title: Modified Two-stage Ileal Pouch-Anal Anastomosis Results in Lower Rate of Anastomotic Leak Compared with Traditional Two-stage Surgery for Ulcerative Colitis.
abstract: OBJECTIVE
  There is a paucity of evidence in ulcerative colitis [UC] comparing the traditional two-stage [total proctocolectomy with ileal pouch-anal anastomosis [IPAA] and diverting ileostomy, followed by ileostomy closure] vs the modified two-stage restorative proctocolectomy [subtotal colectomy with end ileostomy, followed by completion proctectomy and IPAA, without diverting ileostomy]. This study examines the risk of anastomotic leak following IPAA in traditional vs modified two-stage IPAA for UC patients.
  
  
  METHODS
  This was a single-institution, retrospective study of all UC patients who underwent a traditional or modified two-stage IPAA between 2002 and 2013. The primary outcome was anastomotic leak following IPAA.
  
  
  RESULTS
  In all, 460 patients had a two-stage IPAA procedure; 223 [48.5%] patients underwent traditional two-stage IPAA and 237 [51.5%] patients received the modified two-stage procedure. There was more preoperative enteral corticosteroid use [44.7% vs 33.2%, p = 0.04] before the first surgery in the modified two-stage group compared with the traditional two-stage group. The modified two-stage group had higher UC disease severity at presentation [86.9% patients with moderate/severe UC vs 73.1%, p < 0.01]. However, the modified two-stage group had a lower rate of anastomotic leak following IPAA [4.6% vs 15.7%, p < 0.01] and was associated with a lower risk of anastomotic leak on univariate (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.13, 0.52] and multivariate analysis [OR 0.27, 95% CI 0.12, 0.57].
  
  
  CONCLUSIONS
  Patients with ulcerative colitis who received the modified two-stage IPAA had a significantly lower rate of anastomotic leak following pouch creation, compared with the traditional two-stage procedure.
authors.affiliation: Division of Gastroenterology, University of Toronto, Toronto, ON, Canada, Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, ON, Canada.
authors.forename: Eran
authors.initials: E
authors.lastname: Zittan
authors.affiliation: Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, ON, Canada, Division of General Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Wong-Chong
authors.affiliation: Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, ON, Canada, Division of General Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Grace W
authors.initials: GW
authors.lastname: Ma
authors.affiliation: Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, ON, Canada, Division of General Surgery, University of Toronto, Toronto, ON, Canada, Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada, Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada.
authors.forename: Robin S
authors.initials: RS
authors.lastname: McLeod
authors.affiliation: Division of Gastroenterology, University of Toronto, Toronto, ON, Canada, Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, ON, Canada.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Silverberg
authors.affiliation: Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, ON, Canada, Division of General Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Zane
authors.initials: Z
authors.lastname: Cohen
mesh_terms: D000328:Adult; D000368:Aged; D057868:Anastomotic Leak / Q000453:epidemiology / Q000517:prevention & control*; D003093:Colitis, Ulcerative / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy; D016015:Logistic Models; D008875:Middle Aged; D016737:Proctocolectomy, Restorative / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Inflammatory bowel disease; surgery; ulcerative colitis