Extraintestinal Manifestations and Family History of Inflammatory Bowel Disease Increase the Risk of Pouchitis in a State-Level Epidemiology Study

INTRODUCTION

Our understanding of the epidemiology of inflammatory conditions of the pouch and effectiveness of treatment is largely based on selected populations. We created a state-level registry to evaluate the incidence of pouchitis and the effectiveness of treatments used in an initial episode of pouchitis.

METHODS

In a state-level retrospective cohort of all patients undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis between January 1, 2018, and December 31, 2020, we evaluated the incidence of pouchitis and compared the proportion of patients developing recurrent pouchitis and chronic antibiotic-dependent pouchitis according to initial antibiotic therapy.

RESULTS

A total of 177 patients underwent surgery with 49 (28%) developing pouchitis within the 12 months after the final stage of IPAA. Patients with extraintestinal manifestations of inflammatory bowel disease (IBD) were significantly more likely to develop pouchitis within the first 12 months after IPAA (adjusted odds ratio 2.45, 95% confidence interval 1.03-5.81) after adjusting for family history of IBD (adjusted odds ratio 3.50, 95% 1.50-8.18). When comparing the proportion of patients who developed recurrent pouchitis or chronic antibiotic-dependent pouchitis with those who experienced an isolated episode of pouchitis, there were no significant differences among the initial antibiotic regimens used.

DISCUSSION

In a state-level examination of outcomes after IPAA for ulcerative colitis, patients with extraintestinal manifestations of IBD were more likely to develop pouchitis; however, the initial antibiotic regimen chosen did not seem to affect long-term outcomes.

Histologic Predictors of Clinical Outcomes and Healthcare Utilization in Patients With Ileal Pouch-Anal Anastomosis

BACKGROUND

The prognostic significance of histology in ileal pouch-anal anastomosis (IPAA) remains unclear. The aim of this study was to evaluate if histologic variables are predictive of IPAA clinical outcomes and healthcare utilization.

METHODS

This was a retrospective cohort study of patients with IPAA undergoing surveillance pouchoscopy at a tertiary care institution. Pouch body biopsies were reviewed by gastrointestinal pathologists, who were blinded to clinical outcomes, for histologic features of acute or chronic inflammation. Charts were reviewed for clinical outcomes including development of acute pouchitis, chronic pouchitis, biologic or small molecule initiation, hospitalizations, and surgery. Predictors of outcomes were analyzed using univariable and multivariable logistic and Cox regression.

RESULTS

A total of 167 patients undergoing surveillance pouchoscopy were included. Polymorphonuclear leukocytes (odds ratio [OR], 1.67), ulceration and erosion (OR, 2.44), chronic inflammation (OR, 1.97), and crypt distortion (OR, 1.89) were associated with future biologic or small molecule initiation for chronic pouchitis. Loss of goblet cells was associated with development of chronic pouchitis (OR, 4.65). Pyloric gland metaplasia was associated with hospitalizations (OR, 5.24). No histologic variables were predictive of development of acute pouchitis or surgery. In an exploratory subgroup analysis of new IPAA (<1 year), loss of goblet cells was associated with acute pouchitis (OR, 14.86) and chronic pouchitis (OR, 12.56). Pyloric gland metaplasia was again associated with hospitalizations (OR, 13.99).

CONCLUSIONS

Histologic findings may be predictive of IPAA outcomes. Pathologists should incorporate key histologic variables into pouchoscopy pathology reports. Clinicians may need to more closely monitor IPAA patients with significant histologic findings.

Risk factors and outcomes of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Retrospective study of 75 single center cases

OBJECTIVE

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical gold standard in patients with ulcerative colitis (UC). Results are generally satisfactory but there is a significant rate of patients who experience postoperative complications. The aims of our study were to identify the pre- and intraoperative risk factors and their correlation with the reported outcomes.

PATIENTS AND METHODS

A retrospective study was conducted on the medical records of all consecutive patients undergoing restorative proctocolectomy with IPAA for UC in our center from 2010 to 2021. Pre- and intraoperative factors were examined and correlated with pouchitis, endoscopic pouchitis, pouch failure, anastomotic leak, postoperative complications classified according to Clavien-Dindo score and stoma outlet obstruction. A univariate and multivariate statistical analysis was performed.

RESULTS

Out of 75 patients undergoing 3- or 2-stage IPAA surgery, the coexistence of extraintestinal clinical manifestations and preoperative topical rectal stump therapy for active proctitis were significantly associated with the occurrence of pouchitis (OR=4.4, p=0.03 and OR=7.6, p=0.01). Endoscopic pouchitis was found to be related to preoperative topical rectal therapy (OR=10.2, p=0.007), but not to extraintestinal manifestations of disease. Anastomotic leak was found to be significantly related to pouch failure (OR=22.7, p=0.007). Surgical indication for malignancy increased the risk for early complications (Clavien-Dindo >2) (OR=16.0, p=0.04). Young age was associated with the occurrence of outlet stoma obstruction in patients with recent IPAA surgery (OR=0.97, p=0.05).

CONCLUSIONS

Based on observed results, an appropriate preoperative patient assessment aimed at detecting specific risk factors is crucial to identify early or prevent worse outcomes in patients undergoing IPAA surgery.

Increasing Incidence of Pouchitis Between 1996 and 2018: A Population-Based Danish Cohort Study

BACKGROUND & AIMS

Current knowledge regarding the epidemiology of pouchitis is based on highly selected, mostly single-center, patient cohorts. Our objective was to prospectively determine the population-based incidence of pouchitis in patients with ulcerative colitis in the first 2 years after ileal pouch-anal anastomosis and analyze time trends of the incidence of pouchitis.

METHODS

Using national registries, we established a population-based cohort of all Danish patients undergoing proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between 1996 and 2018. The primary outcome was the development of pouchitis within the first 2 years after surgery, evaluated by time period. We used Kaplan-Meier and Cox proportional hazard modeling to evaluate the time to development of pouchitis.

RESULTS

Overall, 1664 patients underwent an ileal pouch-anal anastomosis. The cumulative incidence of pouchitis in the 2 years after ileal pouch-anal anastomosis increased throughout the study period, from 40% in the period from 1996 to 2000 (95% CI, 35%-46%) to 55% in the period from 2015 to 2018 (95% CI, 48%-63%). Patients undergoing surgery between 2015 and 2018 also showed an increased risk of pouchitis compared with the earliest study period (1996-2000) after adjusting for sex, age, and socioeconomic status (hazard ratio, 1.57; 95% CI, 1.20-2.05).

CONCLUSIONS

This population-based study showed a 15% absolute and 38% relative increase in the incidence of pouchitis among patients undergoing surgery between 1996 and 2018, with the greatest cumulative incidence of pouchitis shown in the most recent era (2015-2018). The striking increase in the incidence of pouchitis highlights the need for further research into causes and prevention of pouchitis.

The Cumulative Incidence of Pouchitis in Pediatric Patients With Ulcerative Colitis

BACKGROUND

Despite highly effective therapies, many children develop medically refractory ulcerative colitis (UC) and undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). We sought to determine the incidence, risk, and burden of pouchitis in the first 2 years following the final stage of IPAA in pediatric UC patients.

