Ileal Pouch-anal Anastomosis Procedure Research Articles

Diagnosis and treatment of primary ileal pouch leaks: a 27-year experience at a referral center

Ileal pouch-anal anastomosis (IPAA) is considered the preferred restorative surgical procedure for patients with ulcerative colitis and familial adenomatous polyposis requiring proctocolectomy. Unfortunately, postoperative leaks remain a complication with potentially significant ramifications. This study aimed to provide a comprehensive description of the evaluation, management, and outcomes of leaks after primary IPAA procedures. Between 1995 and 2022, a total of 4058 primary IPAA procedures were performed at Cleveland Clinic. From a prospectively maintained pouch registry, we retrospectively reviewed the data of 237 patients who presented to the pouch center for management. Of these, 114 (3%) had undergone the index IPAA procedure at our clinic (de novo cases), whereas 123 patients had their index IPAA performed elsewhere. Data were missing for 43 patients, resulting in a final cohort of 194 patients. Our cohort had an average age of 41 years (range, 16-76) at the time of leak diagnosis. Overall, 55.2% were males, average body mass index was 24.4kg/m2, and pain was the most prevalent presenting symptom (61.8%), followed by fever (34%). Leaks were confirmed through diagnostic testing in 141 cases, whereas 27.3% were detected intraoperatively. The most common initial diagnoses were pelvic abscess (47.4%) and enteric fistulas (26.8%), including cutaneous (9.8%), vaginal (7.2%), and bladder fistulas (3.1%). By location, leaks occurred at the tip of the "J" (52.6%), at the pouch-anal anastomotic site (35%), and in the body of the pouch (12.4%). A nonoperative management approach was initially attempted in 49.5% of cases, including antibiotic therapy, drainage, endoclip, and endo-sponge, with a success rate of 18.5%. Surgery was eventually required in 81.4% of patients, including (1) sutured or stapled pouch repair (52.5%), with diversion performed in 87.9% of these cases either before or during the salvage surgery; (2) pouch excision with neo-IPAA (22.7%), including 9 patients from the first group; and (3) pouch disconnection, repair, and reanastomosis (9.3%). Pouch failure occurred in 8.4%, with either pouch excision (11.1%) or permanent diversion (4.5%). Ultimately, 12.4% of patients (24 of 194) required permanent diversion, with all necessitating pouch excision. In the 30-day follow-up after salvage surgery, short-term complications arose in 38.7% of patients. The most common complications observed were ileus, pelvic abscess/sepsis, and fever. Leaks after primary IPAA procedures represent an infrequent, yet challenging, complication. Despite attempts at nonoperative management, the success rate is limited. Salvage surgery is associated with a high pouch retention rate, underscoring its importance in the management of post-IPAA leaks.

Laparoscopy-Assisted Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis in Middle Colic Artery Ligation Immediately before Specimen Removal

Introduction: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure for ulcerative colitis (UC). Intestinal ischemia may occur if the main blood vessels are ligated at an early stage of this surgery. Considering that the blood flow in the large intestine can be maintained by preserving the middle colic artery, we have used a new IPAA method: ligating the middle colic artery immediately before removal of the specimens (“M-method”). Here, we evaluated the M-method’s clinical outcomes. Methods: Between April 2009 and December 2021, 13 patients underwent a laparoscopy-assisted IPAA procedure at our institution. The conventional method was used for 6 patients, and the M-method was used for the other 7 patients. We retrospectively analyzed the cases’ clinical notes. Results: The M-method’s rate of postoperative complications (Clavien-Dindo classification grade II or more) was significantly lower than that of the conventional method (14.2% vs. 83.3%). The M-method group’s postoperative stay period was also significantly shorter (average 16.4 days vs. 55.5). There were significant differences in the albumin value and the ratio of the modified GPS score 1 or 2 on the 7th postoperative day between the M- and conventional methods (average 3.15 vs. 2.5, average 4/7 vs. 6/6). However, it is necessary to consider the small number of cases and the uncontrolled historical comparison. Conclusion: Late ligation of the middle colic artery may be beneficial for patients’ post-surgery recovery and can be recommended for IPAAs in UC patients.

