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Length of Bowel Distal to a Diverting Ileostomy (Di) Does Not Influence the Risk of Dehydration After Ileal Pouch-Anal Anastomosis (IPAA)
Sharon Z. Koh*1, Cindy Kallman2, Christopher Watterson2, Karen N. Zaghiyan1, Edward H. Phillips1, Phillip Fleshner1
1Surgery, Cedars Sinai Medical Center, Los Angeles, CA; 2Radiology, Cedars Sinai Medical Center, Los Angeles, CA
Purpose: As the most common early postoperative surgical complication, readmission for dehydration after creation of DI with IPAA ranges between 5-15%. There are no studies that assess whether the length of the afferent limb (AL) or pouch length (PL) influences the rate of readmission prior to closure of the DI. We hypothesized that longer lengths of the AL and PL would increase the risk of readmission for dehydration due to an overall decreased length of absorptive bowel.
Aim: To determine if AL or PL measured at the time of pouchogram is associated with severe dehydration necessitating readmission to the hospital.
Methods: Patients undergoing IPAA with DI between January 2003 and May 2013 were identified. All patients had a pouchogram before DI reversal. AL, PL and combined length (CL=AL+PL) were measured by study personnel blinded to the primary study endpoint. We identified patients with the readmitting diagnosis of dehydration within 60 days of DI creation based on high ileostomy output (>/=1500 ml on the day of readmission) and/or biochemical abnormalities of dehydration (elevated blood urea nitrogen or creatinine). Patients with known renal impairment, previous radiotherapy to the pelvis or prior small bowel resection were excluded.
Results:
Of the 327 study patients, 320 (98%) had surgery for IBD and 7 (2%) underwent surgery for colonic polyposis. 30 (9%) were readmitted for significant dehydration a mean (SD) of 11.8 (±13.5) days after hospital discharge. Clinical features between patients with or without dehydration requiring readmission were comparable except for 2 factors: indication for surgery and number of stages of IPAA. The readmission rate for dysplasia/cancer (20%) was significantly higher than that for medically refractory disease (7%) (p=0.009). In addition, the readmission rate of 2-stage IPAA (12%) was significantly higher vs. 3-stage IPAA (5%) (p=0.03). Mean (SD) lengths of the AL, PL and CL were 50 (±20) cm, 15 (±4) cm, and 65 (±20) cm in the readmitted patient group vs. 45 (±17) cm, 13 (±4) cm and 58 (±17) cm in the non-readmitted group (all p=NS).
Conclusion: Risk of readmission due to dehydration prior to reversal of DI is higher in patients undergoing IPAA for dysplasia/cancer and a 2-stage IPAA. The lengths of the afferent limb and pouch do not predict readmission for dehydration after IPAA with DI. It is possible that patients undergoing 3-stage IPAA become more adept at managing their stoma output during the initial subtotal colectomy with end ileostomy prior to undergoing IPAA compared with patients having a 2-stage procedure. Similarly, patients with medically refractory IBD may have a natural history of more severe or prolonged diarrhea and possibly be better at managing their fluid balance.
| No Readmission (n=297) | Readmission (n=30) | | | Mean (SD) | Mean (SD) | p value | | Afferent limb Length (AL) | 45.1 (16.8) | 49.9 (20.4) | 0.2 | | Pouch Length (PL) | 13.1 (3.6) | 14.6 (4.3) | 0.08 | | Combined Length (CL) | 58.2 (17.4) | 64.5 (20.4) | 0.1 |
All lengths expressed in centimeters (cm)
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