Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis of observational research

Abstract

Purpose: Restorative proctocolectomy(RPC) is performed for patients with refractory ulcerative colitis(UC). This operation is performed in 2 or 3-stages and involves forming a diverting loop ileostomy thought to protect patients from complications related to anastomotic leak. However, some advocate for a modified 2-stage approach, consisting of subtotal colectomy followed by completion proctectomy and ileal pouch anal anastomosis without diverting ileostomy. We present a systematic review and meta-analysis comparing postoperative complication rates between modified 2-stage and traditional RPC with ileal pouch anal anastomosis.Methods: Records were sourced from PubMed/Embase databases. Studies comparing postoperative complications following RPC for ulcerative colitis(UC) were selected according to PRISMA guidelines comparing modified 2-stage(exposure), classic 2-stage, and 3-stage approaches(comparators). The primary outcome measure was safety as measured by postoperative complication rates. We employed random-effects meta-analysis. Results:We included ten observational studies including 1727 patients(38% modified 2-stage). Among pediatric patients, modified 2-stage approaches had higher rates of anastomotic leak than 3-stage approaches(p=0.03). Among adult cohorts with lower preoperative biologic use rates, modified 2-stage approaches had lower leak rates than classic 2-stage approaches(p<0.001). Conclusions:The modified 2-stage approach may be safe for adult patients who otherwise require a 3-stage approach while reducing costs and length of stay. Pediatric patients may benefit

Research trends in ulcerative colitis: A bibliometric and visualized study from 2011 to 2021

“…Zooming in on keywords frequently used by authors in Table 7 , interesting trends, and the future of evidence synthesis emerged, including lines of research on: 1) identification of risk factors, surveillance methods, and surveillance intervals for UC-associated colorectal cancer ( Hata et al, 2019 ; Zhou et al, 2019 ; Zhang and Gan, 2021 ); 2) anti-TNF drugs for UC induction of remission and maintenance therapy ( Guo et al, 2019 ; Vande Casteele et al, 2019 ); 3) surgical treatment of UC which include proctocolectomy with ileal pouch–anal anastomosis ( Drews et al, 2019 ; Luo et al, 2020 ); 4) dysbiosis of the gut microbiota (predominantly bacteria) in the pathogenesis of UC and FMT as a therapeutic strategy for UC ( Blanchaert et al, 2019 ; Khan et al, 2019 ; Guo et al, 2020 ; Liu et al, 2021 ); 5) diagnostic criteria and differential diagnoses for UC ( Smith et al, 2020 ; Wang et al, 2021 ); 6) NF-κB signaling pathway in the pathogenesis of UC and its clinical implication ( Lu and Zhao, 2020 ; Dejban et al, 2021 ).…”

State-of-the-art surgery for ulcerative colitis

“…While there is a paucity of a highquality prospective data comparing modified 2-stage to other approaches, a recent meta-analysis demonstrated that there was an increase in anastomotic leaks in pediatric patients undergoing a modified 2-stage approach when compared to the 3-stage approach. It also showed a lower leak rate in comparison to traditional 2-stage IPAA in patients with increasing exposure to biologics [55]. Large prospective data is still needed to truly assess the utility of this approach.…”

Staging Pouch Surgery in Ulcerative Colitis in the Biological Era

“…A meta-analysis comparing outcome in 10 observational studies including 1,727 patients found the modified twostage approach to have a lower leak rate than the classic twostage approach in adult patients (p <0.001), possibly associated with a lower preoperative use of biologics. 66 In pediatric patients, however, the modified two-stage approach had a higher rate of anastomotic leak than the three-stage approach (p ¼ 0.03). 66 A very interesting on-going trial is the randomized multicenter IDEAL trial initiated by the French group GETAID Chirurgie, comparing modified two-stage and three-stage IPAA.…”

“…66 In pediatric patients, however, the modified two-stage approach had a higher rate of anastomotic leak than the three-stage approach (p ¼ 0.03). 66 A very interesting on-going trial is the randomized multicenter IDEAL trial initiated by the French group GETAID Chirurgie, comparing modified two-stage and three-stage IPAA. 67 The completion of this study will hopefully increase the knowledge on how to deal with these patients in the future.…”