Ileal Pouch-anal Anastomosis Surgery Research Articles

Long Rectal Cuff and Remnant Mesorectum Are Major Preventable Causes of Ileal Pouch Failure.

Long rectal cuff (>2 cm) and remnant mesorectum are known causes of pouch dysfunction due to obstructive defecation, as well as pelvic sepsis after prolonged obstruction. The aim of this study is to report the rates and the management of patients who underwent re-do ileal pouch anal anastomosis due to pouch failure associated with retained mesorectum and long rectal cuff. This is a retrospective study. The investigation is based on a quaternary inflammatory bowel disease center. Patients undergoing re-do ileal pouch anal anastomosis surgery and had long rectal cuff and/or remnant mesorectum between September 2016 and September 2023 were included in the study. The main outcomes were functioning pouch rate and functional results. Of the 245 patients who underwent re-do ileal pouch anal anastomosis surgery, 98 (40%) patients had long rectal cuff and/or remnant mesorectum. Re-do ileal pouch anal anastomosis in this patient group was successful (92%) at a median follow-up of 28 (18-52) months. The retrospective nature of the study and this is the experience of a single specialized center. Long rectal cuff and remanent mesorectum are major causes of pouch failure which can be successfully managed with re-do ileal pouch anal anastomosis surgery. Nearly half of pouch failure patients who had successful re-do ileal pouch anal anastomosis surgery initially received unnecessary biologic therapy before coming to our center. See Video abstract.

Decreased CD3+CD56+ Natural Killer T Lymphocytes and Increased Human Leukocyte Antigen-DR+ Cells in the Inflamed Area of Pouchitis in Ulcerative Colitis Patients.

Pouchitis is an inflammatory condition that affects the ileal pouch during ileal pouch-anal anastomosis surgery. Despite its clinical significance, precise immunological mechanisms underlying pouchitis remain unclear. This study aimed to investigate the lymphocyte profile in the ileal pouch of patients with pouchitis compared to those with familial adenomatous polyposis (FAP) and ulcerative colitis without pouchitis using flow cytometry and immunohistochemical techniques. We prospectively analyzed endoscopic biopsy specimens from the ileal pouches of 15 patients and categorized them into three groups: FAP, ulcerative colitis with an inflammation-free pouch (UC-I), and ulcerative colitis with ulcers and/or erosions in the pouch (UC-UE). Flow cytometry was used to assess various T-lymphocyte markers, including cluster of differentiation (CD) 4, CD8, CD56, and human leukocyte antigen (HLA)-DR. Immunohistochemistry was performed to visualize the spatial distribution of CD3+, CD56+, and HLA-DR+ cells in the pouch mucosa. We observed significantly reduced CD56+/CD3+ and CD8+/CD3+ ratios in the UC-UE group compared to those in the FAP group, indicating a disruption in natural killer T-cell populations. Immunohistochemical analysis revealed that the spatial distribution of lymphocytes differed among the non-inflamed mucosa, dense lymphocyte infiltration, and lymphoid follicles, with these components frequently intermingling. CD56 + cells were less abundant in areas with dense lymphocyte infiltration, whereas HLA-DR+ cells were more abundant. Our study revealed a decrease in CD56+ natural killer T cells and an increase in HLA-DR+-activated T cells in areas with dense lymphocyte infiltration, suggesting an association between these cells and pouchitis in ulcerative colitis. The distinct patterns observed in non-inflamed mucosa, areas with dense lymphocyte infiltration, and lymphoid follicles underscore the need for further analyses of these three segments to elucidate the immunological mechanisms underlying pouchitis.

Extensive Colitis and Smoking Are Associated With Postoperative Complications Within 30 Days of Ileal Pouch-Anal Anastomosis.

Our understanding of outcomes after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is largely based on analyses of selected populations. We created a state-level registry to evaluate the epidemiology of IPAA surgery and pouch-related outcomes across the major healthcare systems performing these surgeries in our state. We created a retrospective cohort of all patients undergoing restorative proctocolectomy with IPAA for UC at 1 of 4 centers between January 1, 2018, and December 31, 2020. The primary outcomes of this study were the rate of complications and all-cause readmissions within the first 30 days of the final stage of IPAA surgery. During the study period, 177 patients underwent IPAA surgery with 66 (37%) experiencing a complication within 30 days. After adjusting for the number of stages in IPAA surgery, patients with extensive UC (odds ratio, 3.61; 95% confidence interval, 1.39-9.33) and current or former smokers (odds ratio, 2.98; 95% confidence interval, 1.38-6.45) were more likely to experience a complication. Among all patients, 57 (32%) required readmission within 30 days. The most common reasons for readmission were ileus/small bowel obstruction (22%), peripouch abscess (19%), and dehydration (16%). In this first state-level examination of the epidemiology of IPAA for UC, we demonstrated that the complication rate after IPAA for UC was 37%, with one-third of patients being readmitted within 30 days. Extensive disease at the time of colectomy appears to be an indicator of more severe disease and may portend a worse prognosis after IPAA.

