Ileal Pouch Research Articles

Early Pouchitis Is Associated With Crohn's Disease-like Pouch Inflammation in Patients With Ulcerative Colitis.

Despite the initial diagnosis of ulcerative colitis (UC), approximately 10% to 20% of patients develop Crohn's disease-like pouch inflammation (CDLPI) after restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate whether early pouchitis, defined as pouchitis within the first year after IPAA, is a predictor of CDLPI. This was a retrospective cohort analysis of patients with UC or IBD unclassified (IBDU) who underwent RPC with IPAA at Mount Sinai Hospital between January 2008 and December 2017. The primary outcome was development of CDLPI. Predictors of CDLPI were analyzed via univariable and multivariable Cox regression models. The analytic cohort comprised 412 patients who underwent at least 1 pouchoscopy procedure between 2009 and 2018. Crohn's disease-like pouch inflammation developed in 57 (13.8%) patients a median interval of 2.1 (interquartile range, 1.1-4.3) years after surgery. On univariable analysis, older age at colectomy (hazard ratio [HR], 0.97; 95% CI, 0.95-0.99) was associated with a reduced risk of CDLPI; although early pouchitis (HR, 2.43; 95% CI, 1.32-4.45) and a greater number of pouchitis episodes (HR, 1.38; 95% CI, 1.17-1.63) were associated with an increased risk. On multivariable analysis, early pouchitis (HR, 2.35; 95% CI, 1.27-4.34) was significantly associated with CDLPI. Time to CDLPI was significantly less in patients who developed early pouchitis compared with those who did not (P = .003). Early pouchitis is significantly associated with subsequent CDLPI development and may be the first indication of enhanced mucosal immune activation in the pouch.

Pelvic floor behavioral treatment for fecal incontinence and constipation in quiescent inflammatory bowel disease

Background and aim Refractory bowel symptoms in quiescent inflammatory bowel disease (IBD) are common but evidence for effective management is limited. We aimed to determine whether behavioral treatment, including pelvic floor muscle training, decreases the severity of functional bowel symptoms in patients with quiescent IBD. Secondary aims were to evaluate the treatment effect on quality of life, psychological well-being and pelvic floor muscle function. Methods This prospective study included IBD patients in remission with persistent symptoms of fecal incontinence or constipation who received up to six sessions of behavioral treatment at monthly intervals. The primary outcome was patient-rated symptom improvement on a 7-point Likert scale (1 = substantially worse, 7 = substantially better). Secondary outcomes included validated symptom scores, quality-of-life, psychological measures, and transperineal ultrasound assessment of pelvic floor muscle activity. Results Thirty-four patients (median age 38 years; 24 females; 18 ulcerative colitis, 13 Crohn’s disease, 3 ileo-anal pouch) were included. Twenty-one of the 29 (72%) patients who completed treatment, or 21 of all 34 (62%) patients, reported moderate or substantial improvement (patient rating of 6 or 7). Symptom scores (p < .001), IBD-specific quality of life (p = .008) and illness perception scores (p = .003) significantly improved. General quality of life, and anxiety and depression scores, did not change significantly. Transperineal ultrasound pelvic floor measures did not correlate with patient-rating of symptom improvement. Conclusion Significant symptomatic improvement occurred in a majority of patients with quiescent IBD. Behavioral treatment should be considered for patients with quiescent IBD and ongoing functional bowel symptoms of fecal incontinence, fecal urgency, or constipation.

Provider Knowledge and Recommendations Regarding Ileoanal Pouch Surgery and Fertility in Women with Ulcerative Colitis.

Provider Knowledge and Recommendations Regarding Ileoanal Pouch Surgery and Fertility in Women with Ulcerative Colitis.

Continent cutaneous urinary diversion with an ileal pouch with the Mitrofanoff principle versus a Miami pouch in patients undergoing cystectomy for bladder cancer: results of a comparative study.

