Modified-two-stage versus three-stage approach in ileoanal pouch surgery for ulcerative colitis

BACKGROUND AND AIMS: The necessity of diverting loop-ileostomy after a staged ileoanal pouch for ulcerative colitis (UC) remains unclear. This study aimed to compare postoperative outcomes between modified-two-stage and three-stage ileoanal pouch procedures for UC. METHODS: This retrospective cohort study included patients ≥18 years with UC or unclassified inflammatory bowel disease who underwent modified-two-stage or three-stage ileoanal pouch surgery from 2016 to 2021 in six European centers, with a follow-up of more than 12 months. The primary outcome was stoma-free rate at the end of follow-up. Secondary outcomes included perioperative practise, length of hospital stay, anastomotic leakage rate, and timing of diagnosis and treatment. RESULTS: Overall, 370 patients were included, of whom 228 (61.6%) underwent a modified-two-stage approach and 142 (38.4%) a three-stage approach. The median length of follow-up was 3.6 years (range: 1.0-7.7). Stoma-free rate was 93.8% (213/227) in modified-two-stage patients and 91.5% (130/142) in three-stage patients (P = .404). Notably, 78.4% of modified-two-stage patients never required an ileostomy, while the remaining 21.6% did receive a secondary ileostomy. While the median length of hospital stay for pouch surgery was longer in the modified-two-stage group, total median length of hospital stay after 1 year was shorter (median 7.0 days [IQR 6.0-11.0] vs 9.0 days [IQR 7.0-12.5], P = .015). The Clavien-Dindo score was higher than II in 22.6% of modified-two-stage patients and in 8.7% of three-stage patients (P < .001). Anastomotic leakage rate was higher after the modified-two-stage procedure (18% vs 5%, P < .001), but diagnosis and treatment occurred earlier (86% within 21 days vs 43%, P = .009). CONCLUSIONS: Both approaches have comparable high stoma-free rates at the end of follow-up. Modified-two-stage avoids a temporary stoma in more than 75% of patients, but has a significantly higher rate of anastomotic leakages. Active and early surveillance of the anastomosis after three-stage procedures could improve postoperative outcomes in this group.