Ileal Pouch-anal Anastomosis Surgery Research Articles

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Rectal eversion: safe and effective way to achieve low transaction in minimally invasive Ileal pouch-anal anastomosis surgery, short- and long-term outcomes.

Ileal pouch-anal anastomosis remains a gold standard in restoring continence in patient with ulcerative colitis. Achieving low transection can be challenging and may require mucosectomy with a hand-sewn anastomosis. Rectal eversion (RE) technique provides a safe and effective alternative for both open and minimally invasive approaches. The purpose of this study is to evaluate short- and long-term outcomes of patients who underwent RE when compared to those who underwent conventional trans-abdominal transection. This is a retrospective review performed at tertiary care center. Patients undergoing proctectomy and pouch surgery by either standard approach or with RE from November 2004 to January 2017 were evaluated. Demographics, post-operative complications, as well as 1- and 3-year functional outcomes were analyzed. Total of 176 underwent proctocolectomy with creation of a J pouch and 88 (50%) had the RE technique utilized. The RE group had a higher rate of corticosteroid use at the time of surgery 59.1 versus 39.8% (p = 0.0156), but otherwise groups were statistically similar. 20 cases (26.1%) of RE group and 54 (61%) of conventional group cases were accomplished in minimally invasive fashion. There was no difference in the rates of 30- and 90-day complications. Functional outcomes data were available for up to 78.4% of patient with trans-abdominal approach and 64.7% in RE group. At 1 and 3 years after surgery, there was no difference in the number of bowel movements, fecal incontinence, or nocturnal bowel movements. The rates of returning to ileostomy or pouch revision were the same. RE technique is safe and effective way to achieve a low transaction in J pouch surgery. The technique provides similar functional outcomes at 1 and 3 years after surgery and can be particularly useful in minimally invasive approaches.

Preoperative exposure to anti-tumor necrosis factor therapy in ulcerative colitis patients undergoing ileal pouch-anal anastomosis (IPAA) is not associated with histological fibrosis: A case control study

BackgroundWe sought to determine whether preoperative exposure to anti-TNF therapy affects objective histological measures of fibrosis in the colorectum. MethodsUlcerative colitis (UC) patients who received infliximab as maintenance therapy pre IPAA surgery were identified and compared to anti-TNF-naïve matched controls by age, sex, BMI, disease duration, albumin levels, and post-operative leak outcome. Hematoxylin and eosin- (H&E) and trichrome-stained slides from the most distal, well-oriented, full-thickness section of colorectum from each patient's total colectomy specimen were evaluated. Blinded histopathological assessment of the degree of fibrosis was performed using a semi-quantitative pictorial scale. ResultsHistological fibrosis in 65 patients from the therapy group was compared to 65 patients from the matched control group. There were no statistically significant differences in the degree of fibrosis observed in any of the bowel layers. In the lamina propria, 29% of the control group and 28% of the treatment group had fibrosis scores ≥3. Fibrosis scores were higher in the submucosa, with both groups having 66% of patients showing scores ≥3. Similarly, in the region above the muscularis propria, 77% of the control group and 80% of the treatment group had fibrosis scores ≥3. In the subserosa, fibrosis scores were lower, with 25% of the control group and 32% of the treatment group having fibrosis scores ≥3. ConclusionResection specimens from UC patients treated with maintenance anti-TNF therapy who underwent IPAA surgery showed no significant differences in the degree of histologic fibrosis in any of the bowel layers compared to a matched control group.

Updates in the management of inflammatory bowel disease during pregnancy.

