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Objective: Identify factors associated with 3- vs. 2-stage procedures for active Ulcerative Colitis (aUC) and determine their impact on surgical outcomes. Design: Retrospective analysis. Setting: Single large academic medical center. Patients: 144 undergoing 3- or 2-stage surgery for aUC. Interventions: None. Main Outcome Measure(s): Factors leading to decision for 3-stage procedure; post-operative outcomes with 3-stage vs. 2-stage procedures; and risks for complications with 3-stage vs. 2-stage procedures. Results: Of 144 patients, only 19.4% had a 3-stage procedure. Decision to perform a 3- vs. 2-stage procedure was affected by emergent status (32% vs. 2.8%; p<0.0001) and hemodynamic instability (apgar score 5.9±0.3 vs. 6.5±0.1; p=0.04), but not by age, gender, BMI, steroids, or anti-TNF use. For patients with 2-stage procedures, multivariate regression revealed that number of peri-operative complications was affected by surgeon experience (p=0.02), but not by emergent status, steroids, or anti-TNF use. 2-stage procedures were associated with more peri-operative complications on univariate analysis (p=0.05), but multivariate regression suggested this difference was due to differences in surgeon experience (p=0.05) rather than creation of a J-pouch at the first operation (p=0.55). Importantly, 2-stage procedures did not change the overall risk of anastomotic leak [OR 1.09 (0.05, 8.07); p=0.94]. Long-term (5.2±0.2 yrs), 2-stage patients had a lower risk of anal stricture and no differences in fistula/abscess formation or pouch failure (Table). Conclusions: Steroids and anti-TNF agents alone do not appear to justify the decision to avoid J-pouch creation at the first operation, as long as the procedure is performed by a high-volume IBD surgeon.

Long Term Complication	3-Stage- vs 2-Stage IPAA
	OR (95% CI)	p-value
Non-surgical Ileus/SBO	0.06 (0.002, 0.54)	0.007
Anal Stricture	8.21 (1.55, 52.3)	0.01
Fistula/Abscess	1.79 (0.36, 7.92)	0.46
Pouch Failure	7.63 (0.22, 210)	0.23