Ileal Pouch-anal Anastomosis For Ulcerative Colitis Research Articles

Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis.

Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis.

Prolyl Hydroxylase Inhibition Mitigates Pouchitis.

Pouchitis is the most common long-term complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or familial adenomatous polyposis (FAP), which can eventually progress to pouch failure, necessitating permanent stoma construction. Hypoxia-inducible transcription factor prolyl hydroxylase-containing enzymes (PHD1, PHD2, and PHD3) are molecular oxygen sensors that control adaptive gene expression through hypoxia-inducible factor (HIF). Emerging evidence supports PHDs as being therapeutic targets in intestinal inflammation. However, pharmacological inhibition of PHDs has not been validated as a treatment strategy in pouchitis. PHD1-3 mRNA and protein expression were analyzed in mucosal pouch and prepouch ileal patient biopsies. After establishment of a preclinical IPAA model in rats, the impact of the pan-PHD small-molecule inhibitor dimethyloxalylglycine (DMOG) on dextran sulfate sodium (DSS)-induced pouchitis was studied. Clinical and molecular parameters were investigated. PHD1, but not PHD2 or PHD3, was overexpressed in pouchitis in biopsies of patients with IPAA for UC but not FAP. In addition, PHD1 expression correlated with disease activity. DMOG treatment profoundly mitigated DSS-induced pouchitis in a rodent IPAA model. Mechanistically, DMOG restored intestinal epithelial barrier function by induction of tight junction proteins zona occludens-1 and claudin-1 and alleviation of intestinal epithelial cell apoptosis, thus attenuating pouch inflammation. Together, these results establish a strong therapeutic rationale for targeting PHD1 with small-molecule inhibitors in pouchitis after IPAA for UC.

Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis

Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis

P089 RACIAL DISPARITIES IN HOSPITAL PRESENTATION AND OUTCOMES AFTER COLECTOMY FOR ULCERATIVE COLITIS

Up to 30% of patients with ulcerative colitis (UC) require colectomy, but whether racial disparities exist in hospital presentation, operation choice, and post-operative outcomes remains unknown. The National Inpatient Sample (NIS) was queried for all admissions between 2006-2014 with a diagnosis of UC and a procedure code for subtotal colectomy with or without an accompanying procedure code for proctectomy and ileal pouch anal anastomosis (IPAA). Univariate comparisons were performed based on race/ethnicity of non-Hispanic white, black, or Hispanic, and linear regression assessed trends in non-elective surgery over time by race. The 2005-2016 National Surgical Quality Improvement Project (NSQIP) was then queried for patients of non-Hispanic white, black, or Hispanic race/ethnicity undergoing subtotal colectomy, total proctocolectomy with or without IPAA, and completion proctectomy with IPAA for UC. To assess the impact of race on major postoperative morbidity, complications were compared between the races and a multivariable model adjusting for comorbidities and other potential risk factors was constructed. The NIS query yielded 4,310 hospitalizations with an operation (3,800 non-Hispanic white, 214 black, 296 Hispanic). Using NIS weighting, this represents 20,859 hospitalizations with an operation (18,390 non-Hispanic white, 1,036 black, 1,432 Hispanic) in the United States over the same period. Black and Hispanic patients more often underwent non-elective surgery than non-Hispanic white patients did (black: 43%, Hispanic: 39%, non-Hispanic white: 32%; p=0.001), and this relationship persisted over the study period (Figure 1). However, neither the use of laparoscopy (black: 40%, Hispanic: 44%, non-Hispanic white: 45%; p=0.57) nor the performance of a restorative operation at the time of elective colectomy (black: 33%, Hispanic: 36%, non-Hispanic white: 32%; p=0.60) differed by race/ethnicity. Within NSQIP, 8,953 operations were analyzed (8,285 non-Hispanic white, 411 black, 257 Hispanic). Black and Hispanic patients experienced increased major post-operative morbidity (black: 30%, Hispanic: 31%, non-Hispanic white: 23%; p<0.001). On multivariable analysis, Hispanic ethnicity was a significant risk factor (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.9) for major morbidity, while black race (OR, 1.2; 95% CI, 1.0-1.5) trended towards significance (Table I). Black and Hispanic patients more often underwent non-elective surgery and suffered increased postoperative morbidity compared to non-Hispanic white patients. However, racial disparities did not exist in the choice to pursue an initially restorative operation or the use of laparoscopy. An emphasis on improved outpatient UC medical management may reduce non-elective operations and postoperative morbidity in racial and ethnic minorities.

