Early Experience with Variant Two-Stage Approach in Surgical Management of Inflammatory Bowel Disease Colitis in the Pediatric Population.

Introduction: Multistaged surgical management of inflammatory bowel disease (IBD), culminating in ileal pouch-anal anastomosis (IPAA), can provide cure for refractory IBD symptoms while maintaining fecal continence. Surgical approaches to IPAA historically included a three-stage approach done by subtotal colectomy (STC) followed by IPAA with diversion. Recently, a variant two-stage approach without diversion at IPAA has become increasingly utilized, yet evidence of the efficacy of this approach is limited. Methods: Retrospective review of patients aged 5-21 years who underwent initial STC, followed by a total proctocolectomy with IPAA +/- diversion for medically refractory IBD from January 2010 to August 2018 (n = 25). Results: Majority of IPAA procedures were done laparoscopically (88.5%). Thirteen patients (52%) underwent two-stage variant IPAA. There were no differences in readmission rates (66.7% versus 53.8%, P = .5) or reoperation rates (50% versus 30.8%, P = .3) between groups. Forty percent of patients experienced a complication after IPAA. Complication rates were similar between two-stage and three-stage IPAA groups (38.5% versus 50%, P = .33). Complications within the two-stage group included anastomotic leak, pouchitis, wound infection, anastomotic stricture, and incarcerated hernia. Complications within the three-stage group included bloody ostomy output, dehydration, anastomotic stricture, small bowel obstruction, and pouch volvulus. Conclusions: Treatment of refractory IBD in children remains challenging, but STC followed by IPAA is an approach that provides symptom relief and preserves continence. Complication rates remained unchanged regardless of whether IPAA was conducted with or without diversion, demonstrating that the two-stage variant approach is a safe and feasible treatment that may reduce subsequent anesthesia exposure and trips to the operating room.