Pouch Failure Rate Research Articles

P0469 Impact of gynecologic malignancy on ileal pouch-anal anastomosis survival: a matched case-control study

Abstract Background Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard operative treatment for patients with medically refractory inflammatory bowel disease or familial adenomatous polyposis requiring colectomy. In patients who develop malignancy after IPAA, chemoradiation has been shown to increase the risk of pouch failure in small studies. We aimed to describe pouch survival in patients who underwent surgery for gynecologic malignancy (GYN-Ca). Methods We retrospectively reviewed adults who underwent IPAA and developed gynecologic cancer afterwards between 2000 and 2023. Patients with IPAA and GYN-Ca were matched using 1:5 nearest neighbor propensity score matching to control patients with history of IPAA only, on age, year of IPAA, colorectal diagnosis, and procedure. Demographics, operative data, complications, and pouch survival were collected. Results We identified 15 patients diagnosed with GYN-Ca after IPAA who underwent surgery (Table 1). The most common GYN-Ca was endometrial cancer (53%); overall, 14 (93.3%) underwent hysterectomy, while 1 (6.7%) underwent salpingo-oophorectomy; 80% had no short-term postoperative complications. After GYN-Ca in IPAA patients, median overall survival was 51 (21-106) months; median disease-free survival was 41.3 (8-106) months. Pouch failure was seen in 5 (33%) patients, of these, 2 patients (40%) had pouch revision, 2 patients (40%) had pouch excision with permanent end ileostomy and 1 patient (20%) had only permanent end ileostomy. Etiology of pouch failure included radiation enteritis of the pouch (n=2, 40%), afferent limb syndrome from IPAA stenosis (n=1, 20%), inlet obstruction due to Crohn’s stricture (n=1, 20%), and recurrent anastomotic leak secondary to invasive ovarian cancer recurrence (n=1, 20%). After matching, 75 control patients were included for a total of 90 unique patients. The pouch failure rate in the Gyn-Ca and matched control groups were 33% vs. 5.3%, p=0.002, respectively. Kaplan-Meier survival analysis (Figure 1) showed a hazard ratio for pouch failure in GYN-Ca patients of 2.34 (p=0.18, robust SE 0.63) compared to matched control patients, a clinically but not statistically significant result likely due to lack of power. Conclusion In experienced hands, surgery for gynecologic malignancy in pouch patients was safe with an accepted rate of post-operative complications. However, the patients who suffered recurrence or underwent chemoradiation were at increased risk of pouch failure compared to healthy control pouch patients. Patients who develop gynecologic malignancy after IPAA should be monitored closely for pouch dysfunction using a multidisciplinary approach to optimize pouch survival after pelvic surgery.

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.

Incidence, Risk Factors, and Outcomes of Chronic Antibiotic-Refractory Pouchitis in Korean Patients with Ulcerative Colitis.

The study investigated the incidence, risk factors, and clinical outcomes of chronic antibiotic-refractory pouchitis (CARP) in Korean patients with ulcerative colitis (UC). This single-center retrospective study included patients with UC who underwent total proctocolectomy with ileal pouch-anal anastomosis at the Asan Medical Center in Korea between January 1987 and December 2022. The primary outcomes were endoscopic remission and pouch failure. The Cox's proportional hazard model was used to identify the risk factors for CARP. The clinical data of 232 patients were analyzed. The most common cause of surgery was steroid refractoriness (50.9%), followed by dysplasia/colorectal cancer (26.7%). Among 74 patients (31.9%) with chronic pouchitis (CP), 31 (13.4%) had CARP, and 43 (18.5%) had chronic antibiotic-dependent pouchitis (CADP). The most frequent endoscopic phenotype was focal inflammation of the pouch (CP, 47.3%; CARP, 35.5%; CADP, 55.8%). Patients with CARP were less likely to use concomitant probiotics than patients with CADP (29.0% vs 72.1%, p<0.01). The endoscopic remission rate of CP, CARP, and CADP was 14.9%, 9.7%, and 18.6%, respectively. The pouch failure rate associated with CP, CARP, and CADP was 13.5%, 16.1%, and 11.6%, respectively. Current smoking status (adjusted hazard ratio [aHR], 2.96; 95% confidence interval [CI], 1.27 to 6.90; p=0.01) and previous use of biologics/small molecules (aHR, 2.40; 95% CI, 1.05 to 5.53; p=0.04) were significantly associated with CARP development. UC patients who were current smokers and previously used biologics/small molecules had a higher risk of developing CARP. Concomitant use of probiotics was less likely to be associated with CARP development.

Functional and postoperative outcomes in ideal pouch-anal anastomosis in patients with parkinson disease and multiple sclerosis.

