Factors associated with ileoanal pouch failure in patients developing early or late pouch-related fistula

Understanding Pouch-Related Fistulae: Don't Lose Track of Time

Patients with early-onset pouch-related fistula (PRF) within 12 months of surgery had significantly higher rates of postoperative anastomotic leakage and abscess, while patients with late-onset PRF had significantly higher rates of Crohn’s-disease-like pouch inflammation.

Management of J-pouch Complications

Most patients with a restorative proctocolectomy with ileal pouch-anal anastomosis do well; however, properly identifying acute and chronic complications are paramount to managing and correcting these complications to allow for optimal pouch function and avoid pouch failure. Inflammatory conditions like pouchitis may require ongoing medical therapy, but surgical intervention may be needed to correct any underlying septic complication and to repair any structural disorders. Patients with signs of pouch failure may be candidates for pouch augmentation or redo pouch surgery and should be referred to high-volume centers before pouch excision is offered if the patient wishes to avoid a permanent ileostomy.

The Pouch Corner: Perianal Fistulas and Ileal Pouches: Examining Fistulas Before and After Pouch Creation

Patients with ulcerative colitis (UC) and Crohn’s disease (CD) proctocolitis are candidates for an ileal pouch-anal anastomosis (IPAA), provided they do not suffer from complex perianal fistulas or small bowel inflammation. UC patients who develop a simple perianal fistula may still be candidates for an IPAA; however, patients with complex perianal fistulas are precluded from having an ileal pouch. After an IPAA, patients may develop perianal fistulas that arise acutely from a technical complication or an anastomotic leak, or as late-onset fistulas as a result of CD-like inflammation of the pouch.

Ileoanal Pouch-Related Fistulas: A Narrative Review

Ileoanal pouch-related fistula (IAPRF) is a possible complication after ileal pouch-anal anastomosis that significantly impacts pouch prognosis and the patient's quality of life. This study aimed to perform a comprehensive narrative review to better classify the epidemiology, risk factors, etiology, management, and outcomes of IAPRF, and to propose an algorithm for its systematic classification. Ten studies comprising 664 patients with IAPRF were identified, with a prevalence ranging from 4% to 45%. The reported fistula types were as follows: pouch-vaginal (n = 236, 35.5%), perineal (n = 139, 21%), enterocutaneous (n = 54, 8%), pouch-anal (n = 53, 8%), presacral (n = 18, 2%), and anastomotic (n = 15, 2%). Postsurgical pelvic sepsis occurred in 21%-37.2% of patients. Twenty additional studies regarding fistula classification divided them according to onset time and etiology, defining 5 categories: anastomotic-related, technical aspects of the surgery, Crohn's disease-like pouch inflammation, cryptoglandular, and malignancy. Pouch excision was reported in up to 70% of patients. Fistulas associated with anastomotic complications, technical surgical issues, and cryptoglandular fistulas warrant surgical management. On the other hand, fistulas associated with inflammation are preferentially managed with biologics or small molecules.

Late anastomotic perforation of the ileum 3 years after intestinal resection

Late perforation of the ileum is a rare and potentially life-threatening complication following intestinal resection. We present a unique case of a woman in her 60s with a history of appendiceal carcinoid tumour, who underwent a right hemicolectomy. Positron emission tomography and surveillance CTs showed normal surgical changes and no recurrent malignancy. Three years postoperatively, she presented with severe abdominal pain. CT revealed a perforation along the ileal wall of the ileocolonic anastomosis. She underwent emergent resection and repeat ileocolonic anastomosis. We conclude that the patient had subclinical ischaemia of the anastomosis, which eventually progressed to perforation 3 years later. We discuss a literature review on late small intestinal anastomotic perforations and their associated risk factors. Our case and literature review emphasise the importance of considering delayed anastomotic leak in postoperative patients with a history of intestinal cancer, inflammatory bowel disease, Roux-en-Y enteroenterostomy or side-to-side anastomosis.

Salvage surgery for pouch-related complication after ileal pouch-anal anastomosis: a report of two cases

BACKGROUND

Pouch-related complications (PRCs), such as pelvic abscesses and perianal complex fistulas, can occur after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). They are often difficult to treat and require salvage surgery. We report two cases of PRC associated with fistulas.

CASE PRESENTATION

First case: A 38-year-old man was diagnosed with UC at age 26 years. Four months after the diagnosis of UC, the patient underwent hand-assisted laparoscopic restorative proctocolectomy, IPAA, and ileostomy for acute fulminant UC. Two years after the closure of the ileostomy, the patient developed a perianal abscess and underwent ileostomy reconstruction. He was referred to our department at 35 years of age, because his symptoms did not improve despite repeated seton drainage of a complicated perineal fistula. We diagnosed PRC with a pelvic abscess and complicated pouch fistula and performed salvage surgery. This diagnosis was revised to Crohn's disease.

SECOND CASE

A 50-year-old man was diagnosed with UC at age 18 years and was administered high doses of steroids; however, his symptoms did not improve. He underwent restorative proctocolectomy, IPAA, and ileostomy at another hospital. The ileostomy was closed, and his condition stabilized thereafter. At 35 years of age, perianal pain developed, and he was diagnosed with a complicated pouch-perineal fistula. A fistula was observed near the staple line of the ileal end closure on the head side of the pouch. Reconstruction of the ileostomy and seton drainage were performed; however, his symptoms did not improve, and he was referred to our hospital. We diagnosed PRC with a pelvic abscess and a complicated pouch fistula and performed salvage surgery. The resected specimen showed strictures in two locations: at the oral site of the afferent limb (at the pouch) and at the IPAA. Both patients returned to society and are currently outpatients.

CONCLUSIONS

We encountered two cases of PRC after IPAA that did not improve with seton drainage or ileostomy. Pouch resection was performed after considering the patient's quality of life and reintegration into society.

Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn's Disease: Experience of a Tertiary Center

BACKGROUND

The leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis.

OBJECTIVE

Determine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn's disease phenotype of the pouch.

DESIGN

Retrospective cohort study of a prospectively maintained, IRB-approved database.

