Modified-2-stage versus 3-stage approach in ileoanal pouch surgery for ulcerative colitis

Abstract Background and Aims The necessity of diverting loop-ileostomy after staged ileoanal pouch for ulcerative colitis remains unclear. This study aimed to compare postoperative outcomes between modified-2-stage and 3-stage ileoanal pouch procedures for ulcerative colitis. Methods This retrospective cohort study included patients ≥18 years with ulcerative colitis or unclassified inflammatory bowel disease who underwent modified-2-stage or 3-stage ileoanal pouch surgery from 2016–2021 in six European centres, with a follow-up of more than 12 months. Primary outcome was stoma-free rate at the end of follow-up. Secondary outcomes included perioperative practice, length of hospital stay, anastomotic leakage rate and timing of diagnosis and treatment. Results Overall, 370 patients were included of which 228 (61.6%) underwent a modified-2-stage approach and 142 (38.4%) a 3-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-2-stage patients and 91.5% (130/142) in 3-stage patients (P = 0.404). Notably, 78.4% of modified-2-stage patients never required an ileostomy, while the remaining 21.6% did receive a secondary ileostomy. While median length of hospital stay for pouch surgery was longer in the modified-2-stage group, total median length of hospital stay after one year was shorter (median 7.0 days (IQR 6.0–11.0) versus 9.0 days (IQR 7.0–12.5), P = 0.015). The Clavien-Dindo score was higher than II in 22.6% of modified-2-stage patients and in 8.7% of 3-stage patients (P <0.001). Anastomotic leakage rate was higher after modified-2-stage (18% versus 5%, P <0.001), but diagnosis and treatment occurred earlier (86% within 21 days versus 43%, P = 0.009). Conclusions Both approaches have comparable high stoma-free rates at the end of follow-up. Modified-2-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 3-stage procedures could improve postoperative outcomes in this group.