P089 RACIAL DISPARITIES IN HOSPITAL PRESENTATION AND OUTCOMES AFTER COLECTOMY FOR ULCERATIVE COLITIS

Up to 30% of patients with ulcerative colitis (UC) require colectomy, but whether racial disparities exist in hospital presentation, operation choice, and post-operative outcomes remains unknown. The National Inpatient Sample (NIS) was queried for all admissions between 2006-2014 with a diagnosis of UC and a procedure code for subtotal colectomy with or without an accompanying procedure code for proctectomy and ileal pouch anal anastomosis (IPAA). Univariate comparisons were performed based on race/ethnicity of non-Hispanic white, black, or Hispanic, and linear regression assessed trends in non-elective surgery over time by race. The 2005-2016 National Surgical Quality Improvement Project (NSQIP) was then queried for patients of non-Hispanic white, black, or Hispanic race/ethnicity undergoing subtotal colectomy, total proctocolectomy with or without IPAA, and completion proctectomy with IPAA for UC. To assess the impact of race on major postoperative morbidity, complications were compared between the races and a multivariable model adjusting for comorbidities and other potential risk factors was constructed. The NIS query yielded 4,310 hospitalizations with an operation (3,800 non-Hispanic white, 214 black, 296 Hispanic). Using NIS weighting, this represents 20,859 hospitalizations with an operation (18,390 non-Hispanic white, 1,036 black, 1,432 Hispanic) in the United States over the same period. Black and Hispanic patients more often underwent non-elective surgery than non-Hispanic white patients did (black: 43%, Hispanic: 39%, non-Hispanic white: 32%; p=0.001), and this relationship persisted over the study period (Figure 1). However, neither the use of laparoscopy (black: 40%, Hispanic: 44%, non-Hispanic white: 45%; p=0.57) nor the performance of a restorative operation at the time of elective colectomy (black: 33%, Hispanic: 36%, non-Hispanic white: 32%; p=0.60) differed by race/ethnicity. Within NSQIP, 8,953 operations were analyzed (8,285 non-Hispanic white, 411 black, 257 Hispanic). Black and Hispanic patients experienced increased major post-operative morbidity (black: 30%, Hispanic: 31%, non-Hispanic white: 23%; p<0.001). On multivariable analysis, Hispanic ethnicity was a significant risk factor (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.9) for major morbidity, while black race (OR, 1.2; 95% CI, 1.0-1.5) trended towards significance (Table I). Black and Hispanic patients more often underwent non-elective surgery and suffered increased postoperative morbidity compared to non-Hispanic white patients. However, racial disparities did not exist in the choice to pursue an initially restorative operation or the use of laparoscopy. An emphasis on improved outpatient UC medical management may reduce non-elective operations and postoperative morbidity in racial and ethnic minorities.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Incidence and Definition of Crohn's Disease of the Pouch: A Systematic Review and Meta-analysis.

A subset of patients who undergo total proctocolectomy with ileal pouch-anal anastomosis (IPAA) creation for ulcerative colitis (UC) will later develop Crohn's disease (CD) of the pouch, which has been associated with significant morbidity. We aimed to analyze the incidence of CD of the pouch and to review the existing diagnostic criteria utilized. A systematic search performed through March 1, 2018, identified 12 studies that reported the incidence of CD of the pouch after IPAA for UC or indeterminate colitis (IC). We compiled all diagnostic criteria utilized in these studies and then performed a meta-analysis using random effects modeling to estimate the overall incidence of CD of the pouch in this population. Among 4843 patients with an IPAA for UC or IC, 10.3% of patients were ultimately diagnosed with CD of the pouch (95% confidence interval [CI], 6.1%-15.4%). The most commonly reported diagnostic criteria were (1) presence of fistula/fistulae, (2) stricture involving the pouch or prepouch ileum, and (3) presence of prepouch ileitis. In a secondary analysis, excluding those studies that included patients with a preoperative diagnosis of IC, the incidence of CD of the pouch was 12.4% (95% CI, 9.0%-16.1%). The estimated incidence of 10.3% will assist gastroenterologists and surgeons in preoperative counseling regarding the potential to develop CD of the pouch. There is an unmet need for common diagnostic criteria for a more standardized approach to the diagnosis of CD of the pouch.