SETTINGS/PATIENTS

Ninety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn's-related perianal disease.

INTERVENTIONS

Two hundred thirty-one operations for perianal or anovaginal fistula(s).

MAIN OUTCOME AND MEASURES

Healing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure.

RESULTS

Overall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m2. More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03-0.43, p = 0.001). Overall pouch failure rate was 12.1%.

LIMITATIONS

Retrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset.

CONCLUSIONS

Pouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.

Controversies in Crohn's Disease Before and After Pouch Surgery

BACKGROUND

IPAA is rarely performed in patients with a known diagnosis of Crohn's disease, although it may be done in highly selected patients with an absence of perianal disease or small bowel inflammation. Patients with a preoperative diagnosis of Crohn's disease are, however, at increased risk of developing Crohn's disease of the pouch. Crohn's disease of the pouch can also occur in people with a preoperative diagnosis of ulcerative colitis; however, it is unknown whether this phenotype is similar to classic Crohn's disease involving an intact bowel, or whether it is a distinct entity.

OBJECTIVE

This study aimed to describe Crohn's disease of the pouch, including luminal inflammation, and fibrostenotic and perforating phenotypes, as well as management of these conditions.

RESULTS

Crohn's disease of the pouch can present in similar ways as classic Crohn's disease, classified as either inflammatory, fibrostenotic, or penetrating. Criteria involving the diagnosis of Crohn's disease of the pouch are stringent to prevent unnecessary treatments, because a diagnosis of Crohn's disease after IPAA for presumed ulcerative colitis can cause mental anguish. Treatment of Crohn's disease of the pouch depends on the presenting phenotype, although therapies are similar to classic Crohn's disease. Endoscopic, or even surgical treatment, may be required for fibrostenotic and fistulizing diseases.

LIMITATIONS

Crohn's disease of the pouch is a newly described disease of patients who undergo an ileoanal pouch anastomosis; and therefore, most of the evidence comes from retrospective trials in patients with an initial diagnosis of ulcerative colitis.

CONCLUSIONS

While Crohn's disease of the pouch is controversial and perhaps a distinct disease within the spectrum of inflammatory bowel diseases, it nonetheless requires long-term medical therapy and close follow-up.

Histopathology of Colectomy Specimens Predicts Endoscopic Pouch Phenotype in Patients with Ulcerative Colitis

BACKGROUND

The endoscopic appearance in patients with "pouchitis" after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be quite heterogenous. Patients with an endoscopic phenotype resembling Crohn's disease (CD) are at high risk of pouch loss.

AIMS

We aimed to assess how the histopathology of colectomy specimens predicts endoscopic pouch phenotypes in UC.

METHODS

We retrospectively assessed pouchoscopies from patients with UC who underwent IPAA and classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted ≥ 6 months from ileostomy takedown. We assessed the clinical and pathological data including deep, focal inflammation, granulomas, and terminal ileal involvement in the colectomy specimens. Logistic regression analysis was performed to identify contributing factors to each phenotype.

RESULTS

This study included 1,203 pouchoscopies from 382 patients with UC. On multivariable analysis, deep inflammation was significantly associated with pouch fistulas (Odds ratio 3.27; 95% confidence interval 1.65-6.47; P = 0.0007). Of the 75 patients with deep inflammation, only two patients (2.7%) were diagnosed with CD based on pathology review. Terminal ileal involvement significantly increased the risk of afferent limb involvement (Odds ratio 2.96; 95% confidence interval 1.04-8.47; P = 0.04). There were no significant associations between other microscopic features and phenotypes.

CONCLUSIONS

We identify histologic features of colectomy specimens in UC that predict subsequent pouch phenotypes. Particularly, deep inflammation in the resected colon was significantly associated with pouch fistulas, a pouch phenotype with poor prognosis.

Perianal Fistula After Ileoanal Pouch in Patients With Ulcerative Colitis: A Review of 475 Patients Operated on at a Major IBD Center

BACKGROUND

Ileoanal pouch anastomosis is the surgical treatment of choice for patients with intractable ulcerative colitis. Perianal disease is a feature that is often present in Crohn's disease and infrequently in ulcerative colitis.

OBJECTIVE

The aim of this study is to identify the incidence and factors associated with the development of postoperative perianal fistula in patients undergoing ileoanal pouch anastomosis for ulcerative colitis.

DESIGN

A prospectively collected database at the time of surgery with subsequent follow-up was utilized.

SETTING

The study was conducted at a high-volume single institution.

PATIENTS

We studied a series of 475 consecutive patients with preoperative diagnosis of ulcerative colitis who underwent ileoanal pouch anastomosis.

MAIN OUTCOME MEASURES

The incidence of postoperative perianal fistula and the factors correlating with its development were primary outcome measures of the study.

RESULTS

The overall number of patients developing perianal fistulas was 44 of 475 (9%). Eleven patients with perianal fistula (25%) required return to ileostomy, of which 7 had pouch excision. Patients who developed a postoperative perianal fistula had a younger age at the onset of disease, had a lower age at index surgery, and were more likely to be subsequently classified as indeterminate colitis or Crohn's disease. Patients developing perianal fistulas were also more likely to develop partial dehiscence or stricture of the ileoanal anastomosis.

LIMITATIONS

This study spans nearly 40 years during which the surgical procedure evolved.

CONCLUSIONS

Young age at the onset of disease, lower age at surgery, and postoperative diagnosis of Crohn's disease and indeterminate colitis were the factors correlating with perianal fistulas. Delayed healing of the ileoanal anastomosis with partial separation and/or stricture also correlated with the onset of perianal fistulas. The severity of rectal inflammation at the time of surgery or the presence of stapled versus handsewn anastomosis did not correlate with the development of perianal fistulas. See Video Abstract at http://links.lww.com/DCR/B705.

