Stoma-less IPAA Is Not Associated With Increased Anastomotic Leak Rate or Long-term Pouch Failure in Patients With Ulcerative Colitis : Diseases of the Colon & Rectum

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Original Contributions: Inflammatory Bowel Disease

Stoma-less IPAA Is Not Associated With Increased Anastomotic Leak Rate or Long-term Pouch Failure in Patients With Ulcerative Colitis

Olecki, Elizabeth J. M.D., M.S.C.R.1; Kronfli, Anthony P. M.D.1; Stahl, Kelly A. M.D.1; King, Steven B.S.2; C. Razavi, Nina B.S.2; Koltun, Walter A. M.D.3

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Diseases of the Colon & Rectum 65(11):p 1342-1350, November 2022. | DOI: 10.1097/DCR.0000000000002274
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Abstract

Proctocolectomy with IPAA is the preferred surgical intervention for patients with ulcerative colitis (UC) requiring colectomy.1,2 Given that up to 30% of individuals with UC will eventually require surgical intervention,2 an IPAA has the potential to improve quality of life of patients with UC by reducing the need for immunosuppression, decreasing cancer risk, and giving them the opportunity to be free from a permanent stoma.3 IPAA can be performed using different approaches, ranging from a 1-stage procedure to a 3-stage procedure, depending on the indication for IPAA and patient factors.

Central to the discussion of the preferred staged approach of IPAA creation is the indication for a diverting loop ileostomy (DLI) at the time of IPAA. Existing literature has found conflicting evidence regarding outcomes of stoma-less IPAAs compared to IPAAs constructed with DLI. Some studies have found no difference in outcomes,2,4 whereas others have demonstrated worse outcomes in IPAA without DLI,5–7 particularly when it comes to anastomotic leak rates and other septic perioperative complications. Although historically presumed to reduce the risk of septic complications associated with anastomotic leak, DLIs have their own unique risks. These include small bowel obstruction (SBO),8 dehydration, exposure to an additional surgery for closure with complication rates ranging from 11% to more than 18%,4,9 and inconvenience and general decreased quality of life associated with ileostomy.

Given the disadvantages of DLI at the time of IPAA, the question of whether DLI can safely be omitted during IPAA creation remains central to the surgical treatment of patients with UC. Unfortunately, many existing studies investigating the use of DLI at the time of IPAA include heterogeneous patient populations that include IPAAs created for familial adenomatous polyposis and Crohn’s disease and compare only 2 surgical approaches instead of including all staged procedures for IPAA creation (1-stage, 2-stage, modified 2-stage procedure,10 and 3-stage procedure). Additionally, many existing studies fail to capture long-term outcomes, including the important outcome of pouch failure rates. Given the lack of clarity of both short- and long-term outcomes in patients with UC undergoing IPAA, this study uses a large IBD database to investigate the primary outcomes of anastomotic leak and pouch failure to compare DLI at the time of IPAA compared to stoma-less IPAA.

PATIENTS AND METHODS

A retrospective review of all patients with a pathologically confirmed diagnosis of UC undergoing an IPAA from 1990 to 2019 was completed using a prospectively collected IBD database maintained at the Milton S. Hershey Medical Center, a tertiary referral center with a specialized IBD program that performs a high volume of IPAA procedures per year. Patients with a preoperative diagnosis of Crohn’s disease were excluded. However, if patients were determined to have Crohn’s disease after IPAA, they were included in this study. All patients undergoing a 1-stage, 2-stage, modified 2-stage,10 and 3-stage procedure were included. Those who had a DLI at the time of IPAA (2- and 3-stage procedures) were analyzed together‚ and those patients who did not have an ileostomy at the time of IPAA creation (1- and modified 2-stage) were analyzed as a group (Fig. 1). To be considered a candidate for a stoma-less IPAA, patients were required to be on minimal oral steroids (<20 mg/d), to be well nourished (albumin >3.5 g/dL), to have normal hemoglobin/hematocrit without transfusion requirement, and to undergo a technically straightforward IPAA creation. Additionally, all stoma-less IPAA anastomoses were performed via a double-stapled technique. All operations were performed by a group of 8 board-certified colorectal surgeons at a single, high-volume institution11 with a multidisciplinary IBD program that included gastroenterology, colorectal surgery, IBD research center, and specialized nursing care.

