohorts. Tertiary referral center. Patients who underwent second redo IPAA procedures between 2004 and 2021 were included in this study. Second redo IPAA. Pouch survival and patient-reported outcomes were measured using the Cleveland Global Quality of Life survey. Twenty-three patients were included (65% women), 20 (87%) with an index diagnosis of ulcerative colitis and 3 (13%) with indeterminate colitis. The final diagnosis was changed to Crohn's disease in 8 (35%) cases. The indication for pouch salvage was the same for the first and second redo procedures in 21 (91%) cases: 20 (87%) patients had both redo IPAAs for septic complications. After a median follow-up of 39 months (interquartile range, 18.5-95.5 months), pouch failure occurred in 8 (30%) cases (7 cases due to sepsis, of whom 3 never had their stoma closed, and 1 case due to poor function); all patients who experienced pouch failure underwent the second redo procedure due to septic complications. Overall pouch survival at 3 years was 76%: 62.5% in patients with a final diagnosis of Crohn's disease versus 82.5% in patients with ulcerative/indeterminate colitis ( p = 0.09). Overall quality-of-life score (0-1) was 0.6 (0.5-0.8). Quality of life and functional outcomes were comparable between first and second redo procedures, except incontinence, which was higher in second redo procedures. Single-center retrospective review. A second pouch salvage procedure may be offered with acceptable outcomes to selected patients with high motivation to keep intestinal continuity. See Video Abstract . ANTECEDENTES:Hasta un 20-40% de los casos de rehacer anastomosis anal con bolsa ileal (IPAA) resultarán en falla de la bolsa. La posibilidad de ofrecer un segundo procedimiento para mantener la continuidad intestinal sigue siendo una decisión controvertida.OBJETIVO:Reportar nuestra experiencia institucional de una segunda re-confección de la anastomosis anal con bolsa ileal.DISEÑO:Revisión retrospectiva; los resultados informados por los pacientes se compararon entre los pacientes que se sometieron a una segunda re-confeccion con los de los pacientes que se sometieron a una la primera re-confeccion utilizando el puntaje de propensión para equilibrar las dos cohortes.AJUSTES ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes que se sometieron a una segunda re-confeccion de de la anastomosis anal con bolsa ileal entre 2004 y 2021.INTERVENCIONES:Segunda re-confeccion de la anastomosis anal con bolsa ileal.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia de la bolsa, resultados informados por los pacientes medidos mediante la encuesta Cleveland Global Quality of Life.RESULTADOS:Se incluyeron veintitrés pacientes (65% mujeres), 20 (87%) con diagnóstico inicial de colitis ulcerosa y 3 (13%) con colitis indeterminada. El diagnóstico final se cambió a enfermedad de Crohn en ocho (35%) casos. La indicación para el rescate de la bolsa fue la misma para la primera y segunda re-confeccion en 21 (91%) casos: 20 (87%) pacientes tuvieron ambas re-confecciones de la anastomosis anal con bolsa ileal por complicaciones sépticas. Después de una mediana de seguimiento de 39 meses (RIC 18,5 - 95,5), se produjo falla de la bolsa en 8 (30%) casos (7 casos debido a sepsis, de los cuales 3 nunca cerraron el estoma y 1 caso debido a una mala función); todos los pacientes que experimentaron falla de la bolsa se sometieron a una segunda re-confeccion debido a complicaciones sépticas. La supervivencia global de la bolsa a los 3 años fue del 76%: 62,5% en pacientes con diagnóstico final de enfermedad de Crohn, versus 82,5% en colitis ulcerativa/indeterminada ( p = 0,09). La puntuación general de calidad de vida (0 -1) fue 0,6 (0,5 - 0,8). La calidad de vida y los resultados funcionales fueron comparables entre la primera y la segunda re-confeccion, excepto la incontinencia, que fue mayor en la segunda re-confeccion.LIMITACIONES:Revisión retrospectiva de un solo centro.CONCLUSIONES:Se puede ofrecer un segundo procedimiento de rescate de la bolsa con resultados aceptables a pacientes seleccionados con alta motivación para mantener la continuidad intestinal. (Traducción- Dr. Francisco M. Abarca-Rendon ).