Pouch abandonment is extremely rare even in the reoperative setting: A high-volume referral center experience

BackgroundIleal pouch anal anastomosis is the preferred method for restoration of intestinal continuity after proctocolectomy. Successful ileal pouch anal anastomosis requires adequate reach of the ileal mesentery to the pelvis. Reach issues are a common cause for intraoperative pouch abandonment; however, data regarding contemporary abandonment rates are rare and nonexistent in the revisional setting. MethodsA retrospective review was conducted of consecutive ileal pouch anal anastomosis surgery at a single referral center. Both initial or “primary” pouches and revisional pouch surgery were included. ResultsIn total, 447 attempts at pouch anal anastomosis were made, with an 1.6% overall rate of intraoperative abandonment. Pouch abandonment was attributed to inadequate mesenteric reach during 3 surgeries, desmoid tumors in 2 surgeries, and insufficient remaining small bowel in 2 surgeries. Twelve patients required lengthening maneuvers including 6 S pouches (1%) and 6 H pouches (1%). One half (49%) of operations were revisional ileal pouch anal anastomosis surgery. Overall, reach issues led to intraoperative abandonment in only 0.4% of attempted primary pouches and 1.0% of revisional surgeries. A preoperative diagnosis of familial adenomatous polyposis was associated with pouch abandonment (P < .001). ConclusionExtremely low pouch abandonment rates as a result of mesenteric reach can be achieved even in the revisional setting at a high-volume center with institutional expertise. In the revisional setting, intra-abdominal desmoids or the potential for short gut affects pouch abandonment rates as much as reach issues.

A Rat Model of Pouchitis Following Proctocolectomy and Ileal Pouch-Anal Anastomosis Using Dextran Sulfate Sodium.

Ulcerative colitis (UC) is a chronic immune-mediated disease that affects the entire colon and rectum with a relapsing and remitting course, causing lifelong morbidity. When medical treatment is ineffective, especially in cases of massive gastrointestinal bleeding, perforation, toxic megacolon, or carcinogenesis, surgery becomes the last line of defense to cure UC. Total colorectal resection and ileal pouch-anal anastomosis (IPAA) offer the best chance for long-term treatment. Pouchitis is the most common and troublesome postoperative complication. In this investigation, microsurgery is employed to create an ileal pouch model in experimental rats via IPAA surgery. Subsequently, a sustained rat model of pouchitis is established by inducing inflammation of the ileal pouch with dextran sulfate sodium (DSS). The successful establishment of rat pouchitis is validated through analysis of postoperative general status, weight, food and water intake, fecal data, as well as pouch tissue pathology, immunohistochemistry, and inflammatory factor analysis. This experimental animal model of pouchitis provides a foundation for studying the pathogenesis and treatment of the condition.

Antibiotic Use in the 12 Months Prior to Ileal Pouch-Anal Anastomosis Increases the Risk for Pouchitis

Pouchitis is the most common complication after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC); however, clinical and environmental risk factors for pouchitis remain poorly understood. We explored the relationship between specific clinical factors and the incidence of pouchitis. We established a population-based cohort of all adult persons in Denmark undergoing proctocolectomy with IPAA for UC from 1996-2020. We used Cox proportional hazard modeling to assess the impact of antibiotic, nonsteroidal anti-inflammatory drug (NSAID) exposure, and appendectomy on diagnosis of acute pouchitis in the first 2 years after IPAA surgery. Among 1616 eligible patients, 46% developed pouchitis in the first 2 years after IPAA. Antibiotic exposure in the 12 months before IPAA was associated with an increased risk of pouchitis (adjusted hazard ratio [aHR], 1.41; 95% confidence interval [CI], 1.22-1.64) after adjusting for anti-tumor necrosis factor alpha use and sex. Compared with persons without any antibiotic prescriptions in the 12 months before IPAA, the risk of pouchitis was increased in those with 1 or 2 courses of antibiotics in that period (aHR, 1.30; 95% CI, 1.11-1.52) and 3 or more courses (aHR, 1.77; 95% CI, 1.41-2.21). NSAID exposure in the 12 months before IPAA and appendectomy were not associated with risk of acute pouchitis (P= .201 and P= .865, respectively). In this population-based cohort study, we demonstrated that antibiotic exposure in the 12 months before IPAA is associated with an increased risk of acute pouchitis. Future prospective studies may isolate specific microbial changes in at-risk patients to drive earlier interventions.