F1
FIGURE 1.:
Flow diagram of the pouch procedure stages in stoma-less IPAA (no ileostomy group) and ileostomy group.

Demographic characteristics (age at the time of IPAA, sex, smoking status at the time of IPAA, BMI at the time of IPAA, prednisone usage at the time of IPAA [mg/d], and anti-TNF usage [within 3 months of IPAA]) and operative characteristics (indication for colectomy, case status, estimated blood loss at the time of IPAA, surgical approach, and stage of pouch creation) were obtained through a retrospective review. Short-term outcomes were defined as those occurring within 30 days of surgery and included anastomotic leak (defined as a defect at the anastomotic site that was confirmed by imaging, requiring antibiotics and either percutaneous drainage or reoperation), unplanned return to the operating room for any reason, superficial surgical site infection, deep surgical site infection, thromboembolic event (deep vein thrombosis or pulmonary embolism), perioperative transfusion (including both intraoperatively or postoperatively), and postoperative ileus (requiring nasogastric tube or prolonged nothing by mouth status >7 d). The length of stay (LOS) during IPAA was defined as the number of days the patient remained in the hospital during admission for IPAA surgery. The total LOS is defined as the cumulative LOS for all stages of an IPAA to be created (for 1-stage procedures, this would be 1 admission, and for 3-stage procedures, this would be 3 separate admissions‚ including admission for colectomy, IPAA, and DLI reversal). Long-term outcomes included any complications that occurred >30 days after IPAA to the most recent follow-up, including the requirement for a secondary ileostomy at any time during follow-up; development of Crohn’s disease (defined by pathologic diagnosis or clinical presentation consistent with Crohn’s disease);12 development of a hernia at a previous stoma site; stricture of the pouch (requiring either endoscopic or surgical intervention); development of an anal fistula; development of an SBO (adhesions causing obstructive symptoms confirmed by imaging or surgical exploration); development of pouchitis (antibiotic responsive, antibiotic dependent, or pouchitis requiring biologic therapy); and pouch failure (requiring excision of pouch or permanent secondary ileostomy at any time during follow-up). Anal fistulas were defined by the operating surgeon during examination under anesthesia as either cryptoglandular anal fistula13 or Crohn’s-like (demonstrating physical signs of IBD14 with pathologic confirmation of a diagnosis). Long-term follow-up data were extracted from the most recent clinical patient encounter. All patients were scheduled for regular-interval follow-ups in the immediate postoperative period of 3 to 6 months in the first year after IPAA construction and annually thereafter. Routine pouchoscopy was performed every 1 to 2 years during follow-up unless clinical signs and symptoms required more frequent endoscopic evaluation of the pouch. Long-term data were also extracted from acute visits for any long-term complication of interest.

Continuous variables are presented as median values with interquartile range and categorical variables are expressed as percentages. Univariate analysis was performed to determine subgroup differences between the groups with and without ileostomy at the time of IPAA using the χ2 test for categorical variables and Kruskal-Wallis test for continuous variables. SAS software, version 9.4 (SAS, Cary, NC)‚ was used for all statistical analyses. All statistical tests were 2-sided and α was set at a significance level of 0.05. This study received approval from the institutional review board of the Human Subject Protection Office at the Penn State College of Medicine.