The Role of Diversion During Ileal Pouch Anal Anastomosis (IPAA) Creation in Pediatric Ulcerative Colitis

IntroductionIn pediatric ulcerative colitis (UC), surgery is often postponed until disease is life-threatening or refractory to immune suppression. In these settings, diverting ileostomy (DI) is theorized to have a protective effect on the new anastomosis. However, analyses have been performed only in single-institution series and the true impact of performing DI at the time of IPAA on postoperative outcomes is unclear. MethodsWe performed a retrospective cohort study using claims data from the International Business Machines (IBM) MarketScan® database. Patients were sorted to the DI group if they carried a CPT code for ostomy closure within 6 months of index procedure. We examined demographics, preoperative risk factors, and performed regression analysis to compare 30-day postoperative outcomes between groups. ResultsWe identified 317 patients ≤18yo that underwent IPAA procedure and met inclusion criteria from 2000 to 2019. Of these, 238 patients were assigned to the IPAA + DI cohort and 79 patients were assigned to the IPAA cohort.Adverse outcomes were comparable between cohorts. Surgical site infection (SSI) rates between IPAA and IPAA + DI were 10.1 vs. 11.3% (p = 0.67). Rates of intra-abdominal drainage procedures were 3.8 vs. 2.1% (p = 0.39). The rates of 30-day readmissions were 16.5 vs. 19.3% (p = 0.39). Creation of a DI was not associated with higher odds of 30-day readmission (OR = 1.4, p = 0.31). ConclusionCreating a DI necessitates an additional surgery for closure and is not associated with decreased adverse outcomes. There is still a role for multicenter studies to define which patient populations may benefit from diversion. Level of EvidenceRetrospective comparative study. Type of StudyLevel III.

Update on Familial Adenomatous Polyposis-Associated Desmoid Tumors.

Desmoid tumors (DT) represent the second high risk of tumor in familial adenomatous polyposis (FAP) patients. Although FAP-associated DTs (FAP-DT) are caused by germline mutations in the adenomatous polyposis coli (APC) gene, extracolonic manifestations, sex, family history, genotype, and the ileal pouch anal anastomosis procedure are all linked to the development of DTs in FAP patients. Multidisciplinary management has replaced aggressive surgery as the preferred treatment of DTs. There is growing evidence to support the use of active surveillance strategy as first-line treatment for FAP-DT patients. Radiotherapy for intra-abdominal desmoids is now rarely used because of severe late toxicity. Pharmacotherapy, however, represents a promising future with the improvement of traditional cytotoxic drugs and the investigation of targeted drugs. Although nonsurgery treatment has been used widely nowadays, surgery remains the mainstay when symptomatic or life-threatening DTs are present. Further research will be needed for more optimal clinical practice.

A91 INTERACTIONS BETWEEN PREGNANCY, DELIVERY, AND ILEAL POUCH-ANAL ANASTOMOSIS FOR INFLAMMATORY BOWEL DISEASE: A RETROSPECTIVE CHART REVIEW

Abstract Background Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that affects people in their reproductive years of life. Surgical treatment for medically refractory UC involves surgery over 2-3 stages, which includes a subtotal colectomy followed by creation of an ileal pouch-anal anastomosis (IPAA), known as a “J pouch”. The IPAA allows preservation of fecal continence and avoids the psychosocial impacts of a stoma. The IPAA procedure is a deep pelvic surgery, which may impact pregnancy outcomes. Caesarean section (C-section) delivery is often performed to avoid anal sphincter and J pouch damage from vaginal delivery. However, literature demonstrates conflicting results regarding the risks of C-section compared to vaginal delivery, including the impact on pouch function. Surveys of clinicians also report varying delivery recommendations. Purpose To describe the delivery methods, pregnancy outcomes and postpartum course of IBD patients with IPAA at Mount Sinai Hospital. Method A retrospective chart review is being performed for female patients at Mount Sinai Hospital (Toronto, Ontario) with a diagnosis of IBD and an IPAA. Eligible patients completed a pregnancy from January 1, 2002-February 1, 2021 post-IPAA surgery and had variables of interest accessible in their electronic medical record. Variables of interest include demographics, pregnancy history, IBD characteristics, IPAA surgery details, pregnancy outcomes, mode of delivery and characteristics, and postpartum complications. Clinical data will be presented as means, medians and frequencies. Differences between variables of interest will be evaluated with Student’s t-test or chi-squared test. Result(s) Three avenues of patient identification yielded 1113 patients to be screened. Inclusion criteria were met for 71 patients and chart review is complete for 36 patients who had a total of 53 pregnancies and delivered 56 babies. Most patients (49%) had a two-stage IPAA surgery, 21% required a three-stage surgery and 30% were undocumented. Most patients’ (55%) IPAA was created through laparotomy, while 13% was through laparoscopic procedure and 32% was undocumented. Seventy-four percent of deliveries were through C-section (75% of primiparous), 69% of which were indicated to protect the patient’s J pouch and 31% for an obstetrical indication. The remaining 26% of deliveries were vaginal, 29% of which were assisted with forceps or vacuum, 57% had tears (37.5% first-, 37.5% second-, and 25% third-degree) and 50% had an episiotomy. Conclusion(s) At Mount Sinai Hospital, most IBD patients with an IPAA who completed a pregnancy had a history of laparotomy to create their IPAA. Most patients (74%) with IBD and an IPAA are delivering through C-section, and mainly to protect their J pouch, which is in line with reports in the literature. Most patients had a tear or episiotomy during vaginal delivery. Rates of third-degree tears may be higher than in the general population. Trends will be further elucidated with advancement of the study. Disclosure of Interest None Declared