Radical cystectomy (RC) is currently the standard of care for non-metastatic muscle invasive bladder cancer. Few studies compare methods of cutaneous continent urinary diversion (CCUD) following RC. Theobjectivewas to compare perioperative morbidity and functional outcomes of CCUD using an ileal pouch with aMitrofanoff efferent versus a Miami ileocolic pouch in patients undergoing cystectomy of pelvic exenteration for bladder cancer. This retrospective two-centre study included all consecutive patients who underwent radical cystectomy or pelvic exenteration with CCUD for bladder cancer between 2001and 2020in two academic French hospitals with a median follow-up time of 5.4years. Patients were divided into two groups according to the type of urinary diversion: Miami ileocolonic pouch (group A) and ileal pouch with Mitrofanoff/Monti principle (group B). Continence rate, ability to perform intermittent self-catheterisation, complications and health-related quality of life (HRQoL) measured by the bladder cancer index were evaluated. Thirty-one patients were included. Continence was achieved in 11 out of 14 patients (79%) in group A versus 12 out of 17 patients (71%) in group B (P = 0.3). A significantly higher rate of cutaneous tube stenosis was reported in group B compared to group A (eight (47%) vs. one (7%) patient, respectively; P = 0.02). HRQoL outcomes were similar in both groups except less digestive discomfort observed in group A. When comparing the ileal pouch with Mitrofanoff/Monti's principle with a Miami pouch, no significant differences were found regarding continence rate, ability to self-catheterise, long-term complication rate and overall patient satisfaction.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

MASS CYTOMETRY ANALYSIS OF CROHN’S DISEASE-LIKE PHENOTYPE OF THE ILEOANAL POUCH FOLLOWING ILEAL POUCH-ANAL ANASTOMOSIS FOR ULCERATIVE COLITIS

Abstract BACKGROUNDS For patients with medically refractory ulcerative colitis (UC), total proctocolectomy and ileal pouch-anal anastomosis (IPAA) has been the definitive surgery of choice. Approximately 10% of patients who were initially diagnosed with UC and underwent an IPAA, subsequently develop a condition referred to as Crohn’s disease-like phenotype of ileoanal pouch (CDP). CDP is typified by ulcers in the pre-pouch ileum, stricture involving the pouch or pre-pouch ileum, and/or fistulas. The etiology of CDP remains unknown and remains difficult to diagnose and treat. To define the mucosal immunology of CDP, we analyzed ileal samples from patients with CDP and patients with a normal pouch and pre-pouch ileum using mass cytometry (CyTOF). METHODS Ileal mucosal biopsies from patients with a history of CDP with long-segmental pre-pouch ileitis (n=10) and those with a normal pouch and pre-pouch ileum after IPAA for UC (n=9) were collected during routine pouchoscopy, frozen in medium, and processed, barcoded and analyzed in one CyTOF experiment. Data were analyzed by using viSNE for dimensionality reduction and CITRUS for clustering in Cytobank. RESULTS Compared with patients with a normal pouch/ileum, we observed the following in ileal samples from CDP based on viSNE analysis (Figure 1): 1) A decreased abundance of CD8+CD103+ tissue-resident T cells (TRM). This result is similar to data from colonic mucosal samples in patients with UC (our internal data not shown here and others), but unlike data from prior studies derived from inflamed ileal mucosal specimens in patients with CD (native bowel anatomy without IPAA) which had increased CD8+ TRM. 2) An increase in CD4+CD103-CD161+ Th17 cells previously linked to an activated Th17 phenotype in Crohn’s disease specimens. 3) Increased CD4+CD103-CD45RA+ T cells associated with reduced IL-10/IL-4 and increased TNF-a in IBD. 4) A higher abundance of CD4+CD103-TIGIT+ T cells that were previously shown to predict severity of pediatric IBD. 5) A decrease in CD8+CD103+CD127+ TRM in CDP, although its role in IBD is unclear. The findings from viSNE were confirmed by CITRUS (Figure 2). Further analyses of pouch samples as well as ileal samples from UC and CD with native GI anatomy (for comparison) using CyTOF and scRNAseq are currently underway. CONCLUSIONS We used mass cytometry to identify immune cells specific to ileal mucosa from patients with CDP. Interestingly, immune cells from the inflamed pre-pouch ileum share some features of those from either UC or CD with native bowel anatomy. We also identified an altered immune cell population which appears to be specific to CDP. These data reveal a unique immune landscape of CDP which may serve as a foundation for identifying therapeutic approaches that target specific cell populations for medical management of CDP.

