Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis

Abstract

BACKGROUND: Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA. OBJECTIVE: The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a single tertiary care IBD center. PATIENTS: All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified. MAIN OUTCOME MEASURES: The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks. RESULTS: The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05). LIMITATIONS: This study was limited by its retrospective design and evolving electronic medical charts system. CONCLUSIONS: The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693. LENTO Y CONSTANTE GANA LA CARRERA: UN CASO SÓLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA ANTECEDENTES: Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal. OBJETIVO: El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal. DISEÑO: Este fue un estudio de cohorte retrospectivo. ENTORNO CLÍNICO: Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino. PACIENTES: Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas. RESULTADOS: La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05). LIMITACIONES: Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución. CONCLUSIONES: La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.

The Benefits and Drawbacks of Staging Pelvic Pouches

“…15 16 While the impact of biologic therapy on leak rates has not been clearly established, patients who are malnourished or in general poor medical condition can benefit from optimization prior to pouch construction to reduce their leak risk. 17 18 19…”

“…15,16 While the impact of biologic therapy on leak rates has not been clearly established, patients who are malnourished or in general poor medical condition can benefit from optimization prior to pouch construction to reduce their leak risk. [17][18][19] Another drawback of a one-staged procedure is specifically in patients with IC, as a single-stage proctocolectomy will not allow time for pathologic determination prior to definitive pouch construction. For example, if the pathology results as CD, the patient should be informed of a higher failure rate compared to UC.…”

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis

“…17 Additionally, the authors' experience with IPAA formation has shown that three-stage IPAA has significantly fewer anastomotic leaks and pelvic abscesses than one-stage and two-stage procedures. 18 Conversely, some studies on diverted pouches revealed that they are associated with higher rates of small bowel obstructions and more reoperations. 19,20 These obstructions may be due to obstacles with ostomy formation or with the ostomy site, such as a large body habitus that requires greater mobilization and tension to reach the abdominal wall.…”

“…17 Additionally, the authors' experience with IPAA formation has shown that three-stage IPAA has significantly fewer anastomotic leaks and pelvic abscesses than one-stage and two-stage procedures. 18…”

Restorative Proctocolectomy for Ulcerative Colitis: Different Strategies for Different Situations

“…To the Editor-We read the article on restorative proctocolectomy by Plietz et al 1 with great interest. Although we commend the authors on their study, we cannot agree with their conclusion.…”