OPTIMIZATION OF OUTCOMES IN PATIENTS UNDERGOING RE-DO SURGERY FOR A FAILED ILEAL POUCH ANAL ANASTOMOSIS DUE TO PELVIC SEPSIS
Eren Esen*1, Arman Erkan1, Erman Aytac2, Tarik H. Kirat1, Feza H. Remzi1
1Surgery, NYU Langone Health, New York, NY; 2Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
Background: Pelvic sepsis is the most common cause of ileal pouch anal anastomosis (IPAA) failure and most common indication for re-do IPAA. Management of sepsis and salvage of the IPAA is a complex process which requires individually planned treatment strategy. This study aims to evaluate the outcomes of 3-stage transabdominal redo-surgery for failed IPAAs due to pelvic sepsis in a comparative manner.
Methods: Patients who underwent re-do IPAA in 9/2016 – 10/2019 for failed IPAAs were included. All patients without dysplasia/neoplasia underwent 3-stage re-do IPAA consisting of creation of a loop ileostomy, re-do IPAA surgery, and ileostomy closure. Patients were divided into two groups according to their re-do IPAA indications (Group 1: Pelvic sepsis, Group 2: Non-sepsis). Perioperative, mid-term postoperative, functional outcomes and quality of life scores were compared two groups.
Results: Ninety-one patients were included (pelvic sepsis, n=60; non-sepsis, n=31). Preoperative patient and primary pouch characteristics were comparable. While all patients had ileostomy 6 months prior to their re-do IPAA in pelvic sepsis group, there were 4 patients underwent re-do IPAA without prior ileostomy due to dysplasia/neoplasia (p=0.012). All patients had diverting loop ileostomy at the time of redo-IPAA surgery. Re-do ileal pouch configurations were similar. Mucosectomy with handsewn anastomosis was more commonly performed in pelvic sepsis group [pelvic sepsis, n=48 (80%) vs non-sepsis, n=17 (55%), p=0.012]. Operative time and estimated blood loss were comparable (mean, pelvis sepsis: 278±64 min vs non-sepsis 263±96, p=0.46), (median, pelvic sepsis: 325 ml vs non-sepsis: 200 ml, p=0.065), respectively. Overall postoperative morbidity, 30-day and mid-term pelvic sepsis rates were similar (Table 1). Patients in non-sepsis group had more frequent daily bowel movements (median, pelvic sepsis: 5.5 vs non-sepsis: 7.5, p=0.046). Other functional outcomes and restrictions were similar and shown (Table 2). Redo IPAA failed in 2 patients immediately after salvage surgery and received pouch excision with permanent end ileostomy in pelvic sepsis group. Pouch survival rates were 91% and 96% in pelvic sepsis and non-sepsis groups respectively (p=0.65) within in 14 months median follow-up after ileostomy closure. The median quality of life scores were higher in pelvic sepsis group (pelvic sepsis: 0.8, non-sepsis: 0.7, p=0.04). Patients were equally happy after redo-IPAA surgery and majority of them recommended surgery to others if required.
Conclusions: 3-stage salvage strategy seems to be a rational option providing acceptable outcomes in patients with a failed IPAA caused by pelvic sepsis likely due to the fact that it brings the feasibility to perform re-do IPAA with equivalent success rates compared to nonsepsis group.
Comparison of the short- and mid-term complications between pelvic sepsis vs non-sepsis groups
Comparison of the mid-term functional outcomes between pelvic sepsis and non-sepsis groups
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