The best pregnancy outcomes for women with inflammatory bowel disease (IBD) occur when their disease is in remission at conception and remains in remission throughout pregnancy. Active IBD can lead to adverse pregnancy outcomes, including spontaneous abortion, pre-term birth and low birthweight. The majority of women with IBD who are taking maintenance medication will require medication throughout the pregnancy to prevent disease relapse. Most IBD medications are considered safe in pregnancy and breastfeeding, except for methotrexate. Pre-conception counselling should be arranged with the patient's IBD specialist and should include discussions regarding the importance of optimising disease control before and during pregnancy as well as the medication management plan for pregnancy. Patients with IBD should be reassured that their fertility is normal when the disease is quiescent, with the exception of women who have had pelvic surgery. IBD activity should be carefully monitored during pregnancy using non-invasive techniques, and disease flares during pregnancy should be treated promptly with escalation of therapy in consultation with the patient's IBD specialist. Mode of delivery should be determined by obstetric need; however, caesarean delivery is preferred for women with a history of ileal pouch anal anastomosis surgery or active perianal Crohn's disease.

Early first episode of pouchitis after ileal pouch–anal anastomosis for pediatric ulcerative colitis is a risk factor for development of chronic pouchitis

BackgroundThe predictive factors for chronic pouchitis after ileal pouch–anal anastomosis (IPAA) in pediatric-onset ulcerative colitis (UC) remain unclear. This study evaluated the predictive factors for chronic pouchitis after IPAA in patients with pediatric UC. MethodsThe data from 52 patients with pediatric-onset UC who underwent IPAA in Mie University Hospital were retrospectively reviewed. The endoscopy surveillance was performed yearly or at the timing of the symptom. Chronic pouchitis was defined as antibiotic-dependent/-refractory and relapsing cases. Potential predictors of chronic pouchitis were analyzed. ResultsDuring the first 5 years after IPAA, pouchitis was identified in 32.7%. Of these patients, 12 (70.6%) developed chronic pouchitis. The predictor of chronic pouchitis was a preoperative history of immunomodulator use before IPAA (p = 0.04). Life table analysis revealed that patients with chronic pouchitis tended to develop pouchitis earlier after IPAA than did patients without chronic pouchitis (p = 0.012). Receiver operating characteristic curve analysis showed that the occurrence of pouchitis within 15 months after IPAA surgery predicted the development of chronic pouchitis (sensitivity, 92%; specificity, 80%). ConclusionIn pediatric patients with UC, the predictive factors for chronic pouchitis are immunomodulator use and early occurrence of the first episode of pouchitis within 15 months after IPAA. Level of evidenceIII

Su1883 - Older age at the Time of Ileal Pouch-Anal Anastomosis Surgery is Associated with Chronic Antibiotic Dependent Pouchitis in a Multidisciplinary Inflammatory Bowel Disease Center

Su1883 - Older age at the Time of Ileal Pouch-Anal Anastomosis Surgery is Associated with Chronic Antibiotic Dependent Pouchitis in a Multidisciplinary Inflammatory Bowel Disease Center

MRI defecography of the ileal pouch-anal anastomosis-contributes little to the understanding of functional outcome.

Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients. From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N = 47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy. Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores. It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.

Outcome of restorative proctocolectomy with an ileo-anal pouch for ulcerative colitis: effect of changes in clinical practice.

Surgery for ileal pouch-anal anastomosis (IPAA) has evolved over time, especially since the introduction of laparoscopy. The aim of this retrospective study was to report the impact of surgical evolution on outcome over a period of 25years. All patients who had IPAA surgery for ulcerative colitis from 1990 to 2015 at the University Hospitals of Leuven were included. Patients were divided into three period arms (period A 1990-1999; period B 2000-2009; period C 2010-2015). The main outcome measure was anastomotic leakage. A total of 335 patients (58.8% male) with a median age of 39years (interquartile range 32-49years) at surgery were included. Median follow-up was 5years (interquartile range 2-10years). Overall anastomotic leakage (grades A-C) was 14.9%. A significant decrease in leakage rate was observed over time (from 21.4% in period A to 12.1% in period B to 10.0% in period C; P=0.04). The defunctioning ileostomy rate at the time of pouch construction decreased from 91.7% (period A) to 40.3% (period B) to 11.1% (period C) (P<0.001). We observed an increase in the use of laparoscopy (23.9% in period A vs 72.6% in period B, vs 84.4% in period C; P=0.001) and a shift to a modified two-stage procedure (4.1% in period A, vs 66.7% in period C; P<0.0001). In a monocentric study with some of the data retrieved retrospectively it was not possible to account for the impact of preoperative nutritional status (weight loss, serum albumin level) or disease burden. Other outcome factors were not measured, for example sexual function and fecundity. A higher rate of laparoscopic IPAA surgery, together with a shift towards modified two-stage procedures, was associated with a lower leakage rate despite a reduction in the use of defunctioning ileostomy.

