When Should Ileal Pouch-Anal Anastomosis Be Performed After Inpatient Total Abdominal Colectomy for Acute Medically Refractory Ulcerative Colitis? Experience of 274 Consecutive Patients.

Abstract

Background: Three-stage ileal pouch-anal anastomosis (IPAA) is commonly performed following total abdominal colectomy (TAC) for severe ulcerative colitis (UC). However, the optimal interval between TAC and pouch construction remains unclear.

Methods: A prospectively maintained ileal pouch database (1983-2021) was queried to identify patients with pathologically confirmed UC who underwent three-stage IPAA following urgent TAC for acute disease exacerbation. Patients were stratified by the interval between TAC and IPAA (<6 vs ≥6 months). Baseline characteristics, perioperative outcomes, pouch failure (PF), long-term pouch survival, functional outcomes, and quality of life were compared. Multivariable regression analysis identified factors associated with PF.

Results: A total of 274 patients were included; 99 (36%) underwent IPAA within 6 months of TAC and 175 (64%) underwent delayed reconstruction. Patients undergoing delayed reconstruction were older and had a longer disease duration before colectomy. Hospital stay was shorter in the early reconstruction group (6.4 ± 2.4 vs 7.5 ± 4.5 days; p=0.008), whereas postoperative complications and follow-up were comparable. PF rates were similar between the early and delayed groups (5.1% vs 4.0%; p=0.762). Rates of Crohn's disease conversion (6.1% vs 1.7%; p=0.076), long-term pouch survival (log-rank p=0.70), functional outcomes, and quality of life also did not differ. Findings remained consistent using alternative reconstruction intervals and in a sensitivity analysis restricted to the most recent 20-year operative period (1996-2015). Fistula formation, but not reconstruction timing, was independently associated with PF.

Conclusion: The interval between TAC and IPAA was not associated with PF, long-term pouch survival, functional outcomes, or quality of life. Reconstruction timing may therefore be individualized according to patient recovery and clinical factors without compromising long-term pouch outcomes.