RESULTS

From 1990 to 2018, 414 IPAAs were performed on patients with a diagnosis of UC who met inclusion criteria for this study. Of these patients, 22.0% (91/414) had an IPAA performed without an ileostomy at the time of pouch creation, with 33 of these pouches performed as a 1-stage procedure and 58 performed as a modified 2-stage procedure. The remaining 323 patients had ileostomies at the time of IPAA creation, with 208 constructed through a traditional 2-stage procedure and 115 constructed via 3-stage procedures (Fig. 1). Table 1 demonstrates demographic and perioperative details comparing those who had a stoma-less IPAA construction to those who had a DLI at the time of IPAA. There was no significant difference between the 2 groups in terms of sex, age, preoperative biologic usage, case status (elective vs urgent),15 and surgical approach (open vs laparoscopic) of IPAA creation (p > 0.05). There was a higher percentage of smokers in the stoma-less IPAA group (11% vs 4.6%) compared to the ileostomy group (p < 0.001). The stoma-less IPAA group was also more likely to have normal weight (BMI, 18.5–25 kg/m²; 34.1% vs 20.7%), more likely to be not actively taking oral steroids (83.5% vs 65.3%), and more likely to have an operation for a diagnosis of dysplasia or cancer (17.6% vs 9.9%) when compared to the ileostomy group. Estimated blood loss was significantly lower in the stoma-less IPAA group with a median of 200 mL compared to 300 mL in the ileostomy group. During the course of our study, 1-stage procedure was first identified in the database in 1995 and modified 2-stage procedure in 1994. Figure 2 demonstrates the frequency of each type of procedure (2-stage, 3-stage, and stoma-less IPAA) by year. The distribution of the type of procedure and the use of stoma-less IPAA has been relatively proportionally uniform over time.

TABLE 1. - Perioperative characteristics of those with and without ileostomy at the time of IPAA
Characteristics Stoma-less IPAA (N = 91) Ileostomy at IPAA (N = 323) p
Age, y 0.131
 Mean (SD) 36.6 (11.05) 38.9 (12.35)
 Median 35.8 37
 Interquartile range 26.3–45.4 29.3–47.9
 Range 19.0–59.7 12.7–70.6
Sex 0.472
 Male 54 (59.3%) 205 (63.5%)
 Female 37 (40.7%) 118 (36.5%)
Smoking status <0.001
 Current smoker 10 (11%) 15 (4.6%)
 Unknown 3 (3.3%) 61 (18.9%)
BMI at IPAA 0.002
 Unknown 14 (15.4%) 107 (33.1%)
 Underweight (<18.5 kg/m²) 0 (0%) 4 (1.2%)
 Normal weight (18.5–25 kg/m²) 31 (34.1%) 67 (20.7%)
 Overweight (>25 kg/m²) 46 (50.5%) 145 (44.9%)
Prednisone usage at IPAA 0.001
 No oral prednisone 76 (83.5%) 211 (65.3%)
 <20 mg prednisone 12 (13.2%) 73 (22.6%)
 >20 mg prednisone 0 (0%) 33 (10.2%)
 Unknown 3 (3.3%) 6 (1.9%)
Biologic usage (within 3 mo of surgery) 0.996
 Unknown 2 (2.2%) 7 (2.2%)
 Biologic usage 7 (7.7%) 24 (7.4%)
Indication for colectomy <0.001
 Unknown 0 (0%) 13 (4%)
 Failure medical management 52 (57.1%) 255 (78.9%)
 Toxic colitis 23 (25.3%) 22 (6.8%)
Dysplasia/cancer 16 (17.6%) 33 (10.2%)
Case status 0.131
 Unknown 6 (6.6%) 8 (2.5%)
 Elective 72 (79.1%) 275 (85.1%)
 Urgent 13 (14.3%) 40 (12.4%)
EBL at time of IPAA <0.001
 n 59 231
 Mean (SD) 219.9 (158.10) 362.7 (300.74)
 Median 200 300
 Interquartile range 100.0–300.0 150.0–500.0
 Range 25.0–700.0 15.0–2200.0
Surgical approach 0.613
 Open IPAA 77 (84.6%) 266 (82.4%)
 Laparoscopic IPAA 14 (15.4%) 57 (17.6%)
Data presented as n (%) unless otherwise indicated.
EBL = estimated blood loss.

