Is There Any Association Between Clinical Features or IBD Seromarker Expression and the Efficacy of Aggressive Medical Therapy of de novo Crohnʼs Disease after Ileal Pouch-Anal Anastomosis?

Abstract

Purpose: About 5%-10% of patients with ulcerative colitis (UC) who undergo ileal pouch-anal anastomosis (IPAA) subsequently develop de novo Crohn's disease (CD). Most physicians use a “step-up” approach to medical treatment of de novo CD after IPAA starting with antibiotics, then escalating to 5-ASA products, corticosteroids, immunodulators and biologics. There is little published literature on how effectively medical therapies can salvage CD pouches and avoid permanent ileostomy. In this study, we assessed the effectiveness of medical therapy of de novo CD after IPAA, and investigated whether any clinical or serologic factors were associated with the need for permanent ileostomy and pouch failure (PF). Methods: A prospectively generated clinical database of UC and IC patients who underwent IPAA by a single surgeon was queried for patients who subsequently developed de novo CD. Clinical features and seromarker expression (pANCA, ASCA-IgG, ASCA-IgA, anti-OmpC, anti-CBirl, anti-I2) was assessed before surgery. Clinical phenotypes of de novo CD included inflammatory (pouch or afferent ileal limb inflammation), fistulizing (pouch fistulizing disease), or anal disease. Medications used as pouch salvage (PS) interventions were recorded. PF was defined as the need for permanent ileostomy after failure to respond to medical therapy. Results: Forty patients (21 males and 19 females) with a median age of 33 yr (range, 12-71 yr) comprised the study group. There were 31 patients (78%) with inflammatory CD, 5 patients (13%) with pouch fistulizing CD, and 4 patients (10%) with anal disease. Median follow-up time of the study cohort was 34 months (range, 4 to 132 months). Medical PS was successful in 34 patients (85%) with antibiotics alone (n=22), immunomodulators (n=7) and biologics (n=5). Six patients (15%) failed anti-TNF therapy and and developed PF. Median time to permanent ileostomy was 17 months (range, 0 to 103 months). The incidence of PF was 13% in de novo inflammatory CD, 0% in de novo fistulizing CD and 50% in de novo anal CD (p=0.1). No pre- or post-operative clinical variable was associated with PF. Preoperatively most patients expressed the UC-associated pANCA (78%); CD-associated seromarkers of ASCA-IgG, ASCA-IgA, anti-OmpC, anti-CBirl and anti-I2 were detected in 3%, 13%, 25%, 18% and 18%, respectively. No statistically significant associations were noted between any individual or combination of seromarkers and PF. Conclusion: Aggressive medical therapy of de novo CD after IPAA can avoid permanent ileostomy in 85% of cases. Early results from this prospective study suggest that no clinical or serologic variables appear to be associated with pouch failure in medically treated patients with de novo CD after IPAA. Disclosure: Dr Targan - Founder Prometheus Lab Dr Vasiliauskas - Speakers Bureau, Prometheus Labs.