EPD304 - A Matter of Time: Does Early vs Late Failure Impact Redo Pouch Survival?

Purpose/Background: Anastomotic leaks, pelvic sepsis, inflammatory, and mechnical complications have been previously described as predictors of pouch failure in Ileal pouch-anal anastomosis (IPAA). However, the timing of prior pouch failure and its influence on outcomes following redo IPAA remains poorly understood. This study evaluates the role of timing as a predictor of redo pouch survival, with the goal of guiding clinical decision-making and improving outcomes after redo surgery. We hypothesized timing of pouch failure after index pouch is associated with pouch survival.

Methods/Interventions: A retrospective cohort study from a single referral center was conducted. Patients with a prior IPAA who underwent redo pouch surgery at our institution between 2000-2024 were included. The cohort was stratified into two groups based on time to index pouch failure as defined by rediversion; patients whose pouches failed ≤6-months from index IPAA creation were defined as 'early' and those whose pouches failed after >6-months were defined as 'late'. Redo pouch failure was defined as pouch excision, rediversion after redo pouch, or failure to close ileostomy. The primary outcome was subsequent redo pouch failure. Cox regression was used to evaluate predictors of redo pouch survival.

Results/Outcomes: A total of 320 patients met inclusion criteria: 57 in the early and 263 in the late. Patients were similar in sex (59.6% vs 55.9% Female; p=0.6), BMI (23.8% vs 24.3%; p=0.47) and age at the time of index operation (33.9 vs 30.7; p=0.11). Index pouch leak (50.9% vs. 33.5%; p< 0.013) and pelvic abscess (36.8% vs 14.1%; p< 0.001) were more common indications for redo surgery in the early group, while fistula formation was similar (22.8% vs 26.6%; p=0.55). The rate of all non-inflammatory conditions as indications for redo surgery were similar between both groups. Time from rediversion to redo was longer for the early group compared to the late group (1.73 vs 1.09 years; p=0.009). Following redo surgery, the rate of secondary pouch failure was lower in the early cohort (10.7% vs 22.8%, p=0.04) compared to the late group. Follow-up time was similar for both cohorts (3.4 vs. 3.5 years, p=0.79). Ileostomy closure after redo pouch was similar between groups (96.5% vs 88.6%; p=0.07) as was time to reversal (0.49 vs 0.46 years; p=0.65). On Cox proportional hazard regression analysis adjusting for indication of primary failure, late pouch failure (HR 3.09, 95% CI 1.07-8.87; p=0.04) and inflammatory indications were independent predictors of redo pouch failure (HR 2.40, 95% CI 1.15-5.00; p=0.02).

Conclusion/Discussion: Late failure after index IPAA was associated with increased risk of subsequent pouch failure after redo IPAA independent of the indication for redo pouch and timing of rediversion before redo. These findings can help guide shared decision making before redo pouch surgery.

Redo Pouch Survival Over Time In Patients Who Failed Index Pouch Early vs Late
Redo Pouch Survival Over Time In Patients Who Failed Index Pouch Early vs Late. Cox regression was used to calculate pouch survival over time in both cohorts. Variables included in the model were sex, age, inflammatory indication, BMI and time from rediversion to redo.