Modified 2-stage ileal pouch-anal anastomosis versus 3-stage alternative

Similar long-term outcomes were reported for participants who received modified 2-stage or 3-stage ileal pouch-anal anastomosis (IPAA). However, the modified 2-stage approach should only be performed by experienced surgeons at high-volume centres and in a select group of patients.

Long-term outcomes of modified 2-stage IPAA have not yet been evaluated, according to Dr Stefan Holubar (Cleveland Clinic Foundation, OH, USA) [1]. The modified 2-stage approach is defined as completion proctectomy without loop ileostomy, whereas the 3-stage approach includes completion proctectomy with loop ileostomy. For this study, 223 participants from the Adult Pouch Registry who underwent modified 2-stage IPAA between 1983 and 2019 were matched with 223 participants who underwent 3-stage IPAA. The primary outcome was pouch survival, defined by permanent diversion, pouch excision, and conversion to a Kock pouch.

Long-term pouch survival outcomes were similar between participants who underwent modified 2-stage or 3-stage IPAA (95.5% vs 93.2%; P=0.32; see Figure). However, 3-stage participants had a shorter postoperative length of hospital stay than modified 2-stage participants (5 vs 8 days; P<0.001). Also, a numerically but not significantly higher complication rate was reported in the modified 2-stage arm (17.0% vs 12.1%; P=0.09). Functional outcomes were mostly similar for the investigated approaches. The number of stools per 24 hours was 7 in both groups. Similarly, the proportion of participants requiring seepage protection at night did not significantly differ between the 3-stage and modified 2-stage arm (29.7% vs 24.6%; P=0.31). Participant satisfaction levels were comparable.

Figure: Kaplan-Meier curve for pouch survival (matched pairs) [1]



 

 

 

 

 

Dr Holubar said that modified 2-stage IPAA may be an alternative for patients with limited options. However, he emphasised that the modified 2-stage approach should only be performed by experienced surgeons in high-volume centres. Moreover, the eligible patient profile for modified 2-stage IPAA is highly selective. “Patients should display minimal pouch tension, 3 or lower on a scale from 1 to 10, have perfect betadine leak tests prior to anastomosis, and perfect endoscopic leak tests after anastomosis. Also, the physiology of the patient needs to fit the procedure.”

1. Holubar S, et al. Modified 2-stage vs. 3-stage ileal pouch-anal anastomosis result in equivalent long-term functional outcomes and pouch survival: A matched-pair analysis. OP13, ECCO 2022, 16–19 February.

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Posted on 12 April 202212 April 2022