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Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?
Nathan S Rubalcava1, Natalie A Moreno1, Jeremy Adler2
1Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's Hospital, 1500 E. Hospital Dr, Ann Arbor, MI 48109, USA.
Insights
The modified 2-stage approach for pediatric ulcerative colitis (UC) surgery, delaying pouch creation without a protective ileostomy, is safe for sicker children. This approach shows comparable outcomes to the traditional method.
Area of Science:
- Pediatric surgery
- Gastroenterology
- Inflammatory Bowel Disease
Background:
- Traditional 2-stage surgery for pediatric ulcerative colitis (UC) involves restorative-proctocolectomy (RP/IPAA) with ileostomy, followed by ostomy closure.
- The modified 2-stage approach in the biologic era skips the ileostomy, proceeding directly to RP/IPAA.
- Limited evidence exists on the efficacy and functional outcomes of the modified 2-stage approach in children.
Purpose of the Study:
- To compare outcomes of traditional versus modified 2-stage surgical approaches for pediatric UC.
- To evaluate the safety and efficacy of delaying pouch creation without a protective ileostomy.
Main Methods:
- Retrospective study of pediatric UC patients undergoing traditional or modified 2-stage RP/IPAA between 2010-2019.
- Complications (leak, stricture, wound infection) were assessed at 90 days and 1 year post-second operation.
Main Results:
- The modified group (n=17) had a shorter median time to surgery (7 days) compared to the traditional group (n=40, 25 days).
- Preoperatively, the modified group presented with lower albumin, higher CRP, and more frequent biologic use.
- Stricture requiring dilation was significantly higher in the traditional group (59%) versus the modified group (18%).
- No significant differences were found in pouch leak, bowel obstruction, loperamide dose, or incontinence between groups.
Conclusions:
- Delaying pouch creation to the second operation without a protective ileostomy (modified 2-stage) is a safe approach for pediatric UC patients.
- This modified strategy is suitable for a sicker and more acute pediatric population, with comparable functional outcomes to the traditional method.
Introduction:
Children with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the "modified 2-stage" approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes.
Methods:
This is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation.
Results:
N = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed.
Conclusion:
Delaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.
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