A Multicentre Evaluation of Risk Factors for Anastomotic Leakage After Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease.

BACKGROUND: Anastomotic leakage is a major complication after restorative proctocolectomy with ileal pouch-anal anastomosis [IPAA]. Identification of patients at high risk of leakage may influence surgical decision making. The aim of this study was to identify risk factors associated with anastomotic leakage after restorative proctocolectomy with IPAA. METHODS: Between September 1990 and January 2015, patients who underwent IPAA for inflammatory bowel disease [IBD] were identified from prospectively maintained databases of three tertiary referral centres. Retrospective chart review identified additional data on demographic and surgical variables. Multivariable regression models were developed to identify risk factors for anastomotic leakage. Separate analyses were performed for type of procedure. RESULTS: A total of 640 patients [56.9% male] were included, with a median age of 38 years [interquartile range 29-48]; 96 [15.0%] patients developed anastomotic leakage. Multivariable regression analysis demonstrated that being overweight (body mass index [BMI] > 25], (odds ratio [OR] 1.92; 95% confidence interval [CI] 1.15 - 3.18), and American Society of Anesthesiologists classification [ASA score > 2] [OR 1.91; 95% CI 1.03 - 3.54] were independent risk factors for anastomotic leakage in patients who underwent a completion proctectomy. A disease course of > 5 years [OR 2.34; 95% CI 1.42 - 3.87] and concurrent combination of anti-tumour necrosis factor [TNF] and steroids [OR 6.40; 95% CI 1.76 - 23.20] were independent risk factors for anastomotic leakage in patients who underwent a proctocolectomy and IPAA. CONCLUSIONS: Independent risk factors for anastomotic leakage in IBD patients undergoing IPAA are BMI >25, ASA score >2, disease course > 5 years, and concurrent steroid and anti-TNF treatment, with a different risk profile for one-stage proctocolectomy and completion proctectomy procedures.

Defunctioning Ileostomy is not Associated with Reduced Leakage in Proctocolectomy and Ileal Pouch Anastomosis Surgeries for IBD.

BACKGROUND: Anastomotic leakage is a serious complication after restorative proctocolectomy with ileal pouch-anal anastomosis. Previous studies have shown significantly decreased leak rates in diverted patients with less severe clinical consequences. The aim of this study was to evaluate short- and long-term outcome of selective ileostomy formation in a multicentre cohort of patients undergoing pouch surgery. METHODS: In a retrospective study, 621 patients undergoing pouch surgery for inflammatory bowel disease [IBD] were identified from three large centres. Anastomotic leakage was defined as any leak confirmed by either contrast extravasation on imaging or during surgical re-intervention. RESULTS: In 305 patients [49.1%], primary defunctioning ileostomy was created during pouch surgery and 41 [6.6%] patients received a secondary ileostomy because of a leaking non-diverted pouch. Primary ileostomy formation was associated with male sex, weight loss, American Society of Anesthesiologists score [ASA] > 2, steroid use, one-stage surgery, hand-sewn anastomosis, and blood transfusion. Leak rates were comparable between diverted and non-diverted patients [16.7% vs 17.1%, p = 0.92], which remained unchanged in subgroups with immunosuppressive medication. Having had an ileostomy was demonstrated to be an independent predictor of small bowel obstruction (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.45 - 4.67) and pouch fistulas [OR 3.05, 95%CI 1.06 - 8.73]. The 10-year pouch survival was comparable for patients with and without ileostomy [89% versus 88%, p = 0.718]. CONCLUSIONS: Leakage rates of diverted and non-diverted pouches in IBD patients were similar and relatively high. Defunctioning was independently associated with long-term complications. A staged approach without defunctioning might be the best strategy.