FSTULA PERIANAL POSTERIOR A RESERVORIO ILEOANAL EN PACIENTES CON COLITIS ULCERATIVA UNA REVISIN DE PACIENTES OPERADOS EN UN CENTRO PRINCIPAL DE EII

ANTECEDENTES:El reservorio ileoanal es el tratamiento quirúrgico de elección para los pacientes con colitis ulcerativa intratable. La enfermedad perianal es una característica que a menudo está presente en la enfermedad de Crohn y con poca frecuencia en la colitis ulcerativa.OBJETIVO:El objetivo del estudio es identificar la incidencia y los factores asociados con el desarrollo de fístula perianal posoperatoria en pacientes sometidos a reservorio ileoanal por colitis ulcerativa.DISEÑO:Base de datos recopilada prospectivamente en el momento de la cirugía con seguimiento subsecuente.ENTORNO CLÍNICO:El estudio se llevó a cabo en una única institución de gran volumen.PACIENTES:Estudiamos una serie de 475 pacientes consecutivos con diagnóstico preoperatorio de colitis ulcerativa a los que se les realizó reservorio ileoanal.PRINCIPALES MEDIDAS DE VALORACIÓN:La incidencia de fístula perianal posoperatoria y los factores que se correlacionan con su desarrollo fueron las principales medidas de resultado del estudio.RESULTADOS:El número total de pacientes que desarrollaron fístulas perianales fue 44 de 475 (9%). Once pacientes con fístula perianal (25%) requirieron volver a la ileostomía, de los cuales 7 tuvieron resección del reservorio. Los pacientes que desarrollaron fístula perianal posoperatoria tenían edad más temprana al inicio de la enfermedad, menor edad en el momento de la cirugía inicial y tenían más probabilidades de ser clasificados posteriormente como colitis indeterminada o enfermedad de Crohn. Los pacientes que desarrollaron fístulas perianales también fueron más propensos a desarrollar dehiscencia parcial o estenosis de la anastomosis ileoanal.LIMITACIONES:Este estudio abarca casi 40 años durante los cuales ha evolucionado el procedimiento quirúrgico.CONCLUSIONES:Edad temprana al inicio de la enfermedad, menor edad al momento de la cirugía, diagnóstico postoperatorio de enfermedad de Crohn y colitis indeterminada fueron los factores que se correlacionaron con las fístulas perianales. El retraso en la cicatrización de la anastomosis ileoanal con separación parcial y/o estenosis también se correlacionó con la aparición de fístulas perianales. La gravedad de la inflamación rectal en el momento de la cirugía o la presencia de anastomosis con grapas versus anastomosis manual no se correlacionó con el desarrollo de fístulas perianales. Consulte Video Resumen en http://links.lww.com/DCR/B705.

Therapeutic Endoscopy in Postoperative Pouch Complications

Ileal pouch-anal anastomosis (IPAA) or "J"-pouch as it is commonly referred to, is the treatment of choice in patients with medically refractory ulcerative colitis. IPAA can have infectious, inflammatory, and mechanical complications. Currently, there are no Food and Drug Administration-approved medical therapies for these complications. Surgery that may be eventually required can have significant morbidities due to the complexity of IPAA. Endoscopy is fast emerging as a leading modality of treatment for some of these pouch complications. Endoscopy in adjunct with medical treatment can help manage the majority of pouch-related disorders and improve the outcome.

Anastomotic Leak after Ileal Pouch-Anal Anastomosis

There are special considerations when treating anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis. The epidemiology, risk factors, anatomic considerations, diagnosis and management, as well as the short- and long-term consequences to the patient are unique to this patent population. Additionally, there are specific concerns such as "tip of the J" leaks, transanal management of anastomotic leak/presacral sinus, functional outcomes after leak, and considerations of redo pouch procedures.

Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium

Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.

Re-operation surgery following IPAA: is there a role for laparoscopy?

BACKGROUND

Restorative proctocolectomy with ileal J pouch anal anastomosis (IPAA) has become the standard of care for mucosal ulcerative colitis and Familial Adenomatous Polyposis. Some patients require re-operation, including pouch revision, advancement, or excision. Re-operative procedures are technically demanding and usually performed only by experienced colorectal surgeons in a small number of referral centers. There is a paucity of data regarding feasibility, safety, and outcomes of laparoscopic re-operative IPAA surgery. This study aimed to determine the safety and feasibility of laparoscopic approach for re-operative IPAA, trans-abdominal surgery.

METHODS

Retrospective analysis of IRB-approved prospective database for patients who underwent trans-abdominal re-operative IPAA from 2011 to 2018. Patient demographics and operative reports were reviewed to classify type of re-operation into pouch excision, revision, or advancement and further classify as laparoscopic, laparoscopic converted to open, or open surgery. Main outcome measures were post-operative morbidity and mortality.

RESULTS

Seventy-six patients met the inclusion criteria: 19 underwent attempted laparoscopic re-operative IPAA surgery, 12 of whom underwent successful laparoscopic surgery while 7 were converted to laparotomy, for an overall laparoscopic intent to treat 63% success rate. The remaining operations (n = 57) were performed through midline laparotomy. Length of stay (LOS) for patients who underwent laparoscopic surgery was significantly shorter (5.5 vs 9.7 days, p < 0.001) as were abdominal superficial surgical site infections (SSI) (0% vs 18%, p < 0.001) and deep SSI (0% vs 17%, p < 0.001). Laparotomy was performed by 6 colorectal surgeons at our institution while laparoscopy was successfully performed only by the senior author. There was no significant difference in overall complications, re-admission, re-operation, or mortality.

CONCLUSION

Re-operative, trans-abdominal, laparoscopic IPAA is both feasible and safe and has clear benefits compared to laparotomy in terms of LOS and superficial and deep SSI. However, this approach needs to be undertaken only by very experienced, high-volume laparoscopic IPAA surgeons.

Management of pouch-vaginal fistulas - experience from our institution

AIM

Pouch-vaginal fistula (PVF) is an uncommon but serious complication of ileo-anal pouch reconstruction. This study aimed to review the recent management of PVF, in particular the role of anti-tumour necrosis factor (anti-TNF) drugs.

METHOD

All patients presenting for management of PVF to our surgical service between 2007 and 2016 were studied. The median duration of follow-up from diagnosis of PVF was 6 years. Details of the original pouch surgery, timing of presentation of PVF, management and final outcome were recorded. Primary outcome was gastrointestinal (GI) continuity (as defined by the presence or absence of a stoma).