A retrospective cohort study on renal morbidity related to stoma type in inflammatory bowel disease patients following colectomy and ileal pouch-anal anastomosis surgery.

Defunctioning loop ileostomy (DLI) is frequently used to decrease the consequences of anastomotic leak after ileal pouch-anal anastomosis (IPAA) surgery but is controversial because of stoma-associated morbidity. The aim of this study was to describe stoma-associated morbidity in IPAA-DLI patients compared with terminal ileostomy patients. Patients treated with colectomy for inflammatory bowel disease at Skåne University Hospital, Sweden, between 2005 and 2021 were eligible for inclusion. Terminal stoma-related morbidity was measured until 12 months after colectomy, IPAA surgery, or conversion to ileorectal anastomosis, whichever occurred first. DLI-related morbidity was measured until 12 months after IPAA surgery or stoma closure, whichever occurred first. Laboratory data were reviewed up to 18 months after surgery since patients without complications were rarely subjected to blood sampling. Data on patient characteristics, renal function, surgical complications, and readmissions were collected retrospectively. Primary outcomes were DLI- and terminal ileostomy-related renal morbidity, whereas secondary outcomes focused on stoma-related complications. The study cohort consisted of 165 patients with terminal ileostomy after colectomy (median (interquartile range (IQR)): stoma time 30 (15-74) months) and 42 patients with IPAA-DLI (median (IQR): stoma time 4 (3-5) months). One case of anastomotic IPAA leakage was observed. IPAA-DLI patients more often required hospital care due to high-volume stoma output immediately after surgery (0-30 days, 29%) compared with terminal ileostomy patients (4%, p < 0.001). There were no significant differences in acute renal injury (p = 0.073) or chronic renal failure (p = 0.936) incidences between the groups. DLI closure was achieved in 95% of IPAA-DLI patients, with 5% suffering Clavien-Dindo complications > 2. IPAA-DLI patients exhibited higher incidence of short-term high-volume stoma output without higher rates of acute renal injury or chronic renal failure compared with terminal ileostomy patients in this small single-center retrospective study suggesting that the risk of renal morbidity in IPAA-DLI patients may have been overestimated.

Long-term mental and physical quality of life outcomes following ileal pouch anal anastomosis surgery.

This study presents the authors' experience over 14 years of performing restorative procto-colectomy with ileal pouch anal anastomosis (IPAA). The aim was to study the long-term quality of life outcomes and analyse the predictors of pouch function as well as physical and mental wellbeing. This is a single-centre retrospective study conducted in a specialised colorectal surgery unit in the UK. The study included patients who underwent two- or three-staged panproctocolectomy with defunctioning ileostomy for ulcerative colitis (UC) or familial adenomatous polyposis between 2004 and 2018. Data were collected from a prospectively, surgeon-maintained database. Pouch function and quality of life scores were obtained via validated questionnaires. A multivariate analysis was utilised to explore predictors of quality of life and pouch function. The study reports 105 patients who underwent IPAA with a covering ileostomy. The majority of operations were performed for UC (97, 92.4%). The median age of patients was 36 years and the male to female ratio was 1:1. Thirty patients (28.5%) suffered early post-IPAA complications, while pouch failure rate was 11.4% (12/105). Late complications were reported at a rate of 45%. On long-term follow-up, the median Pouch Function Score was 7 (IQR 3-14). Both the physical and mental sections of the quality of life score were at a median indistinguishable from the normal population but had different predictors associated with them. Our findings recognise the complex interplay between physical and psychological wellbeing after pouch surgery and advise psychological counselling where appropriate.

