Abstract
Pouchitis is a major complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). Although there have been many investigations of the neutrophil-to-lymphocyte ratio (NLR) in various diseases, its role in predicting the development of pouchitis remains unclear. We aimed to evaluate the clinical utility of the NLR for predicting the development of pouchitis after IPAA in UC patients. UC patients who underwent IPAA at Osaka City University Hospital between May 2006 and March 2019 were included. The incidence of pouchitis was estimated using the Kaplan-Meier method. Potential preoperative, intraoperative, and postoperative predictors for pouchitis, including various demographic and clinical variables, were analyzed. The combined impact of the NLR and other known prognostic factors were investigated using Cox proportional hazard regression with inverse probability of treatment weighting (IPTW). Forty-nine patients with UC who underwent IPAA were included. The median follow-up period was 18.3 months (interquartile range: 10.7-47.2 months). Eighteen patients (36.7%) developed pouchitis. The incidence of pouchitis was 19.2%, 32.6%, and 45.9% at 1, 2, and 5 years, respectively. NLR was significantly associated with the development of pouchitis in the univariate Cox regression analysis (hazard ratio (HR), 1.14; 95% confidence interval (CI), 1.01-1.28; P = 0.03). The NLR cutoff value of 2.15 was predictive of the development of pouchitis according to receiver operating characteristic analysis (specificity: 67.7%, sensitivity: 72.2%). The incidence of pouchitis was significantly lower in the low NLR group than that in the high NLR group (P = 0.01, log-rank test). Cox regression analyses using IPTW also identified NLR as a prognostic factor for the development of pouchitis by statistically adjusting for background factors (HR, 3.60; 95% CI, 1.31-9.89; P = 0.01). NLR may be a novel and useful indicator for predicting the development of pouchitis after IPAA in UC and should be introduced in clinical practice.
Highlights
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become a standard surgical procedure for medically intractable ulcerative colitis (UC), colitis-associated dysplasia, and cancer [1]
neutrophil-to-lymphocyte ratio (NLR) was significantly associated with the development of pouchitis in the univariate Cox regression analysis (hazard ratio (HR), 1.14; 95% confidence interval (CI), 1.01–1.28; P = 0.03)
We previously reported the utility of NLR as a useful prognostic marker for predicting the long-term outcomes in patients with UC treated with infliximab or tacrolimus therapy [27, 28]
Summary
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become a standard surgical procedure for medically intractable ulcerative colitis (UC), colitis-associated dysplasia, and cancer [1]. The development of pouchitis in patients with UC, as reported in several studies, has been linked to various factors, including primary sclerosing cholangitis [2, 4], other extraintestinal manifestations of inflammatory bowel disease [4, 8, 9], young age at UC diagnosis [4], preoperative terminal ileal inflammation [10, 11], extensive colonic disease [10], presence of interleukin-1 receptor antagonist gene allele 2 [12], total steroid dose of > 10000 mg [13], use of infliximab [14], neutrophil percentage of > 65% [13], and presence of perinuclear antineutrophil cytoplasmic antibodies [15, 16]. Accessible and low-cost markers are required to predict pouchitis in patients with IPAA
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