DOP043 Comparative outcomes of ileal pouch revision vs. excision for pouch failure within the American College of Surgeon National Surgical Quality Improvement Programme

Abstract

Background: Ileal pouch-anal anastomosis (IPAA) is the gold standard for surgical treatment of chronic ulcerative colitis and familial adenomatous polyposis. However, for the failing IPAA, which occurs in approximately 7% of cases, definitive surgical options include pouch revision or pouch excision. We aimed to compare disease characteristics and short-term outcomes of patients undergoing pouch revision vs. pouch excision using a large national clinical database. Methods: Using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) Participant User File we identified all patients who underwent either IPAA excision (CPT 45136) or revision via combined abdominoperineal approach (CPT 46712) for any diagnosis from 2005 to 2016. One patient who had both codes was excluded. Potential differences in baseline characteristics and short-term (30-day) outcomes between groups were compared with univariate analysis. Results: Of 907 146 colon, rectal, and anorectal operations, we identified a sample of 594 pouch re-operative procedures: revision group 78 (13%) and excision group 515 (86%). The groups did not differ with respect to age or BMI (kg/m2) but the revision group included a greater proportion of females (65.4% vs. 51.8%, p = 0.02) and were less likely to be on chronic steroids (3.9% vs. 17.9%, p = 0.0008) relative to the excision group. The revision group was more likely to have a preoperative wound infection (14.1% vs. 6.8%, p = 0.02) and to have received a preoperative transfusion (5.1% vs. 0.97%, p = 0.02). The two groups did not differ with respect to operative time, proportion of emergencies, ASA class, wound class, or concurrent procedures by the same surgical team (e.g. hernia repair). However, revision patients were more likely to have other concomitant procedures by another surgical team (e.g. ureteral stents) during the same operation (83.3% vs. 61.6%, p = 0.0002). Short-term outcomes (Table 1) did not differ between the groups. Overall, 34.6% and 40.2% (p = 0.88) of revision and excision patients experienced a complication. There was no difference in mortality between the revision and excision groups (nil vs. 0.58%, p = 1.0). Conclusions: Despite comparable postoperative short-term outcomes, pouch revision may be under-utilised as reflected by the relatively low proportion of patients selected to undergo pouch revision rather than excision in a large national database. Increased awareness of the indications for pouch salvage or referral to specialised centres may decrease pouch excision rates.