CROHN'S DISEASE LIKE POUCH INFLAMMATION IS ASSOCIATED WITH DECREASED ODDS OF TEMPORARY ILEOSTOMY TAKEDOWN AFTER ILEAL POUCH ANAL ANASTOMOSIS
Maia Kayal*, Michael C. Plietz, Sergey Khaitov, Patricia Sylla, Marla Dubinsky, Alexander Greenstein
Icahn School of Medicine at Mount Sinai, New York, NY
The staged restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) is the gold standard surgery for patients with medically refractory ulcerative colitis (UC). Complications such as anastomotic leak, small bowel obstruction and pouch inflammation may occur after final surgical stage and require the creation of a temporary diverting ileostomy. The aim of this study is to report the long-term outcomes of patients who required a temporary ileostomy, and describe the predictors for successful ostomy takedown and restoration of intestinal continuity.
This was a retrospective chart review conducted at a single tertiary care inflammatory bowel disease (IBD) center at Mount Sinai Hospital (MSH). All patients with UC who underwent RPC with IPAA for medically refractory disease or dysplasia followed by a temporary ileostomy after the final surgical stage between January 2008 and December 2017 were identified through hospital electronic medical records. Predictors of ostomy closure and restoration of intestinal continuity were analyzed using regression methods with odds ratios (OR) and 95% confidence intervals (CI) reported.
Among 664 patients who underwent RPC with IPAA at MSH between 2008 and 2017, 61 (9.2%) required an end (n=14, 23.0%) or loop (n=47, 77.0%) ileostomy after final surgical stage. Of these, 29 (47.5%) patients were female and 32 (52.5%) were male and the median age was 38.2 [interquartile range 28.1-50.8] years. The median time of ileostomy creation from final surgical stage was 5.4 [IQR 0.48-23.04] months. The indication for ileostomy was anastomotic leak in 30 (49.2%) patients, Crohn's disease like pouch inflammation (CDLPI) in 23 (37.7%), small bowel obstruction in 4 (6.6%), refractory anastomotic stricture in 1 (1.6%), pouch dysfunction in 1 (1.6%), sinus tract in 1 (1.6%) and dysplasia in 1 (1.6%).
Restoration of intestinal continuity occurred in 31 (50.8%) patients a median of 3.86 [IQR 3.31-6.58] months after ileostomy creation. Of the 30 patients who did not have ileostomy takedown, 18 (60.0%) were diverted for CDLPI, 8 (26.7%) for an anastomotic leak, 2 (6.7%) for obstruction, 1 (3.3%) for dysplasia and 1 (3.3%) for stricture. Nine (30%) patients ultimately underwent pouch excision. On univariable analysis, longer duration between IPAA and ostomy creation (OR 0.69 95% CI 0.49-0.95) and CDLPI (OR 0.10 95% CI 0.03-0.36) were both associated with decreased odds of ostomy takedown and restoration of intestinal continuity. On multivariable analysis adjusting for age and sex, CDLPI (aOR 0.11 95% CI 0.02-0.59) was associated with a decreased odd of restoration of intestinal continuity.
Patients requiring a diverting ileostomy for CDLPI after IPAA have a very low likelihood of having intestinal continuity restored. Research focusing on better medical management of these patients is warranted.
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