Are radiologic pouchogram and pouchoscopy useful before ileostomy closure in asymptomatic patients operated for ulcerative colitis?

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the "gold standard" procedure for patients with ulcerative colitis (UC) requiring surgical intervention. A de-functioning ileostomy is usually performed, as a step for the IPAA procedure. The aim of this study is to present the methodology and results of the routine double assessment of IPAA integrity in asymptomatic patients prior to the ileostomy reversal and evaluate its necessity. This is a retrospective study of 61 UC patients, who underwent IPAA construction, in 2010-2016. A diverting ileostomy was created after IPAA construction, which was reversed at least 3months later. A double assessment, with pouchogram and pouchoscopy, of IPAA integrity was performed, before stoma closure. Post-operative symptoms and signs of complications, imaging studies, and endoscopic findings were recorded during follow-up. Prior to the ileostomy reversal, both pouchoscopy and pouchogram identified no patient with evidence of anastomotic leakage. During a mean follow-up of 3.67years after ileostomy reversal, 11 patients developed complications but only one had signs of leakage, which presented as a pouch-vaginal fistula. The specificity of both the pouchogram and pouchoscopy reached 100% and the negative predictive value ranged between 98.4 and 100%. The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis, but their combination did not alter the diagnostic accuracy or had any effect in further management. At least, pouchogram could be selectively performed only in patients with high-risk clinical indicators. • The double assessment of ileal pouch-anal anastomosis with pouchogram and pouchoscopy, prior to ileostomy closure, specifically in patients with ulcerative colitis has not been evaluated before. • The specificity of pouchoscopy and pouchogram prior to ileostomy closure, in asymptomatic patients with IPAA for UC, is very high in recognizing an intact anastomosis. • However, their combination did not alter the diagnostic accuracy or had any effect in further management, in asymptomatic patients.

Clinical efficacy of laparoscopic and open total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

Objective To compare the short-term and long-term outcomes between laparoscopic and open total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Methods The retrospective cohort study was conducted. The clinical data of 150 UC patients who underwent total proctocolectomy with IPAA in the Renji Hospital of Shanghai Jiaotong University between January 2003 and December 2016 were collected. Among 150 patients, 87 undergoing laparoscopic total proctocolectomy with IPAA and 63 undergoing open total proctocolectomy with IPAA were respectively allocated into the laparoscopy group and open group. Observation indicators: (1) comparisons of intra-and post-operative situations; (2) postoperative complications; (3) follow-up situation. Follow-up using outpatient examination and telephone interview was performed to detect postoperative recovery and complications up to December 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Comparison between groups of count data was analyzed using the chi-square test. Results (1) Comparisons of intra-and post-operative situations: operation time, volume of intraoperative blood loss, time of initial intestinal stoma exsufflation and duration of hospital stay were respectively (306±3)minutes, (197±12)mL, (62.1± 1.8)hours, (8.2±0.4)days in the laparoscopy group and (224±4)minutes, (308±24)mL, (75.6±2.0)hours, (10.1±0.6)days in the open group, with statistically significant difference between groups (t=16.23, 4.33, 5.03, 2.61, P 0.05). (2) Postoperative complications: cases with postoperative wound infection, retention of urine and frequency of defecation > 4 times / day were respectively 2, 8, 21 in the laparoscopy group and 8, 15, 29 in the open group, with statistically significant differences between groups (χ2=5.25, 4.37, 0.96, P 0.05). Patients with postoperative complications were improved by acid suppression, fasting, anti-infection and fluid infusion. (3) Follow-up situation: 150 patients were followed up for 12-60 months, with a median time of 48 months. There was no abnormality of postoperative anastomotic stoma and intestinal mucosa through comparison of colonoscopy results between pre-operation and 5 year postoperatively. During the follow-up, 50 patients had shapeless stool and irregular defecation (times > 4 times / day) at 3 years after stoma reversion of small intestine bypass, including 21 in the laparoscopy group and 29 in the open group, with a statistically significant differences between groups (χ2=4.72, P 0.05). Conclusion The security of laparoscopic total proctocolectomy with IPAA for UC is equivalent to that of open total proctocolectomy, with the better short-term and long-term outcomes. Key words: Ulcerative colitis; Total proctocolectomy; Ileal pouch-anal anastomosis; Laparoscopy; Efficacy

