Pouch-anal Anastomosis For Ulcerative Colitis Research Articles

Understanding the Lived Experience after Colectomy and Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Qualitative Study

Abstract BACKGROUND The patient experience after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) remains poorly defined, resulting in heterogeneity in clinical assessments and research. We performed a qualitative study to better understand the experience of patients after IPAA for UC, with a focus on the symptoms experienced by patients and the resultant effects on quality of life (QoL). METHODS We conducted semi-structured focus groups among patients who had undergone IPAA for UC. We invited patients with a variety of pouch-related conditions, including patients reporting normal pouch function and those with diagnosed inflammatory conditions of the pouch. We included questions on patients' experiences and symptoms after IPAA based on 4 thematic areas identified by a previously performed systematic review: bowel symptoms, activities, general issues and quality of life, and psychosocial. RESULTS We interviewed 15 individuals over the course of four focus groups. Participants described the significant impact that bowel symptoms after IPAA had on other activities including work and daily life, and their subsequent relation to QoL themes. Participants noted symptoms of frequency, urgency, and incontinence after IPAA, and many shared how these symptoms required them to change their lifestyle, particularly by altering their daily schedule or changing their diet. Nevertheless, most participants reported QoL improvement after IPAA. CONCLUSION In this qualitative study evaluating the experience of patients after IPAA, multiple bowel-related symptoms impact other areas of life and overall QoL. Patients undergoing IPAA for UC represent a unique patient population, and thus patient-centered outcome measures should be designed to standardize their assessment.

P0423 Anastomotic leakage after ileoanal pouch surgery: risk factors and salvage

Abstract Background Chronic anastomotic leakage (AL) is the most common cause of pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis for Ulcerative Colitis. This study aims to investigate the factors associated with AL and successful salvage of leaking anastomoses after ileoanal pouch surgery. Methods This multicentre retrospective cohort study included patients ≥18 years old with Ulcerative Colitis or unclassified Inflammatory Bowel Disease who underwent ileoanal pouch surgery between 2016 and 2021 in six European centres, with >12 months follow-up. The primary outcome was AL rate. Secondary outcomes included factors associated with the occurrence of AL, diagnosis, management and salvage of AL and stoma-free survival. Results 411 patients were included, of which 13.6% (n=56) had a diagnosed AL with a significantly higher rate in low-volume centres. Of the 56 AL, 44 were diagnosed early and 12 late. Three-stage approach was associated with late diagnosis and treatment. AL were managed using various techniques. The overall AL salvage rate was 85.4%, 92% when diagnosed and treated early and 60% when diagnosed and treated late (p=0.010). Successful AL salvage was associated with long-term stoma-free status (p=0.002). The long-term stoma-free rate was 95.5% in patients with early diagnosed and treated leaks, but only 41.7% when diagnosed and treated late (p<0.001). Conclusion Early diagnosis and treatment of AL diminishes the negative effect of AL after ileoanal pouch surgery. Pro-active anastomotic assessment is mandatory to enable early diagnosis and management especially in patients at increased risk of silent leaks such as three-staged patients.

Ileal pouch-anal anastomosis for ulcerative colitis: 30-year analysis on surgical evolution and patient outcome.

Proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for patients with ulcerative colitis with medical refractory disease or dysplasia. The aim of this research was to describe the evolution of ileal pouch-anal anastomosis surgery and surgical outcomes over a three-decade interval in a high-volume referral centre. All consecutive patients undergoing ileal pouch-anal anastomosis for ulcerative colitis between 1990 and 2022 at the University Hospitals of Leuven were retrospectively included. Patients were divided into three interval arms (interval A 1990-2000, interval B 2001-2010 and interval C 2011-2022). The primary outcomes of interest were anastomotic leakage at 30 days and pouch failure. Overall, 492 patients were included. The use of preoperative advanced therapies increased over time (P < 0.001). An increase in laparoscopic procedures (23.2% in interval A, 66.4% in interval B, 86.0% in interval C; P < 0.001) and a shift towards delayed ileal pouch-anal anastomosis (colectomy-first approach with delayed ileal pouch-anal anastomosis construction: 23.0% in interval A, 40.9% in interval B, 85.8% in interval C; P < 0.001) were observed. Anastomotic leakage rate decreased from 16.7% (interval A) to 8.4% (interval C) (P = 0.04). Delayed ileal pouch-anal anastomosis was the most relevant factor in limiting leakage (OR 0.49 (95% c.i. 0.27 to 0.87); P = 0.016). Median follow-up was 7.5 years (interquartile range 2.5-16). Cumulative pouch failure incidence was 8.2%, not significantly different between the three intervals (P = 0.580). Anastomotic leakage was the only significant risk factor for pouch failure (HR 2.82 (95% c.i. 1.29 to 6.20); P = 0.010). Significant changes in the management of ulcerative colitis patients occurred. Despite the widespread use of advanced therapies and the expanded surgical indications, anastomotic leakage rate decreased over time. In the context of a delayed ileal pouch-anal anastomosis, diverting ileostomy could be avoided in selected cases. Anastomotic leakage remains the most relevant risk factor for pouch failure. Pouch failure incidence remained stable over the years.

Predictors of pouch failure and quality of life following ileal pouch-anal anastomosis for ulcerative colitis: a retrospective multicenter study.

This study aimed to investigate the causes of failure after the ileal pouch-anal anastomosis (IPAA) procedure for ulcerative colitis (UC) and to determine the independent risk factors affecting their quality of life. This multi-center cohort study included all UC patients who underwent IPAA at nine referral centers in Türkiye from 2010 to 2018. Centers were categorized as high-volume (≥10 cases/year) or low-volume (<10 cases/year). Outcomes assessed included postoperative complications, pouch failure, and QoL using the Cleveland Global Quality of Life (CGQL) and modified Oresland Score. Logistic and linear regression analyses were used to identify risk factors for pouch failure and QoL determinants, respectively. Of 296 patients included, pouches were constructed in 172 (58.1%) as a two-staged and in the remaining patients as a three-staged procedure. The high-volume center had higher rates of biologic (45.1% versus 16%) and steroid use (63.9% versus 22.1%). The overall pouch failure rate was 4.7% at the end of follow-up of 66.1 months. Independent risk factors for pouch failure included pelvic sepsis (OR = 47.47, P = 0.002), biologic use (OR = 13.45, P = 0.033), chronic pouchitis (OR = 14.31, P = 0.013), postoperative blood transfusion (OR = 7.04, P = 0.048), and low annual case volume (OR = 30.86, P = 0.047). CGQL and Oresland scores averaged 0.77 ± 0.1 and 6.3 ± 1.1, respectively. Factors negatively impacting QoL included two-staged procedures, small bowel obstruction, venous thromboembolism, chronic pouchitis, increased frequency of bowel movements, and low annual case volume. IPAA surgery in UC patients in Türkiye demonstrates acceptable rates of complications and pouch failure, with high patient satisfaction in terms of QoL and functional outcomes. Optimizing long-term results requires enhanced surgical expertise and coordinated multidisciplinary management strategies.

Tryptophan Metabolites Improve Intestinal Mucosal Barrier via the Aryl Hydrocarbon Receptor-Interleukin-22 Pathway in Murine Dextran Sulfate Sodium-Induced Pouchitis.

