Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak

Widmar, Maria; Munger, Jordan; Mui, Alex; Gorfine, Stephen R.; Chessin, David B.; Popowich, Daniel A.; Bauer, Joel J.

doi:10.1007/s00384-019-03240-2

Cited by 19 publications

(12 citation statements)

References 21 publications

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“…Ten out of 43 (27%) diverted patients with a pouch leak, and 53 of 92 (60%) of undiverted patients with a pouch leak underwent an unplanned ostomy within 200 weeks of surgery (p < 0.01). The rate of pouch salvage operations over total follow-up was similar between the two groups, 74% and 78% of patients with a pouch leak [37]. In another retrospective evaluation of 4031 IPAA patients, of whom 357 developed pelvic sepsis with a diverting ileostomy and 31 without, there was a higher rate of reoperation for diverting ileostomy (48%) in patients without diverting ileostomy at time of IPAA compared with patients with diverting ileostomy (12%); p < 0.0001.…”

Section: Controversies One- Two- or Three-stage Ipaamentioning

confidence: 69%

Ulcerative Colitis: Surgical Management

Zaghiyan

Fleshner

2021

The ASCRS Textbook of Colon and Rectal Surgery

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Multidisciplinary management and early surgical referral are crucial in the management of ulcerative colitis patients with moderate to severe colitis. While dysplasia screening and management is changing, surgical referral remains a cornerstone in the management of multifocal and highgrade dysplasia.• Ileal pouch-anal anastomosis is the standard surgery for medically refractory disease, cancer, or dysplasia. One, two, or three-stage surgery may be chosen and tailored to various patient factors including preoperative nutritional status, corticosteroid use, and intraoperative factors. • Alternative approaches such as total proctocolectomy with end ileostomy, continent ileostomy, and ileorectal anastomosis are options that may be considered in select patients. • Long-term functional outcomes of patients undergoing surgery for ulcerative colitis including bowel, sexual, and urinary function, as well as fertility preservation, are important considerations and should be discussed preoperatively and monitored closely in the postoperative setting.

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Section: Controversies One- Two- or Three-stage Ipaamentioning

confidence: 69%

Ulcerative Colitis: Surgical Management

Zaghiyan

Fleshner

2021

The ASCRS Textbook of Colon and Rectal Surgery

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“…However, randomizing by surgery type is a difficult approach, and only one study has randomized by diversion 68. Lastly, surgeons may have a clinical preference towards undiverted surgery in patients who are ‘healthier’ (ie, lack of anastomosis tension, good pelvic dissection, nutritional status and decreased immunosuppressant doses)5 because an undiverted pouch can have more favorable preoperative and operative characteristics and because diversion does not always prevent pouch excision 5 25 69 70. This potential preference might explain why there were so few studies comparing the outcomes directly between IPAA diverted versus undiverted ileostomy procedures.…”

Section: Discussionmentioning

confidence: 99%

“…3 Since 1978, the gold standard surgical treatment of ulcerative colitis (UC) is restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA), which can be performed via laparoscopic or open procedure, in one, two or three stages and constructed with an S-reservoir, a J-reservoir or a W-reservoir. 4 Data from Widmar et al 5 suggest that diversion does not prevent pouch excision and a need for long-term diversion after pouch leak in adult patients. Recently, Khalid et al 6 demonstrated greater probability of anastomotic strictures (odd ratio (OR) 0.40; 95% confidence interval (CI) 0.26 to 0.62, p<0.0001) and pouch failures (OR 0.54 (0.36 to 0.82), p=0.003) in adult diverted than in non-diverted patients, although reoperation was more frequently required in non-diverted patients (OR 2.51 (1.12 to 5.59), p=0.02).…”

Section: Introductionmentioning

confidence: 99%

Postoperative complications of colectomy and J-pouch with ileostomy versus without ileostomy in children with inflammatory bowel diseases: a systematic review and meta-analysis

Oltean

Travis

Kaur

et al. 2022

World Jnl Ped Surgery

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BackgroundThe efficacy of performing a restorative proctocolectomy and J-pouch ileoanal anastomosis without diverting ileostomy in children with inflammatory bowel disease has been a longstanding debate. A systematic review and meta-analysis is presented comparing the occurrence of postoperative complications in children who underwent either the pouch-anal anastomosis (IPAA) with ileostomy (diverted) versus the undiverted procedure.MethodsRecords were sourced from CINAHL, CENTRAL, EMBASE and MEDLINE databases. Studies followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and compared postoperative complications in pediatric patients diagnosed with inflammatory diseases aged less than 18 years who underwent J-pouch with ileostomy versus without ileostomy. The primary outcome was the occurrence of postoperative leaks, and the secondary outcomes were presence of postoperative small bowel obstruction (SBO), pouchitis, stricture and fistula complications. A random-effects meta-analysis was used.ResultsTwenty-three observational studies in the systematic review were included with 658 patients (83% diverted, 17% undiverted). Pooled estimates showed no difference in occurrence of leaks in children who underwent J-pouch/IPAA with ileostomy versus without (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.17 to 1.64, I2=16%). There was no difference in the occurrence of SBO, pouchitis or strictures in children who underwent J-pouch/IPAA with ileostomy versus without (SBO: OR 2.27, 95% CI 0.52 to 9.92, I2=0%, pouchitis: OR 1.76, 95% CI 0.95 to 3.24, I2=0%, strictures: OR 2.72, 95% CI 0.44 to 16.69, I2=66%).ConclusionThe meta-analysis did not find differences in the occurrence of complications in pediatric patients who underwent the IPAA with ileostomy procedure versus without ileostomy.

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“…In those patients who leaked, there was a higher rate of pouch excision in the diverted group, but a higher rate of reintervention within 30 days in the undiverted group. 4 Similarly, a study by Lavryk et al examining 4,031 IPAA patients found no difference in pouch survival between diverted (n ¼ 326) and undiverted patients (n ¼ 31) who experienced pelvic sepsis (88% vs. 87% at 10 years). However, the undiverted group was associated with a higher reoperation rate (48% vs. 12%, p < 0.0001).…”

Section: Undiverted Ipaamentioning

confidence: 92%

Elective and Emergent Surgery in the Ulcerative Colitis Patient

DeLeon

Stocchi

2022

Clin Colon Rectal Surg

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Ulcerative colitis (UC) requires surgical management in 20 to 30% of patients. Indications for surgery include medically refractory disease, dysplasia, cancer, and other complications of UC. Appropriate patient selection for timing and staging of surgery is paramount for optimal outcomes. Restorative proctocolectomy is the preferred standard of care and can afford many patients with excellent quality of life. There have been significant shifts in the treatment of UC-associated dysplasia, with less patients requiring surgery and more entering surveillance programs. There is ongoing controversy surrounding the management of UC-associated colorectal cancer and the techniques that should be used. This article reviews the most recent literature on the indications for elective and emergent surgical intervention for UC and the considerations behind the surgical options.

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Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak

Cited by 19 publications

References 21 publications

Ulcerative Colitis: Surgical Management

Ulcerative Colitis: Surgical Management

Postoperative complications of colectomy and J-pouch with ileostomy versus without ileostomy in children with inflammatory bowel diseases: a systematic review and meta-analysis

Elective and Emergent Surgery in the Ulcerative Colitis Patient

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