EPITHELIAL MITOCHONDRIAL DYSFUNCTION IN CHRONIC POUCHITIS

Abstract BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with refractory ulcerative colitis (UC). However, patients with IPAA are at risk of pouch-related disorders like “pouchitis” with an incidence rate range from 20-50%. The underlying etiopathogenesis of pouchitis has been unclear, which makes management and treatment of active pouchitis difficult. Mitochondrial (Mito) dysfunction is commonly associated with pathogenesis of inflammatory bowel diseases (IBD). We posit the reduced Mito function contributes to chronic pouchitis in IPAA patients. In this study we performed comparative analysis of Mito complex levels in pouchitis patients compared to normal controls. METHODS Biopsies collected from ileal pouches +/- inflammation (n=6), and normal (n=3) and inflamed ileum (CD Ileitis; n=3 mean SES=5.2) were preserved in Allprotect® or formalin. Total RNA was extracted, cDNA synthesized and analyzed by RT-qPCR for genes specific for Mito biogenesis and complexes, cytokines and cellular antioxidant machinery. Formalin-fixed tissues were processed for IHC staining of Mito complex-I (NDUFB6) and complex-IV (MTCO1). RESULTS Transcriptomic analysis of active pouchitis tissue showed significant (**p&amp;lt;0.01) reduction of Mito biogenesis genes (PGC1α: 69.5±13.9%, TFAM: 48.7±14.5%, NRF1:48.9±17.7%) compared to normal pouch. Similar mRNA analysis in CD-ileitis showed 90.6±15.2% reduction in PGC1α gene (**p&amp;lt;0.01) and more than 62% reduction in TFAM and NRF1 genes compared normal ileum. We also observed 21.6±9.8% reduction in Mito complex I (Ndufa1, Ndufa4, Ndufb2, Ndufb6), 33.6±8.7% reduction in complex-IV (Cox5a Cox6a1, Cox5e) and 38.8±11.8% reduction in complex-V (ATP5a, ATP5b, ATP5e) in chronic pouchitis compared to normal controls. In contrast, CD-ileitis showed 59.5±10.2% reduction in Mito complexes at mRNA level compared to normal ileum. Altogether, CD-ileitis showed 26.3% and 23.8% reduction in Mito complexes and biogenesis genes, respectively, compared to pouchitis. At protein level, tissues from chronic pouchitis showed significantly reduced expression of NDUFB6 and MTCO1 compared to normal controls. However, the decreased expression of NDUFB6 and MTCO1 was more pronounced in active CD-ileitis patients. Concertedly, suppression of Mito biogenesis and complex genes correlated with upregulation of pro-inflammatory cytokines (IL1β and IL-6) and concomitant reduction of anti-oxidant genes (Sod1, Sod2, Gpx, Prdx-2,3,4,6). CONCLUSION These data indicate decreased levels of Mito complexes in pouchitis, although reductions are less prominent in active CD. We postulate that Mito dysfunction plays a role in the pathogenesis of chronic pouchitis after IPAA surgery in IBD patients. Furthermore, we posit mitochondria-targeted therapy may deliver therapeutic benefits in refractory pouchitis.

P1142 Antibiotic use in the twelve months prior to ileal pouch-anal anastomosis increases the risk for pouchitis: A population-based Danish cohort study

Abstract Background Pouchitis is the most common complication after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), however clinical and environmental risk factors for pouchitis remain poorly understood. We explored the relationship between specific clinical factors and the incidence of pouchitis. Methods We established a population-based cohort of all adult persons in Denmark undergoing proctocolectomy with IPAA for UC between January 1, 1996 and May 31, 2020. We used Cox Proportional Hazard modeling and logistic regression to assess the impact of antibiotic and non-steroidal anti-inflammatory drug (NSAID) exposure and appendectomy on the primary outcome of diagnosis of acute pouchitis in the first 2 years after IPAA surgery. A 2-year time window was utilized given the clinical relevance of early pouchitis and to mirror prior studies in both administrative claims and the Danish health registers. Results Among 1,616 eligible patients, 738 (46%) developed pouchitis in the first 2 years after IPAA. Among all patients undergoing IPAA surgery for UC, 51% were prescribed antibiotics in the 12 months prior to the index date and 17% were prescribed NSAIDs in the 12 months prior to the index date. In Kaplan-Meier analyses, those persons who were prescribed antibiotics in the 12 months prior to the final stage of IPAA surgery were significantly more likely to develop pouchitis in the 2 years after the index date when compared to patients who were not prescribed antibiotics (p&amp;lt;0.001, Figure 1B). Additionally, male patients demonstrated a decreased risk for pouchitis in the first 2 years after the index date when compared to female patients (p=0.014, Figure 1A). Antibiotic exposure in the 12 months prior to IPAA was associated with an increased risk of pouchitis (adjusted Hazard Ratio [aHR] 1.40, 95% CI 1.21-1.62) after adjusting for year of surgery and sex (Table 1). In a secondary analysis, compared to persons without any antibiotic prescriptions in the 12 months prior to IPAA, the risk of pouchitis was increased in those with 1 or 2 courses of antibiotics in that period (aHR 1.29, 95% CI 1.10-1.51) and 3 or more courses (aHR 1.79, 95% CI 1.43-2.23, Figure 1C). NSAID exposure in the 12 months prior to IPAA and appendectomy were not associated with risk of acute pouchitis (p=0.201 and p=0.865 respectively). Conclusion In this population-based cohort study, we demonstrated that antibiotic exposure in the 12 months prior to IPAA is associated with an increased risk of acute pouchitis. Future prospective studies may isolate specific microbial changes in at-risk patients to drive earlier interventions.

