Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?
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In brief
In brief
Retrospective study of 57 pediatric UC patients comparing traditional vs. modified 2-stage operations found that delaying pouch creation to the second operation without protective ileostomy is safe, even in sicker patients on recent biologics. Modified approach showed lower stricture rates and similar functional outcomes despite operating on more acute cases.
Written by the GCMD Library team from the article.
Abstract
Introduction
Children with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the "modified 2-stage" approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes.
Methods
This is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation.
Results
N = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed.
Conclusion
Delaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.