METHODS

Within the IQVIA Legacy PharMetrics Adjudicated Claims Database, we identified pediatric patients with UC who underwent proctocolectomy with IPAA between January 1, 2007, and June 30, 2015. We utilized International Classification of Diseases-Ninth Revision-Clinical Modification or International Classification of Diseases-Tenth Revision-Clinical Modification codes to identify patients with UC and Current Procedural Terminology codes to identify colectomy and IPAA. Continuous variables were compared using t tests and Wilcoxon rank sum testing, while categorical variables were compared using chi-square testing.

RESULTS

A total of 68 patients with an IPAA were identified. In the first 2 years following IPAA, the cumulative incidence of pouchitis was 54%. Patients with pouchitis required more outpatient visits in the first 2 years after IPAA (mean 21.8 vs 10.2; P = .006) and were more likely to be hospitalized compared with patients without pouchitis (46% vs 23%; P = .045). Patients with pouchitis also demonstrated higher mean total costs in year 1 and year 2 ($27 489 vs $8032 [P = .001] and $27 699 vs $6058 [P = .003], respectively).

CONCLUSIONS

Our findings confirm the high incidence of pouchitis demonstrated in earlier single-center studies of pediatric patients undergoing proctocolectomy with IPAA for UC. Identification of risk factors for pouchitis would be useful to optimize early intervention.

Nonspecific, Acute Pouchitis in Patients With Familial Adenomatous Polyposis: Less Common Than We Think

BACKGROUND

Nonspecific acute pouchitis is common in patients with ulcerative colitis who undergo IPAA, but there is disagreement about the rate at which this occurs in patients with familial adenomatous polyposis.

OBJECTIVE

This study aimed to define the rate at which nonspecific acute pouchitis occurs in patients with familial adenomatous polyposis.

SETTING

This study was conducted at a hereditary colorectal cancer center in a large academic medical center.

DESIGN

This is a retrospective cohort study using prospectively gathered data.

PATIENTS

Patients with familial adenomatous polyposis who have had IPAA were included.

INTERVENTIONS

Symptoms, pouchoscopy and pouch radiography, and pouch biopsy were evaluated.

MAIN OUTCOME MEASURES

The primary outcomes measured were the presence of nonspecific acute pouchitis and the alternative diagnosis of pouch dysfunction.

RESULTS

There were 250 patients with familial adenomatous polyposis who had undergone IPAA; 38 (15.2%) had been labeled as having "pouchitis": 23 men and 15 women. Median age was 55 years (range, 18-90 years). No patient had nonspecific, acute pouchitis as defined by our criteria. In 9 cases, the diagnosis was derived from benign ulcers common in ileal pouches. Stool frequency was the most common symptom associated with the "pouchitis" label, but actual causes for the frequency included poor pouch emptying, poor eating habits, poor bowel habits, and afferent limb syndrome. Median stool frequency was 9, ranging from 4 to 15 per day. Every patient had at least 1 pouch endoscopy, and the median number was 19 per patient (range, 1-21). Nine patients had pouch biopsies to rule out inflammation; all showed chronic active enteritis, a normal finding in ileal pouches.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSIONS

We could not confirm any case of nonspecific acute pouchitis in patients with familial adenomatous polyposis. Those caring for patients with familial adenomatous polyposis who have a pouch should seek causes for pouch-related symptoms other than "pouchitis." See Video Abstract at http://links.lww.com/DCR/B666.POUCHITIS AGUDA INESPECÍFICA EN PACIENTES CON POLIPOSIS ADENOMATOSA FAMILIAR: MENOS COMÚN DE LO QUE PENSAMOSANTECEDENTES:La pouchitis aguda e inespecífica es común en pacientes con colitis ulcerativa, sometidos a anastomosis de bolsa ileoanal, pero no hay acuerdo sobre la frecuencia en que se presenta en pacientes con poliposis adenomatosa familiar (PAF).OBJETIVO:Definir la frecuencia en la que se presenta pouchitis aguda inespecífica en pacientes con poliposis adenomatosa familiar.ENTORNO CLINICO:Centro de cáncer colorrectal hereditario en un gran centro médico académico.DISEÑO:Estudio de cohorte retrospectivo utilizando datos recopilados prospectivamente.PACIENTES:Pacientes con poliposis adenomatosa familiar sometidos a bolsa con anastomosis ileoanal.INTERVENCIONES:Síntomas, proctoscopia, radiografía y biopsia de bolsa ileoanal.PRINCIPALES MEDIDAS DE VALORACION:Presencia de pouchitis aguda inespecífica; diagnósticos alternos de disfunción de la bolsa ileal.RESULTADOS:De 250 pacientes con poliposis adenomatosa familiar sometidos a una anastomosis anal de la bolsa ileal; 38 (15,2%), habían sido etiquetados como "pouchitis", 23 hombres y 15 mujeres. La mediana de edad fue de 55 años (rango de 18 a 90 años). Ningún paciente tuvo pouchitis aguda inespecífica según lo definido por nuestros criterios. En 9 casos el diagnóstico se derivó de úlceras benignas frecuentes en bolsas ileales. La frecuencia de las evacuaciones fue el síntoma más común asociado con la etiqueta "pouchitis", pero las causas reales de la frecuencia, incluyeron un mal vaciado de la bolsa, malos hábitos alimenticios, malos hábitos intestinales y síndrome de asa aferente. La frecuencia media de las evacuaciones fue de 9, con un rango de 4 a 15 por día. A cada paciente se le realizó al menos una endoscopia de la bolsa: la mediana fue de 19 por paciente (rango de 1 a 21). A 9 pacientes se les realizó biopsia de bolsa para descartar inflamación: todos mostraron enteritis activa crónica, un hallazgo normal en las bolsas ileales.LIMITACIONES:Naturaleza retrospectiva del estudio.CONCLUSIONES:No pudimos confirmar ningún caso de pouchitis aguda e inespecífica en pacientes con PAF. Aquellos que atienden a pacientes con PAF con bolsa ileal, deben buscar otras causas para los síntomas relacionados con la bolsa que no sean "pouchitis". Consulte Video Resumen en http://links.lww.com/DCR/B666. (Traducción-Dr. Fidel Ruiz Healy).

Incidence, Risk Factors, and Outcomes of Pouchitis and Pouch-Related Complications in Patients With Ulcerative Colitis

BACKGROUND & AIMS

Acute pouchitis is the most common non-surgical complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We used validated case-finding definitions for pouchitis to search administrative claims data and determine the incidence of pouchitis in the first 2 years after IPAA.

METHODS

We identified all patients who underwent proctocolectomy with IPAA for UC in the IQVIA Legacy PharMetrics Adjudicated Claims Database, from January 1, 2007 through June 1, 2016. The primary outcome was the development of pouchitis within 2 years after IPAA. Secondary outcomes included isolated acute vs recurrent pouchitis, immunosuppressive therapy, further surgery, and admission to the hospital.