National trends and outcomes of total proctocolectomy and completion proctectomy ileal pouch-anal anastomosis procedures for ulcerative colitis.

The purpose of this study is to assess US operative trends and outcomes of ulcerative colitis (UC) patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) or completion proctectomy with IPAA (CP-IPAA). Adult UC patients who underwent TPC-IPAA or CP-IPAA were analysed retrospectively using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Factors associated with 30-day overall and serious morbidity were identified using multivariable logistic regression. A total of 1696 patients were identified, with 958 patients (56.5%) undergoing TPC-IPAA and 738 (43.5%) undergoing CP-IPAA. A greater proportion of TPC-IPAAs were performed each year (except in 2019) compared to CP-IPAAs over the study period (P trend <0.001). Unadjusted analysis showed comparable rates of overall (20.8% vs. 24.4%, P = 0.076) and serious morbidity (14.3% vs. 12.7%, P = 0.352) between TPC-IPAA and CP-IPAA patients. Robotic TPC-IPAA had no differences in complications compared to laparoscopic and open approaches. Robotic CP-IPAA had higher anastomotic leak rates and longer hospital length of stay compared to laparoscopic and open approaches. Obesity was associated with increased odds of overall and serious morbidity for patients who underwent TPC-IPAA. Steroid/immunosuppressive therapy was associated with increased odds of overall and serious morbidity for patients who underwent CP-IPAA. Obese patients should be informed of their increased morbidity risk and offered counselling on weight loss prior to surgery when feasible. Patients on steroid/immunosuppressive therapy within 30 days preoperatively should not undergo CP-IPAA or should delay surgery until they can be safely off those medications.

P252 Male Genitourinary Dysfunction after Minimally Invasive and Open Ileoanal Pouch

Abstract Background Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for IBD or FAP. As these diseases often manifest during adolescence or early adulthood, treatment effects on genitourinary function (GU), sexual function, and fertility are of paramount importance. However, the difference in male GU function and sexual function after minimally invasive IPAA (MIS-IPAA) compared to open-IPAA are unclear. We conducted an observational survey to compare long-term GU functionality in male patients’ post MIS-IPAA or open-IPAA. Methods All adult male patients who underwent IPAA at a single tertiary hospital between 1983 and 2023 were identified, and demographics and clinical data were obtained from our prospectively maintained pouch registry. Patients were surveyed using validated questionnaires (Table 1). The primary outcome was the composite survey scores. Patients were stratified into MIS-IPAA (laparoscopic, robotic, single-incision surgery) or open-IPAA groups based on the mode of pelvic/rectal dissection. Reoperative IPAA procedures (revisions, redo, and excisions), incomplete surveys, patients with permanent ileostomy, and status post prostatectomy were excluded. Results A total of 1,836 patients were surveyed, and 457 (24.9%) submitted a response. After exclusion criteria, 296 responses were analyzed: 236 (79.7%) open-IPAA and 60 (20.3%) MIS-IPAA. In both groups, most patients had ulcerative colitis (88 vs. 89%). Compared to open-IPAA, MIS-IPAA had a similar age at surgery (40.6 vs. 40.9, p=0.88), younger age at survey (48.2 vs 58.2, p&amp;lt;0.001), and shorter interval between surgery and survey (7.7 vs. 17.4, p&amp;lt;0.001). Male MIS-IPAA patients were able to achieve orgasm more successfully than those with open-IPAA (5 vs. 4, p=0.001). No significant difference was observed between MIS- and open-IPAA in erectile function (SHIM score 22.5 vs 21, p=0.22), IBD-specific male sexual dysfunction (IBD-MSDS, 3 vs. 2, p=0.19), lower urinary tract symptoms (LUTS) (CLLS, 4 vs. 6, p=0.16), or use of therapeutic aids for sexual activity (6 vs. 6, p=0.7). There was no difference in global quality of life (CGQoL, 0.83 vs 0.80, p=0.6). There were no differences between the patients who had difficulty conceiving a child (4 vs. 7, p=0.46) and those who experienced infertility (1 vs. 2, p=0.54). Patients experiencing infertility showed no difference in quality of life between the MIS- and open-IPAA groups (FertiQoL, 84.9 vs 85.9, p=0.64). Conclusion Minimally invasive IPAA had a higher preservation of orgasm ability than did open IPAA. There was no difference in erectile function, LUTS, need for therapeutic aids for sexual function, or fertility between MIS and open approach to pelvic dissection in IPAA.