F2
FIGURE 2.:
Frequency of type of procedure (stoma-less IPAA, 3-stage IPAA, and 2-stage IPAA) by year IPAA was performed.

Evaluation of short-term outcomes of the stoma-less IPAA group compared to the group with ileostomy at the time of IPAA is presented in Table 2. The stoma-less IPAA group had a significantly longer median LOS both at the time of IPAA (9.0 d) when compared to the group with ileostomy at the time of IPAA (5.0 d; p < 0.001) and in terms of total LOS‚ with the stoma-less IPAA group having a median of 14.0 days compared to 11.0 days in the ileostomy group (p = 0.001). Although there was a significantly higher rate of infectious complications in the stoma-less IPAA group (superficial surgical site infections [p = 0.010] and deep surgical site infections [p = 0.008]), there was no difference in the need for unplanned reoperation, thromboembolic events (deep vein thrombosis or pulmonary embolism), perioperative transfusion requirements, and postoperative ileus. Notably, there was no significant difference between the 2 groups in terms of rates of anastomotic leaks, with the stoma-less IPAA group having a rate of 3.3% and the ileostomy group having a rate of 1.5% (p = 0.284). Subgroup analysis of the stoma-less IPAA group by stage of procedure revealed that 90% (9/10) of superficial surgical site infections and 100% (4/4) of the deep surgical site infections occurred in the modified 2-stage group, whereas no deep surgical site infections occurred in the 1-stage group. In other words, 94% (15/16) of the surgical infections occurred in patients who came to the operating room with a stoma already in place.

TABLE 2. - Short-term (<30 d) outcomes
Outcomes Stoma-less IPAA (N = 91) Stoma at IPAA (N = 323) p
Anastomotic leak 3 (3.3%) 5 (1.5%) 0.284
Length of stay at IPAA <0.001
 Median 9 5
 Interquartile range 8.0–10.0 5.0–7.0
Total length of stay a 0.001
 Median 14 11
 Interquartile range 10.0–19.0 8.0–15.0
Unplanned return to the operating room 8 (8.8%) 48 (14.9%) 0.135
Superficial surgical site infection 10 (11%) 13 (4%) 0.01
Deep surgical site infection 4 (4.4%) 2 (0.6%) 0.008
Thromboembolic event 1 (1.1%) 12 (3.7%) 0.206
Perioperative transfusion required 9 (9.9%) 29 (9%) 0.79
Postoperative ileus 10 (11%) 25 (7.7%) 0.325
Data presented as n (%) unless otherwise indicated.
aIncluding colectomy, IPAA, and ileostomy reversal, as indicated.

When evaluating long-term outcomes (Table 3), there was no difference in the number of follow-ups between the stoma-less IPAA group and the ileostomy group, with both groups having >8 years of mean follow-up. When comparing the stoma-less IPAA group to the ileostomy group, there was no difference in terms of rates of required secondary ileostomy, development of Crohn’s disease symptoms, pouch strictures requiring intervention, pouchitis, and development of SBO. There was a higher rate of development of anal fistula in the stoma-less IPAA group (13%) compared to the ileostomy group (6.5%; p = 0.042). A majority of the anal fistulas were cryptogenic in nature and unrelated to IBD (9/12 in the stoma-less IPAA group and 14/21 in the ileostomy group). The mean time between IPAA creation and diagnosis of anal fistula was 8.06 (SD 6.7) years. Two fistulas occurred within 6 months of IPAA creation, 1 in each group. These 2 early fistulas were simple, superficial perianal fistulas that resolved with simple fistuolotomy without recurrence and showed no signs of being related to an anastomotic leak. Importantly, there was no significant difference in the rate of pouch failure between the 2 groups, with a long-term pouch failure rate of 4.3% in the stoma-less IPAA group and 6.8% in the ileostomy group (p = 0.386). For the ileostomy group, there was a complication rate of 14.6% at the time of ileostomy closure. Table 4 demonstrates the occurrence of individual short-term (within 30 days of surgery) complications at the time of DLI reversal in the ileostomy group, with the most common being early SBO/prolonged ileus occurring in 11.5% (37/322) of patients at the time of DLI reversal. Of the patients experiencing complications after DLI reversal, 2 required immediate return to the operating room, 1 patient was diagnosed with early SBO‚ and 1 was diagnosed with an anastomotic leak. Additional short-term complications evaluated include surgical site infection, urinary tract infections, readmission within 30 days, thromboembolic events, and anastomotic leak.