Patchy colitis, and young age at diagnosis and at the time of surgery predict subsequent development of Crohn's disease after ileal pouch-anal anastomosis surgery for ulcerative colitis.

Background and AimA proportion of patients having total proctocolectomy and ileal pouch‐anal anastomosis (IPAA) for ulcerative colitis (UC) are later diagnosed with Crohn's disease (CD). The aim of this study was to identify preoperative and perioperative predictors for the subsequent development of CD in patients who had IPAA for presumed UC.MethodsA retrospective case–control study of patients undergoing IPAA surgery for presumed UC was undertaken. Cases were patients who had a revised diagnosis of CD after surgery. Preoperative and perioperative variables were examined and analyzed.ResultsFifteen cases were compared with 39 controls. Patients aged ≤25 years at initial UC diagnosis were more likely to develop CD compared to those aged >25 years (odds ratio, OR [95% confidence interval, CI]: 7.1 [1.6–31.3]; P = 0.01). Patients aged ≤30 years at the time of colectomy had an increased risk of subsequent development of CD compared to those aged >30 years (OR [95% CI]: 4.5 [1.3–16.0]; P = 0.02). Cases were more likely to have patchy colitis on their colectomy specimen (OR [95% CI]: 6.7 [1.1–41.8]; P = 0.04). There was no significant difference between groups regarding transmural inflammation, ileitis, or fissuring ulcers on colectomy specimens, or preoperative C‐reactive protein (CRP), albumin, family history, and smoking status.ConclusionPredictors of the development of CD in the pouch include young age at diagnosis and at the time of surgery, and patchy colitis in the resected colon.

Evaluation of nutritional status and quality of life before and after IPAA surgery of patients with severe ulcerative colitis

Objective To evaluate the effects of restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) on nutritional status and quality of life of patients with severe ulcerative colitis (UC) . Methods A total of 64 UC patients′ nutritional status and quality of life, who met the inclusion criteria and underwent IPAA surgery, were assessed by multiple nutritional evaluation indexes and the Chinese version of the inflammatory bowel disease quality of life questionnaire (IBDQ) before IPAA, three months after IPAA and three months after ileostomy closure respectively. The effects of IPAA surgery on nutritional status and quality of life were analyzed, and the data of quality of life were compared with reference values from 64 healthy people. Results Before IPAA, the prevalence of subnormal levels of body mass index (BMI) , hemoglobin (Hb) , serum concentrations of albumin (ALB) , prealbumin (PA) and transferrin (TFN) were 40.63%, 78.13%, 59.38%, 73.44%, 58.30% lower than the normal reference. Three months after IPAA, the prevalence of subnormal levels of BMI, Hb, ALB, PA and TFN were 35.94%, 4.69%, 3.13%, 34.38%, 0. Three months after ileostomy closure, the prevalence of subnormal levels of BMI, Hb, ALB, PA and TFN were 20.31%, 7.81%, 0, 6.25%, 0. The overall IBDQ before IPAA were 44.54 and 76.53 for 3 months after IPAA that all were lower than those of the healthy people with statistical significances (t=41.19, 9.26; P 0.05) . The overall quality of life and four domains scores were similar to the healthy population three months after ileostomy closure with no statistical significance (P>0.05) . Conclusions The nutritional status and quality of life of UC patients before IPAA were poor. IPAA surgery can significantly improve the nutritional status and quality of life of UC patients. Key words: Ulcerative colitis; Quality of life; Nutritional status; Surgical treatment

Predictors of pouchitis after ileal pouch-anal anastomosis in pediatric-onset ulcerative colitis.