THIRD TIME’S THE CHARM? INDICATIONS AND LONG-TERM OUTCOMES AFTER REDO-REDO ILEAL POUCH ANAL ANASTOMOSIS

Abstract BACKGROUND Pouch failure after redo ileal pouch anal anastomosis (IPAA) occurs in 20-40% of cases. The decision to offer a second redo procedure to maintain intestinal continuity is controversial, and scarce evidence exists regarding long-term pouch survival and functional outcomes after redo-redo IPAA. METHODS We retrospectively analyzed our prospectively collected pouch registry for redo IPAA procedures and identified all patients who underwent a second redo IPAA procedure from 2004 to 2021. Our primary outcome was pouch survival, defined as no pouch excision or rediversion. Figures are frequency (percentage) and median (interquartile range). RESULTS Twenty-three patients met inclusion criteria (65% female, 4% of all redo IPAAs). The index diagnosis was ulcerative colitis in 20 (87%) cases and indeterminate colitis in 3 (13%). The median interval between the index pouch and the second redo was 36 (24 – 90) months, while the median time between the first and second redo was 16 (9 – 36.5) months. Only 8 (35%) of patients had their stoma closed between the first and second redo. In 15 (65%) cases both redo procedures were done at our center. The indication for pouch salvage was the same for the first and second redo in 21 (91%) cases (Figure 1): 20 (87%) patients both redo for septic complications. Second redos were done transabdominally in 21 (91%) of cases, and 14 (61%) involved pouch excision and construction of a neo-pouch. All were handsewn, and the final pouch configuration was “J” in 18 (78%) and “S” in 5 (22%) cases (Figure 2). Twenty (87%) had their stoma closed after the second redo. After a median follow up of 39 months (18.5 – 95.5), 10 (44%) patients experienced pouch failure (due to sepsis in 9 cases of which 3 never had their stoma closed, and poor function in 1). Pouch survival was 81% at 1-year, and 76% at 3-years. The median interval between second redo and pouch failure was 12 months (3 – 50.5). Postoperative Cleveland Global Quality of Life surveys were available for 17 (74%) patients. After a median interval of 14 (6 – 40) months, the overall quality of life score (0 -1) was 0.6 (0.5 – 0.8). The median number of bowel movements was 6 (5 – 8) during daytime, 2 (2 – 4) at night, for a total of 8 (6.5 – 12.5) per 24 hours. Urgency occurring most days of the week was reported by 30%, frequency by 14%, seepage during the day by 71% and at night by 86%. Dietary restrictions were reported by 50% of patients, social restrictions by 44%, work restrictions by 62.5%, and sexual restrictions by 50%. CONCLUSION A second redo pouch procedure may be offered with acceptable outcomes to a very select group of patients who are highly motivated to maintain intestinal continuity.

S3338 Use of the IBD Disk Tool for Evaluation of Patient Reported Outcomes (PRO) in Patients Suffering From Recurrent Pouchitis

Introduction: Although the primary treatment for UC is medical, approximately 20% to 30% of patients with Ulcerative Colitis (UC) will undergo proctocolectomy. Ileal Pouch anal anastomosis (IPAA) surgery is an option for patients to restore gut continuity post proctocolectomy. The majority of patients will develop pouchitis. We report patient use and applicability of the IBD-Disk in pouchitis patients at a tertiary IBD Centre in the West Midlands. Methods: 11 patients attending the pouch clinic at a tertiary IBD centre in West Midlands were interviewed over a 6 month period (December 2020 to May 2021) with regards to their functional disability using the IBD Disk. In addition they were asked to provide their insights as to what additional symptoms should be included as part of the Disk. This element was deemed crucial as the original IBD Disk did not include patient involvement in its design. Results: 9/11 (82 %) were male. Age ranged from 35 to 73 years, mean 51 years. 8/11 (72 %) were White British and the remaining were Asian. Mean pouch duration was 18 years, range 3 to 30 years. Except for 1 patient, all others had a single IPAA procedure. 5/11 (45 %) had a single course of antibiotics with a maximum duration of a month, namely Ciprofloxacin or Metronidazole. Out of the 10 components of the IBD Disk, lack of energy and feeling tired was the most important for our patients with a mean score of 7.3/10 followed by abdominal pain with a mean score of 6.7 and difficulty sleeping with a mean score of 6.4. The lowest scoring domains were education and work, mean score 3.5 followed by interpersonal interactions 3.7. Additional symptoms that were important to this patient group but not included in the IBD Disk were mental wellbeing, rectal bleeding and fever. Incontinence for liquid stools also proved to be an important concern to 82% (9/11) of patients. Further aspects of concern comprised needing to wear a pad or plug, inquiring about their health on the day of the clinician visit and the effect of food on their pouch symptoms (54.5%) (6/11). Conclusion: The IBD Disk was used to assess its potential in our pouchitis patients. Its limitation however is that it is not designed for pouchitis specifically and was not developed with patient involvement. This work would suggest however that the IBD disk may be adaptable for use in this patient group by the addition of the following symptoms- mental well being, rectal bleeding, fever and incontinence.

