THIRD TIME'S THE CHARM? INDICATIONS AND LONG-TERM OUTCOMES AFTER REDO-REDO ILEAL POUCH ANAL ANASTOMOSIS
Marianna Maspero*, Olga Lavryk, Stefan D. Holubar, Jeremy M. Lipman, Scott Steele, Tracy L. Hull
Cleveland Clinic, Cleveland, OH
Background: Pouch failure after redo ileal pouch anal anastomosis (IPAA) occurs in 20-40% of cases. The decision to offer a second redo procedure to maintain intestinal continuity is controversial, and scarce evidence exists regarding long-term pouch survival and functional outcomes after redo-redo IPAA.
Methods: We retrospectively analyzed our prospectively collected pouch registry for redo IPAA procedures and identified all patients who underwent a second redo IPAA procedure from 2004 to 2021. Our primary outcome was pouch survival, defined as no pouch excision or rediversion. Figures are frequency (percentage) and median (interquartile range).
Results: Twenty-three patients met inclusion criteria (65% female, 4% of all redo IPAAs). The index diagnosis was ulcerative colitis in 20 (87%) cases and indeterminate colitis in 3 (13%). The median interval between the index pouch and the second redo was 36 (24 – 90) months, while the median time between the first and second redo was 16 (9 – 36.5) months. Only 8 (35%) of patients had their stoma closed between the first and second redo. In 15 (65%) cases both redo procedures were done at our center. The indication for pouch salvage was the same for the first and second redo in 21 (91%) cases (Figure 1): 20 (87%) patients both redo for septic complications. Second redos were done transabdominally in 21 (91%) of cases, and 14 (61%) involved pouch excision and construction of a neo-pouch. All were handsewn, and the final pouch configuration was "J" in 18 (78%) and "S" in 5 (22%) cases (Figure 2). Twenty (87%) had their stoma closed after the second redo. After a median follow up of 39 months (18.5 – 95.5), 10 (44%) patients experienced pouch failure (due to sepsis in 9 cases of which 3 never had their stoma closed, and poor function in 1). Pouch survival was 81% at 1-year, and 76% at 3-years. The median interval between second redo and pouch failure was 12 months (3 – 50.5). Postoperative Cleveland Global Quality of Life surveys were available for 17 (74%) patients. After a median interval of 14 (6 – 40) months, the overall quality of life score (0 -1) was 0.6 (0.5 – 0.8). The median number of bowel movements was 6 (5 – 8) during daytime, 2 (2 – 4) at night, for a total of 8 (6.5 – 12.5) per 24 hours. Urgency occurring most days of the week was reported by 30%, frequency by 14%, seepage during the day by 71% and at night by 86%. Dietary restrictions were reported by 50% of patients, social restrictions by 44%, work restrictions by 62.5%, and sexual restrictions by 50%.
Conclusion: A second redo pouch procedure may be offered with acceptable outcomes to a very select group of patients who are highly motivated to maintain intestinal continuity.
Figure 1. Indications to first and second redo, and pouch outcomes (Sankey diagram)
Figure 2. Pouch configuration at index, first and second IPAA
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