Few studies have reported on the incidence and risk factors for pouchitis following colectomy and ileal pouch-anal anastomosis (IPAA) in patients with pediatric-onset ulcerative colitis (UC). We aimed to determine clinical predictors for the development of pouchitis following IPAA in this population. We performed a retrospective chart review of all pediatric UC cases that were diagnosed at the Schneider Children's Medical Center of Israel between 1981 and 2013 and who underwent colectomy during disease course. Potential predictors for pouchitis and chronic pouchitis including various demographic, clinical, endoscopic, and histological variables at diagnosis and at the time of surgery were assessed. Of 188 patients with pediatric-onset UC, 33 (18%) underwent colectomy and IPAA surgery. During a median postsurgical follow-up of 7.6 (range: 1-21.5) years following IPAA, 20/33 (60%) patients developed pouchitis including 11/33 (33%) patients who developed chronic pouchitis. Kaplan-Meier survival estimates of the cumulative probability for pouchitis were 9% at 1 year and 36 and 55% at 5 and 10 years, respectively. Multivariate Cox models showed that older age at colectomy (hazard ratio: 0.86, P=0.024) was a protective factor, whereas preoperative vitamin-D deficiency (≤20 ng/ml) (hazard ratio: 4.4, P=0.021) increased the risk for pouchitis. Age at diagnosis, sex, disease extent, and preoperative therapeutic regimens did not affect the risk of pouchitis. Long-term risk for pouchitis is significantly high in pediatric-onset UC after IPAA. Vitamin-D deficiency and younger age at colectomy may increase the risk for pouchitis.

Paradoxical Impact of Ileal Pouch-Anal Anastomosis on Male and Female Fertility in Patients With Ulcerative Colitis

Birth rates in males with ulcerative colitis and ileal pouch-anal anastomosis have not been studied. This study aimed to estimate birth rates in males and females with ulcerative colitis and study the impact of ileal pouch-anal anastomosis. This was a retrospective registry-based cohort study that was performed over a 30-year period. Records for parenting a child from the same period were cross-linked with patient records, and birth rates were calculated using 15 through 49 years as age limits. All data were prospectively registered. All patients with ulcerative colitis and ulcerative colitis with ileal pouch-anal anastomosis between 1980 and 2010 were identified in Danish national databases. The primary outcomes measured were birth rates in females and males with ulcerative colitis and ulcerative colitis with ileal pouch-anal anastomosis. We included 27,379 patients with ulcerative colitis (12,812 males and 14,567 females); 1544 had ileal pouch-anal anastomosis (792 males and 752 females). Patients with ulcerative colitis have slightly reduced birth rates (males at 40.8 children/1000 years, background population 43.2, females at 46.2 children/1000 years, background population 49.1). After ileal pouch-anal anastomosis, males had increased birth rates at 47.8 children/1000 years in comparison with males with ulcerative colitis without ileal pouch-anal anastomosis (40.5 children/1000 years), whereas females had reduced birth rates at 27.6 children/1000 years in comparison with females with ulcerative colitis without ileal pouch-anal anastomosis (46.8 children/1000 years). Only birth rates were investigated and not fecundability. Furthermore, there is a question about misattributed paternity, but this has previously been shown to be less than 5%. Ulcerative colitis per se has little impact on birth rates in both sexes, but ileal pouch-anal anastomosis surgery leads to a reduction in birth rates in females and an increase in birth rates in males. This has clinical impact when counseling patients before ileal pouch-anal anastomosis surgery.