S0777 Time Trend Analysis of Pre-Operative Characteristics and Post-Operative Pouch Outcomes in UC Patients Undergoing Ileal Pouch Anal-Anastomosis

INTRODUCTION: Proctocolectomy and ileal pouch anal anastomosis (IPAA) is the treatment of choice for patients with medically resistant ulcerative colitis. In this retrospective cohort study, we aimed to observe trends in pre-operative characteristics and post-operative pouch outcomes experienced by patients undergoing IPAA based on the decade of the surgery. METHODS: We obtained electronic medical record data from patients at our tertiary Inflammatory Bowel Disease Center. Patients with a pre-operative diagnosis of UC who underwent an IPAA procedure between January 1990 and May 2017 were included in this study and were followed until December 31, 2019. We stratified the data according to the decade of surgery and assessed differences between groups using t-tests for continuous data and Chi-square tests for categorical variables. We used Kaplan Meier curves to visualize the probability of pouch survival based on the decade of surgery. We also created a Cox proportional hazards model and adjusted for covariates to determine factors associated with pouch failure (defined as pouch excision). RESULTS: A total of 322 patients were included in the study and the median length of follow-up was 8.9 years. 10% of patients experienced pouch failure. Over time, there was a significant increase in the percentage of patients treated with anti-TNF therapies before surgery, the number of IPAAs conducted with stapled anastomoses, and the number of three-stage surgical procedures (Table 1). Pouch survival analysis stratified by decade of surgery demonstrated a significant decrease in the probability of pouch survival in more recent years (Figure 1). A Cox proportional hazard model adjusted for covariates showed that patients having an IPAA in the 2000s or 2010s had 5-times (AHR: 4.68; 95% CI: (1.43–15.34), P < 0.05) and 17-times (AHR: 17.23 95% CI: (3.51–84.57), P < 0.001) greater likelihoods of pouch failure, respectively, than patients who had their surgeries in the 1990s (Table 2). CONCLUSION: This study demonstrates that the likelihood of pouch failure in patients who underwent surgery in the most recent decade is greater than those who underwent surgeries in prior decades. Increased exposure to anti-TNF therapies in this population suggests that these patients may have more refractory disease. Additional studies should be conducted in order to further elucidate the underlying drivers of this association.Table 1.: Study PopulationTable 2.: Adjusted Cox Proportional Hazard Model For Pouch Failure. A Cox proportional hazards model was used to determine factors associated with pouch failure (defined as pouch excision). The multivariable model included all variables found to be statistically significant in univariable analyses along with covariates thought to be associated with pouch failure. A P-value less than 0.05 was considered to be statistically significantFigure 1.: Pouch Survival Probability For UC Patients Based on Decade of IPAA. Data were stratified according to the decade that surgery was performed. For patients who underwent multi-stage procedures, this was defined as the decade that the first stage was performed. Statistical differences between groups were determined using a log-rank test and a P-value less than 0.05 was considered statistically significant.

Anastomotic leak does not affect long-term and longitudinal functional outcomes after ileal pouch surgery for ulcerative colitis when managed aggressively.

Ileal pouch-anal anastomosis (IPAA) is an effective surgical alternative to a permanent ileostomy following proctocolectomy in patients with ulcerative colitis (UC). Anastomotic leakage (AL) is a serious postoperative complication of an intestinal anastomosis that is associated with increased morbidity and mortality. The aim of this study was to evaluate the longitudinal long-term functional outcomes of patients who had IPAA that was complicated by AL. A retrospective longitudinal cohort study was performed of patients who had an IPAA procedure at a tertiary referral centre and a metropolitan private centre in Australia, over a 14-year period (October 2003-October 2017). The long-term functional outcome was assessed using objective clinical measures such as the number of bowel motions during the day and overnight, ability to defer defaecation and the presence of faecal incontinence, and repeated at annual intervals. A total of 138 patients [mean age 38.5 (± 16.9) years, 72 males] satisfied the inclusion criteria. AL was diagnosed in 14 (10%) patients [mean age 38.8 (± 17) years, 10 males], 11 (79%) of which were managed with surgery. The median bowel motion frequency during the day and overnight remained stable over a median of 62 (28-91) months follow-up, with no significant difference between those who had AL or not (p = 0.6, p = 0.1 respectively). The incidence of faecal incontinence remained low, and the majority of patients in both groups were able to defer defaecation for more than 60min. Six patients (4.3%) had their pouch excised. There is no statistical difference in longitudinal function between patients who experienced AL after IPAA surgery for UC compared with those who did not. Therefore, an acute AL does not negatively impact long-term functional outcomes in IPAA patients.

