Advertisement

Comparable perioperative outcomes, long-term outcomes, and quality of life in a retrospective analysis of ulcerative colitis patients following 2-stage versus 3-stage proctocolectomy with ileal pouch-anal anastomosis

  • Grace C. LeeEmail author
  • Sarah E. Deery
  • Hiroko Kunitake
  • Caitlin W. Hicks
  • Adriana G. Olariu
  • Lieba R. Savitt
  • Ashwin N. Ananthakrishnan
  • Rocco Ricciardi
  • Richard A. Hodin
  • Liliana G. Bordeianou
Original Article
  • 104 Downloads

Abstract

Purpose

Many surgeons assume 3-stage ileal pouch-anal anastomosis (IPAA) is safer than 2-stage IPAA in patients with active ulcerative colitis (UC), although recent data suggest outcomes are comparable. This study aimed to compare perioperative complications, late complications, and functional outcomes after 2- versus 3-stage IPAA in patients with active UC.

Methods

A retrospective review was conducted of patients who underwent 2- or 3-stage IPAA for active UC from 2000 to 2015 in a high-volume institution. Patients completed quality-of-life surveys 6 months following ileostomy reversal. Perioperative and late complications were recorded. Outcomes were compared with the Fisher exact test, and multivariable logistic regression was used to adjust for potential confounders.

Results

We identified 212 patients who underwent 2- or 3-stage IPAA for active UC, of whom 157 patients (74.1%) underwent 2-stage procedures and 55 (25.9%) underwent 3-stage procedures. More patients undergoing 2-stage procedures were taking immunomodulators preoperatively (46.3% vs. 23.1%, p = 0.01), but there was no difference in use of steroids (p = 0.09) or biologic agents (p = 0.85). Three-stage procedures were more likely to be urgent (78.6% vs. 30.2%, p < 0.001). There were no differences in perioperative complications (p = 0.50), anastomotic leak (p = 0.94), pouchitis (p = 0.45), pouch failure (p = 0.46), perceived quality of life (p = 0.68), number of bowel movements per day (p = 0.27), or sexual satisfaction (p = 0.21) between the 2- and 3-stage groups.

Conclusions

Patients undergoing 2-stage compared to 3-stage IPAA for active ulcerative colitis have comparable outcomes and quality of life following ileostomy reversal. Two-stage IPAA appears to be safe and appropriate, even in high-risk patients.

Keywords

Ulcerative colitis IPAA Two-stage Three-stage Quality of life 

Notes

Acknowledgments

GCL is currently receiving support from a National Institutes of Health T32 grant (Research Training in Alimentary Tract Surgery, DK007754-13).

Funding

GCL is currently receiving support from the National Institutes of Health T32 Research Training in Alimentary Tract Surgery grant DK007754-13.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This article does not contain any studies with animals performed by any of the authors.

Informed consent

For the data collection aspect of this study (Protocol #2008P002110), formal consent was waived by the IRB. For the survey portion of the study (Protocol #2011P001407), informed consent was implied by voluntary completion of the survey, as approved by the IRB.

