Can bedside criteria predict complications after Ileal Pouch-Anal Anastomosis for chronic Ulcerative Colitis?

Abstract

Truelove and Witts' criteria remains the gold standard for assessment of disease severity in ulcerative colitis, but it's clinical use is not ideal given its reliance on the combination of clinical, laboratory, and radiographic variables. In a recent study reporting the feasibility of minimally invasive subtotal colectomy and ileal pouch-anal anastomosis (IPAA) for fulminant colitis, we described surgical selection criteria which can be assessed at the bedside, including 1) recent (prior 6 weeks) hospitalization, 2) recent transfusion, 3) malnutrition (weight loss, hypoalbuminemia, or need for parenteral nutrition), or 4) immunosuppression (corticosteroids or infliximab). We aimed to determine if these criteria were associated with overall or infectious complications when present in a cohort of patients who underwent 2-stage IPAA. We identified all adult patients with CUC who underwent hand-assisted laparoscopic total proctocolectomy TPC-IPAA (stage 1 of 2) at our institution from 2004 - 2009 using a prospectively maintained database. Disease extent and severity was assessed according to the Montreal classification. Univariate analysis was performed to assess associations with overall or infectious complications after IPAA. Multivariate logistic regression analysis was performed to assess associations with overall 30-day complications. Data are frequency (proportion), median (interquartile range). Over 5-years, 212 patients underwent HALS-IPAA. Overall age was 35 (26 - 46) years, 88 (41%) women, BMI 25.3 (21.3 - 28.4) kg/m2. According to the Montreal classification of extent, 172 (80%) had pancolitis (E3), 34 (16%) had left-sided colitis (E2), and 8 (3.7%) had ulcerative proctitis (E1), and severity was classified as follows: 7 (3.2%) had severe colitis (S3), 84 (39%) moderate colitis (S2), 100 (48%) mild colitis (S1), and 23 (11%) asymptomatic (S0). A total of 169 (79%) were receiving steroids or infliximab, 49 (23%) had been recently hospitalized, 27 (13%) had evidence of malnourishment, and 16 (7.4%) had recent transfusion. Median operative time was 290 (241 - 354) minutes, 16 (7.4%) were converted to laparotomy, and the median post-operative length of stay was 5 (4 - 7) days. Overall 81 (38%) of patients developed a complication of any grade; 29 of these (13.5% overall) were infectious complications. On univariate analysis, neither Montreal classification extent or severity, nor any of the 4 clinical criteria were associated with overall complications; recent hospitalization (p= 0.5), transfusions (p= 0.82), immunosuppression (p= 0.96) were not associated with infectious complications, while malnutrition was associated with post-operative infections (p= 0.04). When stratified by the number of selection criteria present (2 or more, 3 or more) no statistically significant associations were noted with either overall or infectious complications on univariate analysis. On multivariate analysis of predictors for overall complications, including adjustment for disease severity, no statistically significant associations were noted; multivariate analysis of infectious complications was limited by the absolute number of events. In patients undergoing 2-stage ileal pouch-anal anastomosis, malnutrition appears to be a risk factor for post-operative infectious complications. Further study in a larger cohort is needed to determine if this association is independent of disease severity, extent, or other clinically important variables.