RESULTS

A total of 23 patients were identified (median age 45 years) of whom nine had pelvic sepsis at the time of original pouch surgery. Management included local surgical repair, defunctioning ileostomy, pouch excision and anti-TNF therapy. GI continuity was achieved in 12 patients (52%). Healing of the PVF was achieved in 12 patients (52%). Pelvic sepsis was significantly associated with the need for a long-term ileostomy (P = 0.009). Biological therapy was used in 12 patients, of whom seven maintained GI continuity. Patients with late presentation PVF (60 months or longer postsurgery) and those with clinical features of Crohn's disease appeared to benefit from anti-TNF treatment.

CONCLUSION

PVF remains a challenging problem with overall healing rates and GI continuity rates of just over 50%. Anti-TNF therapy may have a role in patients with late presentation PVF and those with features suggestive of Crohn's disease.

Anastomotic Sinus That Developed From Leakage After a Rectal Cancer Resection: Should We Wait for Closure of the Stoma Until the Complete Resolution of the Sinus?

Purpose

The aims of this study were to identify the clinical characteristics of an anastomotic sinus and to assess the validity of delaying stoma closure in patients until the complete resolution of an anastomotic sinus.

Methods

The subject patients are those who had undergone a resection of rectal cancer from 2011 to 2017, who had a diversion ileostomy protectively or therapeutically and who developed a sinus as a sequelae of anastomotic leakage. The primary outcomes that were measured were the incidence, management and outcomes of an anastomotic sinus.

Results

Of the 876 patients who had undergone a low anterior resection, 14 (1.6%) were found to have had an anastomotic sinus on sigmoidoscopy or a gastrografin enema before their ileostomy closure. In the 14 patients with a sinus, 7 underwent ileostomy closure as scheduled, with a mean closure time of 4.1 months. The remaining 7 patients underwent ileostomy repair, but it was delayed until after the follow-up for the widening of the sinus opening by using digital dilation, with a mean closure time of 6.9 months. Four of those remaining seven patients underwent stoma closure even though their sinus condition had not yet been completely resolved. No pelvic septic complications occurred after closure in any of the 14 patients with an anastomotic sinus, but 2 of the 14 needed a rediversion due to a severe anastomotic stricture.

Conclusion

Patients with an anastomotic sinus who had been carefully selected underwent successful ileostomy closure without delay.

Outcomes of Ileal Pouch Excision: an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Analysis

BACKGROUND

This study aimed to define the incidence and risk factors of postoperative morbidity and mortality after pouch excision (PE).

METHODS

ACS-NSQIP database was queried for patients who underwent PE between 2005 and 2015. Main outcome measures were 30-day mortality, major morbidity, overall surgical site infections (SSI), reoperation, and length of stay (LOS). Risk factors associated with these outcomes were assessed using multivariate logistic or quantile regression.

RESULTS

Three hundred eighty-one patients underwent PE (mean age 47.7(±15.3) years; 51.7% female). Mean body mass index (BMI) was 24.6(±5.7) kg/m², 55.4% were ASA class 1-2 and 18.4% were immunosuppressed. Mean operative time was 252(±112.7) min, 98% were elective cases, and median LOS was 7(5-11) days. Twenty-eight percent experienced major morbidity, including SSIs (21.5% overall, 9.2% superficial, 3.7% deep, 10.3% organ space), sepsis (9.5%), urinary tract infection (5.8%), and postoperative pneumonia (2.4%). The observed venous thromboembolism rate was low, with 0.5 and 0.8% of patients suffering pulmonary embolism and deep vein thrombosis, respectively; 5.5% required reoperation. Postoperative mortality was 0.8%. On multivariate logistic regression, smoking (OR 3.03 [95% CI 1.56, 5.88]) and operative time (OR 1.003 [95% CI 1.0003, 1.0005) were associated with increased odds of major morbidity. Smoking (OR 3.29 [95% CI 1.65, 6.54]) and operative time (OR 1.002 [95% CI 1.000, 1.004]) were independent risk factors for overall SSI. LOS was significantly increased in patients with major morbidity (3.29 days [95% CI 1.60, 4.99]) and increased operative time (0.013 days [95% CI 0.007, 0.018]).

CONCLUSIONS

PE is an operation with significant risk of morbidity. However, mortality was low in the present cohort of patients. Patients who were smokers and had longer operative time had increased risk of overall infectious complications and major morbidity. Furthermore, major morbidity and operative time were associated with increased hospital length of stay following PE.

Endoscopic fistulotomy in inflammatory bowel disease (with video)

BACKGROUND AND AIMS

Fistulas in patients with inflammatory bowel disease (IBD) pose a key challenge in the management of these patients. We aimed to describe a novel endoscopic method to treat patients with IBD who have fistulas.

METHODS

A cohort of 29 consecutive patients with fistulas and IBD were identified in the registry of our interventional IBD unit. An endoscopic fistulotomy with needle-knife was performed. The primary outcome was healing of the fistula without the need for surgical intervention.

RESULTS

A total of 29 patients underwent endoscopic fistulotomy; and the mean (± standard deviation) age of patients undergoing the procedure was 44.2 ± 14.6 years. Thirteen patients were male (44.8%), and 16 were female (55.2%). Twenty-six patients (89.6%) achieved complete resolution of the fistula as confirmed by endoscopy with a guidewire and/or cross-sectional abdominal imaging, with 10 patients (34.4%) requiring a single endoscopic treatment session. Three patients (10.3%) had a persistent fistula and required surgical intervention. One patient had postoperative bleeding requiring blood transfusion and hospitalization.

CONCLUSION

Endoscopic fistulotomy with a needle-knife appears to be safe and effective in treating IBD-related fistulas.

