Are There Advantages to Modified 2-Stage vs. 3-Stage Restorative Proctocolectomy with Ileoanal Pouch? An IBD Collaborative of NSQIP Database Analysis

Document Type

Conference Proceeding

Publication Date

5-2025

Publication Title

Diseases of the Colon and Rectum

Abstract

Purpose/Background: While a 3-stage restorative total proctocolectomy with ileoanal pouch (IPAA) is the most common surgical option for ulcerative colitis, there is an added morbidity associated with a loop ileostomy. As a result, surgeons occasionally consider a modified 2-stage approach. Using the Inflammatory Bowel Disease (IBD) collaborative of the National Surgical Quality Improvement Program (NSQIP) Database, which collects additional data points specific to ulcerative colitis surgery, our aim was to compare the perioperative outcomes of the modified 2-stage procedure to a traditional 3-stage approach.

Methods/Interventions: The IBD collaborative of NSQIP began collecting data in 2017 and now consists of 23 sites. We queried the database (n = 6879) to identify patients who underwent ileoanal pouch creation with (a traditional 3-stage) or without (modified 2-stage) an ileostomy creation. Data from 1/1/2017 to 12/31/2022 were included. Demographics, perioperative variables and postoperative complications were compared between the two groups. Numeric data was analyzed using Wilcoxon Rank Sum. Categorical data was analyzed using Chi-Square or Fisher’s Exact test. All analyses were assessed using a p-value of 0.05.

Results/Outcomes: A total of 107 patients underwent immediate IPAA (1-stage: 5 patients, classic 2-stage: 102 patients) whereas 445 patients underwent delayed IPAA (modified 2-stage: 23 patients, 3-stage: 422 patients). Although modified 2-stage patients were significantly older (47 vs. 34 years, p = 0.0002), were more likely to have hypertension (35% vs. 10%, p=0.02) and had more biologic use 60 days prior to surgery (48% vs. 6%, p< 0.001), there was no difference in sex, race, body mass index, ASA classification, preoperative albumin levels or presence of dysplasia. There was no significant difference in perioperative variables such as need for blood transfusion or duration of surgery between the modified 2-stage and 3-stage groups. A composite rate of any complication was not difference between the groups (22% vs. 22%), specifically grade III or IV Clavien-Dindo Complications (13% vs 17%). There were no anastomotic leaks in the modified 2-stage versus 3.8% in the traditional 3-stage (n=7). In terms of unplanned return to the operating room there were 2 (8.7%) in the modified 2-stage and 15 (5%) in the 3-stage. A higher proportion of patients were discharged to their permanent residence with a 3-stage than a modified 2-stage IPAA (100% vs 87%; p = 0.0001).

Conclusion/Discussion: Less than 5% of ileoanal pouch creations in the Inflammatory Bowel Disease collaborative of NSQIP are done via a modified 2-stage approach. Despite the small number, these data suggest that it is a safe option in select cases of ulcerative colitis while avoiding a 3rd surgery for loop ileostomy reversal.

Volume

68

Issue

5

First Page

e722

Comments

American Society of Colon & Rectal Surgeons (ASCRS) Annual Scientific Meeting, May 10-13, 2025, San Diego, CA

Last Page

e722

DOI

10.1097/DCR.0000000000003735

ISSN

1530-0358

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