THIRD TIME’S THE CHARM? INDICATIONS AND LONG-TERM OUTCOMES AFTER REDO-REDO ILEAL POUCH ANAL ANASTOMOSIS

Abstract BACKGROUND Pouch failure after redo ileal pouch anal anastomosis (IPAA) occurs in 20-40% of cases. The decision to offer a second redo procedure to maintain intestinal continuity is controversial, and scarce evidence exists regarding long-term pouch survival and functional outcomes after redo-redo IPAA. METHODS We retrospectively analyzed our prospectively collected pouch registry for redo IPAA procedures and identified all patients who underwent a second redo IPAA procedure from 2004 to 2021. Our primary outcome was pouch survival, defined as no pouch excision or rediversion. Figures are frequency (percentage) and median (interquartile range). RESULTS Twenty-three patients met inclusion criteria (65% female, 4% of all redo IPAAs). The index diagnosis was ulcerative colitis in 20 (87%) cases and indeterminate colitis in 3 (13%). The median interval between the index pouch and the second redo was 36 (24 – 90) months, while the median time between the first and second redo was 16 (9 – 36.5) months. Only 8 (35%) of patients had their stoma closed between the first and second redo. In 15 (65%) cases both redo procedures were done at our center. The indication for pouch salvage was the same for the first and second redo in 21 (91%) cases (Figure 1): 20 (87%) patients both redo for septic complications. Second redos were done transabdominally in 21 (91%) of cases, and 14 (61%) involved pouch excision and construction of a neo-pouch. All were handsewn, and the final pouch configuration was “J” in 18 (78%) and “S” in 5 (22%) cases (Figure 2). Twenty (87%) had their stoma closed after the second redo. After a median follow up of 39 months (18.5 – 95.5), 10 (44%) patients experienced pouch failure (due to sepsis in 9 cases of which 3 never had their stoma closed, and poor function in 1). Pouch survival was 81% at 1-year, and 76% at 3-years. The median interval between second redo and pouch failure was 12 months (3 – 50.5). Postoperative Cleveland Global Quality of Life surveys were available for 17 (74%) patients. After a median interval of 14 (6 – 40) months, the overall quality of life score (0 -1) was 0.6 (0.5 – 0.8). The median number of bowel movements was 6 (5 – 8) during daytime, 2 (2 – 4) at night, for a total of 8 (6.5 – 12.5) per 24 hours. Urgency occurring most days of the week was reported by 30%, frequency by 14%, seepage during the day by 71% and at night by 86%. Dietary restrictions were reported by 50% of patients, social restrictions by 44%, work restrictions by 62.5%, and sexual restrictions by 50%. CONCLUSION A second redo pouch procedure may be offered with acceptable outcomes to a very select group of patients who are highly motivated to maintain intestinal continuity.

Social Media Influences Redo Pouch Surgery Referral More Than Index Surgeons

Introduction: Redo ileal pouch anal anastomosis (IPAA), the procedure of choice for IPAA, is mainly attempted in specialized centers but referral patterns for redo IPAA are not well known. Social media may be a valuable tool for patients to find surgeons. In our study we evaluated referral patterns of redo IPAA. Methods: All redo IPAA procedures performed at our center for IPAA failure between 09/2016 and 02/2022 were included. Patient demographics, disease characteristics and referral patterns were reported. Results: A total of 141 patients with IPAA failure who had redo IPAA surgery were included. The median age was 40 years. The median time between the index surgery and the redo surgery was 5 years (interquartile range: 2-11). There were 108 ulcerative colitis, 25 indeterminate colitis and 8 familial adenomatous polyposis patients. Referrals for 49 patients were via social media or word of mouth (33.1%), 48 were referred by gastroenterologists (32.4%), 33 by colorectal surgeons (22.3%) and 1 by an oncologist (0.7%). The index case was done by our team in 11 patients (7.4%). A significant majority of patients, 30%, were from outside of our center’s tristate area. Conclusion: Social media and patient-patient interaction was the number one referral source, followed closely by the gastroenterologists. The small number of referrals by the primary surgeon is a source of concern since the majority of redo IPAAs are done to fix surgical failures.