Poor Outcomes of Complicated Pouch-Related Fistulas after Ileal Pouch-Anal Anastomosis Surgery

BACKGROUND AND AIMS

Development of a pouch-related fistula tract is an uncommon but highly morbid complication to restorative proctocolectomy with ileal pouch-anal anastomosis. Pouch failure with permanent ileostomy is reported in 21%-30% of patients, yet the factors contributing to pouch excision remain poorly defined. The aim of this study was to determine the incidence and treatment results of complicated pouch-related fistula, as well as to evaluate factors involved in excision after pouch failure.

MATERIAL AND METHODS

The study was conducted as a retrospective study. All patients with diagnosed pouch-related fistulas were registered with information related to fistula classification, treatments, and outcome.

RESULTS AND CONCLUSION

The final analysis included 48 (10.7%) of the 447 total ileal pouch-anal anastomosis patients with complicated pouch-related fistulas. Pouch-vaginal fistulas, pouch-perianal fistulas, and other pouch-related fistulas were observed in 19 (63%), 29 (60%), and 10 (21%) patients, respectively, corresponding to an accumulated risk of 8%, 6%, and 2%, respectively. Time from ileal pouch-anal anastomosis surgery to fistula presentation was 24 (0.2-212) months. Overall pouch failure, defined as pouch excision or a diverting stoma, was seen in 34 (71%) patients, while pouch excision was seen in 23 (48%) of the patients. Patients who developed Crohn's disease had a significantly higher risk of pouch excision, as did patients with an early onset of the fistula after ileal pouch-anal anastomosis (P = 0.006 and P = 0.007, respectively). In conclusion, the present study demonstrated a high risk of pouch failure in patients with complicated pouch-related fistulas. Furthermore, it showed that Crohn's disease and the development of early onset fistulas are associated with pouch excision.

Chronic, nonspecific, postinfectious, retroperitoneal fibrosis and ureteral obstruction

INTRODUCTION

Two cases of severe ureteral obstruction following nonspecific, postinfectious, chronic retroperitoneal fibrosis are described, which both originated by a primitive intestinal pathology.

PATIENTS

This complication was observed in two women: first, 65 years old, submitted for ulcerative colitis to a total proctocolectomy, with ileo-pouch-anal anastomosis, complicated by an anastomotic fistula; and second, 66 years old, operated with an extended left hemicolectomy, for an adenocarcinoma of the recto-sigmoid colon complicated with a vaginal fistula. In these cases, computerized tomography demonstrated a unilateral hydronephrosis, secondary to a complete obstruction of the ureter; a subsequent nephro-ureterectomy became necessary. Histology demonstrated nonspecific inflammatory lesions.

DISCUSSIONS

Postinfectious, chronic inflammation of the retroperitoneum acts on the ureteral and peri-ureteral tissues, inducing an inflammatory and then a fibrotic process.

CONCLUSIONS

We underline the opportunity of a precocious and radical treatment of every retroperitoneal infection.

Nonbloody Diarrhea but Not Significant Weight Loss at Diagnosis Is Associated with the Development of Denovo Crohn's Disease After Ileal Pouch-anal Anastomosis for Ulcerative Colitis

BACKGROUND

Denovo Crohn's disease (CD) develops in 5% to 10% of patients after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) leading to increased morbidity and rates of pouch failure. Initial nonbloody diarrhea and weight loss at diagnosis are independent risk factors for a change in diagnosis from UC to CD in nonsurgical patients. We investigated whether these features were risk factors for denovo CD in a longitudinal cohort of patients with UC undergoing IPAA.

METHODS

Prospective profiles of patients with UC undergoing IPAA followed over a 22-year period by 1 surgeon were analyzed. Denovo CD was diagnosed when mucosal inflammation (5 or more ulcers) involved the small bowel mucosa proximal to the ileal pouch any time after surgery and/or when a pouch fistula or other perianal complication developed more than 3 months after ileostomy closure. Patients with inflammatory bowel disease unclassified, acute pouchitis, chronic pouchitis, and those lost to follow-up were excluded from analysis. Cox regression analysis was performed for statistical significance.

RESULTS

Of the 199 study patients included in the analysis, denovo CD developed in 42 patients (21%). Patients who developed denovo CD had an increased incidence of nonbloody diarrhea (n = 12; 29%) compared with patients who had no evidence of pouch inflammation (n = 25; 16%) (P = 0.03). In contrast, the incidence of weight loss was not significantly increased in patients with denovo CD (n = 7; 17%) compared with patients who never had pouch inflammation (n = 16; 10%) (P = 0.12).

CONCLUSIONS

Initial nonbloody diarrhea is associated with denovo CD after IPAA. This association warrants close consideration before surgery.

Ileo-anal pouch excision: A review of indications and outcomes

Restorative proctocolectomy (RP) is the surgical treatment of choice for ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). A devastating complication for both patient and surgeon is failure of the pouch that requires excision. There is currently no single paper in the literature that consolidates the indications for ileo-anal pouch excision and the subsequent outcomes following this procedure. A literature search was carried out to identify articles on RP and ileal pouch-anal anastomosis. The main search terms used were “RP”; “ileal pouch-anal anastomosis” or “ileal reservoir” or “ileal pouch”; “failure of ileal pouch-anal anastomosis” and “excision of ileal pouch-anal anastomosis”. The search was completed using electronic databases MEDLINE, PubMed and EMBASE from 1975 to June 2014. Characteristics of patients with pouch failure differ between institutions. Reported overall excision rates of the pouches vary and in this review ranged from 0.93% to 12.8%. Age and lower institutional volume (less than 3.3 cases) were independent predictors of pouch failure; however surgeon case load was not. The main reasons identified for excision are sepsis (early cause), Crohn’s disease and poor functional outcomes (both late causes). Pouch cancers in UC and FAP are still rare but 135 cases exist in the literature. The most common complication following excision is persistent perineal sinus. The decision to excise a pouch should not be taken lightly and an awareness of the technical pitfalls and complications that can occur should be fully appreciated.

Review of our ileal pouch experience in the light of literature

OBJECTIVE

Retrospective proctocolectomy is a distinguished, sphincter saving treatment used for the treatment of ulcerative colitis and FAP disease. We aimed to evaluate ileal pouch interventions performed at our clinic and their results in the light of literature.