Advantages of total proctocolectomy with straight ileoanal anastomosis plus pedicled omental transposition for familial adenomatous polyposis: a preliminary study

PurposeTo achieve excellent postoperative bowel function in familial adenomatous polyposis (FAP) patients, it is important to reconstruct the digestive tract. The aim of this study is to preliminarily discuss the advantages of total proctocolectomy with straight ileoanal anastomosis (TPC-SIAA) plus pedicled omental transposition for FAP.MethodsA retrospective study was carried out in two hospitals analysing data for FAP patients who underwent surgical treatments between 2015 and 2021. Perioperative outcomes and early and mid-term anal functions were analysed.ResultsAfter excluding 4 patients who underwent total proctocolectomy with permanent ileostomy, 10 patients were enrolled in the study. Among the 10 patients, 3 received TPC-SIAA plus pedicled omental transposition, 3 received total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA), and 4 received total colectomy with ileal pouch-rectal anastomosis (TC-IPRA). Except for one case conversion to laparotomy, laparoscopic surgery was performed for the other cases. The incidence of early postoperative complications was apparently higher with pouch anastomosis (57.1%) than straight anastomosis (0%). Frequencies of bowel movement and low anterior resection syndrome (LARS) score were higher for TPC-SIAA than the other two surgical procedures in the early term; over time, however, the frequencies of bowel movement and LARS score both showed a decreasing trend. In addition, combined with anorectal pressure detection and magnetic resonance imaging defecography at the 3rd month after TPC-SIAA plus pedicled omental transposition, defecation coordination was good. The dynamics and receptivity of the new rectum tended to be as expected.ConclusionAlthough the three surgical procedures are safe and feasible surgical options for FAP, TPC-SIAA plus pedicled omental transposition is more consistent with intestinal physiology, with good intestinal compliance, and anal function tended to be as expected over time. Nevertheless, more extensive studies are needed to confirm these benefits.

OUTCOMES OF TOTAL PROCTOCOLECTOMY (TPC) WITH ILEAL POUCH ANAL ANASTOMOSIS (IPAA)

Abstract BACKGROUND Total proctocolectomy (TPC) followed by ileal pouch anal anastomosis (IPAA) is the surgery of choice for eligible ulcerative colitis patients who are refractory to medical therapy or develop complications such as adenocarcinoma or dysplasia. Although associated with excellent quality of life, IPAA can lead to complications including chronic antibiotic-refractory pouchitis, anatomical complications, and development of Crohn’s disease. These outcomes remain a clinical challenge. The aim of this study was to evaluate the rate of complications and their treatment following TPC with IPAA to assess for predictors of adverse postoperative outcomes. METHODS This was a single center, retrospective study from January 1,2010 to December 31, 2020. We included patients who underwent TPC with IPAA and reported at least one episode of pouchitis, some of whom also had additional complications. Chronic pouchitis was defined as recurrent episodes of biopsy-proven inflammation or as reported in the patient record based on clinical presentation and responsiveness to treatment. Crohn’s disease of the pouch was defined as pre-pouch ileitis or development of a fistula more than 6 months post-operatively. Data is presented as number of cases and proportions. RESULTS A total of 44 subjects who underwent IPAA (52% female, mean age 46.4 ± 11.3 years) were included. The rate of acute pouchitis was 9%, the rate of chronic pouchitis was 75%. In the chronic pouchitis group, 45% were antibiotic-dependent and 7% were antibiotic-refractory. We found that 70% of subjects required the initiation of medical therapy to treat symptoms of pouchitis, with the majority requiring chronic antibiotics (73%) (Table). A total of 10 subjects (23%) required biologics and 10 subjects (23%) required chronic steroid therapy. Anatomic complications were noted in 23 subjects (52%), the most common being abscess/fistula formation (30%), followed by stricture formation (27%). Anatomic complications appeared more likely to occur when more time had elapsed since the original surgery. 10 subjects (23%) needed repeat surgery and 9 subjects (20%) developed Crohn’s disease of the pouch. CONCLUSIONS In our cohort, we found that nearly two thirds of subjects required medical therapy to treat pouchitis following IPAA including 25% requiring treatment biologic/immunosuppressant therapy. In addition, one quarter required repeat surgery for treatment of complications. Limitations of this study include a tertiary patient population and small sample size. We found a lack of standardized characterization of pouchitis with respect to symptoms and lab abnormalities. In future work, we plan to use this data to develop a prospective, multi-center study to establish a standardized database of patients who underwent IPAA. This will help better understand factors that influence outcomes and guide management.