Timing of prophylactic colectomy in familial adenomatous polyposis.

The aim was to evaluate the timing of prophylactic colectomy in patients with familial adenomatous polyposis (FAP) in Finland. All Finnish FAP patients were included from the years 1963-2018. Among the 452 FAP patients studied, 252 were called up as relatives of the proband. Of these, 180 underwent prophylactic colectomy. Patient data including mutation characteristics and surgical technique were collected. We assessed the timing of prophylactic colectomy in relation to the time of diagnosis, time of decision for surgery and age. There were 94 (52%) colectomies with ileorectal anastomosis, 79 (44%) proctocolectomies with ileal pouch-anal anastomosis and seven (4%) proctocolectomies with an ileostomy. Median age at diagnosis and at the time of surgery was 20.9 and 25.2years, respectively. The median time from decision to operate to undergoing surgery was 4months. There were eight (4%) cancers in the colectomy specimens, but none was found during the annual follow-ups after the first-round endoscopy. After genetic testing became available, the diagnosis was made primarily by either genetic testing in 52 (49%) or endoscopy in 54 (51%) patients at a median age of 17.8 and 19.3years, respectively. Thirty-eight (21%) patients died during follow-up, 23 (61%) for FAP-related reasons and only six from rectal cancer. The relative survival of 30years from diagnosis was 84% and 78% in men and women, respectively. For those who underwent surgery, timing of prophylactic surgery was successful as there were no unexpected colorectal cancers found in colectomy specimens among the screened patients. Two major improvements over the study period have changed the treatment of FAP patients: one is the introduction of the ileal pouch-anal anastomosis procedure and the other is the availability of genetic testing. FAP-related extra-colonic malignancies affect the relative survival of these patients after prophylactic surgery.

A New Rat Model of Pouchitis After Proctocolectomy and Ileal Pouch-Anal Anastomosis Using 2,4,6-Trinitrobenzene Sulfonic Acid

BackgroundPouchitis is a common complication after ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis. However, an ideal model remains lacking. Therefore, we aimed to establish an appropriate model resembling human pouchitis. MethodsSprague-Dawley rats were randomly assigned to five groups: TNBS group, DSS group, NS group (following IPAA procedure, administrated with TNBS enema, DSS orally, normal saline enema, respectively), NI group (underwent IPAA), and sham group (underwent switch abdominal surgery). General status, weight change, hematochezia, and fecal scores were recorded. Fecal microbiota were counted under a microscope and analyzed by 16S rRNA gene high-throughput sequencing. Specimens of ileal pouch and small intestine (proximal, mid, distal) were collected to evaluate myeloperoxidase and occludin expression by immunohistochemistry and mRNA expression of pro-inflammatory markers by PCR. ResultsGeneral status, hematochezia, fecal score, and increased mRNA expression of interleukin-6 and TNF-α in the TNBS group were similar to those in the DSS group, whereas the TNBS-induced model displayed a more stable weight change and more serious dysbacteriosis, not only was fecal bacterial diversity reduced, the dominant microbiota was altered. Histopathology scores of the distal small intestine in the TNBS group were lower compared with those in the DSS group (P < 0.05). A significant difference in myeloperoxidase and occludin expression in the small intestine was also detected between the TNBS and DSS groups. ConclusionsOur model mimicked the characteristics of human pouchitis and avoided potential side effects in the small intestine, and thus could be employed for further research.

P103 FULMINANT CLOSTRIDIUM DIFFICILE ENTERITIS IN A PATIENT WITH ULCERATIVE COLITIS FOLLOWING TOTAL COLECTOMY RELIEVED BY ILEAL DECOMPRESSION