TABLE 3. - Long-term (>30 d) outcomes of study population stratified by stoma-less IPAA group and IPAA with ileostomy group
Outcomes Stoma-less IPAA (N = 91) Ileostomy at IPAA (N = 323) p
Follow-up, y 0.461
 n 82 295
 Mean (SD) 8.5 (6.9) 8.1 (6.8)
 Median 7 6.7
 Interquartile range 3.0–13.0 1.9–12.9
Pouch failure rate 4 (4.4%) 22 (6.8%) 0.401
Secondary ileostomy 2 (2.2%) 12 (3.7%) 0.479
Development of Crohn’s disease symptoms 8 (8.8%) 27 (8.4%) 0.896
Stoma at hernia site 2 (2.2%) 15 (4.6%) 0.299
Pouch stricture 10 (11%) 45 (13.9%) 0.465
Development of anal fistula 12 (13.2%) 21 (6.5%) 0.038
 Crohn’s-like 3 (25%) 7 (33.3%)
 Cryptogenic 9 (75%) 14 (67.7%)
Development of small bowel obstruction 13 (14.3%) 55 (17%) 0.533
Development of pouchitis 0.135
 Antibiotic-responsive pouchitis 41 (45.6%) 157 (49.4%)
 Antibiotic-dependent pouchitis 3 (3.3%) 18 (5.7%)
 Pouchitis requiring biologics 5 (5.6%) 5 (1.6%)
Data presented as n (%) unless otherwise indicated.

TABLE 4. - Complications associated with ileostomy reversal
Outcomes Stoma-less IPAA (N = 91) Ileostomy at IPAA (N = 322) p
Complication(s) at time of stoma reversal <0.001
 No complication at time of DLI reversal 91 (100%) 276 (85.4%)
 Complication(s) at time of DLI reversal 0 (0%) 47 (14.6%)
Type of complications at ileostomy reversal
 Prolonged ileus/early small bowel obstruction - 37 (11.5%)
 Superficial site infection - 9 (2.8%)
 UTI - 3 (0.9%)
 Readmission <30 days - 3 (0.9%)
 Anastomotic leak - 2 (0.6%)
 Organ space infection - 2 (0.6%)
 DVT - 1 (0.3%)
Clostridioides difficile infection - 1 (0.3%)
Data presented as n (%).
DLI = diverting loop ileostomy; DVT = deep vein thrombosis; UTI = urinary tract infection.

DISCUSSION

This retrospective study suggests that the addition of a DLI at the time of IPAA in select patients was not associated with a statistically significant decrease in the short-term risk of anastomotic leak or the long-term risk of pouch failure when compared to stoma-less IPAA creation. Patients without DLI did have a higher observed rate of anastomotic leak (3.3%) compared to those with DLI (1.5%); however, it is important to note that this was not significant on statistical analysis (p = 0.284) and that rates of anastomotic leak observed in this study were low overall compared to existing literature that cites an anastomotic leak rate after IPAA between 0.5% and 15%.16,17 Although this study found that the omission of an ileostomy at the time of IPAA is associated with increased overall LOS and some complications, such as surgical site infections and long-term development of anal fistulas, the omission avoids the risk of all complications at the time of subsequent loop ileostomy reversal. Ileostomy reversal brings with it a significant risk of complications, 14.6% in this study, including prolonged ileus, surgical site infections, and, to a lesser extent, serious complications such as organ space infections and anastomotic leaks.

