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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
SexMale29 (42.6%)6 (46.2%)1.000
Female39 (57.4%)7 (53.8%) 
Age (yrs) 44.2 ± 14.045.6 ± 15.70.450†
≥4043 (63.2%)10 (76.9%)0.526
<4025 (36.8%)3 (23.1%) 
BMI≥2511 (16.2%)0 (0%)0.197
<2557 (83.8%)13 (100%) 
Disease extentLt. colon21 (30.9%)1 (7.7%)0.102
T colon24 (35.3%)3 (23.1%)0.528
Whole colon23 (33.8%)9 (69.2%)0.028
Op indicationMedically intractable60 (88.2%)0 (0%)0.000
Malignancy or dysplasia8 (11.8%)0 (0%)0.000
Fulminant colitis0 (0%)4 (30.8%)0.000
Toxic megacolon0 (0%)2 (15.4%)0.000
Massive bleeding0 (0%)7 (53.8%)0.000
AnastomosisDouble stapling65 (95.6%)13 (100%)1.000
Hand-sweing3 (4.4%)0 (0%) 
Mean follow up period (month)84.7 ± 49.785.1± 61.40.985
     

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
ComplicationEarly complication11 (16.2%)7 (53.8%)0.007
Late complication16 (23.5%)1 (7.7%)1.000
Both complication13 (19.1%)4 (30.8%)0.456
No complication28 (41.2%)1 (7.7%)0.026
Early pouch related complication7 (10.3%)6 (46.2%)0.005
 Pouch related bleeding3 (4.4%)3 (23.1%)0.049
 Pelvic abscess2 (2.9%)3 (23.1%)0.027
 Anastomosis site leakage or rupture2 (2.9%)1 (7.7%)0.413
Early pouch unrelated complication21 (30.9%)10 (76.9%)0.004
 Wound complication13 (19.1%)4 (30.8%)0.456
 Ileus5 (7.4%)3 (23.1%)0.113
 Intra-abdominal bleeding2 (2.9%)5 (38.5%)0.001
 DVT2 (2.9%)0 (0.0%)1.000
 Pneumonia1 (1.5%)1 (7.7%)0.297
 Severe diarrhea1 (1.5%)0 (0%)1.000
Late pouch related complication22 (32.4%)4 (30.8%)1.000
 Pouchitis16 (23.5%)3 (23.1%)1.000
 Pouch-vaginal fistula6 (8.8%)0 (0.0%)0.582
 Perianal abscess/fistula4 (5.9%)2 (15.4%)0.245
 Anastomosis stricture2 (2.9%)1 (7.7%)0.413
Late pouch unrelated complication13 (19.1%)2 (15.4%)1.000
  Ileus11 (16.2%)2 (15.4%)1.000
 Incisional hernia2 (2.9%)0 (0.0%)1.000


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