RESULTS

Among 594 patients, the cumulative incidence of pouchitis within 2 years of IPAA was 48% (95% CI, 44%-52%). The cumulative incidence of isolated acute pouchitis was 29% (95% CI, 26%-33%). Compared to patients with isolated acute pouchitis, patients who received a diagnosis of recurrent pouchitis (cumulative incidence, 19%: 95% CI, 16%-22%) demonstrated increased outpatient visits, emergency department visits, and inpatient admissions (all P < .001). Patients who developed pouchitis were more likely to have a history of primary sclerosing cholangitis (adjusted odds ratio [aOR], 3.94; 95% CI, 1.05-14.8) and anti-tumor necrosis factor alpha therapy prior to colectomy (aOR 1.63; 95% CI, 1.09-2.45). Among patients with pouchitis, the cumulative frequency of new immunosuppressive therapy was 40% (95% CI, 35%-46%) and the cumulative incidence of pouch excision was 1.0% (95% CI, 0.4%-3.0%). The cumulative incidence of a new diagnosis of Crohn's disease after IPAA for UC was 9.0% (95% CI, 7.2%-11%).

CONCLUSIONS

In a geographically diverse population, 48% of patients with UC developed pouchitis within the first 2 years after IPAA. Patients with pouchitis had greater use of healthcare resources, indicating a significant burden of disease.

IPAA in Known Preoperative Crohn's Disease: A Systematic Review

BACKGROUND

Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure.

OBJECTIVE

This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease.

DATA SOURCES

A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews.

STUDY SELECTION

The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected.

INTERVENTION

Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology.

MAIN OUTCOMES MEASURES

The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate.

RESULTS

Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified.

LIMITATIONS

This investigation was limited by the small number of studies with significant study heterogeneity.

CONCLUSION

In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

Greater Peripouch Fat Area on CT Image Is Associated with Chronic Pouchitis and Pouch Failure in Inflammatory Bowel Diseases Patients

BACKGROUND

The causes of chronic antibiotic refractory pouchitis (CARP) and pouch failure in inflammatory bowel disease (IBD) patients remain unknown. Our previous small study showed peripouch fat area measured by MRI was associated with pouchitis.

AIMS

To explore the relationship between peripouch fat area on CT imaging and pouch outcomes.

METHODS

This is a historical cohort study. Demographic, clinical, and radiographic data of IBD patients with abdominal CT scans after pouch surgery between 2002 and 2017 were collected. Peripouch fat areas and mesenteric peripouch fat areas were measured on CT images at the middle pouch level.

RESULTS

A total of 435 IBD patients were included. Patients with higher peripouch fat areas had a higher prevalence of CARP. Univariate analyses demonstrated that long duration of the pouch, high weight or body mass index, the presence of primary sclerosing cholangitis or other autoimmune disorders, and greater peripouch fat area or mesenteric peripouch fat area were risk factors for CARP. Multivariable analyses demonstrated that the presence of primary sclerosing cholangitis or autoimmuned disorders, and greater peripouch fat area (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.016-1.047, P < 0.001) or mesenteric peripouch fat area were independent risk factors for CARP. Of the 435 patients, 139 (32.0%) had two or more CT scans. Multivariable Cox proportional hazard analyses showed that "peripouch fat area increase ≥ 15%" (OR 3.808, 95%CI 1.703-8.517, P = 0.001) was an independent predictor of pouch failure.

CONCLUSIONS

A great peripouch fat area measured on CT image is associated with a higher prevalence of CARP, and the accumulation of peripouch fat is a risk factor for pouch failure. The assessment of peripouch fat may be used to monitor the disease course of the ileal pouch.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on pouchitis in ulcerative colitis. Part 1: Epidemiology, diagnosis and prognosis

Pouchitis is a common complication in ulcerative colitis patients after total proctocolectomy. This is an unspecific inflammation of the ileo-anal pouch, the aetiology of which is not fully known. This inflammation induces the onset of symptoms such as urgency, diarrhoea, rectal bleeding and abdominal pain. Many patients suffering from pouchitis have a lower quality of life. In addition to symptoms, an endoscopy with biopsies is mandatory in order to establish a definite diagnosis. The recommended index to assess its activity is the Pouchitis Disease Activity Index (PDAI), but its modified version (PDAIm) can be used in clinical practice. In accordance with the duration of symptoms, pouchitis can be classified as acute (<4 weeks) or chronic (>4 weeks), and, regarding its course, pouchitis can be infrequent (<4 episodes per year), recurrent (>4 episodes per year) or continuous.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Abdominal Visceral Fat Area and Chronic Pouchitis after Ileal Pouch-Anal Anastomosis

Chronic pouchitis (CP) after ileal pouch-anal anastomosis is a significant clinical problem. Adipose tissues produce antiinflammatory cytokines and chemokines. We evaluated the association between abdominal visceral fat area (VFA) and CP. Patients with a preoperative CT evaluation were included. The diagnosis of CP was confirmed in all cases by endoscopy with afferent ileal limb intubation. Patients were allocated into groups of high VFA and low VFA. The study cohort of 52 patients had a median body mass index of 22 (range, 14-32). Indications for surgery were medically refractory disease in 46 (88%) patients and cancer/dysplasia in six (12%) patients. Median VFA was 27.1 (range, 1-144). Six (12%) patients developed CP. Low VFA patients were significantly younger (29 vs 45 years; P < 0.0001), had lower body mass index (20.4 vs 24.7; P < 0.0001), had surgery more commonly for medically refractory disease than for cancer or dysplasia (100 vs 77%; P = 0.02), and had a higher incidence of CP than high VFA patients (23 vs 0%; P = 0.02). Multiple linear regression analysis demonstrated that only low VFA was associated with CP (P = 0.009). An association is present between VFA and CP after ileal pouch-anal anastomosis, implicating adipocytes in the pathogenesis of inflammatory bowel disease.

Surgical management of inflammatory bowel disease: A low prevalence, developing country perspective

OBJECTIVE

To determine the outcomes of surgical management of inflammatory bowel disease.

METHODS

The retrospective case series was conducted at Aga Khan University Hospital, Karachi, and comprised medical record of adult patients operated between January 1986 and December 2010 for inflammatory bowel disease. Outcomes consisted of complications till last follow-up and 30-day mortality (disease or procedure related). Functional status of patients with ileal pouch was determined via telephone. SPSS 16 was used to analyse data.

RESULTS

Of the 36 patients whose records were reviewed, 21(58%) were males, and body mass index was less than 23 in 34(91%). A total of 27(75%) patients underwent elective surgery for their condition. Ileal pouch was formed in 9(25%). Overall mortality was 14(38.8%). Overall incidence of complications was 26(72%), with wound infection being the most common early morbidity in 11(30.5%). Late morbidity included pouchitisin 4/9 (44.9%) and strictures 2/36 (5.5%).On telephonic follow-up, 6 of the remaining 7patients (85%) with ileal pouch were satisfied with the functional results of the procedure.

CONCLUSIONS

The retrospective case series represents results from a developing country with low prevalence of inflammatory bowel disease and hence limited experience.

