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Construction of Ileal Pouch in Emergency Operation for Ulcerative Colitis: Is It Safe and Feasible?
HongYeol Yoo^*, Seung-Bum Ryoo, Eun Kyung Choe, Sang Hui Moon, Kyu Joo Park
General surgery, Seoul National University Hospital, Seoul, Korea (the Republic of)

Introduction
Ileal pouch-anal anastomosis (IPAA) has become a standard procedure for the treatment of Ulcerative colitis (UC). But, in the emergency setting, IPAA usually avoided, because the complexity of procedure and prolonged operation time, as well as higher incidence of postoperative morbidity. However, if performed precisely with shortened operation time and diverting ileostomy, IPAA may be feasible in the emergency settings. We evaluated our results of IPAA performed in emergency setting.
Materials and methods
The prospectively collected 81 patients who underwent total procto-colectomy with IPAA between March 1998 and February 2015 were analyzed with retrospective review of medical records. Emergent IPAA were performed in the patients who had massive bleeding, fulminant colitis or toxic megacolon. Elective IPAA were performed in medical intractability, dysplasia or malignancy.
Results
There were 35 male and 46 female patients underwent 68 elective IPAA operations and 13 emergency IPAA operations. The median age of the elective IPAA was 43.0 years and those of the emergency IPAA were 48.0 years (P = 0.734). UC involving the whole colon consisted of 33.8% in the elective IPAA and 69.2% in the emergency IPAA (P = 0.028). All of the ileal pouches were J-pouch and were performed with either the double-stapling technique (n = 69) or a hand-sewn (n = 3) technique. Early complication was present in 16.2% (n = 11) in the elective IPAA and 35.8% (n = 7) in the emergency IPAA group (P = 0.007). The pouch related complication including pouch bleeding and pelvic abscess were also more frequent in the emergency IPAA group (46.2% vs. 10.3%, P = 0.005). These early pouch-related complications were managed conservatively. The average follow up period was 84.7 months in the elective IPAA and 85.1 months in the emergency IPAA (P = 0.985). Regarding the late complications, there were no significant difference between the two groups (P = 1.000). Pouch related complications, such as pouchitis, pouch-vaginal fistula, perianal fistula, anastomosis strictures were also not significantly different between the two groups. Late pouch unrelated complications, such as ileus and incisional hernia did not show any differences between two groups. We had two patients (2/68 = 2.9%) who had their pouch excised, none of whom from to the emergency IPAA group.
Conclusions
Emergency IPAA showed significantly higher early complications but were successfully managed with conservative treatments. And there were no significant difference in the rate of late complications. Our results may indicate that IPAA might be a reasonable procedure even in the emergent setting in UC.
Clinical characteristics of the patients

Characters		Elective IPAA (n=68)	Emergent IPAA (n=13)	P value
Sex	Male	29 (42.6%)	6 (46.2%)	1.000
	Female	39 (57.4%)	7 (53.8%)
Age (yrs)		44.2 ± 14.0	45.6 ± 15.7	0.450†
	≥40	43 (63.2%)	10 (76.9%)	0.526
	<40	25 (36.8%)	3 (23.1%)
BMI	≥25	11 (16.2%)	0 (0%)	0.197
	<25	57 (83.8%)	13 (100%)
Disease extent	Lt. colon	21 (30.9%)	1 (7.7%)	0.102
	T colon	24 (35.3%)	3 (23.1%)	0.528
	Whole colon	23 (33.8%)	9 (69.2%)	0.028
Op indication	Medically intractable	60 (88.2%)	0 (0%)	0.000
	Malignancy or dysplasia	8 (11.8%)	0 (0%)	0.000
	Fulminant colitis	0 (0%)	4 (30.8%)	0.000
	Toxic megacolon	0 (0%)	2 (15.4%)	0.000
	Massive bleeding	0 (0%)	7 (53.8%)	0.000
Anastomosis	Double stapling	65 (95.6%)	13 (100%)	1.000
	Hand-sweing	3 (4.4%)	0 (0%)
Mean follow up period (month)		84.7 ± 49.7	85.1± 61.4	0.985

1) † Student's t test for continuous variables.
2) All others are χ2 test for dichomous variables.
Complications after ileal-pouch anal anastomosis

		Elective IPAA (n=68)	Emergent IPAA (n=13)	P value
Complication	Early complication	11 (16.2%)	7 (53.8%)	0.007
	Late complication	16 (23.5%)	1 (7.7%)	1.000
	Both complication	13 (19.1%)	4 (30.8%)	0.456
	No complication	28 (41.2%)	1 (7.7%)	0.026
Early pouch related complication		7 (10.3%)	6 (46.2%)	0.005
	Pouch related bleeding	3 (4.4%)	3 (23.1%)	0.049
	Pelvic abscess	2 (2.9%)	3 (23.1%)	0.027
	Anastomosis site leakage or rupture	2 (2.9%)	1 (7.7%)	0.413
Early pouch unrelated complication		21 (30.9%)	10 (76.9%)	0.004
	Wound complication	13 (19.1%)	4 (30.8%)	0.456
	Ileus	5 (7.4%)	3 (23.1%)	0.113
	Intra-abdominal bleeding	2 (2.9%)	5 (38.5%)	0.001
	DVT	2 (2.9%)	0 (0.0%)	1.000
	Pneumonia	1 (1.5%)	1 (7.7%)	0.297
	Severe diarrhea	1 (1.5%)	0 (0%)	1.000
Late pouch related complication		22 (32.4%)	4 (30.8%)	1.000
	Pouchitis	16 (23.5%)	3 (23.1%)	1.000
	Pouch-vaginal fistula	6 (8.8%)	0 (0.0%)	0.582
	Perianal abscess/fistula	4 (5.9%)	2 (15.4%)	0.245
	Anastomosis stricture	2 (2.9%)	1 (7.7%)	0.413
Late pouch unrelated complication		13 (19.1%)	2 (15.4%)	1.000
	Ileus	11 (16.2%)	2 (15.4%)	1.000
	Incisional hernia	2 (2.9%)	0 (0.0%)	1.000

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