Pouchitis is the commonest complication after ileal pouch-anal anastomosis for ulcerative colitis. The protective effect of tryptophan metabolites on the mucosal barrier may be an effective method for treating pouchitis. The role of tryptophan metabolites on pouchitis remained unclear. We aimed to establish a murine model of dextran sulfate sodium-induced pouchitis to examine the roles of tryptophan metabolites in its pathogenesis. This is a study combined clinical patient data and animal research. A total of 22 patients were enrolled: 5 with familial adenomatous polyposis after ileal pouch-anal anastomosis, eight ulcerative colitis patients after ileal pouch-anal anastomosis patients with pouchitis, and 9 ulcerative colitis patients after ileal pouch-anal anastomosis with normal pouch. The demographic data and fecal samples of patients were collected. Male C57BL/6 mice were purchased from a licensed breeder and underwent ileal pouch-anal anastomosis to establish murine model of pouch. The bloods, feces, tissues of mice were collected. This study was performed in an academic medical center in China. The demographic data of patients were observational collected. The mice underwent ileal pouch-anal anastomosis were divided into six groups: control group with chow diet, dextran sulfate sodium, 6-formylindolo[3,2-b] carbazole + dextran sulfate sodium, high tryptophan diet + dextran sulfate sodium, CH-223191 + dextran sulfate sodium, indole-3-carboxaldehyde + dextran sulfate sodium. Animals were sacrificed after dextran sulfate sodium for 7 days. Fecal tryptophan metabolite level and microbiome composition, the severity of pouchitis, intestinal mucosal barrier function, and activation of the aryl hydrocarbon receptor-interleukin 22 pathway were assessed. Patients with pouchitis had lower fecal microbial diversity and indole-3-acetic acid levels. In murine pouchitis model, high-tryptophan diet increased fecal levels of 3-indoleglyoxylic acid, indole-3-aldehyde, and indole. A high-tryptophan diet and intraperitoneal aryl hydrocarbon receptor ligand 6-formylindolo[3,2-b] carbazole injection alleviated pouchitis. Tryptophan metabolites improved pouch mucosal barriers. aryl hydrocarbon receptor inhibitors exacerbated experimental pouchitis and disrupted the mucosal barrier; however, the aryl hydrocarbon receptor ligand indole-3-carboxaldehyde reversed this effect. This study was limited by small human sample size and lacking an Aryl hydrocarbon receptor knockout mouse model. A high-tryptophan diet and aryl hydrocarbon receptor ligand alleviated dextran sulfate sodium-induced pouchitis in murine ileal pouch-anal anastomosis model, which might be through regulating epithelial tight junctions and promoting goblet-cell differentiation, as well as maintaining the integrity and function of the mucosal barrier. This study provides a rationale for the clinical application of Aryl hydrocarbon receptor ligands in the treatment of pouchitis. See Video Abstract.

2-Stage and 3-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis show comparable short- and long-term outcomes

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) represents the standard treatment for therapy-refractory, malignant or complicated ulcerative colitis (UC) and can be performed as a 2-stage or 3-stage procedure. This study aimed to compare the short- and long-term outcomes after 2- and 3-stage IPAA in patients with UC in our department. A retrospective analysis of 176 patients with UC who received 2- or 3-stage restorative proctocolectomy with IPAA at our institution from 2001 to 2021 was performed. Outcomes for short-term (morbidity, longer hospital stay, readmission) and long-term (pouch failure and quality of life) parameters were compared between the 2- and 3-stage procedure. Regarding short-term outcomes for all patients, in-hospital morbidity and readmission rates after any surgical stage were observed in 69% and 24%, respectively. Morbidity and readmission did not differ significantly between the 2- and 3-stage procedure in uni- and multivariate analysis. Median length of hospital stay for all stages was 17 days. The 3-stage procedure was identified as an independent factor for longer hospital stay (OR 3.8 (CI 1.3–10.8), p = 0.014). Pouch failure and failure of improved quality of life during long-term follow-up occurred both in 10% of patients, with no significant differences between the 2- and 3-stage procedure in uni- and multivariate analysis. Our data suggest that both the 2- and 3-stage proctocolectomy with IPAA demonstrate favourable and comparable postoperative short- and long-term outcomes, with a high rate of improved quality of life in patients with UC.

Are Small Molecules Effective in Treating Inflammatory Pouch Disorders Following Ileal Pouch-Anal Anastomosis for Ulcerative Colitis? Here Is Where We Stand.