Ileal Pouch Anal Anastomosis (IPAA) for colitis; development of Crohn's and Pouchitis

BackgroundChronic pouchitis and Crohn's disease after Ileal pouch anal anastomosis (IPAA) for ulcerative colitis could be a larger issue than previously reported. MethodsAll patients receiving care for their IPAA over a 10-year period at a community hospital were included. Primary outcomes were incidence of Crohn's disease and pouchitis. ResultsThe study included 380 IPAA patients. Indication for pouch creation was either UC (n = 362) or indeterminate colitis (n = 18). Cumulative incidence of Crohn's was 19.5%. Five-, 10- and 20-year incidence of Crohn's was 3.4%, 8.4% and 16.9%. Chronic pouchitis occurred in 28.7%. Mean time to pouchitis and Crohn's diagnosis was 8.4 (SD ± 8.0) and 11.6 (SD ± 7.5) years. Pouch failure occurred in 12.4%. Patients who developed Crohn's were more likely to suffer pouchitis and pouch failure (OR 3.5, 95%CI 2.0–6.0 and 5.3, 95%CI 2.8–10.1). ConclusionDuring long term follow up, almost 20% are diagnosed with Crohn's contributing significantly to pouch failure.

Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis.

Simple SummaryProctocolectomy with ileal pouch-anal anastomosis is the intervention of choice for ulcerative colitis and familial adenomatous polyposis requiring surgery. However high-grade dysplasia and cancer in the anal transitional zone and ileal pouch after 20 years is estimated to be 2 to 4.5% and 3 to 10% in ulcerative colitis and familial polyposis, respectively. The risk factors for ulcerative colitis are the presence of pre-operative dysplasia or cancer, disease duration > 10 years and severe villous atrophy. For familial polyposis, the risk factors are the number of pre-operative polyps > 1000, surgery with stapled anastomosis and the duration of follow-up. Even if anal transitional zone and ileal pouch cancers seldom occur following proctectomy for ulcerative colitis and familial adenomatous polyposis, the high mortality rate associated with this complication warrants close endoscopic monitoring, mainly every year with pouchoscopy including chromoendoscopy.Proctocolectomy with ileal pouch-anal anastomosis is the intervention of choice for ulcerative colitis and familial adenomatous polyposis requiring surgery. One of the long-term complications is pouch cancer, having a poor prognosis. The risk of high-grade dysplasia and cancer in the anal transitional zone and ileal pouch after 20 years is estimated to be 2 to 4.5% and 3 to 10% in ulcerative colitis and familial polyposis, respectively. The risk factors for ulcerative colitis are the presence of pre-operative dysplasia or cancer, disease duration > 10 years and severe villous atrophy. For familial polyposis, the risk factors are the number of pre-operative polyps > 1000, surgery with stapled anastomosis and the duration of follow-up. In the case of ulcerative colitis, a pouchoscopy should be performed annually if one of the following is present: dysplasia and cancer at surgery, primary sclerosing cholangitis, villous atrophy and active pouchitis (every 5 years without any of these factors). In the case of familial polyposis, endoscopy is recommended every year including chromoendoscopy. Even if anal transitional zone and ileal pouch cancers seldom occur following proctectomy for ulcerative colitis and familial adenomatous polyposis, the high mortality rate associated with this complication warrants endoscopic monitoring.

DOP36 Efficacy and safety of vedolizumab in patients with chronic active pouchitis refractory to anti-TNF therapy: Results of a retrospective multicenter study

