Modified Two-stage Ileal Pouch-Anal Anastomosis Results in Lower Rate of Anastomotic Leak Compared with Traditional Two-stage Surgery for Ulcerative Colitis

Zittan, Eran; Wong-Chong, Nathalie; Grace, William J.; McLeod, Robin S.; Silverberg, Mark S.; Cohen, Zane

doi:10.1093/ecco-jcc/jjw069

Cited by 84 publications

(64 citation statements)

References 42 publications

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“…The fourth period covered the years 2010 to 2013. 1757 patients identified from previous study [26] 67 with missing data 34 with data found Based on the between-hospital differences in average annual pouch procedures performed, we categorized hospital volume as very low (1-5 cases/year), low (6-10 cases/year), intermediate (11)(12)(13)(14)(15)(16)(17)(18)(19)(20) cases/year) and high (> 20 cases/year). For this categorization, we divided the total number of procedures performed at a department by the total number of calendar years in which pouch procedures were performed.…”

Section: Covariatesmentioning

confidence: 99%

“…The most important risk factors for pouch failure are pelvic sepsis [8][9][10][11], Crohn's disease (CD), chronic antibiotic-resistant pouchitis, and 'idiopathic' pouch dysfunction [9,12,13]. Currently, controversy exists as to the importance of timing of the restorative pouch procedure in relation to the colectomy [14] and the merits of temporary faecal diversion to reduce the risk of failure of the pouch are debated [15][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

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Pouch failures following ileal pouch–anal anastomosis for ulcerative colitis

et al. 2018

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Aim Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure. MethodThe study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis.Results Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10-and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio (aHR) 1.39, 95% CI 1.10-1.75]. Primary nondiversion (aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume (aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy.Conclusion In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure.

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Section: Covariatesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Pouch failures following ileal pouch–anal anastomosis for ulcerative colitis

et al. 2018

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“…(92) A recent study concluded that patients with the modified twostage IPAA reported significantly lower anastomotic leaks, despite suffering from more severe UC activity and higher preoperative use of steroids. (93) The advantage of the three-stage and the modified two-stage IPAA is that it can be performed in emergency settings as it allows time to improve the patients' nutritional status, treat anemia, and withdraw from immunomodulating medications before going through a more complex pelvic dissection with a high risk anastomosis. (92,94) Other studies concluded that the three-stage IPAA is associated with more intraoperative hemodynamic instability and lower use of immune modulators.…”

Section: Surgical Reconstruction For Ulcerative Colitismentioning

confidence: 99%

Cancer and reconstructive surgery in Inflammatory bowel disease

Abdalla

2019

Linköping University Medical Dissertations

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Ulcerative colitis (UC) is a chronic inflammatory disease that affects the colon. According to the literature, some thirty percent of UC patients may require a subtotal colectomy and ileostomy due to failure of medical treatment, acute toxic colitis or dysplasia/cancer diagnosis. Some patients choose to get continence restored with either an ileorectal anastomosis (IRA) or an ileal pouch-anal anastomosis (IPAA). Worldwide most surgeons prefer an IPAA to an IRA, despite reports of pouchitis, impaired fertility and fecundity. Fear of recurring proctitis and fear of rectal cancer in the remaining rectum is contributing to the choice of an IPAA. Little is known regarding the outcomes of IRA compared with IPAA in UC patients. We aimed to investigate the anorectal function, quality of life (QoL), risk of failure and rectal cancer in patients with UC restored with IRA and IPAA respectively. Methods: Data about all Inflammatory bowel disease (IBD) patients was obtained from the Swedish National Patient Register (NPR) between 1964-2014 and in one study from the Linköping University Hospital medical records 2006-2012. Patients who developed cancer were identified from the Swedish National Cancer Register. We investigated the risk of cancer and inflammation, functional outcome and failure as well as the quality of life for IRA and IPAA patients. Investigation of risk for cancer in IRA and IPAA compared with the background population was performed using survival analytic techniques: uni-and multivariate regression, Kaplan Meier curves and standardized incidence ratio. Results: Twelve percent (7,889 /63,795) of UC patients required colectomy according to the NPR. The relative risk for rectal cancer among patients with an IRA was increased (SIR 8.7). However, the absolute risk was 1.8% after a mean follow up of 8.6 years and the cumulative risk 10-and 20-years after IRA was 1.6% and 5.6%, respectively. Risk factors for rectal cancer were primary sclerosing cholangitis in patients with an IRA (hazard ratio 6.12), and

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“…Some centers have attempted to abbreviate the hospital course of acute severe UC patients by performing a modified two-stage procedure (colectomy followed by IPAA and ileostomy takedown). Zittan et al[ 49 ] demonstrated significantly lower rates of anastomotic leak (4.6% vs 15.7%) when comparing modified 2-stage IPAA to the traditional 2-stage procedure (colectomy with pouch formation followed by ileostomy takedown). Swenson et al[ 50 ] demonstrated equivalent patient outcomes with significantly lower hospital cost in patients with resolved severe colitis after colectomy who underwent a modified two-stage IPAA vs a three-stage procedure.…”

Section: Staged Approachmentioning

confidence: 99%

Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?

Andrew

Messaris

2016

WJGS

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Acute severe ulcerative colitis (UC) is a highly morbid condition that requires both medical and surgical management through the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouch-anal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

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Modified Two-stage Ileal Pouch-Anal Anastomosis Results in Lower Rate of Anastomotic Leak Compared with Traditional Two-stage Surgery for Ulcerative Colitis

Abstract: Patients with ulcerative colitis who received the modified two-stage IPAA had a significantly lower rate of anastomotic leak following pouch creation, compared with the traditional two-stage procedure.

Cited by 84 publications

References 42 publications

Pouch failures following ileal pouch–anal anastomosis for ulcerative colitis

Pouch failures following ileal pouch–anal anastomosis for ulcerative colitis

Cancer and reconstructive surgery in Inflammatory bowel disease

Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?

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