References

  1. 1.
    Ross H, Steele SR, Varma M, Dykes S, Cima R, Buie WD, Rafferty J (2014) Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum 57:5–22CrossRefGoogle Scholar
  2. 2.
    Targownik LE, Singh H, Nugent Z, Bernstein CN (2012) The epidemiology of colectomy in ulcerative colitis: results from a population-based cohort. Am J Gastroenterol 107:1228–1235CrossRefGoogle Scholar
  3. 3.
    McGuire BB, Brannigan AE, O’Connell PR (2007) Ileal pouch-anal anastomosis. Br J Surg 94:812–823CrossRefGoogle Scholar
  4. 4.
    Lightner AL, Mathis KL, Dozois EJ, Hahnsloser D, Loftus EV Jr, Raffals LE, Pemberton JH (2017) Results at up to 30 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Inflamm Bowel Dis 23:781–790CrossRefGoogle Scholar
  5. 5.
    Murphy PB, Khot Z, Vogt KN, Ott M, Dubois L (2015) Quality of life after total proctocolectomy with ileostomy or IPAA: a systematic review. Dis Colon Rectum 58:899–908CrossRefGoogle Scholar
  6. 6.
    Heuschen UA, Hinz U, Allemeyer EH, Autschbach F, Stern J, Lucas M, Herfarth C, Heuschen G (2002) Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg 235:207–216CrossRefGoogle Scholar
  7. 7.
    Shibata C, Funayama Y, Fukushima K et al (2006) Factors affecting the bowel function after proctocolectomy and ileal J pouch-anal anastomosis for ulcerative colitis. J Gastrointest Surg 10:1065–1071CrossRefGoogle Scholar
  8. 8.
    Hare NC, Arnott ID, Satsangi J (2008) Therapeutic options in acute severe ulcerative colitis. Expert Rev Gastroenterol Hepatol 2:357–370CrossRefGoogle Scholar
  9. 9.
    Mor IJ, Vogel JD, da Luz MA, Shen B, Hammel J, Remzi FH (2008) Infliximab in ulcerative colitis is associated with an increased risk of postoperative complications after restorative proctocolectomy. Dis Colon Rectum 51:1202–1207 discussion 1207-1210CrossRefGoogle Scholar
  10. 10.
    Richardson D, deMontbrun S, Johnson PM (2011) Surgical management of ulcerative colitis: a comparison of Canadian and American colorectal surgeons. Can J Surg 54:257–262CrossRefGoogle Scholar
  11. 11.
    Hicks CW, Hodin RA, Bordeianou L (2013) Possible overuse of 3-stage procedures for active ulcerative colitis. JAMA Surg 148:658–664CrossRefGoogle Scholar
  12. 12.
    St-Louis E, Iqbal S, Feldman LS, Sudarshan M, Deckelbaum DL, Razek TS, Khwaja K (2015) Using the age-adjusted Charlson comorbidity index to predict outcomes in emergency general surgery. J Trauma Acute Care Surg 78:318–323CrossRefGoogle Scholar
  13. 13.
    Livingston EH, Passaro EP Jr (1990) Postoperative ileus. Dig Dis Sci 35:121–132CrossRefGoogle Scholar
  14. 14.
    Lipman JM, Kiran RP, Shen B, Remzi F, Fazio VW (2011) Perioperative factors during ileal pouch-anal anastomosis predict pouchitis. Dis Colon Rectum 54:311–317CrossRefGoogle Scholar
  15. 15.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (2000) Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43:9–16 discussion 16-17CrossRefGoogle Scholar
  16. 16.
    Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A (1997) The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 49:822–830CrossRefGoogle Scholar
  17. 17.
    Rosen R, Brown C, Heiman J et al (2000) The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 26:191–208CrossRefGoogle Scholar
  18. 18.
    Zotti P, Del Bianco P, Serpentini S et al (2011) Validity and reliability of the MSKCC bowel function instrument in a sample of Italian rectal cancer patients. Eur J Surg Oncol 37:589–596CrossRefGoogle Scholar
  19. 19.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (1999) Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 42:1525–1532CrossRefGoogle Scholar
  20. 20.
    Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF (1994) Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc 69:409–415CrossRefGoogle Scholar
  21. 21.
    Hicks CW, Hodin RA, Savitt L, Bordeianou L (2014) Does intramesorectal excision for ulcerative colitis impact bowel and sexual function when compared with total mesorectal excision? Am J Surg 208(499–504):e494Google Scholar
  22. 22.
    Levack MM, Savitt LR, Berger DL, Shellito PC, Hodin RA, Rattner DW, Goldberg SM, Bordeianou L (2012) Sigmoidectomy syndrome? Patients’ perspectives on the functional outcomes following surgery for diverticulitis. Dis Colon Rectum 55:10–17CrossRefGoogle Scholar
  23. 23.
    Penna C, Daude F, Parc R, Tiret E, Frileux P, Hannoun L, Nordlinger B, Levy E (1993) Previous subtotal colectomy with ileostomy and sigmoidostomy improves the morbidity and early functional results after ileal pouch-anal anastomosis in ulcerative colitis. Dis Colon Rectum 36:343–348CrossRefGoogle Scholar
