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IPAA-related sepsis significantly increases morbidity of ileoanal pouch excision
Antonio M Maya1, Marylise Boutros, Giovanna DaSilva
1Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida.
Background:
Perineal wound complications after ileoanal pouch excision remain a significant cause of morbidity.
Objective:
The purpose of this work was to describe the incidence, outcomes, and predictors of perineal wound complications after pouch excision.
Design:
This was a retrospective medical chart review.
Settings:
The study was conducted in a single clinical institution.
Patients:
Patients who underwent pouch excision at our institution from July 1992 through July 2012 were identified. Patient and perioperative variables were reviewed. Multivariate and univariate analyses were undertaken.
Main Outcome Measures:
Perineal wound (including perineal wound infection and persistent perineal sinus [nonhealing by 6 months]) and perineal hernia were measured.
Results:
A total of 47 patients (mean age, 46 years; 42.6% men) with familial adenomatous polyposis (10.6%), mucosal ulcerative colitis (61.7%), or Crohn's disease (27.7%) underwent pouch excision, including 36.2% for IPAA-related sepsis (presacral abscess; perineal-, sacral-, or pouch-vaginal fistula; and anastomotic defect), 44.7% for pouch dysfunction, 10.6% for refractory pouchitis, and 8.5% for neoplasia. Fourteen (29.8%) developed perineal wound complications, including 100% perineal wound infection, 28.6% persistent perineal sinus, and 7.1% perineal hernia. Perineal wound infection was associated with delayed healing (>6 weeks; 71.4% vs 24.2%; p = 0.002) and IPAA-related sepsis (28.6% vs 0%; p = 0.001). Patients with and without perineal wound complications were similar in age, diagnoses, fecal diversion, immunosuppression, comorbid conditions, nutrition, and surgical variables. Most patients underwent intersphincteric dissection (87.2%) with primary perineal closure (97.0%). Perineal wound complications were significantly associated with IPAA-related sepsis as an indication for pouch excision (57.1% vs 27.2%; p = 0.05), intraoperative pouch perforation (35.7% vs 9.1%, p =0.03), and smoking (21.4% vs 3.0%; p = 0.04). IPAA-related sepsis and a current smoking status (OR, 19.3 [95% CI, 1.8 -488.1]) are significant independent predictors on multivariate logistic regression (OR, 6.4 [95% CI, 1.4-30.2]) of perineal wound complications. All of the patients with persistent perineal sinus achieved successful healing at a median of 734 days (range, 363-2182 days), requiring a median of 1.5 procedures.
Limitations:
This was a single-center retrospective review with a small sample size.
Conclusions:
Preoperative IPAA-related sepsis and current smoking are significant risk factors for perineal wound complications after pouch excision.
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