Abstract Background Total coloproctectomy with ileoanal anastomosis (IAA) is the procedure of choice for patients with treatment-resistant ulcerative colitis (UC). It is most often curative, but can be complicated by pouchitis in 30% of cases, which becomes chronic in 10% of patients. Its treatment is not codified after failure of conventional treatments and a first line of anti-TNF. The objective of our study was to determine the efficacy and safety of vedolizumab (VDZ) in patients with anti-TNF refractory chronic pouchitis. Methods This was a retrospective, multicenter study conducted in 17 hospital centers. Patients were selected from July 2019 to January 2021. All patients had chronic pouchitis refractory to a first line of anti-TNF. We evaluated clinical, endoscopic and biological characteristics at initiation of VDZ therapy, at week (W) 10 as well as at W52. The primary objective of the study was to assess clinical response (improvement ≥ 50% in stool frequency and rectal bleeding) at W52. Secondary objectives were to assess clinical response and remission (absence of symptom) at W10, endoscopic response (improvement ≥ 50% of endoscopic lesions) and remission (mucosal healing) at W10 and 52. Adverse events were also collected. Results Forty-nine patients were included in the study (23 women, 26 men, mean age 48 years). Thirty-one patients (63%) had received only one line of biologic. Forty-four (90%) patients had endoscopic evaluation before initiation of VDZ, and 25 (51%) patients at W10 and 52. CRP was assessed in all patients at baseline, 43 (88%) patients at W10, and 33 (67%) patients at W52.At W10, 17 (34%) patients were clinically responders without corticosteroids, of whom 3 (6%) were in remission; among the 25 patients evaluated, endoscopic response was obtanine in 5 (20%) patients and endoscopic remission in 11 (44%) patients. At W52, 22 (44%) patients were clinically responders, 12 (24%) of whom were in remission; endoscopic response was obtained in 15 (60%) patients and endoscopic remission in 5 (20%) patients. Although there was a trend for CRP to decrease during follow-up (17.3 mg/L at inclusion vs. 7.9 mg/L at W52) in the responder group, there was no significant difference between this subgroup and the non-responder patients at W52. Eight patients (16%) had adverse events, leading to discontinuation of treatment in three of them. Optimization of VDZ at W10 was the only factor predicting nonresponse at W52: 40% in the non-responder group vs 8% in the responder group (p=0.05). At 1 year, 69% of patients were continuing treatment. Conclusion This retrospective multicenter study shows that VDZ is a therapeutic option that may be considered in the treatment of chronic pouchitis refractory to anti-TNF.

OP13 Modified 2-stage vs. 3-stage ileal pouch-anal anastomosis result in equivalent long-term functional outcomes and pouch survival: A matched-pair analysis

Abstract Background Long-term outcomes data after modified 2-stage ileal pouch anal anastomosis (IPAA), defined as completion proctectomy (CP) and IPAA without loop ileostomy, is lacking. We aimed to describe long-term functional results, patient satisfaction, and pouch survival in a cohort of patients from a high-volume center. We hypothesized selective m2-stage can result in comparable long-term pouch survival relative to a 3-stage approach. Methods Our institutional ileal pouch database was retrospectively reviewed to identify patients who underwent index IPAA surgery from 1983–2019. Adults &amp;gt;18 years of age who underwent CP with IPAA were included. At our specialized institution, m2-stage is performed selectively based on surgeon judgement. Patients were stratified into 2 groups (3-stage vs m2-stage) and matched on a 1:1 basis based on age ±5, year of operation ±3, gender, preoperative diagnosis, double-stapled vs handsewn, and laparoscopy. Primary outcome was pouch survival, with pouch failure defined as permanent diversion, pouch excision, or conversion to a Kock pouch. Results In total, 2,433 patients were included, of whom 2,198 (90.3%) underwent 3-stage IPAA and 235 (9.7%) m2-stage IPAA. Matching resulted in 223 matched pairs, and long-term pouch survival (95.5% vs 93.2%, p=0.32) did not significantly differ (Figure 1). Short-term outcomes in the matched pairs revealed a shorter postoperative length of stay in the 3-stage patients (5 vs 8 days, p&amp;lt;0.001), but no significant difference in postoperative complications (12.1% vs 17%, p=0.09) was seen between the matched 3-stage and m2-stage patients, respectively. Functionally, there was no difference in the number of stools/24 hours (7 vs 7, p=0.33) or in proportion of patients requiring seepage protection at night (29.7% vs 24.6%, p=0.31). However, 3-stage patients required significantly more seepage protection during the day (25.1% vs 15.0%, p=0.02). Regarding pouchitis, there was no difference in the proportion of patients reporting recent symptoms (33.4% vs 33.3%, p=1.0), episodes in the last year (0 vs 0, p=0.51), or pouchitis requiring continuous medication (16.7% vs 10.1%, p=0.10). Patient satisfaction was similar as no difference in the proportion of those who would have surgery again (90.4% vs 93.7%, p=0.34), those who would recommend surgery (94% vs 95.5%, p=0.68), or overall patient satisfaction with surgery on a scale of 1 – 10 (highest) (3 vs 7, p=0.07) was reported. Figure 1: Kaplan-Meier curve for pouch survival (matched pairs) Conclusion Long-term outcomes were similar in patients who underwent modified 2-stage and 3-stage IPAA. Modified 2-stage IPAA is an alternative for selected patients with limited options if performed at high-volume centers in experienced hands.