Backwash ileitis does not affect pouch outcome in patients with ulcerative colitis with restorative proctocolectomy

BACKGROUND & AIMS

There has been controversy over the significance of active inflammation of the terminal ileum (also known as backwash ileitis) in patients with ulcerative colitis (UC) and idiopathic inflammatory bowel disease of indeterminate type for diagnosis and pouch construction. We investigated the impact of backwash ileitis on pouch outcome after restorative proctocolectomy with ileoanal pouch anastomosis.

METHODS

Data from patients with backwash ileitis (n = 132) were compared with those from 132 matched controls without ileal inflammation for age, sex, and type of proctocolectomies with ileal pouch construction (1- or 2-stage). We evaluated terminal ileal sections from original colectomies of 2213 patients with either UC or idiopathic inflammatory bowel disease of indeterminate type, collected during a 21-year period, for extent and severity of chronic and active ileitis. Clinical pouch outcomes were assessed through a longitudinally maintained clinical outcome database that systematically catalogued all short-term and long-term pouch complications, including pouchitis, sepsis, impaired long-term pouch survival, and conversion to Crohn's disease.

RESULTS

Regardless of severity or extent, backwash ileitis was not correlated with any clinical outcome examined, short-term or long-term.

CONCLUSIONS

Ileal inflammation is not a contraindication for restorative proctocolectomy with ileal pouch construction in patients with UC or idiopathic inflammatory bowel disease of indeterminate type. Ileal inflammation with pancolitis is not a useful criterion for classifying otherwise typical UC as colitis of indeterminate type, because pouch outcomes are not affected.

Ileal reservoir with ileo-anal anastomosis: long-term complications

Coloproctectomy with ileo-anal anastomosis (CP-IAA) has been in use for 30 years. This intervention is the standard technique when surgery is indicated for familial adenomatous polyposis (FAP) and for ulcerative colitis (UC). Although the surgery is safe with mortality of less than 1%, it is associated with a morbidity of 18-70%. We thought a literature review about long-term complications would be enlightening. Pouchitis is the most common complication; it occurs in 70% of patients over 20 years follow-up; small bowel obstruction affects 25% of patients and pelvic sepsis occurs in 20-30% within 10 years. CP-IAA can impact the patient's sexual life due to erectile and ejaculatory dysfunction, dyspareunia, and incontinence of stool during sexual intercourse. Nevertheless, patients with long-standing UC describe an overall improvement in their sexual function after surgery. The failure rate varies from 3.5 to 15%; major causes of failure are sepsis, unrecognized Crohn's disease, and poor functional results. Cases of dysplasia and cancer have been reported in the reservoir, but more particularly when there is retained colonic glandular mucosa. The transitional zone should be monitored whenever there are risk factors for colon neoplasia. The relatively high morbidity of CP-IAA should not overshadow the good functional results of this technique.

A prospective analysis of clinical variables, serologic factors, and outcome of ileal pouch-anal anastomosis in patients with backwash ileitis

PURPOSE

The outcome of ileal pouch-anal anastomosis in patients with backwash ileitis is controversial. We prospectively compared the outcomes of ileal pouch-anal anastomosis in colitis patients with backwash ileitis and colitis patients without backwash ileitis.

METHODS

Consecutive colitis patients undergoing ileal pouch-anal anastomosis were reviewed. All patients were classified after surgery as being either backwash ileitis-positive or backwash ileitis-negative. Serum drawn preoperatively was assayed, using enzyme-linked immunosorbent assay, for anti-Saccharomyces cerevisiae, anti-outer membrane of porin C, anti-CBir1, anti-I2, and perinuclear anti-neutrophil cytoplasmic antibody. Outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohn's disease (small inflammation above the pouch inlet or pouch fistula).

RESULTS

Out of 334 patients, 39 (12%) were backwash ileitis-positive. Compared with backwash ileitis-negative patients, backwash ileitis-positive patients had a higher incidence of pancolitis (100% vs 74%; P = .0001), primary sclerosing cholangitis (15% vs 2%; P = .001) and high-level (>100 enzyme-linked immunosorbent assay units/ml) perinuclear anti-neutrophil cytoplasmic antibody expression (29% vs 9%; P = .001). After a median follow-up of 26 months, 53 patients (16%) developed acute pouchitis, 37 (11%) developed chronic pouchitis, and 40 (12%) developed de novo Crohn's disease. There was no significant difference between the backwash ileitis-positive and backwash ileitis-negative patient groups in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohn's disease.

CONCLUSION

There was a significantly higher incidence of pancolitis, primary sclerosing cholangitis, and high-level perinuclear anti-neutrophil cytoplasmic antibody expression in backwash ileitis-positive patients than in backwash ileitis-negative patients. The incidence of acute pouchitis, chronic pouchitis, and de novo Crohn's disease after ileal pouch-anal anastomosis does not differ significantly between backwash ileitis-positive and backwash ileitis-negative patients.

Pouchitis

While restorative proctocolectomy with ileal pouch-anal anastomosis has significantly improved the quality of life in patients with underlying ulcerative colitis who require surgery, complications can occur. Pouchitis as the most common long-term complication represents a spectrum of disease processes ranging from acute, antibiotic-responsive type to chronic antibiotic-refractory entity. Accurate diagnosis using a combined assessment of symptoms, endoscopy and histology and the stratification of clinical phenotypes is important for treatment and prognosis the disease. The majority of patients respond favorably to antibiotic therapy. However, management of chronic antibiotic-refractory pouchitis remains a challenge.

Portal vein thrombi after restorative proctocolectomy: serious complication without long-term sequelae

PURPOSE

Portal vein thrombi have been observed after restorative proctocolectomy and ileal pouch-anal anastomosis, and present as a clinical spectrum of abdominal pain, fever, and leukocytosis. Anticoagulation treatment is usually associated with resolution of symptoms. However, the long-term consequences and effect on pouch function are not known. The purpose of this study was to analyze the long-term functional outcome of patients with confirmed portal vein thrombi after restorative proctocolectomy.

METHODS

A retrospective study of all patients undergoing restorative proctocolectomy from January 1997 to 2000 was performed. A case-control study was designed that matched 37 patients with confirmed portal vein thrombi in this period with 133 patients without portal vein thrombi; the groups were compared with respect to pouch function and quality of life by using the Global Cleveland Clinic Quality of Life Questionnaire for pelvic pouch patients.

RESULTS

The mean follow-up was 4.73 (range, 4.21-7.28) years. The percentage of male patients was 58.8. The most common diagnosis was ulcerative colitis (62.4 percent). There were no significant differences between portal vein thrombi patients and controls with respect to pouch function (number of bowel movements, urgency, incontinence), episodes of pouchitis, or quality of life.

CONCLUSIONS

Portal vein thrombi can be a serious complication after restorative proctocolectomy that usually resolves with anticoagulation therapy. Long-term pouch function and quality of life are not affected.

A prospective multivariate analysis of clinical factors associated with pouchitis after ileal pouch-anal anastomosis

BACKGROUND & AIMS

Although acute pouchitis (AP) after ileal pouch-anal anastomosis (IPAA) for UC is common and easily treated, chronic pouchitis (CP) remains a difficult management issue. The aim of this study was to identify important clinical risk factors associated with AP or CP.