  24. 24.
    Nicholls RJ, Holt SD, Lubowski DZ (1989) Restorative proctocolectomy with ileal reservoir. Comparison of two-stage vs. three-stage procedures and analysis of factors that might affect outcome. Dis Colon Rectum 32:323–326CrossRefGoogle Scholar
  25. 25.
    Galandiuk S, Pemberton JH, Tsao J, Ilstrup DM, Wolff BG (1991) Delayed ileal pouch-anal anastomosis. Complications and functional results. Dis Colon Rectum 34:755–758CrossRefGoogle Scholar
  26. 26.
    Lefevre JH, Bretagnol F, Ouaissi M, Taleb P, Alves A, Panis Y (2009) Total laparoscopic ileal pouch-anal anastomosis: prospective series of 82 patients. Surg Endosc 23:166–173CrossRefGoogle Scholar
  27. 27.
    Mege D, Figueiredo MN, Manceau G, Maggiori L, Bouhnik Y, Panis Y (2016) Three-stage laparoscopic ileal pouch-anal anastomosis is the best approach for high-risk patients with inflammatory bowel disease: an analysis of 185 consecutive patients. J Crohns Colitis 10:898–904CrossRefGoogle Scholar
  28. 28.
    Kennedy ED, Rothwell DM, Cohen Z, McLeod RS (2006) Increased experience and surgical technique lead to improved outcome after ileal pouch-anal anastomosis: a population-based study. Dis Colon Rectum 49:958–965CrossRefGoogle Scholar
  29. 29.
    Lim M, Sagar P, Abdulgader A, Thekkinkattil D, Burke D (2007) The impact of preoperative immunomodulation on pouch-related septic complications after ileal pouch-anal anastomosis. Dis Colon Rectum 50:943–951CrossRefGoogle Scholar
  30. 30.
    Bikhchandani J, Polites SF, Wagie AE, Habermann EB, Cima RR (2015) National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis. Dis Colon Rectum 58:199–204CrossRefGoogle Scholar
  31. 31.
    Shannon A, Eng K, Kay M, Blanchard S, Wyllie R, Mahajan L, Worley S, Lavery I, Fazio V (2016) Long-term follow up of ileal pouch anal anastomosis in a large cohort of pediatric and young adult patients with ulcerative colitis. J Pediatr Surg 51:1181–1186CrossRefGoogle Scholar
  32. 32.
    Peyrin-Biroulet L, Germain A, Patel AS, Lindsay JO (2016) Systematic review: outcomes and post-operative complications following colectomy for ulcerative colitis. Aliment Pharmacol Ther 44:807–816CrossRefGoogle Scholar
  33. 33.
    de Zeeuw S, Ahmed Ali U, Donders RA, Hueting WE, Keus F, van Laarhoven CJ (2012) Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies. Int J Color Dis 27:843–853CrossRefGoogle Scholar
  34. 34.
    Hicks CW, Hodin RA, Bordeianou L (2014) Semi-urgent surgery in hospitalized patients with severe ulcerative colitis does not increase overall J-pouch complications. Am J Surg 207:281–287CrossRefGoogle Scholar
  35. 35.
    Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH (1998) J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 85:800–803CrossRefGoogle Scholar
  36. 36.
    Fazio VW, Tekkis PP, Remzi F et al (2003) Quantification of risk for pouch failure after ileal pouch anal anastomosis surgery. Ann Surg 238:605–614 discussion 614-607Google Scholar
  37. 37.
    Saraidaridis JT, Hashimoto DA, Chang DC, Bordeianou LG, Kunitake H (2018) Colorectal surgery fellowship improves in-hospital mortality after colectomy and proctectomy irrespective of hospital and surgeon volume. J Gastrointest Surg 22:516–522Google Scholar
  38. 38.
    Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES (1999) Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 125:250–256CrossRefGoogle Scholar
  39. 39.
    Porter GA, Soskolne CL, Yakimets WW, Newman SC (1998) Surgeon-related factors and outcome in rectal cancer. Ann Surg 227:157–167CrossRefGoogle Scholar
  40. 40.
    Hannan EL, Radzyner M, Rubin D, Dougherty J, Brennan MF (2002) The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer. Surgery 131:6–15CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Grace C. Lee
    • 1
    Email author
  • Sarah E. Deery
    • 1
  • Hiroko Kunitake
    • 1
  • Caitlin W. Hicks
    • 2
  • Adriana G. Olariu
    • 3
  • Lieba R. Savitt
    • 1
  • Ashwin N. Ananthakrishnan
    • 4
  • Rocco Ricciardi
    • 1
  • Richard A. Hodin
    • 1
  • Liliana G. Bordeianou
    • 1
  1. 1.Division of General and Gastrointestinal Surgery, Department of SurgeryMassachusetts General HospitalBostonUSA
  2. 2.Department of SurgeryJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Department of MedicineUniversity of North CarolinaChapel HillUSA
  4. 4.Division of Gastroenterology, Department of MedicineMassachusetts General HospitalBostonUSA

Personalised recommendations