P108 Identifying Patient-Centered Future Research Priorities: A Report from the Patient Reported Outcomes after Pouch Surgery (PROPS) Delphi Consensus Study

Abstract Background The Patient Reported Outcomes after Pouch Surgery (PROPS) Delphi Consensus Study recently described Ileoanal Pouch Syndome – the constellation of functional outcomes that should be the focus of future research. Importantly, several additional items not related to bowel function were identified by patients as critical to their quality of life. The aim of this abstract is to highlight these additional items. Methods Three panels of expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients: (A) patients, (B) colorectal surgeons, (C) gastroenterologists/other clinicians. IPAA patients were recruited by advertisements on the social media pages of a national patient advocacy groups. Clinicians were recruited by a 14 member scientific committee with the aim of selecting experts in inflammatory bowel disease and IPAAs. A starting list of items was generated by systematic literature review. Three rounds of Delphi surveys were employed to select high priority items based on an a priori threshold. Participants had the opportunity to suggest additional symptoms not included in the starting list. A final online consensus meeting with representation from all three expert panels was held to finalize a consensus statement. Results After three rounds of voting, 195 patients, 62 colorectal surgeons, and 48 gastroenterologists/other specialists completed all three rounds. In the patient group, 95% had UC and J-pouch anatomy. In the early Delphi rounds, approximately 74% of patients identified impact on sexual function/intimacy as a high priority outcomes, while 70% of patients identified impact on ability to conceive as a high priority. Similarly, 78% of patients believed that risk of pouchitis was a high priority, compared to 47% of surgeons and 66% of gastroenterologists. Furthermore, patients participating in the subsequent online focus groups and final consensus meeting felt strongly that future research on delivery of care, long term follow up, and proper consent before surgery (including accurate counseling on function and perception of being “cured”) were critical areas for future research. Conclusion PROPS was the first study to identify key functional outcomes after pouch surgery with direct input from a large panel of IPAA patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function. In addition to the identification of key bowel function outcomes, the study highlighted additional patient-centered core outcomes that clinicians should focus future research efforts on.

P437 Reoperations and long-term survival of Kock’s continent ileostomy in Inflammatory bowel disease patients: a population based national cohort study from Sweden

Abstract Background Kock’s continent ileostomy is an option after proctocolectomy for patients not suitable for ileal pouch anal anastomosis or ileorectal anastomosis. Ulcerative colitis is the most common indication for continent ileostomy. The aim of this study was to evaluate the long-term outcome of continent ileostomy. Methods All patients with inflammatory bowel disease and a continent ileostomy were identified from the Swedish National Patient Register. Data on demographics, diagnosis, reoperations, and excisions of the continent ileostomy was obtained. Patients with inconsistent diagnostic coding were classified as IBD-unclassified. Results Some, 727 patients were identified, 428 (59%) with Ulcerative colitis, 45 (6%) with Crohn’s disease and, 254 (35%) with IBD-unclassified. After a median follow-up time of, 27 (IQR, 21–31) years, 191 (26%) patients had never had revisional surgery. Some, 1,484 reoperations were performed on, 536 (74%) patients, the median number of reoperations was, 1 (IQR, 0–3) per patient. The continent ileostomy was excised in, 77 (11%) patients. Reoperation within the first year after reconstruction was associated with higher rate of revisions (IRR, 2.90 p&amp;lt;0.001) and shorter time to excision (HR, 2.38 p&amp;lt;0.001). Constructing the continent ileostomy after year, 2000 was associated with increased revision and excision rates (IRR, 2.7 p&amp;lt;0.001 and HR, 2.74 p=0.013). IBD-unclassified was associated with increased revisions (IRR, 1.3 p&amp;lt;0.001) and the proportion of IBD-unclassified patients almost doubled from the, 1980s (32%) to after, 2000 (50%). Conclusion Continent ileostomy is associated with substantial need for revisional surgery, but most patients get to keep their reconstruction for a long time.