Abstract A 20 year old female with a history of Ulcerative colitis status post total colectomy and end ileostomy was admitted to the intensive care unit with septic shock. She had initially been diagnosed with fulminant ulcerative pancolitis three months prior, and after failing to respond to dual therapy with high dose infliximab and azathioprine, she underwent total colectomy and end ileostomy as the first part of a staged ileal pouch-anal anastomosis procedure. Upon presentation to the emergency department, she endorsed fevers, chills, abdominal pain, and decreased stomal output. Diagnostic workup was notable for polymerase chain reaction (PCR) positive for Clostridium difficile toxin A and toxin B. She began treatment with oral vancomycin and IV flagyl, but remained critically ill with persistent fevers, vasopressor requirement and imaging showing 4.1 cm dilation of her distal ileum. As such the decision was made to attempt decompression via placement of a rectal tube into her ileostomy, after which her ostomy output improved from &amp;lt;20cc/day to 7L in the ensuing 48 hours. During this time she defervesced, was taken off of vasopressors, and was able to be discharged from the hospital one week later. Infectious agents are the most common cause of diarrhea worldwide. Amongst implicated culprits, C. difficile is both the most common nosocomial infection and the most common cause of death due to gastrointestinal infections. Mechanisms of infectious diarrhea include formation of various toxins as well as cellular adherence and invasion (1). In the case of C. difficile, the gram positive anaerobe produces both an enterotoxin (toxin A) and a cytotoxin (toxin B). In patients found to have C. difficile infections (CDI), the vast majority are affected by colitis. There is a small prevalence of extracolonic CDI, including extraintestinal in a small subgroup (0.17%)(2). According to literature, extracolonic CDI carries a 20% mortality rate. Out of those cases of extracolonic CDI, the majority (4/7 in a small case series), had a history of a previous colonic surgery (3). It has been postulated that the reason for increased prevalence amongst patients with previous colonic surgery is the adaptation of ileal flora to resemble fecal flora following ileostomy (3). Although not considered to be standard of care, colonic decompression has been described for patients with toxic megacolon refractory to medical therapy. In a seven patient series which looked at decompressive colonoscopy with intracolonic perfusion of vancomycin in patients with toxic megacolon, 57% had complete resolution (5). In a patient who has undergone ileostomy and who had a significant amount of dilation on her imaging, we felt that her clinical scenario was analogous to megacolon, and that an escalation in therapy was warranted. Image 1. CT Abdomen showing diffuse ileal dilation

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.

Long-term outcomes following restorative proctocolectomy ileal pouch-anal anastomosis in pediatric ulcerative colitis patients: Multicenter national study in Japan.

BackgroundFew studies have investigated surgical outcomes following a colectomy in pediatric patients with ulcerative colitis (UC).PurposeThis study aimed to determine long‐term outcomes in a large cohort of pediatric patients who underwent proctocolectomy with ileal pouch‐anal anastomosis (IPAA) for UC.MethodsPediatric patients (<17 years old) who underwent surgery at 12 different hospitals in Japan between May 1979 and March 2015 were included in this study. Information was obtained by the use of a questionnaire survey.ResultsThere were 113 (53.3%) male and 99 (46.7%) female pediatric patients. The most common indication for elective surgery was failure of medical management, whereas emergency surgery was carried out for fulminant cases. A hand‐sewn IPAA was used with a mucosectomy in 112 (52.8%), stapled anastomosis in 93 (43.9%), and not specified in 7 (3.3%) patients. Small bowel obstruction and surgical site infection were the most frequent early postoperative complications (POC), whereas pouchitis, small bowel obstruction, and perianal fistula were frequent late POC. The most common late POC was pouchitis, found in 38 (17.9%) of the patients, whereas pouch failure was noted in 11 patients at the latest follow‐up examination. Cumulative pouch survival rate after 10 years was 91.7%. There were no significant differences regarding gender or anastomotic procedure in relation to cumulative pouch survival rate.ConclusionTo avoid pouch failure following an IPAA procedure, it is important to recognize that pouchitis or an anal fistula may lead to this condition in pediatric UC patients.

P325 Risk factors for lymph node involvement in patients undergoing ileal pouch-anal anastomosis for ulcerative colitis complicated by colorectal cancer in the biological years

Patients affected by ulcerative colitis (UC) have an increased risk of developing colorectal cancer (CRC), being extensive and long-standing disease associated with neoplasia. Little is known about the predictors for nodal positivity (N+) at time of surgery, especially since the introduction of biologics. The aim of this study was to compare patients undergoing ileal pouch-anal anastomosis (IPAA) for CRC complicating UC for demographic characteristics and perioperative variables depending on the lymph node involvement at the histology. Since 2002, patients undergoing an IPAA procedure for UC complicated by CRC were retrospectively included. N+ patients were compared with a control group of patients without nodal involvement (N−) for demographic characteristics, use of biological drugs, clinical features. Statistical tests for comparison of continuous or categorical variables were used as appropriate. Forty-eight patients were included. Surgical data are reported in Table 1. Perioperative variables of patients undergoing IPAA for ulcerative colitis complicated by colorectal cancer. Variables are presented as N(%) or median (range) Perioperative variables of patients undergoing IPAA for ulcerative colitis complicated by colorectal cancer. Variables are presented as N(%) or median (range) Histological findings are detailed in Table 2 while perioperative risk factors for nodal involvement are reported in Tables 3 and 4. Data of biologic drugs are reported in Table 5. Pathological features. Variables are presented as N (%) or median (range) Pathological features. Variables are presented as N (%) or median (range) Patients and UC clinical features according to nodal involvement (p value was considered statistically significant when <0.05) Patients and UC clinical features according to nodal involvement (p value was considered statistically significant when <0.05) Indication to surgery, age at surgery, and cancer localisation based on nodal involvement (p value was considered statistically significant when <0.05) Indication to surgery, age at surgery, and cancer localisation based on nodal involvement (p value was considered statistically significant when <0.05) History of preoperative biological treatment History of preoperative biological treatment A younger age at diagnosis of UC (p = 0.039) and at IPAA surgery (p = 0.010) identifies patients at a higher risk of nodal involvement. Duration, activity, and extension of disease at the time of surgery are not associated with nodal positivity. A history of the use of more than one biological agent increases significantly the chance of nodal metastases. Despite the bias of limited numbers and the retrospective nature, our study suggests that younger patients with a history of biological treatment (especially if more than one agent) should undergo a more intensive endoscopic and clinical follow-up.

