Are all 2-stage operations for pediatric patients with ulcerative colitis similar?

Introduction: Traditionally, pediatric patients with fulminant UC have undergone a 2-stage operation: restorative proctocolectomy/ileal-pouch anal anastomosis (RP/IPAA), with diversion in the first operation, followed by ostomy closure in the second. In the era of biologic medications, children requiring surgery are presumably sicker, therefore, pediatric surgeons have modified their strategy: initial subtotal-colectomy with diversion, followed by RP/IPAA. The second operation may be done without diversion as patients are theoretically healthier compared to their initial operation. Despite increased use of this “modified 2-stage” approach without ileostomy at IPAA creation, evidence of its efficacy and functional outcomes is limited in pediatric patients. We sought to compare the timing of pouch creation in 2-stage operations to determine short and long-term outcomes in matched groups.

Methods: Pediatric patients with UC who underwent a traditional 2-stage RP/IPAA with ileostomy in the first operation (traditional-group) and modified 2-stage RP/IPAA without an ileostomy in the second operation (modified-group) between 2011-2019 were retrospectively analyzed. Descriptive statistics were used to analyze the data.

Results: N=57 (Traditional=40, Modified=17). Median time to surgery from consultation was shorter in the modified-group (5 days [IQR 5,17] vs. 23 [6,68], p=0.03). Greater number of the modified-group took biologics (p=0.002), particularly within 30 days of surgery (53% vs 23%, p=0.02). The modified-group had a lower albumin level (2.5[2,2.8] vs. 3.6[3,4.1], p=0.007). Total length of stay was longer in the modified-group (26 days [21,33] vs 20[13,24], p=0.03). Total operative times were comparable (p=0.72). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (45% vs. 18%, p=0.05). No difference in leak (p=0.13), SBO (p=0.62), loperamide dose (p=0.21), or incontinence (p=0.29).

Conclusion: Once a patient has recovered from a subtotal colectomy for UC, the modified 2-stage RP/IPAA without ileostomy is an effective operative approach with comparable post-operative and functional outcomes to the traditional 2-stage RP/IPAA.