Multivariate Prediction of Intraoperative Abandonment of Ileal Pouch Anal Anastomosis

Background Restorative total proctocolectomy with IPAA may not be feasible in some patients because of technical intraoperative limitations. Objective This study aimed to assess preoperative predictors for intraoperative IPAA and review management. Design This is a retrospective review. Setting This study was conducted at Cleveland Clinic between January 2010 and May 2018. Patients Patients ≥18 years of age who underwent ileoanal pouch surgery were included. Patients with successful pouch creation as planned were grouped as "successful IPAA creation." Operative reports of patients who underwent alternative procedures were reviewed to identify cases when the pouch was preoperatively planned but intraoperatively abandoned (IPAA-abandoned group). Multivariate logistic regression models were developed to determine predictors of intraoperative pouch abandonment. We also reviewed the management of patients in whom the initial pouch creation failed. Main outcome measures The primary outcomes measured were preoperative predictors for intraoperative ileoanal pouch abandonment. Results A total of 1438 patients were offered an ileoanal pouch; 21 (1.5%) experienced pouch abandonment due to inadequate reach (n = 17) and other technical reasons (n = 4). These patients underwent alternative procedures such as end or loop ileostomy with/without proctectomy. Multivariate logistic regression analysis indicated male sex (OR, 6.021; 95% CI, 1.540-23.534), BMI (OR, 1.217; 95% CI, 1.114-1.329), and a 2-stage procedure (OR, 14.510; 95% CI, 4.123-51.064) as independent factors associated with intraoperative abandonment of pouch creation. Alternative procedures were total proctocolectomy with end ileostomy (n = 14) and total abdominal colectomy with end ileostomy without proctectomy (n = 7). Ultimately, pouch creation was achieved in 6 of 21 patients after a median interval of 8.8 (range, 4.1-34.8) months. All patients had intentional weight loss before a reattempt and total abdominal colectomy with end ileostomy without proctectomy as their initial procedure. Limitations This study was limited by its retrospective nature. Conclusions Ileoanal pouch abandonment is rare and can be mitigated by initial total abdominal colectomy and weight loss. Male, obese patients are at a higher risk of failure. Intraoperative assessment of ileoanal pouch feasibility should occur before rectal dissection. See Video Abstract at http://links.lww.com/DCR/B156. PREDICCION MULTIVARIANTE DEL ABANDONO INTRAOPERATORIO DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL: La proctocolectomia total restaurativa con anastomosis de bolsa ileoanal puede no ser posible en algunos pacientes debido a limitaciones tecnicas intraoperatorias.Evaluar los predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal y revisar el manejo.Revision retrospectiva.Cleveland Clinic entre Enero de 2010 y mayo de 2018.Pacientes > 18 anos que se sometieron a cirugia de bolsa ileoanal. Los pacientes con una creacion exitosa de la bolsa segun lo planeado se agruparon como "creacion exitosa de anastomosis de bolsa ileoanal". Se revisaron los informes operativos de los pacientes que se sometieron a procedimientos alternativos para identificar los casos en que la bolsa se planifico preoperatoriamente pero se abandono intraoperatoriamente (grupo de "anastomosis anal de bolsa ileoanal abandonada"). Se desarrollaron modelos de regresion logistica multivariante para determinar los predictores del abandono intraoperatorio de la bolsa. Tambien revisamos el manejo de pacientes que fallaron en la creacion inicial de la bolsa.Predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal.A un total de 1438 pacientes se les ofrecio una bolsa ileoanal; 21 (1.5%) experimentaron abandono de la bolsa debido a un alcance inadecuado (n = 17) y otras razones tecnicas (n = 4). Estos pacientes se sometieron a procedimientos alternativos como ileostomia final o de asa con / sin proctectomia. El analisis de regresion logistica multivariante indico genero masculino (OR, 6.021; IC 95%, 1.540-23.534), indice de masa corporal (OR, 1.217; IC 95%, 1.114-1.329) y procedimiento en 2 etapas (OR, 14.510; IC 95%, 4.123-51.064) como factores independientes asociados con el abandono intraoperatorio de la creacion de la bolsa. Los procedimientos alternativos fueron la proctocolectomia total con ileostomia final (n = 14) y la colectomia abdominal total con ileostomia final sin proctectomia (n = 7). Finalmente, la creacion de la bolsa se logro en 6/21 pacientes despues de un intervalo medio de 8.8 (rango, 4.1-34.8) meses. Todos los pacientes tuvieron perdida de peso intencional antes de la reintenta y colectomia abdominal total con ileostomia final sin proctectomia como procedimiento inicial.Naturaleza retrospectiva.El abandono de la bolsa ileoanal es raro y puede mitigarse mediante la colectomia abdominal total inicial y la perdida de peso. Los pacientes masculinos y obesos tienen un mayor riesgo de fracaso. La evaluacion intraoperatoria de la viabilidad de la bolsa ileoanal debe ocurrir antes de la diseccion rectal. Consulte Video Resumen en http://links.lww.com/DCR/B156. (Traduccion-Dr. Yesenia Rojas-Kahlil).