P2.P314: Pediatric Restorative Proctocolectomy with IPAA: Impact of Technique on Clinical Outcomes

Background: Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is performed in patients with colitis secondary to inflammatory bowel disease (IBD) using variable techniques. IPAA can be performed in one, two, or three stages, with a stapled or handsewn technique for anastomosis. Ambiguity exists as to which technique poses better outcomes, with no data analyzing pediatric IBD patients.

Methods: A single-center retrospective cohort study of 122 patients who underwent IPAA from 2010 through 2022 was performed. Patient variables included demographics, disease characteristics, and operative details. Outcomes of interest included: anastomotic stricture, anastomotic leak, cuffitis, pouchitis, and need for reoperation. Stricture was defined as a stenotic ileoanal anastomosis that required dilations either in the operating room or outpatient setting. Pouchitis and cuffitis were defined as endoscopic diagnosis of inflammation of the ileal pouch or rectal cuff and confirmed by endoscopic biopsy. Analysis was conducted using Stata software with the use of Fisher’s exact test and Wilcoxon rank sum test.

Results: Our cohort included 122 patients with a median age at presentation of 14 years (IQR 6.5 years) and median age at first operation of 15 years (IQR 12.5, 17.5). 98% of patients had ulcerative colitis and 2% had IBD unclassified (IBD-U). 40% of patients underwent two-stage IPAA and 60% underwent three-stage IPAA. 75% had a hand-sewn anastomosis and 25% had a stapled EEA anastomosis. There was no difference in stricture rate between hand-sewn and stapled anastomosis (25% vs 16%, p=0.335). Anastomotic leak was observed in 2% of handsewn anastomosis (n=2) and in none of the stapled patients. The number of stages did not impact stricture rate. All strictures were managed with dilations and none required reoperation. In patients who developed strictures, time to stoma closure did not differ based on anastomosis type.

43% of hand-sewn patients and 48% of stapled patients experienced pouchitis (p=0.592). No significant difference in pouchitis rate was observed between two-stage and three-stage procedures (37% vs 49%, p=0.17). 13% of stapled patients experienced cuffitis. 13% of all patients with pouchitis had a change of diagnosis to Crohn’s disease or Crohn’s like disease of the pouch, with no significant difference when compared for anastomosis type or number of stages. One patient underwent pouch excision for medically refractory pouchitis.

Conclusion: In our cohort of patients who underwent pediatric restorative proctocolectomy with IPAA, there was no difference in rate of stricture, anastomotic leak, and pouchitis when comparing stapled and handsewn anastomosis, or two-stage and three-stage IPAA. Medical features of the disease likely contribute more to outcome than surgical approach.