Incidence, prevalence, and risk factors for pouchitis

Pouchitis is a complication of restorative proctocolectomy and ileal pouch-anal anastomosis surgery in patients who undergo the procedure for the treatment of inflammatory bowel disease or familial adenomatous polyposis. Patients can present with increased stool frequency, urgency, fecal seepage, and abdominal cramps. The reported cumulative frequency rates of pouchitis 10 years after IPAA surgery range from 23% to 60% in IBD patients and 0% to 11% in FAP patients. Although the pathogenesis of pouchitis is unclear, several risk factors for pouchitis have been identified including extraintestinal manifestations of inflammatory bowel disease, autoimmune disorder(s), severity of disease, serologic markers (serum IgG4, autoantibodies to bacterial antigens, p-ANCA, and anti-CBir1 flagellin antibody), genetic markers (NOD2 mutation), smoking, and certain dietary factors. In this review, we will focus on the incidence, prevalence, and risk factors associated with pouchitis.

P132 Cooperation to improve quality of IPAA surgery in IBD: south Netherlands experience

Background: Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for IBD is low volume surgery. In The Netherlands from 2009 quality and volume indicators have been defined for low volume oncologic procedures and since 2015 also for IPAA surgery following the ECCO guidelines. The two South Netherlands IBD centers (The Zuyderland Hospital [ZH], Maastricht University Medical Center [MUMC]) started to collaborate to meet the volume norm on IPAA surgery and deliver optimal quality. The present study describes the outcome of surgery in this cooperation and aims at defining further priorities in surgical care. Methods: Data were collected from the prospective South Limburg IBD cohort which includes all newly diagnosed IBD patients of the two centers since 1991. All non-surgical data and the core surgical data are included in this database. More specific surgical information was collected retrospectively. Results: Fifty-four patients were included that received an IPAA between January 2010 and December 2015. In 2015 the volume norm of >10 was reached, contrary to the 3 preceding years. Mean age was 39.6 (17–82) and mean disease duration 7.5 yrs (1–22.5). 35 patients (62%) previously underwent a subtotal colectomy, 13 in an open procedure, 22 laparoscopically. 41 (76%) of IPAA's were performed laparoscopically, 93% were stapled and in 44% a temporary ileostoma was performed. Three ileostomies were given due to postop complications. Postop diagnosis was UC in 52 patients, IBD-U in 1 and CD in 1. Major early complications were small bowel obstruction (n=14), partial anastomotic dehiscence (n=7), pouch bleeding (n=2), distal anastomotic stricture occurred in 9 patients. Pouch failure occurred in 5 patients resulting in 4 permanent ileostomies, two of which due to chronic pouchitis. Conversion from laparoscopic to open procedure was positively associated with anastomotic dehiscence. Stool frequency at follow-up was median 7.6/24hrs; 41% of patients used no antidiarrheal medication. Full continence was achieved in 77%. No data on sexual function could be retrieved. From 2015, one team (EB and LS) operated all patients. Incidence of leakage seemed lower after cooperation, although conclusions require a larger cohort. Conclusions: The cooperation resulted in increase from a low- to a medium volume center. Several focus points have been defined based on the results observed: progressive cooperation and optimal multidisciplinary approach to optimize timing of surgery and outcome; continue implementation of novel techniques; prospective registration of all surgical parameters including quality of life and sexuality; evolve as a regional referral and expert center and increase patient numbers.

Predictors of Pouchitis After Ileal Pouch-Anal Anastomosis in Children.

