(P062) INTERVAL ANAL STUMPECTOMY AFTER ANAL SPARNG PROCTECTOMY OR POUCH EXCISION FOR IBD

Background: Rarely, anal-sparing proctectomy or pouch excision, in which the anorectal junction is transected with a transverse stapler to close the anal canal, may be performed to avoid the risk of perineal wound dehiscence in high-risk patients, such as those on high-dose steroids or with severe hypoalbuminemia. After a patient’s recovery, the anal canal may be secondarily excised to treat the ongoing symptoms of mucus drainage and obviate the need for surveillance anoscopy. We aimed to describe our institutional experience in performing delayed anusectomy, also called anal stumpectomy, after undergoing either completion proctectomy or pouch excision for inflammatory bowel disease (IBD). 

Methods: We queried our prospectively maintained colorectal surgery registry from 2002-2021 for patients with a diagnosis of IBD who underwent interval anal stumpectomy after anal-sparing proctectomy. Patient baseline characteristics, short- and long-term complications, and perineal wound healing rates were evaluated.  

Results: We identified 34 patients who underwent interval anusectomy after anal-sparing proctectomy. Median age at proctectomy was 43.5 years (IQR 32-56), with 20 (58.8%) being female. Diagnoses included Crohn’s disease (52.9%), ulcerative colitis transitioning to Crohn’s (29.4%), and ulcerative colitis (17.6%). Index procedures were proctectomy/proctocolectomy (76.5%) and pouch excision (23.5%), with adjuncts like omental flaps (18%) and a bladder flap (3%). All patients had risk factors for perineal wound dehiscence, including steroid dependence (58.8%), TPN dependence (11.8%), diabetes (14.7%), obesity (5.9%), and perineal/pelvic sepsis (26.5%/8.8%). Postoperatively, 2 (5.9%) had anal stump dehiscence. Symptoms prompting delayed anusectomy included mucopurulent discharge (73.5%), pain (14.7%), bleeding (14.7%), and stump surveillance issues (2.9%). Indications were symptom control (32.4%), fistulas (32.4%), abscesses (11.8%), and other complications. Seven (20.6%) were on biologics before surgery. Anusectomy was perineal in 73.5% and abdominoperineal in 26.5%, with inter-sphincteric dissection in 88%. No intraoperative complications occurred. Perineal wounds healed in 73.5% within six months; four (12%) required reoperation for wound debridement. 

Conclusion: A staged approach addressing reversible risk factors like steroid dependency, TPN use, and nutritional status led to a 76% perineal wound healing rate in high-risk patients. This approach is safe and effective, but patients and surgeons should be aware of potential symptoms from the remaining anal canal, the need for surveillance, and risks such as staple line dehiscence and fistulization. When indicated, interval anal stumpectomy can typically be performed via transperineal intersphincteric dissection.