Ulcerative colitis (UC) management encompasses conventional and advanced treatments, including biological therapy and small molecules. Surgery, particularly in the form of ileal pouch-anal anastomosis (IPAA), is indicated in cases of refractory/severe disease. IPAA can lead to acute complications (e.g., acute pouchitis) as well as late complications, including chronic inflammatory disorders of the pouch. Chronic pouchitis, including the antibiotic-dependent (CADP) and antibiotic-refractory (CARP) forms, represents a significant and current therapeutic challenge due to the substantial need for evidence regarding viable treatment options. Biological therapies have shown promising results, with infliximab, adalimumab, ustekinumab, and vedolizumab demonstrating some efficacy in chronic pouchitis; however, robust randomized clinical trials are only available for vedolizumab. This narrative review focuses on the evidence concerning small molecules in chronic pouchitis, specifically Janus kinase (JAK) inhibitors and sphingosine-1-phosphate receptor (S1P-R) modulators. According to the preliminary studies and reports, Tofacitinib shows a potential effectiveness in CARP. Upadacitinib presents variable outcomes from the case series, necessitating further evaluation. Filgotinib and ozanimod demonstrate anecdotal efficacy. This review underscores the need for high-quality studies and real-world registries to develop robust guidelines for advanced therapies in post-IPAA inflammatory disorders, supported by vigilant clinical monitoring and ongoing education from international IBD specialist societies.

The Natural History After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Population-Based Cohort Study From the United States.

There are limited data regarding the natural history after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). The principal objectives of this study were to identify 4 key outcomes in the natural history after IPAA within 1, 3, 5, and 10 years: the incidence of pouchitis, Crohn's-like disease of the pouch, use of advanced therapies after IPAA, and pouch failure requiring excision in a network of electronic health records. We performed a retrospective cohort study in TriNetX, a research network of electronic health records. In addition to evaluating incidence rates, we also sought to identify factors associated with pouchitis and advanced therapy use within 5 years of IPAA after 1:1 propensity score matching, expressed as adjusted hazard ratios (aHRs). Among 1,331 patients who underwent colectomy with IPAA for UC, the incidence of pouchitis increased from 58% in the first year after IPAA to 72% at 10 years after IPAA. After propensity score matching, nicotine dependence (aHR 1.61, 95% confidence interval [CI] 1.19-2.18), antitumor necrosis factor therapy (aHR 1.33, 95% CI 1.13-1.56), and vedolizumab prior to colectomy (aHR 1.44, 95% CI 1.06-1.96) were associated with an increased risk of pouchitis in the first 5 years after IPAA. The incidence of Crohn's-like disease of the pouch increased to 10.3% within 10 years of IPAA while pouch failure increased to 4.1%. The incidence of advanced therapy use peaked at 14.4% at 10 years after IPAA. The incidence of inflammatory conditions of the pouch remains high in the current era, with 14% of patients requiring advanced therapies after IPAA.

P214 Effects of rectal stump proctitis on short-term postoperative complications after proctectomy and ileal pouch-anal anastomosis for Ulcerative Colitis

Abstract Background Inflammation of the rectal stump (proctitis) after subtotal colectomy with ileostomy for ulcerative colitis (UC) is common. Proctitis may affect the postoperative outcomes of ileal pouch-anal anastomosis (IPAA). This study aims to explore associations between rectal stump proctitis and short-term postoperative complications (POCs) after proctectomy and IPAA for UC. Methods This retrospective single-centre study included patients who underwent proctectomy, IPAA and protective ileostomy for UC from 2000-2023. Data were retrieved from our prospectively-maintained database. Exclusion criteria were dysplasia or cancer (103 pts), missing pathology results (50 pts), undetermined colitis or Crohn’s Disease features at proctectomy (18 pts). All patients underwent three-staged IPAA and were divided into four groups according to the rectal stump proctitis status at pathology: remission, mild, moderate, and severe proctitis. A stepwise binary logistic regression analysis was performed for each short-term outcome. Models included variables with a different distribution according to the outcome (p-value ≤0.1). Results We included 785 patients who underwent proctectomy and IPAA. At pathology, remission was achieved by 162 (20.6%) patients, while proctitis of the rectal stump was mild in 211 (26.9%), moderate in 246 (31.3%), and severe in 166 (21.1%) patients, respectively. Table 1 details population characteristics and outcomes according to the proctitis status. Patients with moderate and severe proctitis received more preoperative biologics and ongoing systemic steroids at surgery. While they underwent previous abdominal surgery less frequently, the laparoscopy rate was lower with a longer postoperative length of stay. At multivariate (Table 2), Medical POCs were independently associated with ongoing antibiotics (OR 2.29 [1.01-5.20] p=0.047) and ASA score≥3 (OR 1.93 [1.11-3.35] p=0.019). Surgical POCs were independently associated with ongoing systemic steroids (OR 2.09 [1.19-3.68] p=0.011, while ongoing antibiotics (OR 0.2 [0.04-0.86] p=0.031) and laparoscopy (OR 0.53 [0.28-1.00] p=0.049) were protective. Intra-abdominal septic complications (IASCs) and abdominal/pelvic abscesses were independently associated with the proctitis status (OR 1.1 [1.06-2] p=0.018 and OR 1.56 [1.08-2.25] p=0.017, respectively). Conclusion Rectal stump proctitis was independently associated with postoperative abdominal and pelvic abscesses and IASCs after proctectomy and IPAA for UC. The association between proctitis and IPAA’s long-term outcomes and pouch failure need to be further explored.

