Do outcomes differ after 3-Stage versus 2-Stage Ileal Pouch-Anal Anastomosis for chronic Ulcerative Colitis?
Bibliographic record
Abstract
Given concerns of increased post-operative complications associated with anti-TNF-alpha antibody therapy, some surgeons are increasingly offering patients with chronic ulcerative colitis (CUC) a 3-stage approach to ileal pouch-anal anastomosis (IPAA). We aimed to assess outcomes after the 1st of 2-stages compared with the 2nd of 3-stages in a cohort of patients who underwent hand-assisted laparoscopic surgery (HALS). We identified all adult patients with CUC who underwent total proctocolectomy (TPC-IPAA, stage 1 of 2) and patients who underwent completion proctectomy (CP-IPAA, stage 2 of 3) at our institution from 2004 - 2009 using a prospectively maintained database. Univariate analysis assessed differences in 30-day outcomes after stage 1 of 2 as compared with stage 2 of 3. Data are frequency (proportion) or median. Over 5-years, 243 patients underwent HALS restorative proctocolectomy: TPC-IPAA (n= 212, 88%) or CP-IPAA (n= 30, 12%). At time of IPAA, patients in these two groups were not significantly different with respect to age, gender, BMI, medical comorbidities, and ASA classification. Two cases in TPC-IPAA had concurrent cancer, while none in the CP-IPAA did (p= 0.47). TPC-IPAA patients were less likely to have had prior abdominal (21% vs. 100%, p<0.0001) or intestinal surgery (1.4% vs. 100%, p<0.0001) compared to CP-IPAA. In regards to colitis medications, TPC-IPAA were more likely to be receiving 5-ASA (59% vs. 17%, p<0.0001), corticosteroids (75% vs. 23%, P<0.0001) or Immunomodulators (37% vs. 3.3%, p<0.0001); 13% of the TPCIPAA group, and none of the CP-IPAA group were receiving biologic therapy (p= 0.0006). In terms of severity of disease, according to the Montreal classification, TPC-IPAA had more severe disease than CP-IPAA (p<0.0001), while 23% and 13% were recently hospitalized (p= 0.2), 8% and 10% were recently transfused (p= 0.7), 12.8% and 30% were malnourished (p= 0.02), and 78.8% and 6.7% were had recently received either corticosteroids or biologic therapy (p<0.0001). In terms of surgical outcomes, 16 (7.5%) of TPC-IPAA were converted to laparotomy (most commonly for obesity, n= 4). Intra-operative complications occurred in TPC-IPAA was 8 (3.8%, most commonly for bleeding, n= 7), and after CP-IPAA none (0%, p= 0.14). TPC-IPAA had longer operative times (291 vs. 187, p<0.0001), and similar lengths of stay (5 vs. 5 days, p= 0.83) and readmissions (15.5% vs. 16.7%, p= 0.87). A total of 8% had re-operation after TPC-IPAA, and none after CP-IPAA (p= 0.03). Overall complications of any grade occurred in similar proportions (38% and 43%, p= 0.58). There were a total of 6 (2.8%) anastomotic leaks after TPC-IPAA, and none after CP-IPAA (p= 0.2). There were no mortalities in either group. Ileal pouch-anal anastomosis at the time of completion proctectomy, as compared with total proctocolectomy, is associated with shorter operative times, fewer intra-operative complications and reoperations, with similar rates of readmissions and overall complications. Further study in a larger cohort is needed to determine if a 3-stage approach to IPAA is associated with a lower anastomotic leak rate - the most important determinant of long-term pouch function and patient quality of life.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".