Transanal completion proctectomy with close rectal dissection and ileal pouch‐anal anastomosis for ulcerative colitis

Laparoscopic dissection in the pelvis is still a challenge. A transanal approach to rectal dissection allows better visualization during the dissection of the rectum and the creation of an anastomosis. Although initially used for patients with rectal cancer, the transanal approach may also have benefits in the surgical treatment of ulcerative colitis (UC). The aim of this study was to describe our initial experience with transanal completion proctectomy and ileal pouch-anal anastomosis for UC. This study included all consecutive patients who underwent transanal completion proctectomy and ileal pouch-anal anastomosis for UC between September 2017 and February 2018. Eleven patients were included in the study; they had a median age of 30 years (range, 13-51 years). The median operative time was 285 min (range, 190-375 min). There were no intraoperative complications or conversions to open surgery. Postoperative complications occurred in only one patient (anastomotic leak), and the median length of hospital stay was 7 days (range, 5-37 days). Our initial experience with transanal completion proctectomy and ileal pouch-anal anastomosis shows promising results, demonstrating the feasibility of the transanal approach in patients with UC.

Small Bowel Obstruction After Ileal Pouch-Anal Anastomosis With a Loop Ileostomy in Patients With Ulcerative Colitis.

Purpose Small bowel obstruction (SBO) remains a common complication after pelvic or abdominal surgery. However, the risk factors for SBO in ulcerative colitis (UC) surgery are not well known. The aim of the present study was to clarify the risk factors associated with SBO after ileal pouch-anal anastomosis (IPAA) with a loop ileostomy for patients with UC.Methods The medical records of 96 patients who underwent IPAA for UC between 1999 and 2011 were reviewed. SBO was confirmed based on the presence of clinical symptoms and radiographic findings. The patients were divided into 2 groups: the SBO group and the non-SBO group. We also analyzed the relationship between SBO and computed tomography (CT) scan image parameters.Results The study included 49 male and 47 female patients. The median age was 35.5 years (range, 14–72 years). We performed a 2- or 3-stage procedure as a total proctocolectomy and IPAA for patients with UC. SBO in the pretakedown of the loop ileostomy after IPAA occurred in 22 patients (22.9%). Moreover, surgical intervention for SBO was required for 11 patients. In brief, closure of the loop ileostomy was performed earlier than expected. A multivariate logistic regression analysis revealed that the 2-stage procedure (odds ratio, 2.850; 95% confidence interval, 1.009–8.044; P = 0.048) was a significant independent risk factor associated with SBO. CT scan image parameters were not significant risk factors of SBO.Conclusion The present study suggests that a 2-stage procedure is a significant risk factor associated with SBO after IPAA in patients with UC.

Early Pouchoscopy Is Not Helpful for Surveillance of Dysplasia in the Ileal Pouch

