Traynor Michael D, Yonkus Jennifer, Moir Christopher R, Klinkner Denise B, Potter D Dean
Department of Surgery, Mayo Clinic, Rochester, Minnesota.
Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota.
J Laparoendosc Adv Surg Tech A. 2019 Oct;29(10):1207-1211. doi: 10.1089/lap.2019.0106. Epub 2019 Aug 13.
Restoration of intestinal continuity by ileal pouch-anal anastomosis (IPAA) following subtotal colectomy may not require a temporary, protective ileostomy. Diversion contributes to patient discomfort, cost, and additional operative risk at the time of subsequent reversal. We compared the outcomes of pediatric patients undergoing modified two-stage to three-stage IPAA after recovering from subtotal colectomy. We reviewed children (age <18) who underwent IPAA creation for ulcerative or indeterminate colitis from January 1, 2007 to December 31, 2017. Patient characteristics, operative details, 30-day complications, and postoperative length of stay (LOS) were abstracted. Total LOS for the three-stage group included both the IPAA and the ileostomy reversal operations. Univariate comparisons between patients undergoing modified two-stage and three-stage operations were performed. A total of 43 patients underwent IPAA after subtotal colectomy; 32 (74%) underwent a three-stage approach, and 11 (26%) had a modified two-stage approach. Operative approach was laparoscopic in 33 (77%), planned open in 9 (21%), and converted to open in 1 (2%). Single-incision technique was used in 12 of 33 (36%) laparoscopic cases. Modified two-stage procedures had shorter total median LOS (7 days versus 9 days, = .005). Incidence of postoperative leak, readmission, return to the operating room, and maximum 30-day Clavien-Dindo scores at the time of IPAA creation did not differ between modified two- and three-stage approaches (all > .05). The modified two-stage approach to IPAA creation resulted in fewer hospital days compared to the three-stage approach. Considering the risks and patient burdens of diversion, further research is needed to assist in decisions regarding protective ileostomy after completion proctectomy with IPAA.
全结肠切除术后通过回肠储袋肛管吻合术（IPAA）恢复肠道连续性可能无需临时保护性回肠造口术。转流会给患者带来不适、增加费用，并在后续还纳时带来额外的手术风险。我们比较了全结肠切除术后接受改良两阶段与三阶段IPAA手术的儿科患者的结局。我们回顾了2007年1月1日至2017年12月31日期间因溃疡性结肠炎或不确定性结肠炎接受IPAA手术的18岁以下儿童。提取患者特征、手术细节、30天并发症及术后住院时间（LOS）。三阶段组的总住院时间包括IPAA手术和回肠造口还纳手术。对接受改良两阶段和三阶段手术的患者进行单因素比较。共有43例患者在全结肠切除术后接受了IPAA手术；32例（74%）采用三阶段手术方式，11例（26%）采用改良两阶段手术方式。33例（77%）手术方式为腹腔镜手术，9例（21%）计划开放手术，1例（2%）中转开放手术。33例腹腔镜手术中有12例（36%）采用单切口技术。改良两阶段手术的总中位住院时间较短（7天对9天，P = 0.005）。改良两阶段和三阶段手术方式在IPAA手术时术后渗漏、再次入院、返回手术室的发生率及30天内最高Clavien-Dindo评分方面无差异（均P > 0.05）。与三阶段手术方式相比，改良两阶段IPAA手术方式导致的住院天数更少。考虑到转流的风险和患者负担，需要进一步研究以协助在IPAA直肠切除术后决定是否行保护性回肠造口术。
