Modified two-stage ileal pouch-anal anastomosis: equivalent outcomes with less resource utilization

A three-stage operative approach to ileal pouch-anal anastomosis is usually undertaken in patients presenting with severe colitis. Increasingly, however, we have performed a two-stage modified ileal pouch-anal anastomosis (colectomy followed by ileal pouch-anal anastomosis without ileostomy). The present study sought to evaluate the safety, results, cost, and length of hospital stay using this modified approach compared to that of the traditional three-stage ileal pouch-anal anastomosis.

Clinical and financial data were gathered by retrospective review of patients undergoing ileal pouch-anal anastomosis at our institution since 1995. Complications were defined as any event prolonging hospitalization or requiring readmission and were included in the analysis up to six months after final surgery. Functional performance was assessed as of the last clinic visit. Data were compared with Student's t-test and chi-squared analysis. Multivariate analysis was also used to assess risk factors.

A total of 23 patients who underwent the two-stage modified procedure and 31 patients who had the three-stage procedure were identified. The two groups were found to be statistically comparable in terms of patient age, gender, duration of illness, and preoperative hematocrit. Follow-up was shorter in the modified group because of its more recent introduction (9.7 months vs. 30.5 months mean follow-up). Ninety-five percent of patients were on immunosuppressive medication before colectomy, but all were off it before the reconstruction. clinical outcomes after ileal pouch-anal anastomosis were equivalent in terms of the number of bowel movements, prevalence of fecal incontinence, and the use of hypomotility medications. No patients with the two-stage modified procedure had anastomotic complications requiring stoma creation. One patient in the three-stage group required re-creation of a stoma after stoma closure for perianal complications suggesting Crohn's disease. Total hospital cost was significantly less in the modified group: USD $27,270 vs. $38,184 (P = 0.0119). Length of stay was also shorter in the two-stage modified group although missing absolute statistical significance (21.0 days vs. 26.0 days, P = 0.0882).

Interval ileal pouch-anal anastomosis reconstruction without a stoma (two-stage modified procedure) after colectomy is functionally equivalent to the traditional three-stage protocol in terms of clinical outcome. However, it has the advantage of overall lower hospital costs and probably a shorter length of hospital stay.