S148 Long-Term Quality-of-Life and Functional Outcomes After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

S148 Long-Term Quality-of-Life and Functional Outcomes After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

The Comparative Effectiveness of Ciprofloxacin and Metronidazole for an Initial Episode of Pouchitis: A Propensity-Matched Study.

There is minimal evidence regarding the comparative effectiveness of individual antibiotics in the treatment of pouchitis. We sought to evaluate the comparative effectiveness of ciprofloxacin monotherapy, metronidazole monotherapy, and combination therapy (ciprofloxacin and metronidazole) in the treatment of an initial episode of pouchitis after ileal pouch-anal anastomosis for ulcerative colitis (UC). We performed a retrospective cohort study in TriNetX, a global federated research network of electronic health records. Primary outcomes were failure of initial antibiotic therapy and the development of recurrent pouchitis in the first 12 months after an initial episode of pouchitis. One-to-one propensity score matching was performed for age, sex, race, primary sclerosing cholangitis, nicotine dependence, obesity, and previous exposure to tumor necrosis factor inhibitors between the cohorts. Among 271 patients who developed pouchitis (mean age at ileal pouch-anal anastomosis 35.8 years, male sex 57%) and were treated with ciprofloxacin, metronidazole, or combination therapy, 190 (70%) developed recurrent pouchitis. After propensity score matching, there was no significant difference in the odds of early relapse or nonresponse with ciprofloxacin compared with metronidazole monotherapy (adjusted odds ratio 0.56, 95% confidence interval 0.23-1.34) or when either monotherapy was compared with combination therapy. There was also no significant difference in odds of recurrent pouchitis when comparing patients treated with ciprofloxacin with metronidazole monotherapy (adjusted odds ratio 0.86, 95% confidence interval 0.40-1.84) or either monotherapy with combination therapy. In this retrospective cohort study, we demonstrated no significant difference in the real-world effectiveness of ciprofloxacin, metronidazole, or combination therapy for the initial episode of pouchitis.

Functional outcomes after transanal ileal pouch-anal anastomosis for ulcerative colitis: narrative review of the current literature.

The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) for ulcerative colitis was introduced in 2015 and has since been shown to be a safe and feasible technique, although the impact of this approach on patient function remains unclear. A systematic literature review was performed to identify studies exploring functional outcomes and quality of life after Ta-IPAA. Seven papers were identified, which all demonstrated satisfactory functional outcomes after Ta-IPAA as measured by tools such as Cleveland Global Quality of Life (CGQOL), Oresland Score (OS), Pouch Functional Score (PFS), and Inflammatory Bowel Disease Questionnaire (IBDQ). Many gaps in the literature were identified including paucity of follow-up data beyond the 1-year mark, lack of fertility and fecundity assessment as functional outcomes, and limited evaluation of objective physiologic anal sphincter function. The Ta-IPAA therefore shows promise for good functional results in the short-term, although further research will be required to evaluate the stability of function over time as the technique becomes increasingly integrated into modern surgical practice.

HOSPITALIZATION TRENDS IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH POUCHITIS: A POPULATION-BASED STUDY

Pouchitis is a complication of total colectomy and ileal pouch-anal anastomosis for ulcerative colitis that can lead to hospitalization. We aimed to assess trends of hospitalization rates and health care utilization in patients with pouchitis from 2010 – 2019.