P435 High rate of vitamin deficiencies in patients after total proctocolectomy and pouch surgery- results from a prospective cohort

Abstract Background Patients with ulcerative colitis (UC) undergoing total proctocolectomy with ileal pouch anal anastomosis (pouch surgery) may be prone to develop nutritional deficiencies. Here we aimed to evaluate the rates of vitamin deficiencies and their risk factors in these patients. Methods Patients after pouch surgery were consecutively enrolled in a tertiary referral center. Pouch behavior determined clinically (normal pouch; recurrent acute pouchitis; chronic pouchitis; Crohn’s like disease of the pouch), disease activity, inflammatory markers and serum vitamin D, B12 and folic acid levels were repeatedly assessed. Body mass index (BMI) and the use of dietary supplements were recorded at each visit. Results A total of, 136 patients (mean age-, 47.5±16 years, mean BMI-, 24.9±5 Kg/m2, female gender, 58%) underwent, 721 study visits. Average visits/patients:, 5 (range, 1–15); between-visit interval:, 5±4 months. Normal pouch:, 41%, recurrent acute pouchitis, 24%, chronic pouchitis/ Crohn’s like disease of the pouch:, 35%. Vitamin D deficiency (&amp;lt;25 nmol/L) and insufficiency (25–75 nmol/L) were detected in, 6.5% and, 82% of patients, respectively. Vitamin B12 deficiency (&amp;lt;221 pmol/L) was detected in, 29%, and folic acid deficiency (&amp;lt;7 nmol/L) in, 9.5% of patients. After controlling for disease activity and inflammatory markers, vitamin D deficiency was positively associated with pouch age (i.e interval from the ileostomy closure, OR=, 1.47, 95%CI, 1.1–1.9, p=, 0.007). Vitamin B12 deficiency was positively associated with BMI (OR=1.07, 95%CI, 1.001–1.14, p=0.045), and folic acid deficiency was inversely associated with patient’s age (OR=, 0.95, 95%CI, 0.9–0.99, p=0.017). Of patients with vitamin D, B12 and folic acid insufficiencies or deficiencies, only, 60/121 (49.6%), 17/40 (42%), and, 4/13 (30%), respectively, reported the use of appropriate dietary supplements throughout the long-term follow-up. Conclusion In a longitudinal follow up of patients with UC after pouch surgery, we detected significant vitamin D, B12 and folic acid deficiencies and identified specific risk factors. Insufficient active correction with dietary supplements was noticed. Screening and improved correction of nutritional deficiencies should be a part of the routine pro-active multidisciplinary care of patients after pouch surgery.

MASS CYTOMETRY ANALYSIS OF CROHN’S DISEASE-LIKE PHENOTYPE OF THE ILEOANAL POUCH FOLLOWING ILEAL POUCH-ANAL ANASTOMOSIS FOR ULCERATIVE COLITIS

For patients with medically refractory ulcerative colitis (UC), total proctocolectomy and ileal pouch-anal anastomosis (IPAA) has been the definitive surgery of choice. Approximately 10% of patients who were initially diagnosed with UC and underwent an IPAA, subsequently develop a condition referred to as Crohn’s disease-like phenotype of ileoanal pouch (CDP). CDP is typified by ulcers in the pre-pouch ileum, stricture involving the pouch or pre-pouch ileum, and/or fistulas. The etiology of CDP remains unknown and remains difficult to diagnose and treat.

OUTCOMES OF TOTAL PROCTOCOLECTOMY (TPC) WITH ILEAL POUCH ANAL ANASTOMOSIS (IPAA)

Total proctocolectomy (TPC) followed by ileal pouch anal anastomosis (IPAA) is the surgery of choice for eligible ulcerative colitis patients who are refractory to medical therapy or develop complications such as adenocarcinoma or dysplasia. Although associated with excellent quality of life, IPAA can lead to complications including chronic antibiotic-refractory pouchitis, anatomical complications, and development of Crohn’s disease. These outcomes remain a clinical challenge. The aim of this study was to evaluate the rate of complications and their treatment following TPC with IPAA to assess for predictors of adverse postoperative outcomes.

Outcomes of Ileoanal Pouch Anastomosis in Pediatric Ulcerative Colitis Are Worse in the Modern Era: A Time Trend Analysis Outcomes Following Ileal Pouch-Anal Anastomosis in Pediatric Ulcerative Colitis.