BACKGROUND: Pouch surveillance recommendations for dysplasia after ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC) have yet to be established. The major determinant for developing pouch cancer is dysplasia or carcinoma prior to colectomy. The aim of this study is to describe the findings of our dysplasia surveillance protocol and to examine the yield of early pouchoscopy (6 months) in detecting dysplasia. METHODS: This is a retrospective cohort study based on data collection of patients at the UPR IBD clinics with IPAA for UC that consented to participate in a research protocol approved by the UPR Medical Sciences Campus IRB (#1250200). Current practice in our clinics is to start surveillance pouchoscopy 6 months after the pouch is functional, repeat at 12 months and yearly afterwards. A minimum of 6 biopsies of the ileal pouch and 2 of the cuff are evaluated by experienced pathologists using Riddell's criteria for dysplasia. Data collected includes demographics, medical history and indications for UC surgery, symptoms, pouch function, endoscopic and histologic findings. Of 120 patients identified, 5 were excluded due to development of Crohn's of the pouch, and 8 were excluded due to missing data and biopsy results. The total sample for this study was 107 patients. Variables examined were: age, sex, date of diagnosis, date of colectomy, time of follow up, time of detection of pouchitis, time of detection of cuffitis, and time of detection of dysplasia. Data analysis consisted of descriptive statistics using frequencies, means, standard deviations and incidence rate of dysplasia (SPSS, v23). RESULTS: The study population consisted of 54 males (50.5%) and 53 females (49.5%). The mean age was 37.6 years + 14.5. Nineteen (17.8%) subjects had dysplasia prior to surgery and 3 (2.8%) had colon cancer. Mean follow- up was 87.6 + 60.6 months with a range of 3.2-257.1. Pouch failure occurred in 3 (2.9%), Endoscopic or histologic pouchitis was reported at least once in 93 (88.6%) and cuffitis in 79 (73.8%). Complications included 1 leak, 14 strictures (all successfully dilated), and 1 perianal fistula. Dysplasia in the pouch was reported in 2 patients (1.9%), with a mean time of 47.3 months (range 35-59.6) after surgery. Dysplasia was no longer present on follow-up. Both had dysplasia or carcinoma in situ before colectomy. The incidence rate of dysplasia was 0.0026 per person-year. There was no significant association between pouchitis and dysplasia. CONCLUSION(S): The incidence rate of dysplasia after IPAA in the study population was very low, and first appeared almost 3 years after the surgery. Our results support starting protocol surveillance pouchoscopies after one year of pouch functionality. This will decrease costs and burden to patients without increasing risk of missing the development of dysplasia. We did not analyze studies performed for evaluation of symptoms, as these are outside the scope of the dysplasia surveillance protocol. The impact of the incidental finding of pouchitis in the management and long-term outcome of the patients is also of interest and should be analyzed.

Ileal Pouch of Ulcerative Colitis Patients Exhibit Impaired Autophagy

BACKGROUND: Total rectocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgery of choice for patients with ulcerative colitis (UC) that are refractory to clinical treatment and for familial adenomatous polyposis (FAP) with many rectal polyps. The main complication after this procedure is the pouch inflammation (pouchitis) that can affect up to 45 percent of patients who are submitted to IPAA for UC, and only five percent of the FAP patients who undergo the same procedure. Previous studies have shown increased pro-inflammatory cytokines in the ileal pouch (IP) mucosa of UC patients, even in the absence of clinical, endoscopic and histological inflammation. Autophagy is an evolutionarily conserved catabolic pathway that consists of selective degradation of cellular components and a homeostatic mechanism that protects cells exposed to stress situations (toxins, starvation), and defects in this pathway have been reported in inflammatory bowel diseases. However, there are no studies on the IP. Therefore, we studied markers for autophagy in the IP mucosa of UC and FAP patients comparing them to controls with a normal distal ileum. METHODS: Sixteen patients with IP in "J" shape, asymptomatic and with endoscopically normal mucosa were evaluated. The control group consisted of eight patients with normal colonoscopy. Gene expression was analyzed by qPCR and protein levels by immunoblotting and immunofluorescence. This study was approved by the Ethics Committee of the University of Campinas and was performed in accordance with the Declaration of Helsinki. All results were reported as means ± SEM. Data were analyzed by non-parametric Test, comparing all groups. The level of significance was set at P<0.05. RESULTS: There was a significant decrease in the transcriptional levels of ATG5, MAP1LC3A and BAX in the FAP group (P<0.05). There was also a decrease in the protein level of Beclin-1 in the UC and FAP compared to the control group (P<0.05). Although the LC3II levels by immunoblot were higher in the UC group, total LC3 and LC3/p62 co-localization were lower in the immunofluorescence analysis in the UC and FAP compared to the control group (P<0.05). Corroborating to these results, there was an increase of p62 by immunoblot in the UC group, compared to controls (P<0.05). CONCLUSION(S): These results indicate impaired macroautophagy mechanism in the IP. In FAP, decreased autophagy may be related to impaired apoptosis, otherwise in UC, may be mainly due to increased Toll-Like Receptors (TLR) activation. These findings may explain the inflammation predisposition, mainly in the IP mucosa of UC patients. Acknowledgments: We thank FAPESP (São Paulo Research Foundation) for financial support. Negreiros LMV (co-author) received scholarship from FAPESP. We are grateful to Prof. Tristan Torriani for English grammar revision. We thank Francesca Ramos and José Diego Botezelli for technical assistance and the staff of the Life Sciences Core Facility (LaCTAD) from State University of Campinas (UNICAMP), for the Cell Biology analysis.

