Post Ileal Pouch-anal Anastomosis Research Articles

Prevalence of Clostridioides difficile Infection After Ileal Pouch-anal Anastomosis in Patients With Chronic Antibiotic-dependent Pouchitis and Crohn's-like Disease of the Pouch.

Recurrent or chronic antibiotic therapy is a therapeutic hallmark of chronic antibiotic-dependent pouchitis (CADP) or Crohn's-like disease of the pouch. Antibiotics alter the gut microbiome, which may increase the risk of Clostridioides difficile infection (CDI). The aim of this study was to determine the prevalence of CDI in patients with CADP and Crohn's-like disease of the pouch. We conducted a retrospective cohort study of patients with CADP or Crohn's-like disease of the pouch at a tertiary academic medical center. The primary outcome was prevalence of CDI. Secondary outcomes included antibiotic therapy at the time of CDI diagnosis, treatment regimens for CDI, and subsequent outcomes. Overall, 18 of 198 (9.1%) included patients developed CDI. Treatment with antibiotics at the time of CDI diagnosis occurred in 7 of 18 (39%) patients. Preoperative history of CDI was significantly associated with increased risk of developing CDI following ileal pouch anal anastomosis (IPAA) compared with those with no prior history of CDI (12 of 18 [67%] vs 11 of 180 [6%]; P < .001). In 16 of 18 (89%) patients, CDI treatment was initiated with predominantly oral vancomycin (72%) or metronidazole (17%). Although chronic inflammatory conditions of the pouch arise postoperatively, the prevalence of CDI in this population appears to be similar compared with the general population of patients with inflammatory bowel disease prior to and post IPAA. Preoperative CDI appears to be the greatest risk for postoperative CDI and may require extra vigilance in the assessment of CDI after IPAA.

Pyloric gland metaplasia: Potential histologic predictor of severe pouch disease including Crohn’s disease of the pouch in ulcerative colitis

Crohn’s disease of the pouch (CDP) is seen in a subset of ulcerative colitis (UC) patients following ileal pouch-anal anastomosis (IPAA). Histologic or clinical predictors of CDP are unknown. UC patients with subsequent CDP diagnosis were identified. The rationales for the diagnosis, the interval from the initial signs of CDP to the diagnosis, family history and smoking history were reviewed. Archived pathology materials were reviewed for the presence of pyloric gland metaplasia (PGM) and compared with those from UC with similar severity of pouchitis with CDP (matched UC controls), random UC controls, and ileocolectomies from primary CD patients. CDP diagnosis was made in 26 (18.1%) of 144 patients; all of them met commonly used diagnostic criteria for CDP. The diagnosis was rendered on average 15 months after the initial CD-like signs. PGM was found in 58% of CDP, more common than random UC controls but no different from primary CD and matched UC controls. PGM preceded first signs of CD in a subset. Patients with a family history of CD were more likely to develop CDP than those without a family history of any type of inflammatory bowel disease. Smoking status did not affect the likelihood of developing CDP. Finding PGM in proctocolectomy, ileostomy and follow-up biopsies in UC patients post IPAA may warrant close follow up for the potential development of pouchitis. Some of these patients, especially those with family history of CD, may further progress and develop severe disease meeting the clinical diagnostic criteria for CDP.

Family History of Crohn’s Disease (CD) May Be a Risk Factor for Developing de novo CD following Ileal Pouch Anal Anastomosis (IPAA) for Ulcerative Colitis (UC)

Abstract Introduction/Objective A subset of patients with an established diagnosis of UC develops signs of CD (de novo CD) following IPAA. While the etiology and risk factors of de novo CD remain largely unknown, preliminary studies have shown controversial results regarding family history of inflammatory bowel disease (IBD) and smoking history. Methods Patients that underwent IPAA for UC, with at least 1 year of follow-up, were identified (n=161; 1996 to 2018). We retrospectively reviewed the electronic medical records. Patients that were diagnosed with de novo CD during the follow-up period were further identified. Smoking history and family history of IBD were evaluated. Chi square test was performed to compare the frequencies. Odds ratio (OR) and 95% confidence intervals (CIs) were estimated by logistic regression model. P&amp;lt;0.05 was considered statistically significant. Results 29 de novo CD were identified. At the time of proctocolectomy, the family history of IBD and smoking history was documented in 152 UC patients including 27 that subsequently developed de novo CD. 23 of 152 had a family history of IBD (12 UC, 9 CD and 2 IBD, NOS). 19/129 (14.7%) UC patients without a family history of any type of IBD, 4/9 (44.4%) with a family history of CD, and 4/12 (33.3%) with a family history of UC developed de novo CD. Patients with a family history of CD were more likely to develop de novo CD post IPAA than those without a family history of any type of IBD (OR 4.63, 95% CI 1.14-18.82, p=0.03). Family history of UC did not correlate with development of de novo CD (OR 2.90; 95% CI 0.79-10.57, p=0.108). At the time of proctocoletomy, 11 were current smokers, 25 were former smokers, and 116 never smoked. In de novo CD group, there were 4/27 (14.8 %) former smokers and 23/27 (85.2 %) never smokers. No de novo CD patient was current smoker. In the UC group that remained as UC following IPAA, 11/125 (8.8%) were current smokers, 21/125 (16.8 %) former smokers, and 93/125 (74.4 %) were never smokers. Current smoking status was not associated with development of de novo CD (p = 0.214). Conclusion Family history of CD may be a risk factor for developing de novo CD following IPAA for UC. Current smoking status was not associated with development of de novo CD following IPAA for UC.