Robotic versus laparoscopic ileal pouch-anal anastomosis (IPAA): a systematic review and meta-analysis.

Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is a curative and cancer preventative procedure in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). It can be technically difficult laparoscopically, and hence the robotic platform has been suggested as a way to enable minimally invasive surgery in more patients. This systematic review examines robotic proctectomy or proctocolectomy with IPAA. A limited meta-analysis was performed on data comparing the robotic approach to laparoscopy. We searched MEDLINE, EMBASE and the Cochrane database for case series of robotic IPAA procedures and studies comparing the robotic to laparoscopic or open procedures. Data examined includes operating time, conversion to open, length of stay, complications, blood loss, return of bowel function, reoperation rate and functional outcomes. Five non-randomised studies compared robotic to laparoscopic techniques; one compared robotic to open surgery and three case series are included. Operating time was significantly longer in robotic cases. Estimated blood loss was significantly less in three of four studies which reported this; hospital stay was significantly less in two. There were nonsignificant reductions in complications and readmission rates. Pooled analysis of four papers with adequate data showed a nonstatistically significant trend to less complications in robotic procedures. Three studies assessed functional and quality of life outcomes, with little difference between the platforms. Available data suggests that the robotic platform is safe to use for IPAA procedures. There is minimal evidence for clinical advantages, but with little data to base decisions and significant potential for improvements in technique and cost-effectiveness, further use of the platform for this operation is warranted. It is vital that this occurs within an evaluation framework.

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.

Distribution of Elective Ileal Pouch-Anal Anastomosis Cases for Ulcerative Colitis: a Study Utilizing the University Health System Consortium Database

BackgroundTrends and distribution of ileal pouch-anal anastomosis (IPAA) procedures for patients with ulcerative colitis (UC) are unknown. We examined the frequency, distribution, and volume-outcome relationship for this relatively infrequent procedure using a large national data source. MethodsData were obtained from the University HealthSystem Consortium (UHC) for patients with a primary diagnosis of UC admitted electively and who underwent surgical intervention between 2012 and 2015. ResultsThe mean age of the study population (n = 6875) was 43 years and 57% were men. Among these, one-third (n = 2307) underwent an IPAA, while 24% (n = 1160) underwent total abdominal colectomy, 16% (n = 1134) underwent proctectomy, and 2% (n = 108) underwent total proctocolectomy with end ileostomy. The frequency of IPAA cases among all elective surgical cases was relatively stable at 33–35% over the study period. A total of 131 hospitals, out of 279 hospitals participating in the UHC (47%), performed IPAA. UHC contains all inpatient data on more than 140 (> 90%) academic medical centers in the US and their affiliates. Most hospitals (101) performed < 5 cases annually. The median number of IPAA cases performed annually was 1.8 [IQR 0.8 – 4.3]. The top 10 hospitals performed one-half (48%) of IPAA cases, but only 18% of another type of complex pelvic dissection cases such as low anterior resection. Short-term postoperative complications after IPAA, however, were similar regardless of IPAA volume. ConclusionsNearly one-half of IPAA cases were performed at only 10 hospitals out of the 131 hospitals performing IPAA in the study. IPAA procedures are infrequently performed by most academic medical centers in the US. The redistribution of IPAA procedures, likely a result of previously established referral patterns and centralization, has a potential impact on the training of future colorectal fellows as well as access to care.

Lower fecal pH may be a novel indicator of pouchitis after IPAA in patients with FAP or metachronous Lynch syndrome.

