Increasing experience of modified two‐stage transanal ileal pouch–anal anastomosis for therapy refractory ulcerative colitis. What have we learned? A retrospective analysis on 75 consecutive cases at a tertiary referral hospital

Abstract

Aim Ileal pouch–anal anastomosis (IPAA) should be delayed to a second stage in patients with ulcerative colitis and prolonged exposure to medical therapy. However, there is still discussion about whether a modified two‐stage approach is preferable to a three‐stage approach. Recently, a transanal approach has been introduced to overcome the well‐known difficulties of laparoscopic pelvic surgery. This paper presents short‐term outcomes of transanal IPAA (Ta‐IPAA) according to a modified two‐stage approach. Methods Data from all patients who underwent a modified two‐stage Ta‐IPAA for ulcerative colitis refractory to medical therapy were retrieved retrospectively from a prospective database. A comprehensive complication index was used for 90‐day postoperative complications. Conversion, duration of surgery, hospital stay and reoperation were considered. A logistic regression model was used to assess risk factors for peri‐pouch sepsis. Results Seventy‐five (68.8%) patients were identified from 109 consecutive IPAAs. Median operation time was 159 min. Conversion rate was 4%. Mean comprehensive complication index was 7. All anastomotic leaks (10.6%) were treated with diverting ileostomy. Additionally, active rescue with transanal drainage and early resuturing of the anastomotic gap was performed in six patients. Ileostomy closure occurred after a median period of 5.4 months. At univariable analysis, factors associated with peri‐pouch sepsis were male gender and age at IPAA construction. Conclusions A modified two‐stage Ta‐IPAA is safe and feasible. Standardization and reproducibility of the technique are reflected in few conversions and intra‐operative complications. Finally, morbidity and anastomotic leak do not differ from those reported in previous Ta‐IPAA series with a variable proportion of multistage procedures.

Routine diversion following delayed IPAA construction does not reduce the incidence of pouch‐related sepsis or failure in patients with ulcerative colitis

“…Further, diverting ileostomy has also been associated with negative psychological impacts and a poor quality of life before closure [38]. Another emerging advantage of a modified 2-stage approach is the possibility for early salvage in the setting of anastomotic leak [20,36,37]. It is theorized that non-diversion results in earlier leak identification which better allows for trans-anal repair with endosponge.…”

“…Two studies directly compared 2‐stage and modified 2‐stage procedures and demonstrated a shorter length of stay and no increased risk of anastomotic leak in the modified two stage group [33, 34]. Specifically addressing the question of diverting ileostomy, again the results are conflicting, and as a limitation, studies have often grouped indications and included 1‐stage procedures which are no longer applicable to the UC population [8, 9, 13–20]. Few studies have directly compared delayed construction techniques (modified 2‐stage vs. 3‐stage).…”

“…While encouraging, these studies were limited by their small sample size, lack of long-term follow-up and highly selected patient populations. This has prompted several subsequent population-based and retrospective analyses which have reported conflicting findings, resulting in no clear consensus [8,9,[14][15][16][17][18][19][20].…”

“…. Specifically addressing the question of diverting ileostomy, again the results are conflicting, and as a limitation, studies have often grouped indications and included 1-stage procedures which are no longer applicable to the UC population[8,9,[13][14][15][16][17][18][19][20]. Few studies have directly compared delayed construction techniques (modified 2-stage vs. 3-stage).…”

Minimally Invasive and Robotic Surgery for Ulcerative Colitis

“…Overall, it appears that taIPAA offers improved visualization and access during the low pelvic dissection, likely lower conversion rates, and similar postoperative and functional outcomes. 45 Despite the theoretical benefit of improving the rectal transection and avoiding multiple stapler firings, there does not appear to be a difference in rates of anastomotic leak, 41,46 though future studies with larger sample sizes are needed to better evaluate this new technique. 45…”