Risks factors associated with the development of Crohn's disease after ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis.

Following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), up to 16% of patients develop Crohn's disease of the pouch (CDP) which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA. A literature search of MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. Seven studies with 1,274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (WMD -2.85; 95% CI -4.39 to -1.31; p=0.0003; I2 54%) and age at pouch surgery (WMD -3.17; 95% CI -5.27 to -1.07; p=0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (OR 2.43; 95% CI 1.41 to 4.19; p=0.001; I2 31%), along with a history of smoking (OR 1.80; 95% CI 1.35 to 2.39; p<0.0001; I2 0%). Other factors including sex, primary sclerosing cholangitis and current smoking were found not to increase risk of CDP. Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.

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.

Impact of the body mass index on the retention of the anorectal mucosa after double-stapled ileal pouch-anal anastomosis for ulcerative colitis

BackgroundDouble-stapled ileal pouch-anal anastomosis (DS-IPAA) is easy to construct and has a good functional outcome in patients with ulcerative colitis (UC). However, retention of the anorectal mucosa may lead to a subsequent risk of inflammation and neoplasia. This study aimed to identify factors associated with the retention of a large amount of anorectal mucosa after DS-IPAA.MethodsThe medical records of 163 patients who had undergone one-stage total proctocolectomy and DS-IPAA for UC between 2007 and 2020 were retrospectively reviewed. The patients were divided into two groups according to the length of the retained mucosa. The high anastomosis group was defined as having a retained mucosal length of ≥ 30 mm in the anterior or posterior wall. Clinical factors were compared between the high and low anastomosis groups.ResultsThe high anastomosis group showed a significantly higher body mass index (BMI) (high vs. low: 23.2 vs. 19.0), longer operation time (304 vs. 263) and greater blood loss (357 vs. 240). In the multivariate analysis, high BMI was the only factor significantly associated with high anastomosis (odds ratio 1.32). There was a positive correlation between BMI and the length of the retained mucosa.ConclusionsIn DS-IPAA, BMI showed the strongest association with the retention of a large amount of the anorectal mucosa. In high BMI patients, although the risk of inability of anastomosis is little than that of IPAA with mucosectomy, the possible retention of a large amount of mucosa should be considered.

P205 Impact of histologic disease activity on long-term outcomes in patients with ileal pouch-anal anastomosis for ulcerative colitis

Abstract Background Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can incur in several complications like pouchitis leading to the need of immunosuppressive therapy, hospitalization and pouch failure. Unlike non-operated UC patients, therapeutic goals are an unmet need in UC-IPAA patients and the impact of the histologic activity on the development of complications is unknown. The aim of the study was to assess the association between histology and the risk of long-term negative outcomes in UC subjects with IPAA. Methods This is a single-center, retrospective study which included UC adult patients with IPAA undergoing at least one pouchscopy with biopsies in the pouch body after ileostomy closure. Pouch biopsies were blindly reviewed by a gastrointestinal pathologist with expertise in IBD. Histologic disease remission was defined as a Pouchitis Disease Activity Index (PDAI) histology subscore £ 1. Negative outcomes were: IPAA related complications (acute or chronic pouchitis, hospitalization, pouch failure) and escalation of medical therapy (start of immunosuppressive or biologics). Both descriptive and inferential statistical analyses carried out Results A total of 66 patients were included (male n=37; 56,1%) of whom 40,9% (n=27) had histological activity at the baseline pouchscopy. The characteristics of the study population are represented in table 1. The median time of follow up was 38,5 months (range 12-151). During the study period, 27 patients (40,9%) developed acute pouchitis and 10 patients (15,2%) chronic pouchitis. Thirty-nine subjects (59,1%) required antibiotic therapy while 8 subjects required systemic steroids (12,1%). Furthermore, 15 patients (22,7%) started immunomodulatory therapy with either azathioprine or biologic agents. Six patients (9,1%) needed pouch-related hospitalization and 1 patients (1,5%) experienced pouch failure. Chronic pouchitis and the need of immunosuppressive/biology therapy was observed more frequently in patients with pouch histologic activity (29,6% vs. 5,1%, and 40,7% vs. 10,3%, respectively) (P&amp;lt;0.05). After adjusting for risk factors for pouchitis, the presence of histologic activity remained an independent risk factor for developing acute pouchitis (OR 4.10, 95% CI 1.39-12.04; P= 0.010), chronic pouchitis (OR 8.51, 95% CI 1.51-47.80, P=0.015) and the need for immunosuppressive or biologic therapy (OR 6.98, 95% CI 1.69-28.80; P=0.007). Conclusion Histologic activity was associated with an increased risk of developing both acute and chronic pouchitis and with the need for immunosuppressive/biologic therapy. Future research will clarify whether histologic remission might be considered as a therapeutic target for UC-IPAA patients developing pouchitis.

