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

BACKGROUND: Rediversion before redo ileal pouch-anal anastomosis (IPAA) may reduce pelvic inflammation and optimize pouch salvage outcomes. We hypothesized that the 3-stage approach to pouch revision, compared with 2-stage approach, was associated with a lower risk of pouch failure. STUDY DESIGN: This was a single-quaternary referral center retrospective cohort study of a prospectively maintained pouch registry. Patients were stratified into 2 groups: 3-stage redo IPAA, 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 and 2024 were included: 3-stage (n = 356; 70%) or 2-stage (n = 153; 30%). Most were women (58.3%), with an overall median age of 39 years. Ulcerative colitis (85.6%) was the most common indication for IPAA. After a median follow-up of 3.2 years, redo pouch failure occurred in 19.4% of the 3-stage group vs 32% in the 2-stage group (p = 0.002). On Cox proportional modeling, the 3-stage approach was associated with improved pouch survival (hazard ratio 0.68, 95% CI 0.46 to 0.99; p = 0.04); septic indications were also associated with a higher failure risk (hazard ratio 1.73, 95% CI 1.14 to 2.64; p = 0.01). CONCLUSIONS: The 3-stage approach to redo pouch surgery was associated with lower risk of redo pouch failure than the 2-stage approach. Initial rediversion should be strongly considered in patients presenting with pouch septic complications before pouch revision.