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UC patients with delayed IPAA have fewer complications after surgery
LAS VEGAS — Patients with ulcerative colitis who underwent ileal pouch anal anastomosis experienced fewer complications when the surgery was performed in the traditional three stages rather than in two stages, according to new research presented at the Crohn’s & Colitis Congress.
“The risks between two- and three-stage procedures are not well described, and there are no prospective national reports of postoperative adverse events,” Bharati Kochar, MD, of the University of North Carolina at Chapel Hill School of Medicine, said during her presentation. “Therefore, in our study we aimed to evaluate adverse events within 30 days after IPAA creation from a national database and compare adverse events between two- and three-stage procedures.”
Kochar and colleagues performed a cohort study using prospective data from the National Surgical Quality Improvement Program that was collected between 2011 and 2015. They identified 2,390 IPAA procedures, 1,571 of which were two-stage procedures in which the pouch was created at the time of colectomy, and 819 were three-stage procedures in which pouch creation was delayed.
The researchers noted that 51% of patients who underwent the two-stage procedure were on chronic immunosuppression before surgery, compared with 15% of those who underwent the three-stage procedure (P < .01).
After adjusting for age, sex, race, BMI, smoking, diabetes, albumin and co-morbidities, Kochar and colleagues found that patients who had the three-stage procedure with delayed pouch creation experienced significantly fewer unplanned reoperations (RR = 0.42; 95% CI, 0.24-0.75), major adverse events (RR = 0.72; 95% CI, 0.52-0.99), and minor adverse events (RR = 0.48; 95% CI 0.32-0.73) compared with those who underwent the two-stage procedure.
They also performed a sub-analysis of adverse events in 2,460 patients who underwent total abdominal colectomy with ileostomy (TAC), of whom 69% were on chronic immunosuppression. Adjusted analysis showed patients who underwent TAC also experienced significantly fewer unplanned readmissions (RR = 0.69; 95% CI 0.58-0.81), major adverse events (RR = 0.68; 95% CI, 0.54-0.84) and minor adverse events (RR = 0.79; 95% CI, 0.63-0.98) compared with patients who underwent two-stage IPAA with pouch creation at the time of colectomy.
“We found that delayed pouch procedures are associated with lower risk of unplanned reoperations, major and minor complications,” Kochar concluded, adding that “immunosuppression at the time of pouch creation may result in an increased risk of adverse events postoperatively.” – by Adam Leitenberger
Reference:
Kochar B, et al. Abstract 11. Presented at: Crohn’s & Colitis Congress; Jan. 19-20, 2018; Las Vegas, NV.
Disclosures: The authors report no relevant financial disclosures.
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Dr. Kochar was able to study a national surgical quality initiative program, identifying IBD patients who had undergone proctocolectomy with ileal pouch anal anastomosis and comparing the two-stage pouch with the three-stage pouch.
One thing that struck me about the results was how strikingly better three-stage pouches were for reducing complications.
Before she presented the results, I was concerned as she was going through the methods that there was going to be a lot of bias by severity or confounding by severity, because we usually do three-stage pouches in the patients with more severe disease, and yet even though they had more severe disease at baseline, those were the patients who had the fewest complications.
So, it was a pretty powerful message that a three-stage approach to proctocolectomy with J pouch was associated with fewer complications for the patients. You really must work with your surgeon, of course, but it’s definitely food for thought, and certainly in our sicker patients and our patients on biologics now, our surgeons are more often offering a three-stage approach rather than a two-stage approach.