Samples Jennifer, Evans Krista, Chaumont Nicole, Strassle Paula, Sadiq Timothy, Koruda Mark
Department of General Surgery, University of North Carolina Healthcare, Chapel Hill, NC; Division of Gastrointestinal Surgery, University of North Carolina Healthcare, Chapel Hill, NC.
Department of General Surgery, University of North Carolina Healthcare, Chapel Hill, NC; Division of Gastrointestinal Surgery, University of North Carolina Healthcare, Chapel Hill, NC.
J Am Coll Surg. 2017 Apr;224(4):557-563. doi: 10.1016/j.jamcollsurg.2016.12.049. Epub 2017 Mar 15.
Ulcerative colitis patients have been historically treated with standard single, 2-, and 3-stage operative approaches. We perform a variant 2-stage procedure beginning with total abdominal colectomy and end ileostomy followed by completion proctectomy and ileal pouch-anal anastomosis (IPAA) without a diverting loop ileostomy. This study evaluates the effectiveness of this innovative alternative.
Patients with ulcerative colitis, admitted to the University of North Carolina Hospital between 2003 and 2010 for IPAA, were eligible for inclusion. The 3-year cumulative incidence of pouch leaks among patients undergoing variant 2-stage were compared with those undergoing classic 2-stage, using inverse probability-of-treatment weighted Kaplan- Meier survival curves, and 95% CIs were estimated using nonparametric bootstrapping.
There were 248 patients who underwent IPAA; 139 (56.1%) underwent classic 2-stage and 109 (43.9%) underwent variant 2-stage. After standardization, there was no significant difference in the 3-year cumulative incidence of pouch leaks between patients undergoing variant 2-stage, compared with the standard single- or 2-stage procedure (risk difference 0.01; 95% CI -0.08, 0.15). At the time of the first surgical procedure, patients undergoing a variant 2-stage were more likely to have lower BMIs (median 22.5 kg/m vs 26.7 kg/m; p < 0.0001), an urgent/emergent procedure (56.9% vs 0.0%; p < 0.0001), biologic use within 2 weeks of surgery (32.1% vs 17.5%; p = 0.003), and high dose steroid use (60.4% vs 16.7%; p ≤ 0.0001).
Variant 2-stage IPAA is a safe and effective operative approach with comparable outcomes in a more acute population based on BMI, steroid use, and urgency of operation.
溃疡性结肠炎患者历来采用标准的单阶段、两阶段和三阶段手术方法进行治疗。我们采用一种改良的两阶段手术方法，首先进行全腹结肠切除术和末端回肠造口术，然后进行全直肠切除术和回肠储袋肛管吻合术（IPAA），不做转流性回肠造口术。本研究评估了这种创新替代方法的有效性。
2003年至2010年期间因IPAA入住北卡罗来纳大学医院的溃疡性结肠炎患者符合纳入标准。使用治疗逆概率加权的Kaplan-Meier生存曲线比较接受改良两阶段手术的患者与接受传统两阶段手术的患者之间3年袋漏累积发生率，并使用非参数自举法估计95%置信区间。
共有248例患者接受了IPAA；139例（56.1%）接受传统两阶段手术，109例（43.9%）接受改良两阶段手术。标准化后，与标准单阶段或两阶段手术相比，接受改良两阶段手术的患者3年袋漏累积发生率无显著差异（风险差异0.01；95%置信区间-0.08，0.15）。在首次手术时，接受改良两阶段手术的患者更有可能BMI较低（中位数22.5kg/m²对26.7kg/m²；p<0.0001）、进行急诊/紧急手术（56.9%对0.0%；p<0.0001）、在手术2周内使用生物制剂（32.1%对17.5%；p=0.003）以及使用高剂量类固醇（60.4%对16.7%；p≤0.0001）。
基于BMI、类固醇使用情况和手术紧迫性，改良两阶段IPAA是一种安全有效的手术方法，在病情更急的人群中具有相似的结果。