Systematic Review With Meta-Analysis: Anti-TNF Therapy in Refractory Pouchitis and Crohn's Disease-Like Complications of the Pouch After Ileal Pouch-Anal Anastomosis Following Colectomy for Ulcerative Colitis.

Inflammatory complications including chronic refractory pouchitis and Crohn's disease (CD)-like complications of the pouch are common complications after ileal pouch-anal anastomosis (IPAA) following colectomy for ulcerative colitis (UC). We performed a systematic review and meta-analysis to evaluate the efficacy of anti-TNF therapy in distinguishing patients with chronic refractory pouchitis from those with CD-like complications of the pouch. We performed a systematic literature search to identify articles and abstracts reporting anti-TNF agents efficacy in treating inflammatory complications of the pouch after IPAA for UC. Short-term and long-term remissions were evaluated at 8 weeks 95%CI[5-10] and 12 months 95%CI[12-18.5], respectively. We identified 21 articles and 3 abstracts including 313 patients treated either with infliximab (n = 194) or adalimumab (n = 119) for inflammatory complications of the pouch. The rates of short-term and long-term clinical remission were 0.50 (95%CI [0.37-0.63]; I2 = 0.57) and 0.52 (95%CI[0.39-0.65]; I2 = 0.59), respectively. The rate of remission after anti-TNF induction therapy seemed to be higher in CD-like complications of the pouch 0.64 (95%CI[0.5-0.77]; I2 = 0.18), compared to refractory pouchitis 0.10 (95%CI [0.00-0.35]; I2 = 0.00) (P = 0.06), whereas no such difference appeared after long-term maintenance therapy 0.57 (95%CI[0.43-0.71]; I2 = 0.32) and 0.37 (95%CI [0.14-0.62]; I2 = 0.47), respectively (P = 0.57). Sensitivity analyses suggested no difference in outcomes. No significant publication bias has been detected. Anti-TNF agents have a clear trend to have higher and faster efficacy in CD-like complications of the pouch compared to refractory pouchitis, highlighting the need to differentiate these two entities both in daily practice and clinical trials.

Systematic review with meta-analysis: the management of chronic refractory pouchitis with an evidence-based treatment algorithm.

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is considered the procedure of choice in patients with ulcerative colitis (UC) refractory to medical therapy. The incidence of pouchitis is 40% at 5 years. Ten to 15% of patients with pouchitis experience chronic pouchitis. To determine the efficacy of medical therapies for the treatment of chronic refractory pouchitis in patients undergoing IPAA for UC. A systematic computer-assisted search of the on-line bibliographic database MEDLINE and EMBASE was performed between 1966 and February 2016. All original studies reporting remission rates following medical treatment for chronic pouchitis were included. All study designs were considered. Remission was defined according to the individual study. Remission endpoints ranged from 15 days to 10 weeks. Chronic pouchitis was defined by each study. Twenty-one papers were considered eligible. Results from all studies combined suggested that overall remission was obtained in 59% of patients (95% CI: 44-73%). Antibiotics significantly induced remission in patients with chronic pouchitis with 74% remission rate (95% CI:56-93%), (P < 0.001). Biologics significantly induced remission in patients with chronic pouchitis with 53% remission rate (95% CI:30-76%), (P < 0.001). Steroids, bismuth, elemental diet and tacrolimus all can induce remission but failed to achieve significance. Faecal microbiota transplantation in a single study was not found to achieve remission. Treatment of chronic refractory pouchitis remains difficult and is largely empirical. Larger randomised controlled trials will help aid the management of chronic pouchitis.