To assess whether fecal pH might be an indicator of pouchitis during the postoperative period in hereditary colorectal cancer (CRC) patients who have undergone ileal pouch anal anastomosis (IPAA). Five consecutive daily pH values of stool samples from 31 familial adenomatous polyposis (FAP) patients and 32 metachronous Lynch syndrome patients who underwent IPAA procedures were reviewed. Patients with pouchitis (pouchitis group, n = 22) were compared with patients without pouchitis (nonpouchitis group, n = 41). A receiver operating characteristic (ROC) analysis was performed to determine the indicative potential of fecal pH for pouchitis. A Mantel-Cox test was also performed to evaluate the survival status of patients with or without pouchitis. Pouchitis was noted in 22 (34.9%) of 63 patients after IPAA. The significance of each daily average fecal pH value and the 5-day overall average fecal pH value was compared between the two groups (P < .01). A cutoff fecal pH value of 7.46 was determined by the ROC analysis for assessing the risk of pouchitis. No significant difference in 5-year overall survival was observed between the two groups. A lower fecal pH value in patients with hereditary CRC after IPAA might be a new indicator of pouchitis.

Early Experience with Variant Two-Stage Approach in Surgical Management of Inflammatory Bowel Disease Colitis in the Pediatric Population.

Introduction: Multistaged surgical management of inflammatory bowel disease (IBD), culminating in ileal pouch-anal anastomosis (IPAA), can provide cure for refractory IBD symptoms while maintaining fecal continence. Surgical approaches to IPAA historically included a three-stage approach done by subtotal colectomy (STC) followed by IPAA with diversion. Recently, a variant two-stage approach without diversion at IPAA has become increasingly utilized, yet evidence of the efficacy of this approach is limited. Methods: Retrospective review of patients aged 5-21 years who underwent initial STC, followed by a total proctocolectomy with IPAA +/- diversion for medically refractory IBD from January 2010 to August 2018 (n = 25). Results: Majority of IPAA procedures were done laparoscopically (88.5%). Thirteen patients (52%) underwent two-stage variant IPAA. There were no differences in readmission rates (66.7% versus 53.8%, P = .5) or reoperation rates (50% versus 30.8%, P = .3) between groups. Forty percent of patients experienced a complication after IPAA. Complication rates were similar between two-stage and three-stage IPAA groups (38.5% versus 50%, P = .33). Complications within the two-stage group included anastomotic leak, pouchitis, wound infection, anastomotic stricture, and incarcerated hernia. Complications within the three-stage group included bloody ostomy output, dehydration, anastomotic stricture, small bowel obstruction, and pouch volvulus. Conclusions: Treatment of refractory IBD in children remains challenging, but STC followed by IPAA is an approach that provides symptom relief and preserves continence. Complication rates remained unchanged regardless of whether IPAA was conducted with or without diversion, demonstrating that the two-stage variant approach is a safe and feasible treatment that may reduce subsequent anesthesia exposure and trips to the operating room.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

Ileal pouch revision vs excision: short-term (30-day) outcomes from the National Surgical Quality Improvement Program.

Ileal pouch-anal anastomosis (IPAA) failure occurs in approximately 5%-10% of patients. We aimed to compare short-term (30-day) postoperative outcomes associated with pouch revision and pouch excision using a large international database. Our null hypothesis was that there is no statistically significant difference in overall postoperative complications between patients selected for pouch revision vs pouch excision. Using the American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 we identified patients who underwent either IPAA revision via the combined abdominoperineal approach [Current Procedural Terminology (CPT) 46712] or IPAA excision (CPT 45136). Differences in baseline characteristics and short-term outcomes between groups were assessed with univariate and matched analyses. We identified 593 reoperative IPAA procedures: revision group 78 (13%) and excision group 515 (86%). The groups had similar age and body mass index (kg/m2 ), but the revision group had more women (65.4% vs 51.8%, P=0.02) and fewer were on chronic steroids (3.9% vs 17.9%, P=0.0008) relative to the excision group. Revision IPAA patients were more likely to have received a preoperative transfusion (5.1% vs 0.97%, P=0.02). Revision and excision were associated with similar postoperative length of stay (9.3 vs 8.6days, 0.44), mortality (nil vs 0.58%, respectively; P=0.99) and short-term morbidity (34.6% vs 40.2%, respectively; P=0.88) at 30 days. Pouch revision and excision have comparable short-term postoperative outcomes, but pouch excision appears to be more commonly utilized. Increased awareness of the indications for pouch revision or referral to specialized centres may improve pouch revision rates.