METHODS

AP and CP were prospectively assessed, and demographic, disease, and treatment characteristics were tabulated. Univariate and multivariate analyses were performed to evaluate associations between AP or CP and potential risk factors.

RESULTS

Two hundred IPAA patients were followed for a median of 24 months (range, 3-117 months). Thirty-six patients (18%) developed AP, and 23 patients (12%) developed CP. On univariate analysis, the use of steroids before colectomy and smoking were associated with the development of AP. CP was associated with male gender, smoking, length of follow-up, extraintestinal manifestations, backwash ileitis, and elevated (450x10(9)/L) platelet count. On multivariate analysis, the following risk factors were found to be independently associated with AP: use of steroids before colectomy (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.5-8.9; P = .004) and smoking (OR, 2.3; 95% CI, 1.1-5.3; P = .04). CP was directly associated with extraintestinal manifestations (OR, 3.5; 95% CI, 1.1-11.1; P = .03), elevated platelet count (OR, 3.1; 95% CI, 1.1-8.9; P = .03), and increased length of follow-up (OR, 1.3; 95% CI, 1.1-1.6; P = .002). Smoking reduced the incidence of CP (OR, 0.2; 95% CI, 0.05-0.74; P = .04).

CONCLUSIONS

Clinical factors associated with AP included use of steroids before colectomy and smoking. Factors directly related to CP were extraintestinal manifestations, elevated platelet count, and length of follow-up after IPAA. Smoking appears to protect against the development of CP.

Anti-Saccharomyces cerevisiae antibodies are associated with the development of postoperative fistulas following ileal pouch-anal anastomosis

Although serologic testing for perinuclear antineutrophil cytoplasmic antibodies (pANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA) is reportedly useful in distinguishing ulcerative colitis (UC) from Crohn's disease (CD), there are few and conflicting reports assessing their utility in predicting postoperative complications after ileal pouch-anal anastomosis (IPAA). We examined the associations between postoperative complications such as pouchitis or fistulas and pANCA and ASCA antibodies in a group of patients who underwent IPAA for UC. We conducted a retrospective chart review of 34 patients initially diagnosed with UC (four of these patients had a diagnosis of indeterminate colitis) who underwent IPAA by a single surgeon, and who had pANCA and ASCA antibody levels measured during their clinical course. Study patients were assigned to four groups based on the pattern of antibody reactivity: pANCA+/ASCA- (16 patients), pANCA-/ASCA+ (nine patients), pANCA+/ASCA+ (five patients), and pANCA-/ASCA- (four patients). The median length of follow-up was 16 months (3-144 months). None of the patients (0 of 16) who were pANCA+/ASCA- had their preoperative diagnosis of UC changed after a median follow-up of 14 months (3-118 months). Of the nine patients with a preoperative diagnosis of UC who were pANCA-/ASCA+, four patients (44%) had their diagnosis changed postoperatively to CD based on clinical findings, with a median follow-up: 15 months (5-98 months). Of 16 patients who underwent IPAA and who were pANCA+/ASCA-, 15 of 16 (93.75%), were free of fistulas postoperatively, with a median follow-up of 14 months (3-118 months). Of nine patients with a preoperative diagnosis of UC who underwent IPAA and who were pANCA-/ASCA+, four of nine (44%; p = 0.04) developed fistulas postoperatively, with a median length of follow-up of 55 months (15-67 months). No relationship between serologic profiles or antibody titer levels and the development of pouchitis was identified. In a cohort of patients undergoing IPAA for UC, serologic profiles may be useful in identifying patients at risk of postoperative fistula formation. Patients who were pANCA-/ASCA+ were at increased risk for the development of fistulas postoperatively compared to patients who were pANCA+/ASCA-, and were also more likely to have their diagnosis changed postoperatively to CD. A larger study is needed to validate these observations.

Risk factors for diseases of ileal pouch-anal anastomosis after restorative proctocolectomy for ulcerative colitis

BACKGROUND & AIMS

Although pouchitis is considered the most common adverse sequela of ileal pouch-anal anastomosis (IPAA), inflammatory and noninflammatory conditions other than pouchitis are increasingly being recognized. The risk factors for these non-pouchitis conditions, including Crohn's disease (CD) of the pouch, cuffitis, and irritable pouch syndrome (IPS), have not been studied. The aim of this study was to assess risk factors for inflammatory and noninflammatory diseases of IPAA in a tertiary care setting.

METHODS

The study consisted of 240 consecutive patients who were classified as having healthy pouches (N = 49), pouchitis (N = 61), CD of the pouch (N = 39), cuffitis (N = 41), or IPS (N =50). Demographic and clinical features were assessed to determine risk factors for each of these conditions by using logistic regression analysis.

RESULTS

Risk factors remaining in the final logistic regression models were for pouchitis: IPAA indication for dysplasia (odds ratio [OR], 3.89; 95% confidence interval [CI], 1.69-8.98), never having smoked (OR, 5.09; 95% CI, 1.01-25.69), no use of anti-anxiety agents (OR, 5.19; 95% CI, 1.45-18.59), or use of NSAIDs (OR, 3.24; 95% CI, 1.71-6.13); for CD of the pouch: a long duration of IPAA (OR, 1.20; 95% CI, 1.12-1.30) and current smoking (OR, 4.77; 95% CI, 1.39-16.25); for cuffitis: arthralgias (OR, 4.13; 95% CI, 1.91-8.94) and younger age (OR, 1.16; 95% CI, 1.01-1.33); and for IPS: use of antidepressants (OR, 4.17, 95% CI, 1.95-8.92) or anti-anxiety agents (OR, 3.21; 95% CI, 1.34-7.47).

CONCLUSIONS

The majority of risk factors for the 4 inflammatory and noninflammatory conditions of IPAA are different, suggesting that each of these diseases has a different etiology and pathogenesis. The identification and modification of these risk factors might help patients and clinicians to make a preoperative decision for IPAA, reduce IPAA-related morbidity, and improve response to treatment.

The ileoanal pouch procedure in the long–term perspective: a critical review

An ileo-pouch anal anastomosis (IPAA) has become the gold standard procedure for ulcerative colitis and familial adenomatous polyposis. Clinical results on the pelvic pouch procedure have often been encouraging; when confronted with the different surgical options, the majority of patients select IPAA as the best operation. However, even if IPAA is a great innovation, it is by no means the first choice for all patients. For patients old enough to join in a responsible discussion, the pros and cons of the various operations must be carefully described; the choice of surgical procedure must meet the patient's wishes and appear soundly based to the surgeon. The young age of most patients has to be considered and a long follow-up time is required to establish whether and, if so, to what extent the operation may adversely impact the patient's continence, sex life, fertility, and quality of life. The risk of cancer transformation in the residual rectal mucosa in the muscular or columnar cuff is another important factor that may influence the eventual decision. This article critically reviews our experience and the literature.

Implications of pouchitis on the functional results following stapled restorative proctocolectomy

PURPOSE

Pouchitis is the most frequent long-term complication of restorative proctocolectomy; its long-term consequences are inadequately described. This prospective study evaluates the effect of pouchitis on the functional results, general health perception, and patient satisfaction.