OP08 Mucosal healing with vedolizumab in inflammatory bowel disease patients with chronic pouchitis: Evidence from EARNEST, a randomized, double-blind, placebo-controlled trial

Abstract Background Mucosal healing (MH) is an important treatment goal for inflammatory bowel disease (IBD). Vedolizumab (VDZ), a gut-selective anti-lymphocyte trafficking agent, has shown potential to achieve MH.1,2 EARNEST, a randomized double-blind placebo-controlled trial of VDZ in chronic pouchitis,3 offers a robust dataset systematically collected from the inflamed pouch mucosa to further explore the impact of VDZ treatment on MH. Methods EARNEST evaluated intravenous VDZ (300 mg) vs placebo (PBO) administered at weeks 0, 2, 6, 14, 22, and 30, in adult patients (pts) with active chronic pouchitis despite antibiotic therapy after proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis. Endoscopic imaging was captured and centrally read at baseline, Week (W) 14, and W34. Total ulceration and SES-CD (modified to apply to a single segment) were evaluated. Microscopic inflammation was also evaluated using the Pouchitis Disease Activity Index (PDAI) histological component. Pre-specified exploratory endpoints included changes in total ulceration and SES-CD remission (score ≤2); MH was defined post-hoc as SES-CD=0 plus PDAI histology score ≤1 (none/mild polymorphic nuclear leukocyte infiltration and no ulceration). Fecal calprotectin (FCP) levels were explored by MH status. PDAI remission (score &amp;lt;7 and ≥3 point-reduction from baseline) and Inflammatory Bowel Disease Questionnaire (IBDQ) remission (score ≥170) were assessed in pts with/without MH at W14. Results In total, 98 pts had endoscopic evaluations (VDZ n=48; PBO n=50). Ulcers/erosions were higher in VDZ pts at baseline with a greater reduction at W14 and W34 with VDZ vs PBO (Table 1). More pts treated with VDZ vs PBO achieved reduction in ulcerated surface area, complete absence of ulceration/erosions and SES-CD remission. At W14, 7/42 (16.7%) pts had MH on VDZ vs 1/40 (2.5%) on PBO. All 7 VDZ pts with MH at W14 were in PDAI remission at W14 and W34; 6/7 (85.7%) pts achieved IBDQ remission at W14 and 5/7 (71.4%) achieved IBDQ remission at both W14 and W34. Of the 35 VDZ-treated pts without MH at W14, 11/35 (31.4%) achieved PDAI remission at W14, 11/35 (31.4%) at W34, and 9/35 (25.7%) at both W14 and W34; 13/35 (37.1%) achieved IBDQ remission at W14, 17/35 (48.6%) at W34, and 12/35 (34.3%) at both W14 and W34. MH was associated with FCP ≤250 µg/g while ~40-60% of pts without MH had FCP &amp;gt;250 µg/g (Table 2). Conclusion VDZ was associated with better control of markers of inflammation vs PBO, based upon improvements in endoscopic/histologic outcomes in the pouch mucosa, as well as improved outcomes reported by pts. These effects of VDZ in the pouch mucosa are consistent with those observed in the wider patient population with IBD.

