3-Stage vs 2-Stage Redo Ileal Pouch-Anal Anastomosis: Setting the Stage for Successful Pouch Salvage

Background: Rediversion prior to redo ileal pouch-anal anastomosis (IPAA) may reduce pelvic inflammation and optimize pouch salvage outcomes. We hypothesized the 3-stage, compared with 2-stage, approach to pouch revision was associated with a lower risk of pouch failure. Methods: This was a single-quaternary referral center retrospective cohort study of a prospectively maintained pouch registry. Patients were stratified into two groups: 3-stage redo IPAA was defined as initial rediversion, followed by redo IPAA with diverting ileostomy, and finally ileostomy reversal; 2-stage procedures omitted initial rediversion. The primary outcome was redo pouch failure, defined as permanent ileostomy with or without pouch excision. Secondary outcomes included postoperative complications and functional outcomes. Results: A total of 509 patients who underwent redo IPAA between 2000-2024 were included: 3-stage (n=356, 70%) or 2-stage (n=153, 30%). Most were female (58.3%), overall median age 39 years. Ulcerative colitis (85.6%) was the most common indication for IPAA. After a median of 3.2 years of follow-up, redo pouch failure occurred in 19.4% of the 3-stage group versus 32% in the 2-stage group (p=0.002). On Cox proportional modeling the 3-stage approach was associated with improved pouch survival (HR 0.68, 95% CI 0.46–0.99; p=0.04); septic indications were also associated with a higher failure risk (HR 1.73, 95% CI 1.14–2.64; p=0.01). Conclusions: The 3-stage approach to redo pouch surgery was associated with lower risk of redo pouch failure compared with the 2-stage approach. Initial rediversion should be strongly considered in patients presenting with pouch septic complications prior to pouch revision.