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Is Conversion of a Failed Ileal Pouch-Anal Anastomosis to a Continent Ileostomy a Predictor of Failure in Long-Term?
Erman Aytac*, David Dietz, Jean Ashburn, Feza H. Remzi
Cleveland Clinic, CLEVELAND, OH
Background: Continent ileostomy (CI) is one of the few surgical options that may be offered to patients with UC or FAP who wish to avoid a permanent ileostomy. Data on long term outcomes of patients who had CI after a failed IPAA is limited. In this study, we aim to evaluate the impact of conversion of a failed IPAA on the long term outcomes of CI.
Methods: Patients who underwent CI construction after failure of an IPAA between 1982-2013 were case matched (1:1) with patients who had CI without having a restorative procedure. The case matching criteria were age (±5), gender, body mass index (±5) and diagnosis. Functional outcomes and long term complications were analyzed. CI revisions that required pouchotomy or re-construction following total or partial excision of CI were defined as major; those without bowel resection were defined as minor revision. CI failure was defined as excision of the pouch and formation of an end ileostomy.
Results: There 81 patients who had a CI after IPAA failure and matching criteria released in two patients for diagnosis. 67 patients fulfilled the case matching criteria and included in the analysis (Table). Follow-up was comparable between the groups (5 vs. 6 years, p=0.442). Septic/infectious complications were the primary reason of IPAA failure [n=40 (60%)]. Requirement of major [n=35(52%) versus n=41 (61%), p=0.756] and minor [n=10 (15 %) versus n=13 (19 %), p=0.492] revisions; number of major [2 (1-8) versus 1 (1-6), p=0.169] and minor [1 (1-3) versus 1 (1-3), p= 0.446] revisions; time to major [1 year (0.5-20) versus 1 year (0.2-28), p=0.736] and minor [1 year (0.1-3) versus 1 year (0.3-7), p=0.891] revisions; and CI failure [n=11(16%) vs. n=16 (24 %), log-rank p =0.638] was comparable between the groups. Intubation per day [5 (1-10) versus 5 (3-8), p=0.804] and per night [1 (0-3) versus 1 (0-2), p=0.700] were similar in patients with CI regardless of prior history of IPAA failure. The causes of CI failure were enterocutaneus/enteroenteric fistula (n=14), valve slippage (n=9), stenosis (n=2), abdominopelvic abscess (n=1) and patient’s request (n=1). 6 [(n=1 (2 %) vs n=5 (8 %), p= 0.208)] patients died during the study period due to other causes unrelated to CI.
Conclusion: Converting a failed IPAA to a CI does not lead to worse outcomes in selected patients. When a redo IPAA is not feasible CI seems as a reasonable alternative in motivated patients.
Case matching criteria and long term complications
| | Failed IPAA (n=67) | No IPAA (n=67) | P value | | Age (y) | 37 (14-62) | 38 (17-63) | 0.972 | | Body mass index (kg/m2) | 23 (16-42) | 24(16-38) | 0.172 | | Gender (Male), n (%) | 24 (36 ) | 24 (36 ) | >0.999 | | Diagnosis, n (%) | | | 0.990 | | Ulcerative colitis | 53 (79) | 51(76) | | | Crohns’s diease | 3 (5) | 3 (5) | | | Familial adenomatous polyposis | 4 (6) | 5 (8) | | | Indeterminate colitis | 4 (6) | 4 (6) | | | Motility disorder | 3 (5) | 4 (6) | | | Follow-up, y * | 5 (1-19) | 6 (1-34) | 0.442 | | Slippage, n (%) | 21 (31) | 22 (33) | 0.853 | | Fistula, n (%) | 14 (21) | 19 (28) | 0.316 | | Intubation difficulty, n (%) | 16 (24) | 11 (16) | 0.282 | | Incontinence, n (%) | 7 (11) | 13 (19) | 0.146 | | Hernia, n (%) | 11 (16) | 7 (11) | 0.311 | | Bowel obstruction, n (%) | 5 (8) | 12 (18) | 0.069 | | Valve prolapse, n (%) | 10 (15) | 7 (11) | 0.436 | | Pouchitis, n (%) | 5 (8) | 6 (9) | 0.753 | | Bleeding, n (%) | 3 (5) | 6 (9) | 0.493 | | Stricture, n (%) | 3 (5) | 6 (9) | 0.493 | | Leakage, n (%) | 6 (9) | 6 (9) | >0.999 | | Afferent limb stricture | 1 (2) | 1 (2) | >0.999 |
(*) after continent ileostomy creation, (**) within the patients who had revision IPAA: Ileal pouch anal anastomosis
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