P598 The utility of the “Low Anterior Resection Syndrome SCORE” in assessing the postoperative outcomes of patients undergoing restorative proctocolectomy with ileal pouch anal-anastomosis for Ulcerative Colitis

Abstract Background Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) in a J-pouch configuration is the treatment of choice for patients with ulcerative colitis. Some patients who have undergone this surgery present symptoms including fecal or gas incontinence, urgency, clustering, and frequency, that occurs after anal sphincter-sparing surgery for the treatment of rectal cancer. There is a lack in standardization and evaluation of functional outcomes. Our aim is to evaluate the effectiveness of the LARS (low anterior resection syndrome) score in this cohort of patients. Methods We conducted a retrospective analysis of a prospectively maintained single center database. We assessed the quality of life by using the Inflammatory Bowel Disease Questionnaire (IBDQ-32). The functional bowel complaints were assessed using the LARS score. Results Between 2015 and 2020, 70 patients with ulcerative colitis underwent total colectomy and subsequent IPAA with J-Pouch configuration. Among these, 49 patients who closed the ileostomy and were followed for at least 6 months, were selected for the present study. Nineteen patients did not have the LARS; among 30 who complained the LARS, 17 had a major LARS (tab.1). The latter had a worse quality of life on the IBDQ-32 questionnaire, especially in relation to urgency and frequency (Fig.1). We compared the two scores using Spearman's test correlation coefficient, detecting a significant correlation (rho -0.7664185; p-value &amp;lt;0.005); a significant correlation between the urgency sub-category with LARS score (rho -0.6515759; p-value &amp;lt;0.005) and frequency (rho -0.6744705; p-value &amp;lt;0.005) was evaluated. Tab 1: Patients characteristics: Fig.1:IBDQ-32 value in different LARS categories Conclusion In our experience LARS score appears to be a useful, effective and simple tool to predict functional outcomes and QoL not only in oncological rectal sphincter-sparing surgery but also in functional surgery for ulcerative colitis.

HOSPITALIZATION TRENDS IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH POUCHITIS: A POPULATION-BASED STUDY

Abstract INTRODUCTION Pouchitis is a complication of total colectomy and ileal pouch-anal anastomosis for ulcerative colitis that can lead to hospitalization. We aimed to assess trends of hospitalization rates and health care utilization in patients with pouchitis from 2010 – 2019. METHODS We performed a retrospective cohort study using the National Inpatient Sample database from 2010 to 2019 of hospitalized patients with a primary discharge diagnosis of pouchitis and a secondary diagnosis of inflammatory bowel disease (IBD), or primary diagnosis of IBD and a secondary diagnosis of pouchitis. We compared baseline characteristics and outcomes of patients admitted from 2010-2014 to 2015-2019. The primary outcome was the rate of hospitalization for pouchitis between the two five-year periods. Secondary outcomes included length of hospital stay (LOS) and total hospitalization charges. We applied discharge weights to generate national estimates. RESULTS A total of 8215 hospitalizations with pouchitis were identified for IBD patients, with 3856 hospitalizations in the 2010 – 14 group and 4359 in the 2015- 19 group. The 2015-2019 group had less females (54.54% vs 46.67%, p =0.002) and increased hospitalization in urban teaching hospitals (71.95% vs 85.67%, p&amp;lt; 0.001) (Table 1). Hospitalizations with a primary diagnosis of pouchitis were lower in the 2015-2019 group (58.91% vs 53.21%, p= 0.024). Over the study period (2010-2019), there was a numeric increase in the pouchitis incidence among hospitalized IBD patients (2.68 in 2010 to 2.87 in 2019 per 1000 discharges, p=0.459), and the number of patients undergoing inpatient pouchoscopy (25.67% in 2010 and 26.55% in 2019, p=0.803). The average inflation-adjusted total hospitalization charges were $12,555 higher in 2019 compared to 2010 (p=0.045). However, there was a decrease in LOS over this period (5.99 days in 2010 to 5.39 in 2019, p=0.182) (Figure 1). DISCUSSION Over the past decade, the overall number of hospitalizations for IBD patients with pouchitis remained stable with a slight numeric increase, but the rate of hospitalization primarily for pouchitis has significantly decreased. Although LOS has numerically decreased, the overall cost of hospitalization has increased for IBD patients with pouchitis. This may be partly due to increased endoscopic evaluation performed during more recent years.