Predictive factors for the development of pouchitis after ileal pouch-anal anastomosis (IPAA) in children have not been well studied. In this retrospective study, the incidence and risk factors that predict pouchitis in children with IPAA will be identified. The records of patients who underwent IPAA surgery at Children's Hospital of Wisconsin between January 2000 and December 2013 were reviewed retrospectively. Patients with clinical, endoscopic, and histological findings consistent with pouchitis were identified. The groups of patients with and without pouchitis or chronic pouchitis were compared to determine which demographic, pathological, or disease characteristics may serve as predictive factors for the development of pouchitis or chronic pouchitis. Out of a total of 60 patients who underwent IPAA, preoperative diagnosis was ulcerative colitis (UC) in 43 and familial adenomatous polyposis (FAP) in 17. Pouchitis was identified in 24 (56%) patients with UC and 2 (12%) patients with FAP. Subgroup analysis of patients with UC revealed that chronic pouchitis occurred in 15 (35%) patients. The median follow-up period from construction of the IPAA was 35 months (range 4.59-104.26 months). The study analysis revealed that a higher Pediatric Ulcerative Colitis Activity Index score at the time of diagnosis was a significant predictive factor for both pouchitis (P = 0.001) and chronic pouchitis (P = 0.02). Patients with UC and a higher PUCAI score at the time of diagnosis have a higher risk for developing pouchitis.

Poor Outcomes of Complicated Pouch-Related Fistulas after Ileal Pouch-Anal Anastomosis Surgery.

Development of a pouch-related fistula tract is an uncommon but highly morbid complication to restorative proctocolectomy with ileal pouch-anal anastomosis. Pouch failure with permanent ileostomy is reported in 21%-30% of patients, yet the factors contributing to pouch excision remain poorly defined. The aim of this study was to determine the incidence and treatment results of complicated pouch-related fistula, as well as to evaluate factors involved in excision after pouch failure. The study was conducted as a retrospective study. All patients with diagnosed pouch-related fistulas were registered with information related to fistula classification, treatments, and outcome. The final analysis included 48 (10.7%) of the 447 total ileal pouch-anal anastomosis patients with complicated pouch-related fistulas. Pouch-vaginal fistulas, pouch-perianal fistulas, and other pouch-related fistulas were observed in 19 (63%), 29 (60%), and 10 (21%) patients, respectively, corresponding to an accumulated risk of 8%, 6%, and 2%, respectively. Time from ileal pouch-anal anastomosis surgery to fistula presentation was 24 (0.2-212) months. Overall pouch failure, defined as pouch excision or a diverting stoma, was seen in 34 (71%) patients, while pouch excision was seen in 23 (48%) of the patients. Patients who developed Crohn's disease had a significantly higher risk of pouch excision, as did patients with an early onset of the fistula after ileal pouch-anal anastomosis (P = 0.006 and P = 0.007, respectively). In conclusion, the present study demonstrated a high risk of pouch failure in patients with complicated pouch-related fistulas. Furthermore, it showed that Crohn's disease and the development of early onset fistulas are associated with pouch excision.

MR Enterography of the Ileoanal Pouch: Descriptive Radiologic Analysis With Endoscopic and Pathologic Correlation.

The purpose of this study was to describe the MR enterography (MRE) appearance of inflammation of the ileoanal pouch after ileal pouch-anal anastomosis (IPAA) surgery and to correlate it with pouch endoscopic and histopathologic findings. All MRE studies performed between October 1, 2007, and September 30, 2013, for patients who had previously undergone IPAA (n = 54) were retrieved. After review of medical records, the patients who underwent MRE, pouch endoscopy, and biopsy within 90 days (14 men, 14 women; mean age, 42.2 years; range, 24-67 years) were selected for inclusion in the study. Two blinded MRI radiologists in consensus retrospectively evaluated MRE studies for multiple MRI features. Two MRI scores were then calculated: an active and a composite inflammation score. A gastroenterologist retrospectively reviewed the pouch endoscopic images, and a pathologist reviewed the slides; both of these investigators were blinded. Both MRI scores were correlated with the pouch endoscopic and histopathologic findings. The composite MRI score had strong positive correlation with the endoscopic score (r = 0.61; p = 0.0005) but weak positive correlation with the histopathologic score (r = 0.31; p = 0.10, not statistically significant). The active inflammation MRI score had moderate positive correlation with the endoscopic score (r = 0.57; p = 0.0017) and weak positive correlation with the histopathologic score (r = 0.20; p = 0.31, not statistically significant). An MRI score ≥ 4 indicated the best results, with sensitivity of 86%, specificity of 79%, positive predictive value of 80%, negative predictive value of 85%, and accuracy of 82% for pouch inflammation. A positive likelihood ratio of 4.00 and negative likelihood ratio of 0.18 were obtained. In patients who have undergone IPAA surgery, the MRE findings strongly correlate with the pouch endoscopic findings with high sensitivity and positive predictive value for pouch inflammation. Therefore, MRE is a useful noninvasive test performed without ionizing radiation that can be used to evaluate patients with clinical symptoms and possibly alleviate the need for endoscopy in a select patient population.