Pouchitis: a tridimensional view

The preferred surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP) is represented by proctocolectomy with ileal pouch-anal anastomosis (IPAA). However, patients with UC who have undergone IPAA are prone to develop several complications, which include surgery related/mechanical complications; inflammatory or infectious disorders; functional disorders; dysplasia or neoplasia; and systemic or metabolic disorders. Pouchitis, which is defined as the acute and/or chronic inflammation of the ileal reservoir, represents the most common long-term adverse sequela after IPAA. Gut microbiota play a pivotal role in the initiation and disease progression of pouchitis. Pouchitis can be classified according to the activity of the disease, the duration of the symptoms, the pattern of the disease or response to antibiotic therapy. Patients with IPAA for UC tend to experience a variety of symptoms, ranging from mild pelvic or perianal discomfort to a debilitating complex of symptoms that may eventually lead to pouch excision thereby necessitating the construction of a permanent ileostomy. To date, the etiology, the diagnosis and the medical management of pouchitis represent a clinical challenge. In fact pouchitis range from a disease with an acute antibiotic-responsive presentation to a chronic antibiotic-refractory form, with subsequent different disease mechanisms and clinical course. A tridimensional and multidisciplinar approach, including endoscopy, histology, and laboratory testing is widely helpful to identify the different phenotypes of the disease and to manage correctly its treatment.

Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery.

Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP). Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment. The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2weeks postoperatively. This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.

De novo Crohn's Disease after Ileal Pouch-Anal Anastomosis for Ulcerative Colitis and Inflammatory Bowel Disease Unclassified: Long-Term Follow-Up of a Prospective Inflammatory Bowel Disease Registry

The risk of de novo Crohn's disease (CD) after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) versus inflammatory bowel disease unclassified (IBDU) or indeterminate colitis (IC) remains debatable. Here, we present updated results after long-term follow-up of a previously studied cohort of 334 patients with UC, IBDU, or IC who underwent IPAA during a 10-year period ending 2007. Of 334 study patients, 56 per cent were male and median age was 38 years (range: 8-81). Patients were classified as UC (n = 237) or IBDU (n = 97) preoperatively and UC (n = 236) or IC (n = 98) postoperatively. After a median follow-up of 76 months (range: 3-236), 63 patients (19%) developed CD within a median of 22 months (range: 1-213) from ileostomy closure compared with the previously published 40 patients (12%) with 26-month follow-up (P = 0.01). The development of de novo CD was similar for patients undergoing IPAA for UC (n = 40; 17%), IBDU (n = 21; 22%) or those classified as having UC (n = 42; 18%) or IC (n = 19; 19%) postoperatively; P > 0.05. Thus, patients with IBDU and IC can expect equivalent long-term outcome to patients with UC after IPAA. Pouch failure occurred in 13 (4%) study patients and was equal among all four groups.

Infliximab to Treat Refractory Inflammation After Pelvic Pouch Surgery for Ulcerative Colitis.

