REDIVERSION OF THE FAILING POUCH: WHY & WHAT HAPPENS NEXT?
Tairin Uchino*, Eddy Lincango, Arielle E. Kanters, Jeremy M. Lipman, David Liska, Michael Valente, Hermann Kessler, Emre Gorgun, Tracy L. Hull, Scott Steele, Stefan D. Holubar
Colorectal Surgery, Cleveland Clinic, Cleveland, OH
Background: IPAA is a technically demanding procedure with many potential complications. Rediversion is often the first step in pouch salvage, but at time of rediversion it may not be clear if a patient will undergo subsequent pouch salvage surgery. The outcomes after rediversion have not previously been reported. We aimed to describe indications for rediversion, short- and long-term outcomes, in a large pouch cohort.
Methods: We queried our institutional pouch registry for patients who underwent index IPAA and subsequent rediversion at our institution from 1991–2022. Pouch patients constructed or rediverted elsewhere, or pouch salvage/excision without rediversion, were excluded. Patients were selected for pouch salvage according to surgeon discretion. Descriptive statistics and Kaplan-Meier analysis described outcomes after rediversion using EZR v1.6, 2022, Tochigi-ken, Japan.
Results: Overall, 188 patients (3.9% of 4,695 index primary pouches) were rediverted. At time of index pouch, median age 32 years, 50.5% were women. Indications for IPAA: UC (85.1%), Crohn's (5.3%), FAP (4.3%), indeterminate colitis (1.1%) and others (4.3%).
Time from prior ileostomy closure to rediversion was 71 months (0-1381). Indications for rediversion were "Inflammatory Reasons" in 95 (50.8%): fistulae (43, 22.9%), pouchitis/cuffitis (31, 16.5%), pelvic/perianal sepsis (18, 9.6%), small bowel Crohn's (5, 2.7%); and "Non-inflammatory Reasons" in 93 (49.5%): obstruction/volvulus (50, 26.6%), functional problems (22, 11.8%), perforations (11, 5.9%), IPAA leaks (9, 4.8%), others (13, 6.9%). Rediversion was performed open in 156 (82.9%) and laparoscopic in 32 (17.1% [9.4% conversions]). Types of rediversion: loop ileostomy in 174 (92%), end-ileostomy in 12 (6.4%), and end-loop ileostomy in 3 (1.6%). The operative time was 100 minutes (16 – 495), estimate blood loss 50 mL (0-750 mL), and median length of stay was 5 days. The Clavien-Dindo ≥3 complication rate was 13.3%, readmission rate 9.6% and reoperations rate 1.6%.
After rediversion, 99 (52.7%) underwent pouch salvage, 58 (30.9%) patients had no further surgery (pouch left in situ), and 31 (16.5%) had pouch excision without attempted salvage; the reasons for pouch left in situ and pouch excision are shown in Figure 1. The 5-year pouch survival for non-inflammatory vs. inflammatory indications was 87.4% vs. 62.4% (p=0.02), respectively (Figure 2). After pouch salvage surgery (n=98), rediversion closure was achieved in 98 (100%), and subsequent median pouch survival was 280 months.
Conclusion: Overall, 4% of our pouches were rediverted, and rediversion after IPAA was a safe initial strategy to manage failing pouches, with half of the rediverted patients going on to attempted pouch salvage; salvage for non-inflammatory indications had a significantly higher pouch salvage rate than those rediverted for inflammatory complications.
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