Restorative versus non-restorative total proctocolectomy: Who doesn't pouch and how do they do?

Area of Science:

• Colorectal Surgery
• Gastroenterology
• Surgical Oncology

Background:

• Ulcerative colitis (UC) management involves surgical options like total proctocolectomy with permanent end ileostomy (TPC-EI) and ileoanal pouch (IPAA).
• Comparative data on TPC-EI versus IPAA in UC patients are limited.
• Understanding reasons for non-restorative surgery and associated complications is crucial for patient counseling.

Purpose of the Study:

• To identify reasons for choosing TPC-EI over IPAA in UC patients.
• To determine the incidence of perineal wound complications following TPC-EI.
• To compare short-term surgical outcomes between TPC-EI and IPAA in UC.

Main Methods:

• Retrospective review of UC patients undergoing proctectomy between 2005-2023.
• Comparison of overall 30-day complication rates between TPC-EI and IPAA groups.
• Multivariable analysis and propensity score matching to adjust for confounding factors.

Main Results:

• Patient preference was the primary reason for TPC-EI (53%), followed by neoplasia and incontinence.
• TPC-EI patients were older, had more comorbidities, and were more likely to be on biologics.
• TPC-EI had a higher overall 30-day complication rate (37.1% vs. 19.2%), driven by perineal wound complications (18.2% vs. 4.5% leaks in IPAA).

Conclusions:

• Patient preference significantly influences the choice of TPC-EI for ulcerative colitis.
• While overall short-term complication rates are comparable after excluding procedure-specific issues, perineal complications are more frequent with TPC-EI.
• These findings are vital for informed preoperative discussions regarding surgical strategies in UC.