Despite significant differences in surgical outcomes between pediatric and adult patients with ulcerative colitis (UC) undergoing colectomy, counseling on pediatric outcomes has largely been guided by data from adults. We compared differences in pouch survival between pediatric and adult patients who underwent total proctocolectomy with ileal pouch-anal anastomosis (IPAA). This was a retrospective single-center study of patients with UC treated with IPAA who subsequently underwent pouchoscopy between 1980 and 2019. Data were collected via electronic medical records. We stratified the study population based on age at IPAA. Differences between groups were assessed using t tests and chi-square tests. Kaplan-Meier curves were used to compare survival probabilities. Differences between groups were assessed using a log-rank test. We identified 53 patients with UC who underwent IPAA before 19 years of age and 329 patients with UC who underwent IPAA at or after 19 years of age. Subjects who underwent IPAA as children were more likely to require anti-tumor nerosis factor (TNF) postcolectomy compared with adults (41.5% vs 25.8%; P < .05). Kaplan-Meier estimates revealed that pediatric patients who underwent IPAA in the last 10 years had a 5-year pouch survival probability that was 28% lower than that of those who underwent surgery in the 1990s or 2000s (72% vs 100%; P < .001). Further, children who underwent IPAA and received anti-TNF therapies precolectomy had the most rapid progression to pouch failure when compared with anti-TNF-naive children and with adults who were either exposed or naive precolectomy (P < .05). There are lower rates of pouch survival for children with UC who underwent IPAA following the uptake of anti-TNF therapy compared with both historical pediatric control subjects and contemporary adults.

The Cumulative Incidence of Pouchitis in Pediatric Patients With Ulcerative Colitis.

Despite highly effective therapies, many children develop medically refractory ulcerative colitis (UC) and undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). We sought to determine the incidence, risk, and burden of pouchitis in the first 2 years following the final stage of IPAA in pediatric UC patients. Within the IQVIA Legacy PharMetrics Adjudicated Claims Database, we identified pediatric patients with UC who underwent proctocolectomy with IPAA between January 1, 2007, and June 30, 2015. We utilized International Classification of Diseases-Ninth Revision-Clinical Modification or International Classification of Diseases-Tenth Revision-Clinical Modification codes to identify patients with UC and Current Procedural Terminology codes to identify colectomy and IPAA. Continuous variables were compared using t tests and Wilcoxon rank sum testing, while categorical variables were compared using chi-square testing. A total of 68 patients with an IPAA were identified. In the first 2 years following IPAA, the cumulative incidence of pouchitis was 54%. Patients with pouchitis required more outpatient visits in the first 2 years after IPAA (mean 21.8 vs 10.2; P = .006) and were more likely to be hospitalized compared with patients without pouchitis (46% vs 23%; P = .045). Patients with pouchitis also demonstrated higher mean total costs in year 1 and year 2 ($27489 vs $8032 [P = .001] and $27699 vs $6058 [P = .003], respectively). Our findings confirm the high incidence of pouchitis demonstrated in earlier single-center studies of pediatric patients undergoing proctocolectomy with IPAA for UC. Identification of risk factors for pouchitis would be useful to optimize early intervention.

Two-time perforation of the ileal J-pouch 6 and 18\xa0years after restorative proctocolectomy and ileal pouch\u2013anal anastomosis for familial adenomatous polyposis: a case report

BackgroundPerforation of the ileal J-pouch after restorative proctocolectomy and ileal pouch–anal anastomosis are extremely rare. There has been no report of perforation of the ileal J-pouch occurring twice over several years. We report the first case of perforation at 6 and 18 years following restorative proctocolectomy.Case presentationThe patient was a 52-year-old man who underwent a two-stage restorative proctocolectomy with a hand-sewn ileal J-pouch anal anastomosis due to familial adenomatous polyposis and sigmoid colon cancer at 34 years of age. At the age of 40, he underwent ileal pouch resection at its blind end, abdominal drainage, and anastomotic dilatation. The patient had a perforation of the blind end of the ileal J-pouch from increased intraluminal pressure, with anastomotic stricture and pervasive peritonitis. The patient had no symptoms for a few years; however, 18 years after the initial surgery and 12 years after the first perforation, the patient presented with severe abdominal pain. Computed tomography demonstrated pneumoperitoneum; accordingly, laparotomy was performed. Upon opening the abdominal cavity, contaminated ascites and inflammatory changes were documented involving the ileum. A 2-mm perforation involving the blind end of the ileal J-pouch was also observed and repaired, followed by temporary loop ileostomy creation. Postoperative endoscopy revealed an ulcer in the ileal J-pouch and a stricture located directly at the anastomosis.ConclusionsThe blind end of the J-pouch repeatedly perforated over the years due to recurrent anastomotic stricture. Regular surveillance is, therefore, considered necessary for the release of stricture, maintenance of anastomotic patency, and prevention of ileal J-pouch perforation.