Trends in the Utilization of Two-Stage Versus Three-Stage Ileal Pouch Anal Anastomosis Among Privately Insured Patients With Ulcerative Colitis in the USA, 2007 to 2023

BACKGROUND: Ileal pouch anal anastomosis can be performed via 2- and 3-stage techniques, with similar short- and long-term clinical outcomes. 2-stage ileal pouch anal anastomosis became the predominant approach in the 2000s; whether this trend has continued remains unknown. OBJECTIVE: To compare trends in the utilization of 3-stage, traditional 2-stage, and modified 2-stage IPAA for ulcerative colitis as well as markers of disease severity over time. DESIGN: Retrospective cohort. SETTING: Privately insured patients from an administrative database. PATIENTS: Non-elderly adults with a diagnosis of ulcerative colitis who underwent ileal pouch anal anastomosis between 2007 and 2023 and remained enrolled in their insurance plan for ≥ 6 months after surgery. MAIN OUTCOME MEASURES: Proportion of patients undergoing 3-stage, traditional 2-stage, and modified 2-stage ileal pouch anal anastomosis; annualized change in disease severity at the time of ileal pouch anal anastomosis creation. RESULTS: Four thousand thirty-nine patients underwent IPAA during the study period (2,179 traditional 2-stage; 1,107 3-stage; and 753 modified 2-stage). The proportion of patients undergoing a traditional 2-stage IPAAs decreased steadily (1.3% points per year [95% CI -1.7 to -0.9]) with a commensurate rise in both 3-stage (0.3% points per year [95% CI -0.02-0.7]) and modified 2-stage operations (0.9% points per year [95% CI 0.6-1.2]). Patients undergoing 3-stage or modified 2-stage IPAA had a more rapid increase in exposure to advanced therapies in the year before surgery (+ 2.9 vs + 2.0% points). Limitations: potential misclassification, generalizability. CONCLUSIONS: More patients are undergoing 3-stage and modified 2-stage operations than traditional 2-stage ileal pouch anal anastomosis. This shift parallels an increase in multiple markers of disease severity at IPAA creation, especially exposure to advanced therapies. See Video Abstract.