Kallis Michelle P, Denning Naomi-Liza, Kvasnovsky Charlotte L, Lipskar Aaron M
Division of Pediatric Surgery, Department of Surgery, Cohen Children's Medical Center at Northwell Health, Queens, New York.
J Laparoendosc Adv Surg Tech A. 2019 Oct;29(10):1239-1243. doi: 10.1089/lap.2019.0202. Epub 2019 Aug 9.
Multistaged surgical management of inflammatory bowel disease (IBD), culminating in ileal pouch-anal anastomosis (IPAA), can provide cure for refractory IBD symptoms while maintaining fecal continence. Surgical approaches to IPAA historically included a three-stage approach done by subtotal colectomy (STC) followed by IPAA with diversion. Recently, a variant two-stage approach without diversion at IPAA has become increasingly utilized, yet evidence of the efficacy of this approach is limited. Retrospective review of patients aged 5-21 years who underwent initial STC, followed by a total proctocolectomy with IPAA +/- diversion for medically refractory IBD from January 2010 to August 2018 ( = 25). Majority of IPAA procedures were done laparoscopically (88.5%). Thirteen patients (52%) underwent two-stage variant IPAA. There were no differences in readmission rates (66.7% versus 53.8%, = .5) or reoperation rates (50% versus 30.8%, = .3) between groups. Forty percent of patients experienced a complication after IPAA. Complication rates were similar between two-stage and three-stage IPAA groups (38.5% versus 50%, = .33). Complications within the two-stage group included anastomotic leak, pouchitis, wound infection, anastomotic stricture, and incarcerated hernia. Complications within the three-stage group included bloody ostomy output, dehydration, anastomotic stricture, small bowel obstruction, and pouch volvulus. Treatment of refractory IBD in children remains challenging, but STC followed by IPAA is an approach that provides symptom relief and preserves continence. Complication rates remained unchanged regardless of whether IPAA was conducted with or without diversion, demonstrating that the two-stage variant approach is a safe and feasible treatment that may reduce subsequent anesthesia exposure and trips to the operating room.
炎症性肠病（IBD）的多阶段手术管理，最终以回肠储袋肛管吻合术（IPAA）告终，可以治愈难治性IBD症状，同时保持大便失禁。IPAA的手术方法历史上包括一种三阶段方法，即通过次全结肠切除术（STC），然后进行带转流的IPAA。最近，一种在IPAA时不进行转流的改良两阶段方法越来越多地被采用，但这种方法疗效的证据有限。回顾性分析2010年1月至2018年8月期间因难治性IBD接受初始STC，随后进行全直肠结肠切除术及IPAA±转流的5至21岁患者（n = 25）。大多数IPAA手术通过腹腔镜进行（88.5%）。13名患者（52%）接受了两阶段改良IPAA。两组之间的再入院率（66.7%对53.8%，P = 0.5）或再次手术率（50%对30.8%，P = 0.3）没有差异。40%的患者在IPAA后出现并发症。两阶段和三阶段IPAA组的并发症发生率相似（38.5%对50%，P = 0.33）。两阶段组的并发症包括吻合口漏、储袋炎、伤口感染、吻合口狭窄和嵌顿疝。三阶段组的并发症包括血性造口输出、脱水、吻合口狭窄、小肠梗阻和储袋扭转。儿童难治性IBD的治疗仍然具有挑战性，但STC后行IPAA是一种能缓解症状并保留控便能力的方法。无论IPAA是否进行转流，并发症发生率均保持不变，表明两阶段改良方法是一种安全可行的治疗方法，可能会减少后续的麻醉暴露和手术室之行。
