EP380 - Complications following total abdominal colectomy with ileorectal anastomosis for functional constipation—should patients be diverted?

Purpose/Background: Total abdominal colectomy (TAC) with ileorectal anastomosis (IRA) has been established as the preferred surgical intervention for patients with medically refractory functional constipation. Rates of anastomotic leak and stricture after TAC with IRA are reported to be 2-32% and 0.5-32%, respectively. However, these rates reflect heterogeneous patient populations, with rates for those with functional constipation not discretely reported. With the paucity of literature on this patient population, we aim to define rates of anastomotic complications for TAC with IRA for functional constipation. We hypothesized preoperative pelvic floor dysfunction and creation of IRA without diverting stoma are factors which will portend a higher risk for anastomotic complication.

Methods/Interventions: A single-center retrospective review of 424 patients undergoing TAC with IRA for functional constipation from 1980-2023 was conducted. Patient demographics and clinical outcomes were queried from a prospectively maintained institutional registry. Pre-operative motility workup, medical therapy regimens, and operative details were identified through chart review. Pelvic floor dysfunction was defined as abnormal results on anorectal manometry. Univariate logistic regression was conducted to assess risk factors associated with anastomotic leak and stricture. Multivariate analysis was used to identify risk factors independently associated with anastomotic complications.

Results/Outcomes: A total of 424 patients were included for analysis. Patients were 96% female with a mean age 42.7 ± 13.1 years. 54.9% of patients were ASA class III/IV. Rates of anastomotic leak and stricture were 3.8% (n=16) and 9.9% (n=42), respectively. For those with leaks, 18.8% had pelvic floor dysfunction (paradox n=1, low tone n=1, hyposensitivity n=1). Hypoalbuminemia was found to significantly increase the odds of leak on univariate analysis (OR=12.3, 95% CI: 2.0-57.7, p=0.023) and multivariate analysis (OR 2.9, 95% CI: 1.5-5.7, p=0.001). Diversion was not associated with lower odds of leak when controlling for hypoalbuminemia (OR 0.46, 95% CI: 0.19-1.1, p=0.08). Factors not associated with increased risk of leak included operative approach (robotic vs laparoscopic vs open, p=1.0), anastomotic configuration (stapled end-to-end vs other stapled configuration vs handsewn, p=0.48), and stapler size (EEA 28 vs 29 vs 31 vs other p=0.46). Among those with stricture, 51.5% had pelvic floor dysfunction (paradox n=12, high tone n=7, low tone n=3, hyposensitivity n=3). Pelvic floor dysfunction (p=0.7), hypoalbuminemia (p=0.26), anastomotic configuration (p=0.08), and stapler size (p=0.16) were not associated with stricture. Multivariate analysis demonstrated that diversion and leak were independently associated with higher odds of stricture (OR 2.1, 95% CI: 1.5-2.9, p< 0.001 and OR 2.3, 95% CI: 1.2-4.2, p=0.009, respectively).

Conclusion/Discussion: Rates of anastomotic complications for TAC with IRA for functional constipation are similar to patient cohorts previously established in the literature. Preoperative nutritional optimization should be considered prior to operative intervention for mitigation of anastomotic leak. Diverting ostomy was not associated with a reduction in leak but did increase the risk of anastomotic stricture. Further studies are required to understand functional outcomes following TAC with IRA in this population.

Table 1.
Table 1. Univariate analysis of risk factors for anastomotic complications
Table 2.
Table 2. Multivariate analysis of risk factors for anastomotic complications