MATERIAL AND METHODS

Medical records of 35 restorative proctocolectomy and J pouch ileo-anal anastomosis surgeries performed at Necmettin Erbakan University, Meram School of Medicine between the years 2006-2013 were retrospectively examined. The patients were assessed according to their age, gender, length of hospital stay, diagnosis, follow-up duration and pouch-related complications. All patients were contacted by phone and they were scheduled for controls at the outpatient clinic.

RESULTS

Nineteen patients were male (54%) and 16 were female (46%). Their mean age was 45 years (21-74). The mean length of hospital stay was 11 (5-20) days. Twenty two (63%) patients were operated on due to FAP, 12 (34%) due to synchronous rectum cancer and colon tumor or polyp, and one (3%) due to ulcerative colitis. All patients received J pouch and protective ileostomy. After the closure of ileostomy, two cases were identified to have J pouch fistulas. The patients were followed up for 6 months to 7 years. They were contacted by phone and they were questioned about their active complaints, number of defecations, urinary and sexual dysfunctions. It was identified that they had 5 (3-8) defecations per day on average and that 4 (11%) cases had one nocturnal defecation. No pouchitis was identified in the follow-up endoscopic examinations.

CONCLUSION

Restorative proctocolectomy and ileo-anal anastomosis technique is a surgical procedure that can be performed with low rates of morbidity and mortality, including the elderly.

Restorative proctocolectomy with a handsewn IPAA: S-pouch or J-pouch?

BACKGROUND

The efferent limb on the S-pouch fits well into the anal canal while the body of the pouch lies on the levators. In contrast, the blunt end of a J-pouch may be distorted as it is forced into the muscular tube of the stripped anus.

OBJECTIVE

The aim of this study is to compare the clinical outcomes and quality of life between patients with S- and J-pouches with a handsewn IPAA.

DESIGN

This study was retrospective.

SETTING

This study was conducted at a high-volume tertiary referral center.

PATIENTS

Patients undergoing a primary handsewn IPAA from 1983 to 2012 were identified.

MAIN OUTCOMES MEASURES

Demographics, operative details, functional outcomes, and quality of life were abstracted.

RESULTS

A total of 502 patients, including 169 patients with an S-pouch (33.7%) and 333 patients with J-pouch (66.3%), met our inclusion criteria; 55.8% (n = 280) were men. Mean age at pouch construction was 37.8 ± 12.5 years. Patients with an S-pouch were younger (p = 0.004) and had a higher BMI (p = 0.035) at pouch surgery. There was no significant difference between patients with S- or J-pouches in other demographics. The frequencies of short-term complications in the 2 groups were similar (p > 0.05), but pouch fistula or sinus (p = 0.047), pelvic sepsis (p = 0.044), postoperative partial small-bowel obstruction (p = 0.003), or postoperative pouch-related hospitalization (p = 0.021) occurred in fewer patients with an S-pouch. At a median follow-up of 12.2 (range, 4.3-20.1) years, patients with an S-pouch were found to have fewer bowel movements (p < 0.001), less frequent pad use (p = 0.001), and a lower fecal incontinence severity index score (p = 0.015). The pouch failed in 62 patients (12.4%), but neither univariate nor multivariate analysis showed a significant association with pouch configuration.

LIMITATIONS

The use of data from a single tertiary referral center was a limitation of this study.

CONCLUSION

We recommend using an S-pouch when constructing an IPAA with a handsewn technique.

Comparable pouch retention rate between pediatric and adult patients after restorative proctocolectomy and ileal pouches

BACKGROUND & AIMS

We compared long-term outcomes between adult and pediatric patients with inflammatory bowel disease (IBD) who underwent restorative proctocolectomy with ileal pouch-anal anastomosis.

METHODS

We performed a retrospective study that analyzed data from consecutive patients with ileal pouches who presented to the subspecialty Pouch Center at the Cleveland Clinic from 2002-2011. Pouch outcomes of 104 pediatric patients (having pouch surgery at age <18 years; 53 male) were compared with those of 1135 adults (having pouch surgery at an age 18 years or older; 632 male).

RESULTS

Pediatric patients had a shorter duration from time of IBD diagnosis to colectomy than adult patients. Fewer pediatric than adult patients had a history of smoking, concomitant extraintestinal manifestations, or dysplasia as the indication for colectomy. However, pediatric patients had higher rates of pouch procedure-related complications, postoperative pouch-associated hospitalization, and postoperative use of anti-tumor necrosis factor (TNF) agents. In multivariate analysis, risk factors for pouch failure included preoperative use of anti-TNF agents (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.05-3.13; P = .032), postoperative use of anti-TNF agents (HR, 2.07; 95% CI, 1.31-3.27; P = .002), Crohn's disease of the pouch (HR, 2.21; 95% CI, 1.28-3.82; P = .005), pouch procedure-related complications (HR, 2.68; 95% CI, 1.55-4.64; P < .001), and postoperative pouch-associated hospitalization (HR, 25.20; 95% CI, 14.44-43.97; P < .001). Being a pediatric patient was not significantly associated with pouch failure in univariate or multivariate analyses (HR, 0.6; 95% CI, 0.32-1.16; P = .13).

CONCLUSIONS

On the basis of an analysis of patients with IBD who underwent restorative proctocolectomy and presented at a subspecialized Pouch Center, patients who had the surgery at a pediatric age tend to have a higher incidence of postoperative pouch complications than adults. However, long-term rates of pouch retention were comparable.

SSAT/ASCRS Joint Symposium: controversies in surgery for ulcerative colitis

The following is a summary of Session 2: Inflammatory and Infectious Bowel Disease within the Maintenance of Certification (MOC) course directed by Jeffrey B. Matthews, MD, President of the Society of Surgery of the Alimentary Tract. This MOC course was held in Orlando, FL, USA on Saturday, May 18, 2013 during Digestive Diseases Week. Multiple disciplines, including gastroenterology, with general and colon and rectal surgery, were represented at the session.