Delayed Ileal Pouch Anal Anastomosis Has a Lower 30-Day Adverse Event Rate: Analysis From the National Surgical Quality Improvement Program

Ulcerative colitis (UC) patients requiring colectomy often have a staged ileal pouch anal anastomosis (IPAA). There are no prospective data comparing timing of pouch creation. We aimed to compare 30-day adverse event rates for pouch creation at the time of colectomy (PTC) with delayed pouch creation (DPC). Using prospectively collected data from 2011-2015 through the National Surgical Quality Improvement Program, we conducted a cohort study including subjects aged ≥18 years with a postoperative diagnosis of UC. We assessed 30-day postoperative rates of unplanned readmissions, reoperations, and major and minor adverse events (AEs), comparing the stage of the surgery where the pouch creation took place. Using a modified Poisson regression model, we estimated risk ratios (RRs) with 95% confidence intervals (CIs) adjusting for age, sex, race, body mass index, smoking status, diabetes, albumin, and comorbidities. Of 2390 IPAA procedures, 1571 were PTC and 819 were DPC. In the PTC group, 51% were on chronic immunosuppression preoperatively, compared with 15% in the DPC group (P < 0.01). After controlling for confounders, patients who had DPC were significantly less likely to have unplanned reoperations (RR, 0.42; 95% CI, 0.24-0.75), major AEs (RR, 0.72; 95% CI, 0.52-0.99), and minor AEs (RR, 0.48; 95% CI, 0.32-0.73) than PTC. Patients undergoing delayed pouch creation were at lower risk for unplanned reoperations and major and minor adverse events compared with patients undergoing pouch creation at the time of colectomy. 10.1093/ibd/izy082_video1izy082.video15776112442001.

Pregnancy Concerns in Patients with Ileal Pouch Anal Anastomosis for Ulcerative Colitis: Time for Increased Education Across Specialties

Pregnancy is an emotionally charged and physically demanding time in a woman’s life. Patients who have had surgery for ulcerative colitis during their reproductive years provide a unique set of challenges for physicians before and during pregnancy. Pregnant women who have undergone surgery for medically refractory ulcerative colitis, usually total abdominal colectomy with ileal pouch anal anastomosis (IPAA), often have a close relationship with their surgeon and gastroenterologist. The patient’s surgeon, gastroenterologist or obstetrician may provide counseling regarding pre-pregnancy issues and pregnancy management, with the advantage that these specialists may have diverse understanding of and approaches to the issues based on their differing training environments, respective literatures, and practice settings. In this issue of Digestive Diseases and Sciences, Bradford et al. [1] assess differences in reproductive and pregnancy-related recommendations in this population using a survey design encompassing multiple clinical vignettes detailing multiple management options. They examined the impact of fertility on IPAA, the timing of IPAA in relationship to pregnancy, delivery recommendations, and who should be providing advice, reporting major differences in advice given among the specialties studied. The data in the literature that support counseling decisions range in focus from the effects of IPAA on fertility and the choice of practitioner providing advice to these patients, which are unsupported by data, to controversial surgical timing issues supported by few data. The authors highlight some of the most difficult areas of decision-making in terms of reproduction in women with a J-pouch. The survey data they obtained were derived from responses to an invitation distributed to two national gastroenterology and surgical professional society email lists. The obstetricians surveyed were from two large obstetric groups in Southern California. Very few of the respondents saw more than five pregnant IBD patients per year and likely far fewer of these patients had J-pouches. Since education informs excellent care, in this very specialized area of inflammatory bowel disease, the presence of key data is essential. A limited Pubmed search shows that the bulk of the information published on pregnancy and ulcerative colitis is in the gastrointestinal and surgical literature (Table 1). Obstetricians—who provide J-pouch patients with pre-pregnancy counseling, discuss pregnancy management issues, and make delivery decisions, may have the least readily available patient resource information. Most of the quality measures for IBD care currently in development in the USA are focused on treatment-related issues rather than physician and patient education [2]. Decreased fertility in patients after IPAA should be the least controversial topic addressed in this manuscript since a large body of literature supports this issue. Patients undergoing traditional IPAA procedures have extensive manipulation of the pelvis that likely leads to adhesions and alterations of tubal anatomy which may adversely affect fertility. In a recent meta-analysis, the relative risk of infertility after IPAA was reported to be 3.91 with average infertility rates 20 % before surgery and 63 % after surgery [3]. A complete laparoscopic approach to IPAA reduces infertility after IPAA: in a two center study, 11 out of 15 patients were able to conceive successfully after laparoscopic IPAA [4]. Similarly in a 50 patient cross-sectional study, the spontaneous pregnancy rate in patients with a K. L. Isaacs (&) Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA e-mail: kim_isaacs@med.unc.edu