P521 Impact of pouch leaks on quality of life and symptoms in patients after ileal pouch-anal anastomosis surgery

Abstract Background Ileal pouch-anal anastomosis(IPAA)is the procedure of choice in patients requiring total proctocolectomy.The reported leak rates after IPAA surgery range from 1-12% with well described significant impact on postoperative morbidity and recovery.However, the long-term impact of salvaged pouch leaks on the broader quality of life outcome and pouch function remains poorly understood.The aim of this study was to compare between patients with and without postoperative leaks after IPAA surgery, hypothesizing that patients with salvaged pouch leaks would have worse long-term quality of life and pouch function compared to matched patients without leaks. Methods This retrospective cohort study included patients who underwent IPAA(n=4058) between 1995-2022.Leak was defined as abscess or fistula requiring intervention, who had definitive resolution of their pouch leaks, whether with conservative treatment or after salvage surgery or pouch excision with end ileostomy creation. The Leak group consisted of 194 patients with treated leaks.The No Leak group included 963 patients without leaks,matched 1:5 on sex, age(± 3 years),and surgery date.Questionnaire data were available for 85 of 194 patients with leaks and 614 of 963 without leaks. Quality of life(QoL) was assessed using SF-36, health status using EORTC QLQ-C30(QoH),and life enjoyment(QoE) using a standardized scale.Bowel movements,seepage,and pad usage were recorded.Outcomes were compared using Mann-Whitney U,t-tests, and chi-square tests. Results A total of 699 patients with IPAA were included, with 85(12%)in the leak group. The median age was 42 (IQR, 31-53) years, and 54% were male. Median time from surgery to the last QoL assessment was 6.58(IQR: 3.5-11.3) years in the Leak group and 6.05 (IQR: 2.5-11.2) days in the No Leak group. Patients with Leaks reported significantly lower QoL (median 7(IQR:5-9)vs8 (IQR:7-9);p&amp;lt;0.001), lower health status on the QoH scale (median 7(IQR: 5-8) vs 8 (IQR :7-9); p&amp;lt;0.001), and lower life enjoyment on the QoE scale (median 7(IQR: 5-8)vs7(IQR :6-9);p=0.003) compared to the No Leak group. A higher proportion of patients in the Leak group reported daytime (49%vs.20%,p&amp;lt;0.001) and nocturnal seepage (66%vs.38%, p=0.001), along with greater daytime(40%vs.22%,p=0.01) and nighttime pad usage (53%vs.30%,p=0.001). There were no significant differences in the number of bowel movements per 24h (p=0.54), daytime bowel movements(p=0.7), or nighttime bowel movements (p=0.695) between the groups. Conclusion In matched cohorts,salvaged pouch leaks were associated with reduced quality of life,health status,and life enjoyment compared with matched patients without leaks.Patients with leaks also had increased rates of seepage and pad usage,indicating worse pouch function.

Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes

Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P<.001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P<.001) or immunomodulators (0% vs 31%, respectively; P<.001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5±78.4 vs 233.8±81.6, respectively; P<.001) and length of stay (LOS; 5.4±3.1 vs 4.2±1.6 days, respectively; P<.001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P=.04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P=.02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P=.01), whereas 3-staged IPAA reduced complications (OR, 0.3; P=.03). ERP was identified as a factor that predicted shorter stays. Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.

Crohn's Disease of the Ileoanal Pouch: A High Rate of Potential Overdiagnoses.