The potential disadvantages of stoma-less IPAA were the higher rates of surgical site infection and longer total LOS. There were higher rates of superficial surgical site infections and deep surgical site infections in stoma-less IPAA compared to IPAA with DLI. However, subgroup analysis revealed that these complications nearly exclusively occurred in patients undergoing a modified 2-stage procedure (13/14 surgical site infections), suggesting these infectious complications were likely related to the closure of a pre-existing ileostomy site at the time of IPAA creation. Additionally, although our study found a higher total LOS in the stoma-less IPAA group compared to IPAA creation with the DLI group (14 vs 11; p = 0.001), previous studies comparing stoma-less IPAA and IPAA created with DLI have found decreased total LOS in stoma-less IPAA groups.4,18 The increased overall LOS in the stoma-less IPAA group in our study is likely due to the inclusion of modified 2-stage procedures in the stoma-less IPAA, most of which were performed for acutely ill patients with toxic colitis, which included presurgical hospitalization for medical management before colectomy. Of the stoma-less IPAA group, 64% of the patients underwent a total abdominal colectomy before IPAA, whereas only 35% of the patients in the DLI group had a previous total abdominal colectomy.

The increased long-term development of anal fistula in the stoma-less IPAA group (13.2%) compared to the group with ileostomy creation at the time of IPAA (6.5%) (p = 0.038) is a novel finding in this study. Many factors have been identified as predisposing for the development of an anal fistula after IPAA‚ including a diagnosis of indeterminate or Crohn’s colitis, a history of previous anal disease, male sex, and development of pelvic sepsis after IPAA construction.19 However, the absence of a DLI at the time of IPAA creation has never previously been investigated as a potential risk factor for the development of anal fistulas.

Although a majority of fistulas were found to be cryptogenic in nature, the development of a Crohn’s-like fistula is a serious complication after IPAA and has been reported to lead to pouch failure up to 70% of the time.20 The rate of development of Crohn’s-like fistulas was found to be similar in both DLI (33%; 7/21) and stoma-less IPAA groups (25%; 3/12). The time to fistula development was an average of 8 years after IPAA creation with only 2 fistulas presenting within 6 months, both of which were treated with simple fistuolotomy and resolved. The relationship between stoma-less IPAA creation and long-term risk of developing an anal fistula, both cryptogenic and Crohn’s-like, is likely multifactorial. This was not the primary outcome of interest‚ and this study lacks the power to delineate differences between these relatively small groups.

Previous research studies investigating the safety of omission of DLI in IPAA patients have had conflicting results, likely due to the heterogeneity of the populations included in these studies, many of which included patients with familial adenomatous polyposis4,5 and preoperatively diagnosed Crohn’s disease,4,21 making the results difficult to apply to patients with only UC. Some studies have found that omission of DLI in patients receiving IPAA increases rates of anastomotic leaks,5,7,22 whereas others have found similar rates of anatomic leak and septic complications.4,21,23 A study performed by Sahami et al21 found results similar to our study in a multi-institutional review demonstrating no difference in anastomotic leak rates in patients with and without DLI at the time of IPAA creation. Of note, the study by Sahami et al had very high rates of anastomotic leak (16.7% in patients with DLI and 17.1% in patients without DLI), which was attributed to inclusion of only patients with IBD (UC and Crohn’s disease) and exclusion of patients with polyposis syndrome from this study.21 We believe that the current study is more representative of expected anastomotic leak rates (approximately 5%)4 and promotes existing evidence supporting the safety of stoma-less IPAA in appropriately selected patients with UC.

In addition to the important short-term outcome of anastomotic leak, this study also demonstrates that omission of DLI at the time of IPAA does not significantly affect rates of long-term pouch failure. Pouch failure is a feared long-term complication of IPAA creation and has been shown to be time dependent with rates between 5% and 13% at 10 years.24 The findings of this study support limited existing studies that demonstrate similar pouch survival when comparing stoma-less IPAA and IPAA with DLI with long-term follow-up of 12 months to 4 years.5,21 To our knowledge, the present study is the longest follow-up of patients with IPAA in the literature comparing pouch failure based on the presence or absence of DLI at the time of IPAA creation, with a follow-up time of more than 8 years in both the stoma-less IPAA group and the ileostomy group. These results support the notion of long-term equivalence in terms of survival of IPAA with DLI and stoma-less IPAA.

