Elsevier

Surgery

Volume 171, Issue 2, February 2022, Pages 299-304
Surgery

Colon/Rectum/Anus
Risk factors for failure of ileal pouch-anal anastomosis in patients with refractory ulcerative colitis

https://doi.org/10.1016/j.surg.2021.07.004Get rights and content

Abstract

Background

Proctocolectomy with ileal pouch-anal anastomosis is the standard surgical procedure for ulcerative colitis refractory to medical treatment. In a few cases, ileal pouch-anal anastomosis cannot be completed due to intraoperative technical problems. The aim of this single-center study was to identify risk factors for a technically failed ileal pouch-anal anastomosis.

Methods

In total, 391 patients with ulcerative colitis who received ileal pouch-anal anastomosis were identified. Clinical and perioperative data from patients with successful ileal pouch-anal anastomosis (IPAA+) were compared to data from failed ileal pouch-anal anastomosis (IPAA-). Definition of failed ileal pouch-anal anastomosis was intraoperative failure to perform ileal pouch-anal anastomosis. Risk factors for failed ileal pouch-anal anastomosis were assessed by logistic regression. Cut-off values were calculated on the basis of receiver operating characteristic curves and the Youden Index.

Results

The rate of failed ileal pouch-anal anastomosis was 26 of 391 (6.6%). In 22 of 26 cases (84.6%), there was an insufficient length of the small intestinal mesentery. Patients with failed ileal pouch-anal anastomosis were more often male (80.8% vs 54.5%, P = .009), older (47.1 ± 14.1 vs 39.2 ± 12.8 years, P = .007), had a higher body mass index 27.2 ± 4.5 vs 23.7 ± 4.3 kg/m2, P < .001), and had extraintestinal manifestations more frequently (65.4% vs 26.3%, P < .001). Further risk factors for failed ileal pouch-anal anastomosis were hypertension and Cushing’s syndrome.

Conclusion

Technical failure of ileal pouch-anal anastomosis is elevated in patients with higher body mass index, with refractory ulcerative colitis, and/or extended immunosuppressive medication. Three-staged ileal pouch-anal anastomosis and optimizing preoperative conditions may help to elevate the rate of successful ileoanal pouch construction in these patients.

Introduction

Since its initial description more than 40 years ago,1 proctocolectomy with ileal-pouch anal anastomosis (IPAA) has evolved into the gold standard for the surgical treatment of ulcerative colitis and colitis-associated intraepithelial neoplasia.2,3 By use of pouch construction and IPAA, stool passage can be reconstructed with good quality of life, and in many cases lifelong use of an ileostomy can be avoided.4, 5, 6 The procedure has undergone continuous technical evolution, with the J-pouch being today’s standard.7 Furthermore, the operation is often performed laparoscopically or with laparoscopic assistance.8 According to the current guidelines of the European Crohn and Colitis Organisation,9 IPAA is performed with a diverting loop ileostomy as a 2-stage procedure, or as a 3-stage procedure in severe cases and long-term pharmacological immunosuppression, with metachronous colectomy, later resection of rectal remnant with IPAA, and diverting loop ileostomy. Regardless of the anastomotic technique, constitutional or technical problems may arise that may render a successful IPAA operation more difficult or even impossible.10,11 In these cases, the procedure ends with terminal ileostomy. The aim of this study was to identify risk factors for a failed IPAA among patients with ulcerative colitis.

Section snippets

Patients

The case-control study included 391 patients who underwent restorative proctocolectomy for histologically confirmed ulcerative colitis from 2000 to 2020 at our tertiary referral center Charité–Universitätsmedizin Berlin, Campus Benjamin Franklin. Indication for surgery was based on the failure of pharmacological therapy, dysplasia, or malignancy, or on acute events (perforation, toxic megacolon, bleeding). If surgery was performed during a high activity of UC or in an emergency setting, a

Patients

The study included a total of 391 patients whose operation was begun primarily with the intention to perform IPAA for UC. Of those, 365 (93.4%) were successful (“IPAA+”) and 26 (6.6%) could not initially be completed with an IPAA as planned (“IPAA-”). If IPAA seemed futile during the index operation, a terminal ileostomy was created. No significant difference in indications for restorative proctocolectomy of the groups IPAA+ versus IPAA- was found (P = .789): failure of pharmacological therapy

Discussion

Restorative proctocolectomy is the gold standard in the curative treatment of severe UC. In a few cases, the procedure could not be completed successfully because it was impossible to perform IPAA. This study aimed to analyze reasons and risk factors for intraoperative failure of IPAA.

In this retrospective, single-center study, we showed that planned IPAA could not be completed in 6.6% of the patients with ulcerative colitis. Male sex, arterial hypertension, extraintestinal manifestations of

Funding/Support

None declared.

Conflict of interest/Disclosure

The authors declare that they have no competing interests.

Acknowledgment

The data collection was done by reviewing the electronic health records at the Charité Universitätsmedizin Berlin. Relevant data were collected in Microsoft Excel and analyzed descriptively. The data are stored on the Charité server and, to avoid a violation of access rights, the data are encrypted using a password only known to the study physicians. The data that support the findings of this study are available, but restrictions apply to the availability of these data, which were used under

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