Approximately 1 in 10 patients with an ileal pouch-anal anastomosis is diagnosed with Crohn's disease of the pouch (CDP). However, this diagnosis may be established inappropriately, as alternative underlying causes necessitating an alternative treatment approach, such as long-term surgical sequelae, may mimic CDP. In this study, we aimed to identify patients diagnosed with and treated for CDP with a (concurrent) alternative diagnosis. Ulcerative colitis and inflammatory bowel disease unclassified patients who underwent ileal pouch-anal anastomosis surgery in a tertiary center between 1990 and 2017 were retrospectively reviewed. Patients with a postoperative diagnosis of CDP for which medical treatment was initiated were identified. Presence of pouchitis, prepouch ileitis, stricture, and fistulas was assessed and histopathological reports were evaluated. Thereafter, cross-sectional images of the pouch in CDP patients were re-evaluated to identify potential long-term surgical sequelae (ie, chronic presacral sinus or perianastomotic fistulas). After a median postoperative follow-up of 6.2 (interquartile range, 2.3-13.5) years, 47 (10%) of 481 patients were diagnosed with CDP. CDP patients had pouchitis (n = 38 [81%]), prepouch ileitis (n = 34 [74%]), strictures (n = 17 [36%]), fistulas (n = 15 [32%]), or a combination. Multiple granulomas were found in 1 pouch resection specimen. Re-evaluation of 40 (85%) patients who underwent magnetic resonance imaging revealed presence of long-term surgical sequelae in 17 (43%) patients. Six (15%) patients demonstrated isolated nonanastomotic fistulas. Re-evaluation of cross-sectional imaging of the pouch revealed that potential alternative causes were found in nearly half of CDP patients. Cross-sectional imaging is therefore recommended early in the diagnostic pathway to exclude an alternative diagnosis.

Very Early Pouchitis Is Associated with an Increased Likelihood of Chronic Inflammatory Conditions of the Pouch.

Chronic inflammatory conditions of the pouch are common after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We aimed to investigate the relationship between acute pouchitis within 180days of the final stage of IPAA surgery (very early pouchitis) and the future development of chronic antibiotic dependent pouchitis (CADP) and Crohn's-like disease of the pouch (CLDP). We performed a retrospective cohort study, evaluating patients who underwent proctocolectomy with IPAA between January 1, 2004 and December 31, 2016. Multivariable logistic regression was used to evaluate the relationship between very early pouchitis and the development of CADP and CLDP. Among 626 patients undergoing IPAA for UC, 137 (22%) developed very early pouchitis, 75 (12%) developed CADP, and 59 (9%) developed CLDP in a median follow-up of 5.18years (interquartile range 0.94-10.8years). Very early pouchitis was associated with a significant increase in the odds of developing CADP (adjusted odds ratio [aOR3.65, 95% CI 2.19-6.10) as was primary sclerosing cholangitis (aOR 3.97, 95% CI 1.44-11.0). Very early pouchitis was associated with increased odds for developing CLDP (aOR 2.77, 95% CI 1.54-4.98) along with a family history of inflammatory bowel disease (aOR 2.10, 95% CI 1.11-3.96). In this cohort, very early pouchitis was associated with an increased risk of developing CADP and CLDP. These findings highlight very early pouchitis as a unique risk factor for chronic inflammatory conditions of the pouch and the need for future studies evaluating potential strategies for secondary prophylaxis strategies in this population.

Short-term outcomes in robotic vs laparoscopic ileal pouch-anal anastomosis surgery: a propensity score match study

PurposeLaparoscopic ileal pouch-anal anastomosis (IPAA) surgery offers improved short-term outcomes over open surgery but can be technically challenging. Robotic surgery has been increasingly used for IPAA surgery, but there is limited evidence supporting its use. This study aims to compare the short-term outcomes of laparoscopic and robotic IPAA procedures.MethodsAll consecutive patients receiving laparoscopic and robotic IPAA surgery at 3 centres, from 3 countries, between 2008 and 2019 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for gender, previous abdominal surgery, ASA grade (I, II vs III, IV) and procedure performed (proctocolectomy vs completion proctectomy). Their short-term outcomes were examined.ResultsA total of 89 patients were identified (73 laparoscopic, 16 robotic). The 16 patients that received robotic surgery were matched with 15 laparoscopic patients. Baseline characteristics were similar between the two groups. There were no statistically significant differences in any of the investigated short-term outcomes. Length of stay trend was higher for laparoscopic surgery (9 vs 7 days, p = 0.072)ConclusionRobotic IPAA surgery is safe and feasible and offers similar short-term outcomes to laparoscopic surgery. Length of stay may be lower for robotic IPAA surgery, but further larger scale studies are required in order to demonstrate this.

