IPAA-Related Sepsis Significantly Increases Morbidity of Ileoanal Pouch Excision


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Abstract

BACKGROUND:Perineal wound complications after ileoanal pouch excision remain a significant cause of morbidity.OBJECTIVE:The purpose of this work was to describe the incidence, outcomes, and predictors of perineal wound complications after pouch excision.DESIGN:This was a retrospective medical chart review.SETTINGS:The study was conducted in a single clinical institution.PATIENTS:Patients who underwent pouch excision at our institution from July 1992 through July 2012 were identified. Patient and perioperative variables were reviewed. Multivariate and univariate analyses were undertaken.MAIN OUTCOME MEASURES:Perineal wound (including perineal wound infection and persistent perineal sinus [nonhealing by 6 months]) and perineal hernia were measured.RESULTS:A total of 47 patients (mean age, 46 years; 42.6% men) with familial adenomatous polyposis (10.6%), mucosal ulcerative colitis (61.7%), or Crohn’s disease (27.7%) underwent pouch excision, including 36.2% for IPAA-related sepsis (presacral abscess; perineal-, sacral-, or pouch-vaginal fistula; and anastomotic defect), 44.7% for pouch dysfunction, 10.6% for refractory pouchitis, and 8.5% for neoplasia. Fourteen (29.8%) developed perineal wound complications, including 100% perineal wound infection, 28.6% persistent perineal sinus, and 7.1% perineal hernia. Perineal wound infection was associated with delayed healing (>6 weeks; 71.4% vs 24.2%; p = 0.002) and IPAA-related sepsis (28.6% vs 0%; p = 0.001). Patients with and without perineal wound complications were similar in age, diagnoses, fecal diversion, immunosuppression, comorbid conditions, nutrition, and surgical variables. Most patients underwent intersphincteric dissection (87.2%) with primary perineal closure (97.0%). Perineal wound complications were significantly associated with IPAA-related sepsis as an indication for pouch excision (57.1% vs 27.2%; p = 0.05), intraoperative pouch perforation (35.7% vs 9.1%, p =0.03), and smoking (21.4% vs 3.0%; p = 0.04). IPAA-related sepsis and a current smoking status (OR, 19.3 [95% CI, 1.8 -488.1]) are significant independent predictors on multivariate logistic regression (OR, 6.4 [95% CI, 1.4–30.2]) of perineal wound complications. All of the patients with persistent perineal sinus achieved successful healing at a median of 734 days (range, 363–2182 days), requiring a median of 1.5 procedures.LIMITATIONS:This was a single-center retrospective review with a small sample size.CONCLUSIONS:Preoperative IPAA-related sepsis and current smoking are significant risk factors for perineal wound complications after pouch excision.

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