Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis of observational research

Purpose Restorative proctocolectomy (RPC) is performed for patients with refractory ulcerative colitis (UC). This operation is performed in 2 or 3 stages and involves forming a diverting loop ileostomy thought to protect patients from complications related to anastomotic leak. However, some advocate for a modified 2-stage approach, consisting of subtotal colectomy followed by completion proctectomy and ileal pouch anal anastomosis without diverting ileostomy. We present a systematic review and meta-analysis comparing postoperative complication rates between modified 2-stage and traditional RPC with ileal pouch anal anastomosis. Methods Records were sourced from PubMed/Embase databases. Studies comparing postoperative complications following RPC for ulcerative colitis (UC) were selected according to PRISMA guidelines comparing modified 2-stage (exposure), classic 2-stage, and 3-stage approaches (comparators). The primary outcome measure was safety as measured by postoperative complication rates. We employed random effects meta-analysis. Results We included ten observational studies including 1727 patients (38% modified 2-stage). Among pediatric patients, modified 2-stage approaches had higher rates of anastomotic leak than 3-stage approaches ( p = 0.03). Among adult cohorts with lower preoperative biologic use rates, modified 2-stage approaches had lower leak rates than classic 2-stage approaches ( p < 0.001). Conclusions The modified 2-stage approach may be safe for adult patients who otherwise require a 3-stage approach while reducing costs and length of stay. Pediatric patients may benefit from lower leak rates when receiving 3-stage compared with modified 2-stage approaches, especially when on biologics. The modified 2-stage approach may be safer than the classic 2-stage approach for adult patients with lower biologic exposure.