Part of the advantage of stoma-less IPAA is avoiding the inherent risks associated with the presence of a DLI and DLI reversal. Previous studies have documented an overall complication rate of 11.4% associated with DLI closure after IPAA25 with early SBO being the most commonly observed complication. The results were similar in our study, with an observed complication rate of 14.6% with early SBO/prolonged ileus as the most common complication. The substantial risk of complications and requirement of an additional surgery and hospitalization are important considerations when evaluating the risks and benefits of DLI creation at the time of IPAA and suggest that selected use, as opposed to routine creation, should be considered.

Although our results demonstrate no significant difference in our primary outcomes of interest, it is important to note the role of patient selection in the results of this study. To be considered a candidate for a stoma-less IPAA in our practice, patients were required to be on minimal to no oral steroids (<20 mg/d), to be well nourished (albumin >3.5 g/dL), to have normal hemoglobin/hematocrit (without transfusion requirement), and to undergo a technically straightforward IPAA creation using a double-stapled technique. All patients were advised before surgery that the decision could be made intraoperatively to create a DLI at the surgeon’s discretion depending on the specifics of the surgical procedure‚ including blood loss, patient anatomy, and tissue quality. The combination of preoperative patient factors, intraoperative findings, and surgeon’s discretion all contribute to appropriate patient selection and was certainly in part responsible for the equivalent outcomes observed in this study.

Although this study provides important insight into the use of DLI at the time of IPAA creation, it should be interpreted within the context of certain limitations. It is important to recognize the strict inclusion criteria that were used to select which patients received stoma-less IPAAs in this study and that these results should only be applied to patients who meet all of these inclusion criteria. This is a retrospective study, which limits the available data that we are able to include, such as specific intraoperative decision-making and details of ileostomy site closure technique‚ which may be related to the infection rate. Although this is one of the largest studies investigating this topic, it is important to note that as a retrospective study, the conclusions of this study are limited by the available number of patients meeting inclusion criteria‚ which therefore limited the ability of this study to reach optimal sample size and statistical power; these limitations should be taken under consideration when applying the results of this study.

Additionally, when interpreting results pertaining to LOS, it is important to note that this study includes total LOS, which includes hospitalization for medical management as well as surgical care in some cases and not only postoperative LOS. Also, given the retrospective nature of our study, we were unable to include functional outcomes, such as the number of daily bowel movements or quality of life over time. Additionally, enhanced recovery after surgery was not standardized at our institution during a majority of the course of this study‚ and we are unable to comment on the impact of early feeding before the return of bowel function in these patients and the potential impact on LOS and other outcomes. Also, caution should be taken when applying results of this study to patients on biologic therapy‚ as this study had a low observed rate of biologic usage at the time of IPAA (<8%) given that about half of the patients included in this study had IPAAs performed before the Food and Drug Administration approval of biologic therapy for the treatment of UC.26 Finally, it is important to note that this study represents the experience of a single institution over a long period, and >80% of the procedures in both the stoma-less IPAA group and the group with DLI were performed as open procedures. However, it is noteworthy that those undergoing laparoscopic IPAA did have a shorter LOS on average compared to those undergoing open procedures (11.6 d vs 14.0 d; p = 0.001).

CONCLUSION

The results of this study suggest that omission of DLI is feasible in select patients and that stoma-less IPAA does not have a statistically significantly higher risk of anastomotic leak or pouch failure when compared to IPAA with DLI in selected patients. Additionally, results from this study reveal high rates of complications associated with the presence of DLI and subsequent reversal, which partially offset its perceived safety.

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Keywords:

Anastomotic leak; IPAA; Pouch failure; Ulcerative colitis

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