An early experience in robotic ileoanal pouch surgery with robotic intracorporeal single-stapled anastomosis (RiSSA) at atertiary referral centre.

A robotic approach to ileal pouch-anal anastomosis (IPAA) surgery offers advantages over other approaches in terms of precision, improved access to the pelvis and less muscular fatigue for the surgeon. The integrity of the anastomosis is also fundamental to successful IPAA surgery. The robotic platform can permit intracorporeal suturing deep within the pelvis to create a single-stapled, double purse-string anastomosis, which may reduce the risk of anastomotic complications. This study describes the safety and early outcomes of robotic intracorporeal single-stapled anastomosis (RiSSA) amongst patients operated consecutively at a tertiary centre immediately before and following the pandemic. A retrospective study of prospectively collected data analysing the outcome of patients undergoing robotic IPAA between 2019 and 2022 was conducted. All procedures were performed with the da Vinci Xi Surgical System (with a hand-assisted suprapubic incision to fashion the pouch). All pouch-anal anastomoses were performed using a double purse-string, single-stapled (RiSSA) method. Demographic, clinical and outcome data were collected. Twenty consecutive patients (nine with ulcerative colitis and 11 with familial adenomatous polyposis) were included with a median age of 25 years (range 16-52); 18 had American Society of Anesthesiologists classification II, and mean body mass index was 24 kg/m2 (range 18.1-34.3). Nine patients (eight ulcerative colitis and one familial adenomatous polyposis) had undergone prior subtotal colectomy and therefore underwent restorative proctectomy with IPAA. Eleven patients underwent restorative proctocolectomy. All procedures were completed robotically. The median length of stay was 9 days (5-49). There were no unplanned admissions to intensive care and no deaths. Three patients were readmitted following hospital discharge for (i) an ileus managed conservatively, (ii) small bowel obstruction managed conservatively and (iii) small bowel obstruction due to constriction at the stoma site necessitating surgery. There were two additional reoperations both for drain complications, one for drain removal and one for drain erosion. On mobilization of the pouch in the latter case, an anastomotic defect was observed. In total, 19/20 patients underwent RiSSA without postoperative anastomotic problems. RiSSA offers a safe and feasible alternative technique to other minimally invasive approaches with low rates of anastomosis-related complications.

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

Risk factors and outcomes of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Retrospective study of 75 single center cases.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical gold standard in patients with ulcerative colitis (UC). Results are generally satisfactory but there is a significant rate of patients who experience postoperative complications. The aims of our study were to identify the pre- and intraoperative risk factors and their correlation with the reported outcomes. A retrospective study was conducted on the medical records of all consecutive patients undergoing restorative proctocolectomy with IPAA for UC in our center from 2010 to 2021. Pre- and intraoperative factors were examined and correlated with pouchitis, endoscopic pouchitis, pouch failure, anastomotic leak, postoperative complications classified according to Clavien-Dindo score and stoma outlet obstruction. A univariate and multivariate statistical analysis was performed. Out of 75 patients undergoing 3- or 2-stage IPAA surgery, the coexistence of extraintestinal clinical manifestations and preoperative topical rectal stump therapy for active proctitis were significantly associated with the occurrence of pouchitis (OR=4.4, p=0.03 and OR=7.6, p=0.01). Endoscopic pouchitis was found to be related to preoperative topical rectal therapy (OR=10.2, p=0.007), but not to extraintestinal manifestations of disease. Anastomotic leak was found to be significantly related to pouch failure (OR=22.7, p=0.007). Surgical indication for malignancy increased the risk for early complications (Clavien-Dindo >2) (OR=16.0, p=0.04). Young age was associated with the occurrence of outlet stoma obstruction in patients with recent IPAA surgery (OR=0.97, p=0.05). Based on observed results, an appropriate preoperative patient assessment aimed at detecting specific risk factors is crucial to identify early or prevent worse outcomes in patients undergoing IPAA surgery.

P287 Clinical characteristics and outcomes of ileal pouch–anal anastomosis (IPAA) inflammation in a Latin American (LA) IBD reference Center (I.

