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

Abstract

Aim 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. Methods 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. Results 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 8.6 days, 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. Conclusions 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.

Leaks From the Tip of the J-pouch: Diagnosis, Management, and Long-term Pouch Survival

“…23,24 The minority of patients, who had the "worst of the worst" leaks with severe peripouch phlegmonous changes and inflammation, required pouch excision. 16,25 Fortunately, with appropriate surgical intervention in experienced centers such as ours, the pouch salvage rate may reach 86.5%. [26][27][28][29] Despite being the largest series to date, our study has several limitations worth mentioning.…”

“…This is not surprising as it is known that redo IPAAs are associated with a higher leak rate and underscores the increased complexity and complication rate with redo pouch surgery. 15,16 Thus, in this patient cohort, extra vigilance should be given for the potential complications of pouch leaks.…”

Crohn's of the Pouch: Now What?

“…The three mainstays of surgery for medically refractory CD of the pouch are proximal diversion, excision, or revision in the form of a redo pouch. 78 79 Barnes et al report surgery rates in their cohort. Indications included fistula repair or small bowel obstruction in 22% and uncontrolled bleeding in 4%.…”

Anastomotic Leak after Ileal Pouch–Anal Anastomosis

“…Potential interventions include nonoperative nothing by mouth (NPO) with TPN, local procedural interventions by radiology or gastroenterology, fecal diversion, surgical control of the leak or sinus (drainage, local repair, transanal fistulotomy, or endosponge therapy), and ultimately pouch revision or excision. 57,58 Antibiotic therapy should have gram negative and anaerobic coverage to cover gastrointestinal flora. Cultures can be performed with drainage procedures and antibiotics can be tailored to sensitivities if predominant organism or antimicrobial resistance is identified.…”

“…Throughout this process, the patient and practitioner need to decide together whether adequate quality of life may be achieved with pouch salvage techniques or whether the best option is either a permanent stoma or pouch revision or excision. 58,59 Success of local interventions or pouch revision will then determine the ability to reverse the diverting ileostomy. Careful consideration of the loop of intestine used for the diverting ileostomy is important to allow for potential use of the diversion site as the apex of a future neo-IPAA; this is typically 20-cm proximal to the pouch inlet.…”