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.

Ileal pouch adenocarcinoma after proctocolectomy for familial adenomatous polyposis

Dear Editor: Familial adenomatous polyposis (FAP) is an inherited disease characterized by the development of hundreds of colorectal adenomas, leading to a 100% lifetime risk of colorectal cancer. Thus, a prophylatic proctocolectomy is recommended for patients with FAP to prevent colorectal cancer. Four surgical strategies are available for patients with FAP: proctocolectomy with permanent ileostomy, proctocolectomy with Kock’s pouch continent ileostomy (Kock), colectomy with ileorectal anastomosis (IRA), and restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). IRA produces good functional results, and this surgery is associated with less morbidity than the other procedures. However, continuing endoscopic surveillance for adenomas in the rectum is necessary, and there is a 13% to 25% cumulative risk of rectal cancer after 15 to 25 years, despite surveillance. On the other hand, both Kock’s pouch construction and IPAA (pouch patients) theoretically eliminate the risk of colorectal cancer and adenomas, and perhaps the need for further lower gastrointestinal surveillance. However, development of ileal adenomas in patients who undergo Kock or IPAA procedures is becoming evident. In a recent study, Parc et al. showed the risk of adenoma development in the ileal pouch was 7%, 35%, and 75% at 5, 10, and 15 years of follow-up, respectively. Furthermore, there are a few reports of the development of adenocarcinomas in the pouch of FAP patients. Although most of the cancers that develop in the pouch are likely from residual rectal or anal transitional epithelium, there are four reports of cancers arising from the ileal pouch mucosa in patients with FAP. The etiology of these true pouch cancers seem to be different from the cancers arising from residual rectal or anal transitional epithelium, and the risks associated with these true pouch are controversial. Here, we report two patients with adenocarcinoma developing in the ileal pouch mucosa. A 55-year-old female presented in 1989, at age 46 years, with gastric adenoma with high-grade dysplasia. A barium enema was performed as part of preoperative evaluation which showed a rectal tumor with multiple synchronous colorectal polyps, and a diagnosis of FAP was made. Her parents and four siblings were unaffected, and it seems that she had a de novo genetic mutation. Colonoscopy confirmed the presence of a rectal tumor and multiple colorectal polyps. Biopsy from the rectal tumor showed a well-differentiated adenocarcinoma. An IPAA was performed. The resected colon had an estimated 100 polyps, and the rectum had an estimated 150 polyps. Histology of the surgical specimen confirmed many tubular adenomas distributed throughout the colon and rectum, and a moderately differentiated rectal adenocarcinoma of 45 mm size M. Tajika (*) : T. Nakamura Department of Endoscopy, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya 464-8681, Japan e-mail: mtajika@aichi-cc.jp

Bleeding Stomal Varices: Case Series and Systematic Review of the Literature

Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.