Correlation between pouch function and sexual function in patients with IPAA

Objective: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for ulcerative colitis refractory to medical treatment and familial adenomatous polyposis. The objective of this study was to study the impact of postoperative pouch function on sexual function. Sexual function after IPAA surgery has also been compared to sexual function in the average Norwegian population. Material and methods: All patients having undergone IPAA from 2000 to June 2013 were identified from the hospital medical record files and sent validated questionnaires regarding their sexual function. Pouch function was scored according to Oresland score through a phone interview. Patients operated on or before June 2012 were asked to answer the same questionnaires twice with an interval of one year to see how stable sexual function is over time. Results: Sixty-eight out of 100 consecutive patients answered the questionnaire regarding both sexual function and pouch function (44 men, 24 women). There was no significant relationship between pouch and sexual function in men (p-value 0.158, corr. coefficient – 0.216). In women there was a significant relationship (p-value - 0.01, corr. coefficient 0.517). There was no significant shift in sexual function during the study period. Conclusion: We found no significant correlation between sexual function and pouch function in men. In women, we found a significant correlation between poor pouch function and impaired sexual function. As similar studies have found, sexual function remains good after IPAA surgery. This is an important information for patients and physicians, both to inform patients correctly prior to surgery, and in the postoperative follow-up.

Management of Ulcerative Colitis and Crohn Disease

There have been considerable advances in the treatment of inflammatory bowel disease (IBD) since the 20th century, and there are multiple options available to the clinician. The management of IBD depends on the location of disease, as well as its clinical, endoscopic and histologic severity. The field is currently undergoing a paradigm shift from a step-up approach (starting treatment with a “milder” medication and, if this treatment fails, moving on to a more powerful medication) to a top-down approach (in which stronger medications are given earlier in the disease course). This review details the medications used to treat IBD, nutrition in IBD patients, and surgical treatment of IBD. Figures show step-up therapy, top-down therapy, strictureplasty technique, gross pathology image of a patient with Crohn disease and previous ileocecal resection, and ileal pouch anal anastomosis surgery. Tables list 5-aminosalicylic acid medications, antibiotics, corticosteroids, immunomodulators, and biologic medications used to treat IBD, as well as causes of nutritional deficiencies in IBD patients. This review contains 5 highly rendered figures, 6 tables, and 96 references.

Management of Ulcerative Colitis and Crohn Disease

There have been considerable advances in the treatment of inflammatory bowel disease (IBD) since the 20th century, and there are multiple options available to the clinician. The management of IBD depends on the location of disease, as well as its clinical, endoscopic and histologic severity. The field is currently undergoing a paradigm shift from a step-up approach (starting treatment with a “milder” medication and, if this treatment fails, moving on to a more powerful medication) to a top-down approach (in which stronger medications are given earlier in the disease course). This review details the medications used to treat IBD, nutrition in IBD patients, and surgical treatment of IBD. Figures show step-up therapy, top-down therapy, strictureplasty technique, gross pathology image of a patient with Crohn disease and previous ileocecal resection, and ileal pouch anal anastomosis surgery. Tables list 5-aminosalicylic acid medications, antibiotics, corticosteroids, immunomodulators, and biologic medications used to treat IBD, as well as causes of nutritional deficiencies in IBD patients. This review contains 5 highly rendered figures, 6 tables, and 96 references.