METHODS

A total of 100 consecutive patients who underwent stapled restorative proctocolectomy for ulcerative colitis were divided into three groups: no pouchitis, acute pouch-itis and chronic pouchitis. Functional results, general health perception, and satisfaction of each group at the latest review were compared only when patients were not symptomatic of active pouchitis.

RESULTS

Pouchitis occurred in 33 patients (17 acute and 16 chronic). There were no significant differences in the long-term functional results between the no pouchitis and acute pouchitis groups. Patients who experienced chronic pouchitis had a significant increase in bowel movements, looseness of stools, urgency, nocturnal seepage, perianal excoriation, and dietary restrictions (P < 0.05). They also had a worse perception of their general health (P < 0.05). Previous chronic pouchitis had no effect on continence, daytime soilage, or gas-feces discrimination. Most patients were satisfied, despite pouchitis, and would recommend the operation to someone else with ulcerative colitis.

CONCLUSIONS

Acute pouchitis is easily treated and results in minimal functional consequences. Even in the absence of clinically active pouchitis, patients who had suffered from chronic pouchitis had poorer functional results and general health perception. This may overshadow the benefits of restorative proctocolectomy. This finding suggests that acute and chronic pouchitis are distinct disease entities and chronic pouchitis may represent a persistent condition that displays episodic symptomatic exacerbation.

J-pouch ileoanal anastomosis in children and adolescents with ulcerative colitis: functional outcome, satisfaction and impact on social life

OBJECTIVES

The aim of this study was to evaluate, over a 10-year period, severe surgical complications, functional outcome, patient satisfaction and impact on social life after colectomy and J-pouch ileoanal anastomosis for children and adolescents <18 years with ulcerative colitis.

METHODS

Data were extracted retrospectively from medical records and obtained by mailed questionnaire.

RESULTS

Thirty patients (18 girls) with a median age of 15 years (range, 7-17 years) were identified. Two patients (7%) had the J-pouch removed because of intractable diarrhea. Twenty-seven of 28 patients with preserved J-pouch answered the questionnaire. The median follow-up was 3.7 years (range, 0.3-9.2 years). Surgical complications included eight of 30 patients (27%) with small bowel obstruction, one of 30 (4%) with intra-abdominal abscess and two of 30 (7%) with perforation of the small intestine. The median number of daytime bowel movements was six (range, 3-10) and the median number of nighttime bowel movements was one (range, 0-2). Twelve patients (44%) were completely continent for stool and mucus, 12 patients (44%) leaked now and then and three (12%) leaked often or always. Antibiotic treatment for pouchitis was given in 13 patients (48%). Seventeen patients (63%) were completely satisfied with the operation, nine patients (33%) found the result fairly good and one patient (4%) was not satisfied. Twenty-six patients (96%) reported their health as completely or fairly good.

CONCLUSIONS

The majority of patients with an intact J-pouch had an acceptable functional result with respect to defecation frequency, continence and number of pouchitis episodes. Most patients reported being satisfied with the procedure.

Incidence and therapeutic outcome of pouchitis for ulcerative colitis in Japanese patients

AIM

The aim of this study was to examine the cumulative risk of pouchitis following restorative proctocolectomy for UC and FAP in Japanese patients, and to assess the response to medical treatment and its outcome.

PATIENTS AND METHODS

521 patients with UC and 117 FAP patients underwent proctocolectomy and received a J-shaped IPAA at our department of surgery. We investigated these patients using PDAI for the diagnostic criteria of pouchitis.

RESULTS

Pouchitis occurred in only 32 UC patients (6.1%). The cumulative risk of developing pouchitis for a UC patient was 7% at 5 years after and 12% at 10 years after surgery. The medical treatment of acute pouchitis was usually oral metronidazole (250 mg twice daily) for 2 weeks or oral ciprofloxacin (200 mg thrice daily) in patients who could not tolerate metronidazole. Single episodes of pouchitis occurred in 21 patients (65.6%) and chronic or frequent relapses of pouchitis in 11 patients (34.4%). Three patients (9.4%) required re-ileostomy. Two patients (6.3%) required pouch excision. There were no patients with complicated dysplasia.

CONCLUSION

The cumulative risk of pouchitis in Japanese UC patients is lower than that of western countries.

Are pANCA, ASCA, or cytokine gene polymorphisms associated with pouchitis? Long-term follow-up in 102 ulcerative colitis patients

OBJECTIVE

Pouchitis is the most frequent complication after ileal pouch-anal anastomosis for ulcerative colitis. This study aims to analyze the frequency and characteristics of pouchitis in long-term follow-up in a large population, and to determine whether a significant association exists between five immunogenetic markers and pouchitis.

METHODS

From a population of over 500 ulcerative colitis patients who had undergone ileal pouch-anal anastamosis 5-12 yr earlier, 102 subjects participated in the study. Using clinical data obtained from interviews and chart reviews, patients were classified into three groups: no pouchitis; 1-2 episodes per year; and >2 episodes per year. Coded sera from the patients were analyzed for ulcerative colitis-associated perinuclear antineutrophil cytoplasmic antibodies and Crohn's disease-associated anti-saccharomyces cerevesiae antibodies. Interleukin-1 receptor antagonist, tumor necrosis factor (TNF), and lymphotoxin beta (lymphotoxin) polymorphisms were also analyzed.

RESULTS

Pouchitis affected 49% of the study population. Antineutrophil cytoplasmic antibodies, anti-saccharomyces cerevesiae antibodies, and lymphotoxin-beta polymorphisms were not associated with pouchitis. Carriage of interleukin-1 receptor antagonist allele 2 was significantly greater among those without pouchitis than those with pouchitis. Patients without pouchitis had a significantly greater carriage rate of TNF allele 2.

CONCLUSIONS

Perinuclear antineutrophil cytoplasmic antibodies and anti-saccharomyces cerevesiae antibodies are not correlated with pouchitis, but interleukin-1 receptor antagonist and TNF may play a role in its development. Further evaluation of these markers in pouchitis will require larger populations, long-term prospective observation, and studies that correlate polymorphisms with specific immunologic functions.

Short- and long-term outcomes of ileal pouch-anal anastomosis for ulcerative colitis

Ileal pouch-anal anastomosis was an important advancement in the treatment of ulcerative colitis. The aim of this study was to determine whether early complications of ileal pouch-anal anastomosis in patients with ulcerative colitis are associated with poor late functional results.

PATIENTS AND METHODS

Eighty patients were operated on from 1986 to 2000, 62 patients with ileostomy and 18 without. The early and late complications were recorded. Specific emphasis has been placed on the incidence of pouchitis with prolonged follow-up.

RESULTS

The ileostomy was closed an average of 9.2 months after the first operation. Fourteen patients were excluded from the long-term evaluation; 6 patients were lost to regular follow-up, 4 died, and 4 patients still have the ileostomy. Of the 4 patients that died, 1 died from surgical complications. Early complications after operation (41) occurred in 34 patients (42.5%). Late complications (29) occurred in 25 patients as follows: 16 had pouchitis, 3 associated with stenosis and 1 with sexual dysfunction; 5 had stenosis; and there was 1 case each of incisional hernia, ileoanal fistula, hepatic cancer, and endometriosis. Pouchitis occurred in 6 patients (9.8%) 1 year after ileal pouch-anal anastomosis, 9 (14.8%) after 3 years, 13 (21.3%) after 5 years, and 16 (26.2%) after more than 6 years. The mean daily stool frequency was 12 before and 5.8 after operation. One pouch was removed because of fistulas that appeared 2 years later.