Post-operative outcome following ileal pouch-anal anastomosis (IPAA)

Background IPAA procedure is the surgery of choice in severe ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The objectives of the study were to assess symptomatic improvement, complications, effect on sexual function and quality of life (QOL) following IPAA procedure. Methods Twenty one patients who underwent IPAA procedure at a tertiary care unit with a minimum of one year follow-up from 2009, were included. QOL was assessed retrospectively prior to surgery and one year after surgery using Cleveland Global Quality of Life Score (CGQLS). Details of pre and post-op symptoms, complications and sexual function were obtained using clinical records, operative notes and interviewer administered questionnaire. Results Male: female ratio was 1.33:1. Fourteen (66.7%) were sexually active and seven (33.3%) were not. Mean age was 40.48(range, 17-69) years. 13(61.9%) had UC and 8(38.1%) had FAP. Mean pre-op CGQL scores for UC and FAP were 0.5754 and 0.7537 respectively. Post-op CGQLS for UC and FAP were 0.7532 and 0.7070. There was no statistically significant difference between CGQL scores against the indication for surgery (P=0.779). Stool frequency was significantly reduced in UC (pre-op=12.4, post-op=5.2 per day, p=0.004) but no difference in FAP (pre-op=2.6, postop= 3.5 per day, p=0.292). Post-operatively, one patient developed erectile dysfunction and another patient developed dyspareunia. Conclusion There is no significant difference of CGQL scores following IPAA procedure in relation to the surgical indication. IPAA significantly reduced stool frequency per day in UC but not in FAP. Erectile dysfunction and dyspareunia are possible sexual dysfunctions following IPAA procedure.

P372 The long term course of patients undergoing ileal pouch-anal anastomosis for ulcerative colitis

Background: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice for patients with ulcerative colitis who require colectomy for medically refractory disease or other complications such as dysplasia. The aim of this study was to evaluate the long term course of patients undergoing IPAA for ulcerative colitis, and to assess the occurrence of pouchitis and other complications. Methods: A retrospective analysis of all records of patients admitted at “Villa Sofia-Cervello” Hospital from 1988 to 2016 who underwent proctocolectomy with IPAA for ulcerative colitis was performed. At least one endoscopic evaluation during follow-up was available for all patients. Results: Among 1,490 patients with ulcerative colitis admitted at “Villa Sofia-Cervello” Hospital during the study period, the records of 71 patients (4.8%) undergoing IPAA were analyzed. The surgical procedure was performed in two stages in the majority of cases (76.0%), and the median time to recanalization was 6 months (I.Q.I. 6.5). The mean duration of follow-up after IPAA procedure was 110±77 months. The occurrence of pouchitis was reported in 48 (67.6%) patients. The time between IPAA and the diagnosis of pouchitis ranged from 1 to 120 months, with a median of 12 months. In addition, 33 out of 48 patients (68.8%) developed chronic pouchitis, while Crohn's disease of the pouch was diagnosed in four patients (8.3%). The stenosis of the anastomosis was reported in 18 patients (37.5%), and the presence of abscesses/fistula in 11 (22.9%). The occurrence of pouch failure was observed in 6 patients (12.5%), all of them suffering from chronic pouchitis complicated by fistulizing disease. No dysplasia nor Cytomegalovirus infection of the pouch were reported. Subgroup analysis of patients developing pouchitis revealed that only the chronic form of this condition was associated with the stenosis of the anastomosis, which conversely was rarely observed when the pouchitis was episodic and did not became chronic (88.9% vs. 11.1%, p=0.04). Conclusions: Our cohort with long term follow-up showed that pouchitis and chronic pouchitis are very frequent events. Conversely, Crohn's disease of the pouch is rare, and no cases of Cytomegalovirus infection of the pouch were reported.