Revision IPAA: strategies for success

The history of ileal pouch-anal anastomosis (IPAA) is one of success with durable surgical and functional results. However, pouch failure, due to infection, mechanical, or functional disability, represents a challenge to both surgeon and patient. Practicing surgeons who deal with the revision pouch face a variety of challenges. Success requires a strategy, which includes critical planning, preparation, and surgical techniques in order that surgeons continue to provide solutions and hope to patients.

Management and outcome of pouch-vaginal fistulas after IPAA surgery

BACKGROUND

After IPAA, the timing, management, and outcome of pouch-vaginal fistulas are poorly defined.

OBJECTIVE

The purpose of this study was to evaluate the frequency, management, and outcome of patients who develop a pouch-vaginal fistula.

DESIGN

This was a retrospective analysis of a prospectively maintained database.

SETTINGS

The study was conducted in a single-center, high-volume tertiary referral colorectal unit.

PATIENTS

Women with a pouch-vaginal fistula after IPAA from 1983 to 2010 were included in the study.

MAIN OUTCOME MEASURES

The healing rate of pouch-vaginal fistulas was measured.

RESULTS

Of 152 patients with a pouch-vaginal fistula after IPAA, 59 fistulas occurred at <12 months, constituting the early onset group, and 43 occurred at >12 months, constituting the late-onset group. Seventy-five patients (77.3%) underwent local repair (48 (49.5%) had ileal pouch advancement flap and 27 (27.8%) had transvaginal repair). The healing rate after ileal pouch advancement flap performed as a primary procedure was 42% and 66% when performed secondarily after a different procedure. The healing rate for transvaginal repair was 55% when done as a primary procedure and 40% when performed secondarily. Nineteen patients underwent redo ileal pouch construction, with an overall pouch retention rate of 40%. At median follow-up of 83 months (range, 5-480 months), 56 (57.7%) of the 102 patients had healed the pouch-vaginal fistula, whereas pouch failure occurred in 34 women (35%, 12 early onset and 22 late onset). Healing of the fistula was significantly lower (22% versus 73%; p < 0.001) and pouch failure higher (52.7% versus 22.7%, p < 0.001) when compared with Crohn's disease. On multivariate analysis, a postoperative delayed diagnosis of Crohn's disease was associated with failure (p = 0.01). No other factors were associated with pouch failure.

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

Pouch-vaginal fistula after IPAA surgery is indolent and may persist after repairs. A delayed diagnosis of Crohn's disease is associated with a poor outcome and a higher chance of pouch failure.

Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties

Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.

Redo Ileal pouch-anal anastomosis combined with anti-TNF-α maintenance therapy for Crohn's disease with pelvic fistula: report of two cases

Pouch failure has been reported to occur after ileal pouch-anal anastomosis for Crohn's disease. We report two cases of patients with Crohn's disease, who underwent redo ileal pouch-anal anastomosis (redo-IPAA) combined with anti-TNF-α maintenance therapy, with good functional results. The first patient, a man with presumed ulcerative colitis, suffered pelvic fistula recurrence and anastomotic dehiscence. He underwent redo-IPAA, at which time longitudinal ulcers were found. Infliximab was started 4 days postoperatively and continued. The second patient, a woman treated for ulcerative colitis, underwent laparoscopic IPAA 8 years later. After the development of a pelvic fistula, twisted mesentery of the ileal pouch was found intraoperatively and Crohn's disease was diagnosed. Adalimumab therapy resulted in fistula closure. Redo-IPAA was performed to normalize the twisted mesentery of the ileal pouch. No complications have been observed in either patient, both of whom have experienced good functional results after closure of the covering stomas.

Operative strategy modifies risk of pouch-related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α therapy

BACKGROUND

Whether preoperative biological therapy increases postoperative complications after restorative proctocolectomy remains controversial.

OBJECTIVE

This study aims to evaluate the influence of preoperative use of biologics on outcomes after restorative proctocolectomy and to assess whether a staged approach modifies any negative influence of these medications.

SETTING

The study was conducted at a single tertiary institution.

DESIGN AND PATIENTS

Patients who were operated on for medically refractory ulcerative or indeterminate colitis were identified and classified by initial surgery, whether subtotal colectomy or total proctocolectomy, then categorized into biologics user and nonuser groups. Demographics, perioperative data, postoperative complications, pouch function, and quality of life were collected.

OUTCOME MEASURE

Cumulative 1-year complication rates were estimated by using the Kaplan-Meier curve, and independent predictors for infectious complications were identified by using Cox proportional hazards regression models.

RESULTS

From 2006 to 2010, 407 and 181 patients underwent initial subtotal colectomy with end ileostomy or total proctocolectomy with IPAA. For the 181 patients who underwent total proctocolectomy straightaway, pre- and perioperative data were comparable for biologics users (n = 25) and nonusers (n = 156). Cumulative 1-year pelvic sepsis rate was significantly greater in patients on biologics (32% vs 16%, p = 0.012). Multivariate analysis demonstrated that preoperative anti-tumor necrosis factor therapy (HR, 2.62; p = 0.027) was an independent risk factor for postoperative pelvic sepsis after total proctocolectomy. After subtotal colectomy, no differences occurred in both 30-day and cumulative 1-year postoperative complications between biologics users (n = 142) and nonusers (n = 265). Outcomes were also similar when biologics users (n = 88) and nonusers (n = 164) underwent subsequent completion proctectomy with ileal pouch creation after initial colectomy.

LIMITATIONS

The retrospective nature of this study and physician's preference were limitations.

CONCLUSIONS

Preoperative exposure to biologics is associated with an increased risk of pelvic sepsis after total proctocolectomy with IPAA. This risk is mitigated by the performance of an initial subtotal colectomy.

Excessive weight gain is associated with an increased risk for pouch failure in patients with restorative proctocolectomy

BACKGROUND

The aim was to evaluate the impact of weight gain on pouch outcomes after ileostomy closure.

METHODS

Consecutive inflammatory bowel disease patients with ileal pouches followed up at our subspecialty Pouch Center from 2002 to 2011 were studied. The association of excessive weight gain (defined as a 15% increase the index weight) with pouch outcomes were evaluated using univariate and multivariate analyses.

