Conversion of ileo-pouch anal anastomosis to continent ileostomy: strategic surgical considerations and outcome

Abstract

Aim: The aim was to evaluate surgical strategies for conversion of failed ileo-pouch anal anastomosis (IPAA) to continent ileostomy (CI), taking morbidity and overall outcome into account. The hypothesis was that complex conversions are equivalent to the primary construction of a CI at the time of proctocolectomy. Method: This was a retrospective analysis of IPAA conversions acknowledging the underlying disease (inflammatory bowel disease [IBD] and non-IBD) and extent of pouch reconstruction (PR): type 1 (without PR), type 2 (partial PR), and type 3 (complete PR). Results: Twenty-six patients (IBD, n = 16; non-IBD, n = 10) were converted (type 1, n = 13; type 2, n = 7; and type 3, n = 6).12/26 patients (46.2%) presented postoperative complications directly related to the conversion with scarification of two pouches. In a mean follow-up time of 7.5 ± 6.6 years, 5/24 patients required revisional surgery. Of these, three required pouch excision. The cumulative probability of reoperation at the end of the second year increased to 21.7% and remained constant thereafter until the maximum follow-up time of 26 years. The total pouch loss rate was 19.2% (5/26), of which all occurred in the first 3 years. No statistically significant differences were found between the conversion types, complications or pouch survival. For all parameters, IBD patients performed slightly unfavourably. Due to the overall small number of respective patients, a differentiated investigation of IBD was not performed. Conclusion: Complex conversion procedures (types 1 and 2) deliver comparable longterm results to new constructions (type 3), thereby limiting the loss of small bowel. IBD compromises outcome versus non-IBD.