Inflammatory pouch complications refractory to first-line therapies remain problematic following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We evaluated infliximab efficacy and associations with therapeutic response. Data from individuals who underwent colectomy and IPAA for UC (2000-2014) were reviewed. Patients with chronic refractory pouchitis (CP) and Crohn's disease (CD)-like outcomes treated with infliximab were included. Pre-treatment parameters and response at median 8 (initial) and 48 weeks (sustained) were measured. Complete response was defined as symptomatic and endoscopic resolution with modified Pouchitis Disease Activity Index (mPDAI) <5. Partial response included mPDAI improvement >2. Serum was analysed for Anti-Saccharomyces cerevisiae antibodies (ASCA), anti-OmpC, anti-CBir1 and perinuclear Anti-Neutrophil Cytoplasmic Antibodies (pANCA). One hundred and fifty-two patients with CP or a CD-like phenotype were identified. Forty-two were treated with infliximab (33% male; age 32.6±2.6 years, 28.5% CD-like). Post-induction response was achieved in 74% (48% complete) and sustained response in 62.6% (29.6% complete). Mean mPDAI and C-reactive protein declined from 8.5±0.3 to 2±3.4 (p < 0.002) and from 29.48±6.2 to 5.76±1.6mg/L (p < 0.001), respectively. Female gender, smoking and presence of anti-CBir1 were associated with infliximab use (p < 0.01) but not response. Pre-treatment mPDAI <10 (p < 0.01), resolution of rectal bleeding (p < 0.001 ) and week 8 endoscopic activity were associated with sustained response (p = 0.04; odds ratio [OR] 2.2; 95% confidence interval [CI] 1.1-16.5]). More than 2 positive antimicrobial antibody titres were associated with non-response (p < 0.05), but did not retain significance in multivariate analysis (p = 0.197; OR 0.632; 95% CI 0.31-1.2). Infliximab can effectively treat inflammatory pouch complications. Pre-treatment mPDAI <10 and early endoscopy may identify responders.

PTU-258 Prevalence and severity of pre-pouch ileitis: a distinct disease entity or a manifestation of refractory pouchitis?

<h3>Introduction</h3> Pre-pouch ileitis (PI) is a complication that can occur after panproctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). It is characterised by inflammation of pre-pouch ileum in the afferent limb of the pouch. Our aims were to assess the prevalence of PI as well as to identify predictive factors and investigate the medications needed for its management. <h3>Method</h3> Data on 546 patients who underwent IPAA for UC was retrospectively collected from three tertiary inflammatory bowel disease (IBD) referral centres. Data was collected from sites in the Netherlands (Academic Medical Centre, Amsterdam), Belgium (Leuven University Hospital) and England (University College London Hospital). PI was considered present if there was endoscopic, as well as histological inflammation in the afferent limb. <h3>Results</h3> PI was present in 33/546 (6%) UC patients, all of these had concurrent pouchitis. 144 (26%) patients had pouchitis without PI. 369 (68%) patients did not have any inflammatory pouch problems. Rates of requiring potent immunosupressive treatment were higher amongst patients with PI than those with pouchitis alone. Patients who went on to develop PI were significantly younger at the time of their UC diagnosis. PSC was significantly more common in patients with PI than those with pouchitis alone. <h3>Conclusion</h3> PI is a much less common and more treatment refractory condition than pouchitis alone. Pouchoscopy should be considered in any patient with symptoms of pouchitis. This should include careful endoscopic evaluation of the afferent pouch limb as well as biopsies of the pre-pouch ileum. Once a diagnosis of PI is made, clinicians should commence immunomodulatory therapy early in the disease course and consider escalating to an anti-TNF if this proves ineffective. <h3>Disclosure of interest</h3> None Declared.

Quality of life, social impact and functional outcome following ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis.

This study aims to assess quality of life (QoL), functional outcome, and social impact following ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP) since Indian data is limited. Data was collected prospectively from patients who underwent IPAA for UC or FAP from 2004 to 2013. QoL and functional outcome at 1, 3, and 5 years after surgery, return to work, and change of job (social impact) were documented. QoL was assessed using the validated Cleveland Global Quality of Life (CGQL) score, the normal score being 1.0. Twenty-five patients were analyzed. Mean CGQL scores before surgery and at 1, 3, and 5 years were 0.5, 0.63, 0.73, and 0.8, respectively. FAP patients had better scores at 3 and 5 years. Only 40 % returned to same job. Sixty-four percent returned to work within a year. The median number of bowel movements per 24 h was less for FAP patients at 3 and 5 years. UC patients on long-term steroids had poorer function at 3 years. Long-term QoL and functional outcomes following IPAA are acceptable. Initial deterioration in QoL, mainly in FAP and long-term adverse social impact in both groups should not be underestimated. UC patients on long-term steroids showed delayed improvement in pouch function.