Restorative versus non-restorative total proctocolectomy: Who doesn't pouch and how do they do?

AIM: Literature comparing total proctocolectomy with permanent end ileostomy (TPC-EI) and IPAA in patients with UC is sparse. We aimed to (a) elucidate reasons for non-restorative surgery in ulcerative colitis (UC), (b) describe the incidence of perineal wound complications and (c) assess differences in short-term outcomes between groups. We hypothesized that non-restorative surgery was associated with a higher overall complication rate than ileoanal pouch (IPAA). METHODS: We identified a sample of patients with UC who underwent proctectomy (2005-2023) at our institution. The primary endpoint was the overall 30-day complication rate. Odds ratios (ORs) and 95% confidence intervals are presented. RESULTS: A total of 821 patients were included: 689 (83.9%) IPAA and 132 (16.1%) TPC-EI (80% and 52% staged proctectomy, respectively). The most common reasons for TPC-EI over IPAA were patient preference (53%), neoplasia (10.6%), incontinence (9.1%) and obesity (7.6%). Compared with IPAA patients, TPC-EI patients were older, had more comorbidities, and more were receiving biologics. Postoperatively, 18.2% of TPC-EI patients developed perineal wound complications, whereas 4.5% of IPAA patients experienced leaks. The overall 30-day complication rate was higher after TPC-EI (37.1% vs. 19.2%, p < 0.0001); however, after excluding these procedure-specific complications, rates were equivalent (22.7% vs. 17.9%, p = 0.23). In multivariable analysis after propensity score matching, TPC-EI remained a significant predictor of any complication (OR 2.84, 95% CI 1.37-6.08, p = 0.006). CONCLUSIONS: Patient preference was the most common reason for permanent ileostomy in UC. Although short-term complication rates were similar overall, perineal complications occurred in 18% after TPC-EI. These data may inform preoperative counselling when discussing surgical options for UC.