Variant Two-Stage Ileal Pouch-Anal Anastomosis: An Innovative and Effective Alternative to Standard Resection in...

Ulcerative colitis patients have been historically treated with standard single, 2-, and 3-stage operative approaches. We perform a variant 2-stage procedure beginning with total abdominal colectomy and end ileostomy followed by completion proctectomy and ileal pouch-anal anastomosis (IPAA) without a diverting loop ileostomy. This study evaluates the effectiveness of this innovative alternative.

Patients with ulcerative colitis, admitted to the University of North Carolina Hospital between 2003 and 2010 for IPAA, were eligible for inclusion. The 3-year cumulative incidence of pouch leaks among patients undergoing variant 2-stage were compared with those undergoing classic 2-stage, using inverse probability-of-treatment weighted Kaplan- Meier survival curves, and 95% CIs were estimated using nonparametric bootstrapping.

There were 248 patients who underwent IPAA; 139 (56.1%) underwent classic 2-stage and 109 (43.9%) underwent variant 2-stage. After standardization, there was no significant difference in the 3-year cumulative incidence of pouch leaks between patients undergoing variant 2-stage, compared with the standard single- or 2-stage procedure (risk difference 0.01; 95% CI -0.08, 0.15). At the time of the first surgical procedure, patients undergoing a variant 2-stage were more likely to have lower BMIs (median 22.5 kg/m² vs 26.7 kg/m²; p < 0.0001), an urgent/emergent procedure (56.9% vs 0.0%; p < 0.0001), biologic use within 2 weeks of surgery (32.1% vs 17.5%; p = 0.003), and high dose steroid use (60.4% vs 16.7%; p ≤ 0.0001).

Variant 2-stage IPAA is a safe and effective operative approach with comparable outcomes in a more acute population based on BMI, steroid use, and urgency of operation.