SSAT - What Factors Affect Surgeons' Decision to Perform Two Versus Three-Stage Operation in Ulcerative Colitis?

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What Factors Affect Surgeons' Decision to Perform Two Versus Three-Stage Operation in Ulcerative Colitis?
Ozgen Isik, Emre Gorgun^*, Meagan Costedio, Gokhan Ozuner, Feza H. Remzi

Colorectal Surgery, Cleveland Clinic, Cleveland, OH

Purpose: Restorative proctocolectomy (RP) with ileal pouch anal anastomosis (IPAA) is the preferred choice of surgical treatment in patients with ulcerative colitis. The aim of this study was to determine the factors influencing surgeons' decision performing 2 versus 3-stage RP/IPAA.
Methods: All patients who underwent total abdominal colectomy (3 stage) or total proctocolectomy with IPAA (2 stage) for ulcerative colitis between 2005 and 2010 were identified from American College of Surgeons National Quality Improvement (ACS-NSQIP) database. The evaluated index surgery was the first stage of 2 different approaches. A logistic regression model of the propensity of 2-stage opposed to 3-stage was conducted. Outcomes for two groups were also evaluated.
Results: In total, 1960 patients (42.8% female) with a median age of 42 (16-90) were included. Total proctocolectomy with IPAA was performed in 1067 (54.4%), and total abdominal colectomy was performed in 893 (45.6%) patients. Table shows the propensity of 3-stage treatment as opposed to 2-stage. 2-stage RP/IPAA was associated with prolonged operating time, increased length of total hospital stay, organ/space surgical site infection (SSI), postoperative sepsis, and need of re-operation (p< 0.05).
Conclusion: Three-stage pouch surgery is generally preferred in unfavorable conditions including high BMI and ASA scores, patients with diabetes, on steroids, lower albumin level, and anemia. Two-stage ileal pouch surgery may be associated with increased postoperative complications if patients are not properly selected.

Logistic Regression Model of the Propensity of 3-Stage Approach (as opposed to 2-stage)

Odds Ratio (95% CI) P-value
BMI (kg/m2, per 5 unit increase) 1.23 (1.09 - 1.38) 0.001
ASA score ≥ 3 1.60 (1.21 - 2.13) 0.001
Diabetes Mellitus 2.62 (1.53 - 4.61) 0.001
Steroid use 1.63 (1.25 - 2.12) <0.001
Ascites Not estimated¶ 0.012
Weight loss 1.92 (1.30 - 2.85) 0.001
Emergency surgery 3.10 (1.40 - 7.72) 0.009
Wound class (contaminated or dirty/ infected) 1.50 (1.08 - 2.10) 0.017
Preoperative Sepsis <0.001
None 1
SIRS 3.87 (2.07 - 7.81)
Sepsis 2.27 (0.69 - 10.4)
Septic Shock Not estimated¶
Preoperative albumin level (g/dl, per 1 unit decrease) 2.10 (1.69 - 2.59) <0.001
Preoperative hematocrit level (%, per 5 unit decrease) 1.16 (1.01 - 1.33) 0.041

¶ Odds ratio not estimated because all patients in this group received TAC.

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