CONCLUSIONS

Ileal pouch-anal anastomosis is associated with a considerable number of early complications. There was no correlation between pouchitis and severe disease, operation with or without ileostomy, or early postoperative complications. The incidence of pouchitis was directly proportional to duration of time of follow-up.

Fate of the pouch in 151 pediatric patients after ileal pouch anal anastomosis

BACKGROUND/PURPOSE

Ileal pouch anal anastomosis (IPAA) offers many pediatric patients a surgical cure for mucosal ulcerative colitis (MUC) with preservation of anal continence. However, some patients incur serious problems after surgery including chronic pouchitis and pouch failure. The goal of this study is to identify clinical and pathologic factors that are associated with an adverse outcome of IPAA.

METHODS

A retrospective analysis of outcome was performed in 151 consecutive patients < or = 21 years of age who underwent IPAA with a mean follow-up of 7.24 years (range, 2 to 15 years). Patients were categorized into 4 outcome groups: A, no pouchitis; B, mild, acute pouchitis; C, chronic refractory pouchitis; and D, pouch failure. Pairwise comparisons were used to test the association between the groups and clinical and pathologic variables including age, sex, duration of symptoms, perianal disease, colonoscopic histology, terminal ileitis, operation type, staged versus unstaged IPAA, colonic specimen histology, early postoperative complications defined as less than 31 days postsurgery, late postoperative complications defined as 31 or more days postsurgery, and pouch fistulae. Crohn's disease as a definitive diagnosis and indeterminant colitis, a histologic diagnosis, also were tested for association with the above variables and outcome groups.

RESULTS

One hundred and fifty-one pediatric patients underwent IPAA utilizing mucosectomy and hand-sewn S or J (n = 44) and stapled J or S-W anastomosis (n = 107) with 0% mortality rate and outcome as follows: group A, n = 54; group B, n = 73; group C, n = 11; group D, n = 13. Variables strongly associated with poor outcome, groups C and D, were duration of symptoms (P =.03), perianal disease (P =.03), late complications (P <.001), pouch fistulae (P <.001), and Crohn's disease (P <.0001). Furthermore, Crohn's disease was associated strongly with female gender (P =.01), perianal disease (P =.004), early (P =.006) and late (P <.001) complications, and pouch fistula (P <.001). The findings of indeterminant colitis, terminal ileitis, and early postoperative complications did not show significant differences between the 4 outcome groups.

CONCLUSIONS

Crohn's disease appears to be an important determinant of postoperative complications, chronic pouchitis, and pouch failure and occurred in 15% of the authors' patients after IPAA. Indeterminant colitis and the intraoperative findings of terminal ileitis are not associated with Crohn's disease or adverse outcome after IPAA in pediatric patients. Operation type and stage do not alter the clinical course after IPAA in pediatric patients.

Pediatric "PSC-IBD": a descriptive report of associated inflammatory bowel disease among pediatric patients with psc

BACKGROUND

Inflammatory bowel disease (IBD) in adults with primary sclerosing cholangitis (PSC) is characterized by pancolonic involvement, a high frequency of rectal sparing, and an increased risk of pouchitis and colorectal neoplasia. The clinical features of IBD in pediatric patients with PSC have not been well described. The aim of this study was to characterize the frequency, clinical features, and natural history of IBD in pediatric patients diagnosed with PSC.

METHODS

A retrospective chart review was performed for all patients 18 years of age or younger diagnosed with PSC seen at the Mayo Clinic between 1975 and 1999. Endoscopic and histologic features and surgical and postsurgical outcomes were recorded.

RESULTS

Fifty-two children with PSC were identified. Forty-three patients (84%) were also diagnosed with IBD. In 36 of 43 cases, there was a sufficient diagnostic evaluation to allow a detailed review. Thirty-two of 36 patients (89%) had ulcerative colitis and 4 of 36 patients (11%) had Crohn's disease. In 4 of 36 patients (11%), IBD was asymptomatic. Although the most frequent endoscopic presentation of IBD was universal colitis, endoscopic rectal sparing was frequently noted (27% of colonoscopic studies). Of the four patients diagnosed with Crohn disease, in none did perianal, fistulizing, or stricturing disease develop. Proctocolectomy was performed in six patients (17%); three operations were performed for dysplasia. Pouchitis complicated four of the five ileal pouch-anal anastomoses procedures.

CONCLUSIONS

Among pediatric patients (1) PSC without IBD is uncommon; (2) asymptomatic IBD may be associated with PSC; (3) because the time to dysplasia may be accelerated, once the diagnosis of IBD is made in the setting of PSC, heightened endoscopic surveillance may be indicated; (4) pouchitis occurs frequently in these patients.

Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis

BACKGROUND & AIMS

Recent reports have suggested the mucosa of an ileal reservoir could be at risk of neoplasia. Risk factors may include the age of the pouch, chronic pouchitis, and previous colonic neoplasia. This study examined a group of such patients to determine the risk of dysplasia.

METHODS

From a cohort of 1221 patients with ileal pouches, 171 patients with possible risk factors were selected. Successful contact was made with 138 patients who were invited for endoscopy and multiple biopsies. Biopsy specimens were stained with H&E and p53, scored for inflammatory changes including villous atrophy, and analyzed by flow cytometry.

RESULTS

One hundred six patients took part and fell into 1 or more of the following clinical categories: chronic pouchitis (n = 34), pelvic pouch for > or =12 years (n = 42); Kock pouch for > or =14 years (n = 29), and neoplasia in colectomy specimen (n = 11). Thirty-three patients had severe villous atrophy. One patient of 106 (95% confidence interval, 0.9% +/- 1.6%) with a long-standing pouch had low-grade dysplasia that was multifocal. DNA analysis by flow cytometry showed aneuploidy in this patient and 2 others.

CONCLUSIONS

These data suggest that the development of dysplasia in ileal pouches performed for ulcerative colitis is probably a rare event within 15-20 years of pouch surgery.

Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses

Total colectomy, mucosal proctectomy, and ileal J pouch-anal anastomosis (IPAA) has become the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to determine the short- and long-term outcomes of patients undergoing IPAA by a single surgeon, correlating intraoperative technical aspects with outcomes, and to characterize better the clinical syndrome of pouchitis. A retrospective review was performed of 114 consecutive patients who underwent IPAA by a single surgeon between December 1987 and August 1996. Clinical follow-up and operative notes were reviewed, and patient questionnaires were obtained for all patients. The mean follow-up was 3 years (range 0.5-8.0 years). The average age of the patients was 39 years (range 16-72 years). There were 64 males and 50 females. Indications for operation were ulcerative colitis (n = 101) and familial polyposis coli (n = 13). Long-term morbidity occurred in 41% of patients (small bowel obstruction 10%, anastomotic stricture 9%). Pouch excision was required in only three patients. Stool frequency (mean +/- SE) was 6.1 +/- 0.2 and did not change with duration of follow-up. Only 7% of patients reported fecal soilage. The incidence of pouchitis was 59% (n = 67), with 4.2 +/- 0.3 episodes of pouchitis per patient. Using multivariate analysis, the factors significantly associated with the incidence of pouchitis were gender (p = 0.008) and duration of follow-up (p = 0. 02). A total of 37 of 50 women (74%) but only 30 of 64 men (47%) developed pouchitis. The incidence of pouchitis increased with the duration of follow-up. The incidences of pouchitis in patients followed for 6 months, 1 year, and 3 years were 25%, 37%, and 50%, respectively. Of patients followed more than 6 years, the incidence of pouchitis was 94% (15/16). There was not a significant correlation between anastomotic tension or the extent of arterial dissection of the ileal mesentery required to achieve IPAA and the incidence of pouchitis. The best antibiotics for pouchitis were metronidazole (54% of patients) and ciprofloxacin (37%). Eleven patients have required nearly continuous antibiotics. Patient satisfaction with the outcome is high, with a mean satisfaction of 8. 4 (0, dissatisfied; 10, extremely satisfied). This review demonstrates a high incidence of pouchitis in patients after IPAA, which is due to the more liberal definition of the syndrome and the complete follow-up achieved in this report compared to previous series. This study also is unique in identifying the significantly higher incidence of pouchitis in women, although the overall satisfaction with the clinical outcome in patients undergoing IPAA remains high.

[Colorectal neoplasms in patients with ulcerative rectocolitis. Their surgical treatment and follow-up]

Patients with ulcerative colitis (UC), especially those with a long-term standing or severe disease, show a higher incidence of colorectal neoplasms. Dysplasia represents the most important risk-factor for malignancy in patients with UC. From 1989 to 1999, 71 patients with UC, were surgically treated at our Institution. Indications for surgery were: non responding disease or refractory bleeding in 61; pathologic evidence of severe dysplasia during endoscopic surveillance in 5 patients, evidence of a neoplasm in the remaining 5 patients. Operative mortality was 1.4%. Infections of the surgical wound has been the most common postoperative complication. In 4 cases pouchitis has been reported. In 7 patients because of progression of the proctitis a second surgical treatment has been made. When surgical treatment is indicated in the course of ulcerative colitis, several operations may be performed. In the large majority of patients, total colectomy, mucosectomy and ileal pouch-anal anastomosis is the procedure of choice.

Health-related quality of life after ileal J-pouch-anal anastomosis for ulcerative colitis: long-term results

BACKGROUND

This questionnaire study examined associations between health-related quality of life and long-term follow-up results with J-pouch anal anastomosis for ulcerative colitis.

METHODS

A two-part questionnaire was sent to patients treated for ulcerative colitis by handsewn J-pouch-anal anastomosis at our institute in the period 1985-95. The health-related quality of life measurement was based on a RAND SF-36 Finnish version of the questionnaire. Scores were compared with the normal Finnish population. The functional status was analysed with a 34-item questionnaire on pouch function and incontinence.

RESULTS

The response rate was 62%. The median follow-up time was 8 years (3 to 13 years). Functional results were acceptable: median number of bowel movements per 24 h was six. Soiling at night occurred in 32%, and inability to differentiate pouch contents in 24% cases. Twenty-four per cent used a pad occasionally, and 9% every day. The functional score and the health-related quality of life score correlated strongly. Poor functional status and a history of chronic pouchitis were associated with lower score. The limiting value after which the score was lower was 10 bowel movements per 24 h in 16%. A compromised anal continence proved to decrease the health-related quality of life as well.

CONCLUSIONS

RAND SF-36 scores seem to provide a useful tool to evaluate the health-related quality of life after pelvic pouch operation for ulcerative colitis. Frequent bowel movements, impaired anal continence, and pouchitis are common in long-term follow-up after ileal pouch operation. The scores were, however, comparable to those in the normal population in terms of adaptation to daily life with a pelvic pouch.

The implications of acute pouchitis on the long-term functional results after restorative proctocolectomy

A prospective study was conducted to determine the implications of acute pouchitis on the long-term functional results of restorative proctocolectomy with J-pouch ileoanal anastomosis (IPAA). Between July 1988 and June 1996, 137 consecutive patients underwent IPAA for treatment of ulcerative colitis. 127 patients (93%) have been available for follow-up. All patients completed diaries detailing bowel habits over a 7-day period at 3, 6, 9, 12, 18, 24 months, and yearly after reestablishment of intestinal continuity. Diaries were completed only during time periods in which patients were not suffering from acute symptomatic pouchitis. Patients with chronic pouchitis (n = 7) were excluded from this study leaving 120 patients for analysis. Fifty patients suffered at least one episode of pouchitis (Pouchitis Group). Seventy patients never had pouchitis (No Pouchitis Group). Patients with a history of pouchitis having significantly more bowel movements per day were more likely to ever have minor incontinence (75% vs. 45%, p < 0.005) or major incontinence (37% vs. 17%, p < 0.02). The stools of Pouchitis Group were less likely to be formed (24% vs. 31%, p < 0.001). Pouchitis Group patients also were more likely to wear a protective pad during the day (21% vs. 7% p < 0.04) or during the night (40% vs. 13%, p < 0.001). Even in the absence of clinically active pouchitis, patients who have suffered at least one episode of pouchitis have a poorer long-term functional result after IPAA. The results of this study suggest that ileal pouchitis may represent a chronic condition that displays episodic symptomatic exacerbations.

Pouchitis

Pouchitis is a major long-term complication of the continent ileostomy as well as the ileoanal pouch anastomosis. When diagnosed on the basis of clinical, endoscopic and histologic features, this syndrome has been demonstrated almost exclusively in patients with ulcerative colitis. The clinical course, the endoscopic findings and the histologic abnormalities resemble those of ulcerative colitis. The association with extra-intestinal manifestations further supports the hypothesis that pouchitis represents ulcerative colitis in the small bowel. All ileal reservoirs show bacterial overgrowth, especially of anaerobes. As a response to this altered intraluminal environment chronic inflammation and incomplete colonic metaplasia occur. The efficiency of metronidazole does suggest that bacteriological factors play an important role in the pathogenesis of pouchitis.

Ileal pouches: adaptation and inflammation

Ileal pouch-anal anastomosis (IPAA) has become the operation of choice following proctocolectomy for ulcerative colitis (UC) and familial adenomatous polyposis. Functioning ileal pouch mucosa undergoes histological changes resembling the colon (colonic metaplasia). The possible role of stasis and luminal factors--bile acids, short-chain fatty acids and bacteria--are discussed. It seems likely that colonic metaplasia is an adaptive response to the new luminal environment in IPAA. Inflammation in the ileal reservoir ('pouchitis') is the most significant late complication in IPAA. It occurs in 20-30% of patients and is virtually confined to those with prior UC. The clinical picture in pouchitis is highly variable; however, it can be easily categorized into three groups. Nevertheless, in most cases it is likely to represent recurrent UC in the ileal pouch. Current treatments and possible preventative strategies for pouchitis have been outlined.