Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
JAMA Surg. 2013 Jul;148(7):658-64. doi: 10.1001/2013.jamasurg.325.
There is an assumption that patients treated with 3-stage procedures for active ulcerative colitis are undergoing a safer surgical approach and thus spared the complications associated with a 2-stage procedure. However, there is a paucity of data addressing the validity of this assumption, and the optimal staging approach for patients traditionally considered at high risk for anastomotic leak remains unclear.
To identify factors associated with 3- vs 2-stage procedures and to determine their impact on surgical outcomes.
Retrospective analysis of patients who underwent 2-stage or 3-stage ileal pouch-anal anastomosis (IPAA) surgery for active ulcerative colitis due to failure of medical management over a 10.5-year period (September 1, 2000, to March 30, 2011). The mean (SEM) follow-up was 5.15 (0.24) years (range, 0.26-11.09 years).
Single large academic medical center.
One hundred forty-four patients treated with 3- or 2-stage IPAA surgery for active ulcerative colitis. Among these patients, 77 were male and 67 were female. The mean (SEM) age was 34.6 (1.0) years (range, 11-67 years). Of the 144 patients, 116 (80.6%) had a 2-stage procedure and 28 (19.4%) had a 3-stage procedure.
Two-stage vs 3-stage IPAA procedures for active ulcerative colitis.
Factors leading to decision for 3-stage procedure, postoperative outcomes with 3-stage vs 2-stage procedures, and risks for complications in patients undergoing 3-stage vs 2-stage procedures. RESULTS Of 144 patients, only 19.4% had a 3-stage procedure. Decision to perform a 3-stage vs 2-stage procedure was affected by emergent status (P < .001) and hemodynamic instability (P = .04) but not by age, sex, body mass index, use of steroids, or use of anti-tumor necrosis factor agents. For patients with 2-stage procedures, multivariate regression revealed that the number of perioperative complications was affected by surgeon experience (P = .02) but not by emergent status, use of steroids, or use of anti-tumor necrosis factor agents. Two-stage procedures were associated with more perioperative complications on univariate analysis (P = .05), but multivariate regression suggested that this difference was due to surgeon experience (P = .02) rather than to creation of an IPAA at the first operation (P = .55). Importantly, 2-stage procedures did not change the risk of anastomotic leak when all operations were taken into account (odds ratio = 1.09; P = .94). In the long term (mean [SEM], 5.2 [0.2] years), patients who underwent 2-stage surgery had a lower risk of anal stricture (odds ratio = 8.21; P = .01) and no differences in fistula or abscess formation or in pouch failure.
In patients with active ulcerative colitis, use of steroids and anti-tumor necrosis factor agents alone do not appear to justify the decision to avoid IPAA creation at the first operation provided that it is performed by a high-volume inflammatory bowel disease surgeon.
人们假设，接受三阶段手术治疗活动期溃疡性结肠炎的患者采用了更安全的手术方法，从而避免了与两阶段手术相关的并发症。然而，关于这一假设的有效性，数据很少，对于传统上认为有吻合口漏风险的患者，最佳分期方法仍不清楚。
确定与三阶段与两阶段手术相关的因素，并确定其对手术结果的影响。
回顾性分析了 10.5 年内（2000 年 9 月 1 日至 2011 年 3 月 30 日）因药物治疗失败而接受两阶段或三阶段回肠袋肛门吻合术（IPAA）治疗活动期溃疡性结肠炎的患者。平均（SEM）随访时间为 5.15（0.24）年（范围，0.26-11.09 年）。
单一大专科学院。
144 例接受三阶段或两阶段 IPAA 手术治疗活动期溃疡性结肠炎的患者。这些患者中，77 例为男性，67 例为女性。平均（SEM）年龄为 34.6（1.0）岁（范围，11-67 岁）。144 例患者中，116 例（80.6%）接受两阶段手术，28 例（19.4%）接受三阶段手术。
两阶段与三阶段 IPAA 手术治疗活动期溃疡性结肠炎。
导致三阶段手术的因素，三阶段与两阶段手术的术后结果，以及三阶段与两阶段手术患者发生并发症的风险。结果：在 144 例患者中，只有 19.4%接受了三阶段手术。决定进行三阶段还是两阶段手术主要取决于紧急状态（P < .001）和血流动力学不稳定（P = .04），但与年龄、性别、体重指数、使用类固醇或使用肿瘤坏死因子拮抗剂无关。对于接受两阶段手术的患者，多变量回归显示，围手术期并发症的数量受外科医生经验的影响（P = .02），但不受紧急状态、使用类固醇或使用肿瘤坏死因子拮抗剂的影响。单变量分析显示两阶段手术与更多围手术期并发症相关（P = .05），但多变量回归表明这种差异是由于外科医生经验（P = .02）而不是由于第一次手术中创建 IPAA（P = .55）。重要的是，当考虑所有手术时，两阶段手术并不能改变吻合口漏的风险（比值比=1.09；P = .94）。在长期（平均[SEM]，5.2[0.2]年）中，接受两阶段手术的患者发生肛门狭窄的风险较低（比值比=8.21；P = .01），而吻合口漏、脓肿或瘘管形成或袋失败的风险没有差异。
在活动期溃疡性结肠炎患者中，单独使用类固醇和肿瘤坏死因子拮抗剂似乎并不能证明避免第一次手术时创建 IPAA 的决定是合理的，前提是由高容量炎症性肠病外科医生进行手术。