Assessment of Age in Ulcerative Colitis Patients with Ileal Pouch Creation—An Evaluation of Outcomes

The aim of the study was to determine if age at the creation of an ileal pouchanal anastomosis (IPAA) has an impact on the outcomes in patients with ulcerative colitis (UC). A retrospective review of all patients who underwent IPAA for UC from 1999 to 2011 was performed. Long-term functional outcome was assessed using both the Cleveland Clinic and St Mark's incontinence scores. Eighty-nine patients, with a median age of 46 (range, 16 to 71) years, formed the study group. The median duration of disease prior to their pouch surgery was 7 (0.5 to 39) years. There were 57 (64%) patients who were aged ≤50 years old and 32 (36%) who were >50 years old. Fifty-seven (64%) patients developed perioperative complications of which 51 (89.5%) were minor. High ileostomy output (n = 21, 23.6%) and urinary symptoms (n = 13, 14.6%) were the most commonly encountered complications. The older patients were more likely to have an ASA score ≥3 and a longer length of stay. Although there was a higher incidence of complications in the older group of patients, the difference was not statistically significant. There were no significant differences in the incidence of severe complications. Forty-nine (55%) patients completed our questionnaire on the evaluation of their functional outcomes. There were no significant differences in the Cleveland Clinic and St Mark's incontinence scores between the older (n = 19, 38.8%) and younger (n = 30, 61.2%) patients. There were also no significant differences in the frequency of bowel movements during the day or overnight after sleep between the 2 groups. IPAA procedure for patients with UC can be safely performed. Long-term functional outcome is not significantly influenced by the age at which the IPAA was created.

A contemporary and critical appraisal of ‘indeterminate colitis‘

Distinguishing ulcerative colitis (UC) from Crohn's disease (CD) is normally based on evaluation of a variety of clinical, radiologic, serologic and pathologic findings, the latter in biopsy and/or resection specimens. Unfortunately, some patients with IBD show overlapping pathologic features of UC and CD, which makes definite distinction between these two disorders difficult or even impossible. In most instances of uncertainty, the patient shows clinical and pathologic features of UC, but in addition, the patient's colon resection specimen reveals one or more CD-like features. In this setting, a diagnosis of indeterminate colitis (IC) is often rendered. IC is not a distinct disease entity, and, thus, it has no diagnostic criteria. The most common causes of uncertainty in IBD pathology that may lead to a diagnosis of IC in a colon resection specimen includes the presence of fulminant (severe and toxic) colitis, insufficient radiologic, endoscopic, or pathologic information (including analysis of prior biopsies) on the patient, failure to utilize major diagnostic criteria as hard evidence in favor of CD, failure to recognize unusual variants of UC and CD that may mimic each other, failure to recognize non-IBD mimics and other superimposed diseases that cause unusual pathologic features in a resection specimen, an attempt to distinguish UC from CD in mucosal biopsies of the colon and ileum, or an attempt to change the patients diagnosis (of UC or CD) based on pouch or diversion-related complications. Details of each of these causes of uncertainty are discussed, in detail, in this review article. A diagnosis of IC should never be made clinically or by pathologists based on evaluation of pre-resection colonic mucosal biopsies. Ultimately, the majority of indeterminate cases represent UC, and, thus, most of these patient can be treated safely with a colectomy combined with an ileal pouch anal anastomosis procedure.

Reduced neurons in the ileum of proctocolectomized rat models.

Ileal pouch-anal anastomosis (IPAA) is the operation of choice following proctocolectomy for patients who suffer from ulcerative colitis and familial adenomatous polyposis. The aim of this study was to morphologically examine the neurons, endocrine cells and mast cells in the ileum of rats subjected to proctocolectomy followed by three different types of ileoanal anastomosis. Rats were subjected to either sham operation or proctocolectomy followed by ileoanal anastomosis end-to-end, side-to-end or IPAA (J-pouch). In comparison to sham-operated rats, the body weight was reduced in rats that underwent proctocolectomy with end-to-end or side-to-end, but not IPAA procedure. In all three models of ileoanal anastomosis, the ileum displayed crypt hyperplasia with a chronic inflammatory infiltrate located in the interstitium, hyperplasia of goblet cells, but reduced protein gene product 9.5 (PGP 9.5)-immunoreactive neurons in the mucosa as well as submucosa. Numbers of endocrine cells in the mucosa (chromogranin A immunostaining) and mast cells in the mucosa and submucosa (Astra blue staining) were unchanged after proctocolectomy. In conclusion, neurons, but neither endocrine cells nor mast cells, were reduced in the ileum of proctocolectomized rats followed by either of three different types of ileoanal anastomosis.