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Original Investigation | New England Surgical Society

Possible Overuse of 3-Stage Procedures for Active Ulcerative Colitis

Caitlin W. Hicks, MD, MS1,2; Richard A. Hodin, MD2; Liliana Bordeianou, MD, MPH2
[+] Author Affiliations
1Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
2Department of Surgery, Massachusetts General Hospital, Boston
JAMA Surg. 2013;148(7):658-664. doi:10.1001/2013.jamasurg.325.
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Importance  There is an assumption that patients treated with 3-stage procedures for active ulcerative colitis are undergoing a safer surgical approach and thus spared the complications associated with a 2-stage procedure. However, there is a paucity of data addressing the validity of this assumption, and the optimal staging approach for patients traditionally considered at high risk for anastomotic leak remains unclear.

Objectives  To identify factors associated with 3- vs 2-stage procedures and to determine their impact on surgical outcomes.

Design  Retrospective analysis of patients who underwent 2-stage or 3-stage ileal pouch–anal anastomosis (IPAA) surgery for active ulcerative colitis due to failure of medical management over a 10.5-year period (September 1, 2000, to March 30, 2011). The mean (SEM) follow-up was 5.15 (0.24) years (range, 0.26-11.09 years).

Setting  Single large academic medical center.

Patients  One hundred forty-four patients treated with 3- or 2-stage IPAA surgery for active ulcerative colitis. Among these patients, 77 were male and 67 were female. The mean (SEM) age was 34.6 (1.0) years (range, 11-67 years). Of the 144 patients, 116 (80.6%) had a 2-stage procedure and 28 (19.4%) had a 3-stage procedure.

Interventions  Two-stage vs 3-stage IPAA procedures for active ulcerative colitis.

Main Outcomes and Measures  Factors leading to decision for 3-stage procedure, postoperative outcomes with 3-stage vs 2-stage procedures, and risks for complications in patients undergoing 3-stage vs 2-stage procedures.

Results  Of 144 patients, only 19.4% had a 3-stage procedure. Decision to perform a 3-stage vs 2-stage procedure was affected by emergent status (P < .001) and hemodynamic instability (P = .04) but not by age, sex, body mass index, use of steroids, or use of anti–tumor necrosis factor agents. For patients with 2-stage procedures, multivariate regression revealed that the number of perioperative complications was affected by surgeon experience (P = .02) but not by emergent status, use of steroids, or use of anti–tumor necrosis factor agents. Two-stage procedures were associated with more perioperative complications on univariate analysis (P = .05), but multivariate regression suggested that this difference was due to surgeon experience (P = .02) rather than to creation of an IPAA at the first operation (P = .55). Importantly, 2-stage procedures did not change the risk of anastomotic leak when all operations were taken into account (odds ratio = 1.09; P = .94). In the long term (mean [SEM], 5.2 [0.2] years), patients who underwent 2-stage surgery had a lower risk of anal stricture (odds ratio = 8.21; P = .01) and no differences in fistula or abscess formation or in pouch failure.

Conclusions and Relevance  In patients with active ulcerative colitis, use of steroids and anti–tumor necrosis factor agents alone do not appear to justify the decision to avoid IPAA creation at the first operation provided that it is performed by a high-volume inflammatory bowel disease surgeon.

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