RESULTS

A total of 846 patients met inclusion criteria, with 470 (55.6%) being men. The mean age at the diagnosis of inflammatory bowel disease and at pouch surgery was 27.2 ± 11.9 years and 37.8 ± 12.8 years, respectively. Patients with weight gain more likely had mechanical or surgical complications of the pouch (18.4% versus 12.3%, P = 0.049), Crohn's disease of the pouch (30.6% versus 18.5%, P = 0.001), Pouch Center visits (2.0 [1.0-4.0] versus 2.0 [1.0-3.0], P = 0.008), and postoperative pouch-related hospitalization (21.1% versus 10.6%, P < 0.001). After a median follow-up of 9.0 (interquartile range = 4.0-14.0) years, 68 patients (8.0%) developed pouch failure. In the multivariate analysis, excessive weight gain was an independent risk factor for pouch failure with a hazard ratio of 1.69 (95% confidence interval = 1.01-2.84, P = 0.048) after adjusting for preoperative or postoperative use of anti-tumor necrosis factor biologics, postoperative use of immunosuppressants, Crohn's disease of the pouch, mechanical or surgical complications of the pouch, and postoperative pouch-associated hospitalization.

CONCLUSIONS

Excessive weight gain after closure of the ileostomy is associated with worse pouch outcomes in patients with inflammatory bowel disease. Appropriate weight control may help improve pouch retention.

The pediatric pouch in inflammatory bowel disease: a primer for the gastroenterologist

Pediatric severe ulcerative colitis that is resistant to current medical treatment can successfully be managed surgically with a colectomy, ileal pouch creation and pouch-anal anastomosis. Key issues that should be considered and discussed before the pouch option can be offered include alternative surgical procedures, pouch function expectations, risk of surgical leak, pelvic sepsis, anastomotic strictures, acute and chronic pouch inflammation, Crohn's disease of the pouch and risk of reduced fertility for females. A long-term risk is malignancy of the residual colonic tissue. The decision to proceed with a pouch or not poses a substantial emotional burden to the child and family. Despite the risk of surgical complications and pouch inflammatory and functional challenges, the overwhelming majority of children and their families are satisfied with their pouch surgery outcomes. Further study is needed to assess preoperative risk predictors, prevention and treatment of complications.

Considerations and complications in patients undergoing ileal pouch anal anastomosis

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

The management of anastomotic pouch sinus after IPAA

BACKGROUND

Anastomotic sinus is a relatively uncommon complication after an IPAA. Disease course is poorly defined, and management can be challenging.

OBJECTIVE

The purpose of this study was to evaluate the frequency, management, and outcome of anastomotic pouch sinus.

DESIGN

This research is a retrospective cohort study from a prospectively collected database.

SETTING

The investigation took place in a high-volume specialized colorectal surgery department.

PATIENTS

Patients with an anastomotic sinus after pouch surgery from 1997 to 2009 were included.

MAIN OUTCOMES MEASURES

The primary outcomes measured were sinus healing and pouch failure.

RESULTS

Of 2286 patients who underwent an IPAA, 45 (2.0%) patients were identified with an anastomotic pouch sinus. There were 32 (71%) males, and the mean age was 40 (±13) years. The pouch sinus was initially managed by observation in 23 (51%) patients, drainage of the sinus in 9 (20%) patients, unroofing of the sinus tract in 8 (18%) patients, sinus closure in 3 (7%) patients, and a diverting ileostomy in 2 (4%) patients. In 28 patients (62%), subsequent treatment was necessary. Sinus healing was achieved in 27 (60%) patients, whereas 15 (33%) eventually developed pouch failure. Of the treatment modalities applied, a strategy with observation as initial treatment was the most successful with a healing rate of 65%. The healing rate was significantly lower in symptomatic patients in comparison with asymptomatic patients (30% vs 84%, p = 0.001). Pouch failure was also higher (45% vs 24%, p = 0.14). No other factors associated with healing rate or pouch failure were identified.

LIMITATIONS

This study was limited by its nonrandomized retrospective design.

CONCLUSION

Anastomotic pouch sinuses after pouch surgery are associated with a high rate of pouch failure. Symptomatic presentation is a significant predictor for low healing rates and is associated with a high risk of pouch failure. Observation and watchful monitoring is the initial treatment of choice when permitted by the patient's condition.

Prognostic modeling of preoperative risk factors of pouch failure

BACKGROUND

The prospect of pouch failure needs to be considered when evaluating the management strategy for patients who may be candidates for an ileo anal pouch. An ability to predict the likelihood and timing of failure preoperatively may influence surgical decision making.

OBJECTIVE

The aim of this study was to define a preoperative prognostic model for ileoanal pouch failure.

DESIGN

A novel random forest methodology was used to evaluate the prognostic significance of 21 preoperative potential risk factors for pouch failure. A forest of 3000 random survival trees was grown to estimate pouch failure for each patient and to identify important risk factors that maximize survival prediction.

SETTINGS

This study took place at a tertiary referral department at a major academic medical center.

PATIENTS

Patients undergoing an ileoanal pouch at this institution between 1983 and 2008 were included.

MAIN OUTCOME MEASURES

The primary outcome measured was pouch survival.

RESULTS

Between 1983 and 2008, 3754 patients underwent ileoanal pouch. Type of resection (total proctocolectomy vs completion proctectomy), type of anastomosis (stapled vs mucosectomy), patient diagnosis (mucosal ulcerative colitis and others vs Crohn's disease) and diagnosis of diabetes had the strongest effect on pouch survival. Predicted survival was worse for completion proctectomy (HR, 1.44; 95% CI, 1.08-1.93), Crohn's disease (HR, 2.37; 95% CI, 1.48-3.79), handsewn anastomosis (HR, 1.72; 95% CI, 1.23-2.42), and diabetes (HR, 2.31; 95% CI, 1.25-4.24). Pouch survival was worse for the oldest group of patients.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSION

Random forest techniques applied to a large number of patients undergoing the ileoanal pouch identify factors associated with pouch failure. Attention directed at these factors may improve outcomes for these patients.