Abstract Background Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) can be associated with a wide spectrum of complications, ranging from a frequently mild acute pouchitis (AP) to Chronic pouch inflammation (CPI, either antibiotic dependent or refractory, CADP and CARP respectively) and Crohn's disease like pouch inflammation (CDLPI). The pathogenesis, still largely unknown, probably is multifactorial, and environment may play a role. We aimed to describe clinical characteristics and outcomes of IPAA inflammation in a Latin American (LA) IBD reference Center. Our main focus is CDLPI, because, despite of UC is reported more frequent in LA, epidemiology is changing, and notably, colon location (within CD) reach the half of the CD casuistic in our hospital, as well as other Argentina locations (Cordoba) and Uruguay, a neighbor Country. Probably, this epidemiological feature could impact in our patient′s evolution. Methods Our hospital has a Coloproctology Team pioneer of IPAA surgery in Argentine and as Clinical IBD Service, we performed a revision in our electronic data base (included from 1990 to current date, and detected 437 pts. with IPAA. Criteria were; modified PDAI (for disease activity), for CPI and CDLPI we adopted that of Shen B, Clin. Gastrienterol hepatol 200, 6:145-58. Results Results We compare 46 CDLPI with 24 CPI pts. (CADP and CARP) and 24 AP. A total of 55 M, 39 F, were evaluated for demographic data and disease complications. Mean age ±SD at complication: CDLPI 33.8±13.8, CPI 34.2±11.2, AP 40.1±13.7, (NS for gender and Age). Median time (IQR) up to each one of 3 complications: 1.6 (4.19), 2.09 (7.17) and 1.34 (2.67), respectively (NS, Median test). Follow–up time was similar: 20.11 (10.9), 13.7 (12.2), 13.9 (15.6), respectively. CDLPI presented inflammatory pattern in: 37 (80.4%), stricturing in 6 (13.04%), fistulizing in 16 (34.8%) Perianal complication: 43.5%. Pre-pouch ileitis in CDLP: 26 (56 5%) vs. CPI 1(4.2%), in AP 0% (p.00000), prepouch strictures (13.04% vs. 0%), significant different, as well as prepouch fistulas (17.4%), with suboclusion in 29% Pouch vaginal fistulas and pouch-cutaneous in 1/5 of patients. Cuffitis in 19%. The original IBD was more severe and extensive p &amp;lt;0.02 in the mentioned subgroup. As regard treatment, IMM treatment in CDLP: was required in 70% vs. 26% in CPI and biologics en 2/3 0.00016, 11% ≥2 biologics. Pouch failure (diversion and resection) was observed in 30% and 13% respectively. Conclusion We are a LA center with high CD prevalence. The complications of surgery must be taken into account. IPAA revolutionized UC surgery, but close monitoring, and new research are required with the future hope of acting proactively.

Long-term outcomes after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis for ulcerative colitis

BackgroundDuring ileal pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC), rectal dissection can be performed via close rectal dissection (CRD) or in a total mesorectal excision plane (TME). Although CRD should protect autonomic nerve function, this technique may be more challenging than TME. The aim of this study was to compare long-term outcomes of patients undergoing CRD and TME.MethodsThis single-centre retrospective cohort study included consecutive patients who underwent IPAA surgery for UC between January 2002 and October 2017. Primary outcomes were chronic pouch failure (PF) among patients who underwent CRD and TME and the association between CRD and developing chronic PF. Chronic PF was defined as a pouch-related complication occurring ≥ 3 months after primary IPAA surgery requiring redo pouch surgery, pouch excision or permanent defunctioning ileostomy. Secondary outcomes were risk factors and causes for chronic PF. Pouch function and quality of life were assessed via the Pouch dysfunction score and Cleveland global quality of life score.ResultsOut of 289 patients (155 males, median age 37 years [interquartile range 26.5–45.5 years]), 128 underwent CRD. There was a shorter median postoperative follow-up for CRD patients than for TME patients (3.7 vs 10.9 years, p < 0.01). Chronic PF occurred in 6 (4.7%) CRD patients and 20 (12.4%) TME patients. The failure-free pouch survival rate 3 years after IPAA surgery was comparable among CRD and TME patients (96.1% vs. 93.5%, p = 0.5). CRD was a no predictor for developing chronic PF on univariate analyses (HR 0.7 CI-95 0.3–2.0, p = 0.54). A lower proportion of CRD patients developed chronic PF due to a septic cause (1% vs 6%, p = 0.03).ConclusionsAlthough differences in chronic PF among CRD and TME patients were not observed, a trend toward TME patients developing chronic pelvic sepsis was detected. Surgeons may consider performing CRD during IPAA surgery for UC.