Impact of sex on 30-day complications and long-term functional outcomes following ileal pouch-anal anastomosis for chronic ulcerative colitis.

To determine the impact of patient sex on operative characteristics, short-term complications, and long-term functional outcomes following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC). A retrospective review was performed on all patients undergoing two- or three-stage IPAA for CUC at our institution between January 2002 and August 2013. Patient demographics, operative characteristics, 30-day postoperative complications, and long-term functional outcomes from annual survey data were analyzed comparing men and women patients. During the study period, 911 IPAAs (542 men, 369 women) were performed. Men were older and were more often obese (both p <0.01). Use of a three-stage approach and laparoscopic approach were similar between men and women, but operation length, intraoperative blood loss, and hospital length of stay were all higher in men (all p < 0.05). At 30days, women had increased rates of superficial surgical site infections and urinary tract infections (both p < 0.05), while men had increased rates of urinary retention (p = 0.03). Five hundred forty-six patients (60%; 307 men, 239 women) responded to the annual post IPAA survey with a median follow-up of 5.1 and 5.0years in men and women, respectively. Women reported increased frequency of daytime stools in the early follow-up period, but this difference resolved with time. Other functional outcomes were similar. Patient sex impacts intraoperative complexity, postoperative length of stay, 30-day postoperative outcomes, and initial long-term function. These findings underscore the need to adjust preoperative counseling regarding IPAA outcomes based on sex.

Significant Variation in Recommendation of Care for Women of Reproductive Age with Ulcerative Colitis Postileal Pouch–Anal Anastomosis

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical option for treatment refractory ulcerative colitis. Infertility risk post IPAA and sphincter injury concerns with vaginal delivery has led to a lack of consensus regarding timing and recommended mode of delivery (MOD) post-IPAA. To better understand these issues, we surveyed gastroenterologists (GI), colorectal surgeons (CRS), and obstetricians (OB) to assess practice variation in recommendations for delivery post IPAA. Clinical vignettes were developed to assess knowledge, attitudes, and beliefs surrounding (1) the impact of IPAA on fertility, (2) IPAA timing around pregnancy, (3) recommended MOD after IPAA and (4) which specialist should advise on MOD. These were emailed to providers using specialty society address lists. Univariate analyses tested differences among groups. A total of 244 GI, 158 CRS and 39 OBs responded to the survey. The majority of GI (67%) and CRS (60%) quoted fertility reduction of >20% post-IPAA versus 11% OB (p < 0.001). More GI than CRS (67 vs. 45%) recommended delaying IPAA until after pregnancy (p < 0.001), and this was more commonly suggested by CRS in practice <10 years (p = 0.01) and <45 years old (p = 0.003). Vaginal delivery was recommended post-IPAA in 43, 20 and 57% for GI, CRS and OB, respectively (p < 0.001). Only 28% CRS versus 59% OB thought OB should primarily advise on MOD (p < 0.001). There is significant intra- and inter-group variation in management of women post-IPAA. There is need for consensus among subspecialists involved in managing women with this complex condition.

Variation in Recommendations for Modes of Delivery Post Ileal Pouch-Anal Anastomosis (IPAA) in Women with Ulcerative Colitis

Purpose: Fertility may be negatively affected in women with ulcerative colitis (UC) after ileal pouch-anal anastomosis (IPAA). However, it is unclear whether women who do conceive after IPAA should undergo vaginal delivery or cesarean section (CS). There are no formal consensus guidelines in this setting among gastroenterologists (GI), colorectal surgeons (CRS) and obstetricians (OB) who often co-manage these patients. This can lead to variation in care, a marker of poor quality. Furthermore, contrasting recommendations by different specialists may be confusing for the patient. Aim: To determine if there is variation among physicians in their recommendations for mode of delivery post-IPAA in a cohort of female UC patients. Methods: A total of 105 patients of child-bearing age at the time of IPAA (18-44 years old) performed by a single surgeon were surveyed via telephone and/or email using a survey instrument developed with input from GIs (n=2) and CRS (n=1) with expertise in IBD. Survey questions included patient demographics, IBD and surgical history, pregnancy history including any infertility work-up, recommendations regarding modes of delivery and delivery history. Results: A total of 44 (42%) patients (mean age; 38 years) specifically answered the survey question regarding mode of delivery recommended by their physicians (OB, High-risk OB, Midwife, GI, CRS). Half of these patients stated they did not discuss this with their physicians as they had no immediate plans (45%) or future plans (55%) for pregnancy post IPAA. Of the 22 seeking a recommendation, all 17 patients who asked their CRS were recommended to undergo CS. Twelve patients also asked a total of 16 OBs; 10 recommended vaginal delivery, 5 recommended CS, and 1 deferred recommendation until a later date. Four patients asked their GI doctor; 2 recommended CS and 2 were given no recommendation. One patient also asked a midwife, who recommended vaginal delivery. Seven had 13 full-term pregnancies; 6 women had a total of 9 CS, and 1 had a total of 4 vaginal deliveries. Of the 15 women who had not yet conceived, 5 were undergoing infertility work-up and 10 had electively deferred conception. However, at the time of a potential future pregnancy, 8 would elect for CS based on previous CRS recommendation, 1 would elect for vaginal delivery despite a CS recommendation and 6 were undecided. Conclusion: In our cohort, there was disconcordance between CRS and OB recommendations for mode of delivery post-IPAA. Patients tended to follow the recommendation of the CRS more than the OB. A study is underway to further examine variation in recommendations among different specialties managing women with IBD of childbearing age pre- and post-IPAA.