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IMPACT OF DUODENECTOMY ON ILEAL POUCH-ANAL ANASTOMOSIS SURVIVAL AND FUNCTIONAL OUTCOMES
Pavel Lenkov
*, Ece Unal, Brian Tang, Joshua Sommovilla, Robert Simon, Daniel Joyce, R Matthew Walsh, Stefan D. Holubar, David Liska
Colorectal Surgery, Cleveland Clinic foundation, Cleveland, OH
Background: In patients with familial adenomatous polyposis (FAP) or ulcerative colitis (UC), may require total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Especially in FAP patients, there can be overlap in the need for IPAA and resection of the duodenum for endoscopically unresectable polyps or duodenal/pancreatic cancer. Literature on the impact of duodenectomy on IPAA outcomes and survival is scarce. We aimed to evaluate our institution’s experience in pouch survival and quality of life (QoL) outcomes in patients who underwent duodenectomy and IPAA.
Methods: We retrospectively reviewed adults who underwent IPAA and duodenectomy between 1993 and 2024. Demographics, operative data, complications, and functional outcomes were collected. Pouch failure was defined as mechanical, neoplastic or functional pouch dysfunction that required operative diversion, and/or pouch revision or excision.
Results: A total of 36 patients with a history of IPAA and duodenectomy were included. Median age was 63 (55-74) years old, and 23 (63.9%) were male. IPAA was either performed for FAP (n=30, 83.3%), or UC (n=6, 16.7%). Types of duodenectomy performed included PSD (n=16, 44.4%), PPPD (n=14, 38.9%), and classic Whipple (n=6, 16.7%). All patients underwent an open approach to duodenectomy, and no patients with malignancy had vessel involvement intraoperatively. Duodenectomy was largely performed for endoscopically unresectable polyps (n=28, 77.8%), and pancreaticoduodenal cancer (n=5, 19.4%). The majority of patients had duodenectomy after IPAA (80.5%). Short term complications within 90 days occurred in 16 patients (44.4%) after duodenectomy. Long term complications occurred in 14 patients. Overall pouch failure was 11.1% (n=4). Median pouch survival in the patients with pouch failure was 12.8 years (10.8-18.1). Causes for pouch failure were pouch dysfunction (50%), desmoid involvement (25%) and pouch prolapse (25%). Of note, both patients with pouch dysfunction, including chronic diarrhea and incontinence, had undergone classic Whipple procedure with resection of the pylorus. Two patients underwent pouch excision with neo-IPAA creation (50%), 1 patient had pouch excision with end ileostomy (25%) and 1 patient had total enterectomy with small bowel transplant due to significant abdominal desmoids (25%). Pouch failure and functional survey results are shown in Table 1.
Conclusion: In patients with history of IPAA and duodenectomy, pouch failure rate was slightly lower in patients who had duodenectomy after IPAA, within the range of 5-10% pouch failure rate for healthy control populations. Duodenectomy timing did not have a clinically significant impact on quality of life after IPAA. Resection of the pylorus may contribute to increased risk of pouch dysfunction, but larger cohort studies are necessary to determine this effect.
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