Patients with multiple sclerosis and Parkinson's disease may experience pelvic floor dysfunction and constipation which can affect ileoanal pouch emptying. This can lead to complications such as pouchitis, pouch dysfunction, and failure. We hypothesized that patients with neurological diseases have a higher rate of pouch failure and complications than healthy controls. Data were sourced from the institutional ileoanal pouch database. Patients with multiple sclerosis or Parkinson's disease, diagnosed before or after pouch construction, were matched to a control group of patients without neurological disease using propensity score-optimal matching. Demographics, postoperative and functional outcomes, and quality of life were analyzed. Twenty-six patients (38%) with multiple sclerosis and 16 (62%) with Parkinson's disease were matched with 42 healthy controls. The overall median age was 39 years, median BMI was 25.3kg/m2, and most patients were female (61.9%). Preoperative colorectal diagnoses included ulcerative colitis (83.3%), indeterminate colitis (9.5%), and Crohn's disease (7.1%). Patients with neurological diseases had higher ASA scores (class III, 57.1% vs. 21.4%; p < 0.01), fewer nocturnal bowel movements (median 0 vs. 2; p < 0.001), fewer bowel movements over 24h (median 6 vs. 8; p = 0.01), and were less likely to recommend IPAA construction (72.7% vs. 97%; p = 0.01) than the controls. Other surgical, functional, and quality-of-life outcomes were similar. Patients with multiple sclerosis or Parkinson's disease might differ in pouch function compared with healthy controls. These neurological diseases might affect pouch function. The rate of pouch failure was similar, showing its feasibility despite multiple sclerosis and Parkinson's disease.

Pelvic Radiation Therapy Increases Risk of Pouch Failure in Patients with Inflammatory Bowel Disease and Ileal Pouch.

The effect of radiation on the ileal pouch is less well studied in patients with inflammatory bowel disease (IBD) and ileal pouch-anal anastomosis. This retrospective study investigates the impact of external radiation therapy on the outcomes of ileal pouches. The study included 82 patients with IBD and ileal pouches, of whom 12 received pelvic radiation, 16 abdominal radiation, 14 radiation in other fields, and 40 served as controls with no radiation. Pouch-related outcomes, including pouch failure, worsening of symptoms, pouchitis, and development of strictures, along with changes in Pouch Disease Activity Index (PDAI) scores pre- and post-radiation were assessed. The pelvic radiation group exhibited a significantly higher rate of pouch failure (25%, p < 0.004) and worsening pouch-related symptoms (75%, p = 0.012) compared to other groups. Although not statistically significant, a higher incidence of pouchitis was observed in the pelvic radiation group (45.5%, p = 0.071). Strictures were more common in the pelvic radiation group (25%, p = 0.043). Logistic regression analysis revealed that pelvic radiation significantly increased the odds of pouch-related adverse outcomes (OR 5.66; 95% confidence interval: 1.61-21.5). Pelvic radiation significantly impacts the outcomes of ileal pouches in patients with IBD, increasing the risk of pouch failure, symptom exacerbation, and structural complications. These findings underscore the need for careful consideration of radiation therapy in this patient population and highlight the importance of closely monitoring and managing radiation-induced pouch dysfunction.

Three-stage versus modified two-stage surgery for ulcerative colitis: a patient-centred treatment trade-off study.

There is ongoing debate about whether ileal pouch-anal anastomosis needs temporary diversion at the time of construction. Stomas may reduce risk for anastomotic leak (AL) but are also associated with complications, emergency department visits and readmissions. This treatment trade-off study aims to measure patients' preferences by assessing the absolute risk of AL and pouch failure (PF) they are willing to accept to avoid a diverting ileostomy. Fifty-two patients with ulcerative colitis, with or without previous pouch surgery, from Mount Sinai Hospital, Toronto, participated in this study. Standardized interviews were conducted using the treatment trade-off threshold technique. An online anonymous survey was used to collect patient demographics. We measured the absolute increased risk in AL and PF that patients would accept to undergo modified two-stage surgery as opposed to traditional three-stage surgery. Thirty-two patients (mean age 38.7 ± 15.3) with previous surgery and 20 patients (mean age 39.5 ± 11.9) with no previous surgery participated. Patients were willing to accept an absolute increased leak rate of 5% (interquartile range 4.5%-15%) to avoid a diverting ileostomy. Similarly, patients were willing to accept an absolute increased PF rate of 5% (interquartile range 2.5%-10%). Younger patients, aged 21-29, had lower tolerance for PF, accepting an absolute increase of only 2% versus 5% for patients older than 30 (P = 0.01). Patients were willing to accept a 5% increased AL rate or PF rate to avoid a temporary diverting ileostomy. This should be taken into consideration when deciding between modified two- and three-stage pouch procedures.

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

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

P366 Risk factors and outcomes of chronic antibiotic-refractory pouchitis in Korean ulcerative colitis patients: a single center retrospective study

Abstract Background Chronic inflammation of the pouch after total proctocolectomy with ileal pouch-anal anastomosis (IPAA) remains a morbid complication in ulcerative colitis (UC). The goal of this study was to investigate risk factors and clinical outcomes of chronic antibiotic-refractory pouchitis (CARP) in Korean patients with UC. Methods This was a single center retrospective study on patients with UC who underwent total proctocolectomy with IPAA at Asan Medical Center in Korea between January 1987 and December 2022. CARP was defined as failure to respond to a 4-week course of a single antibiotic, needing more than 4 weeks of therapy with 5-aminosalicylates, steroids, immunomodulators or biologics/small molecules, while chronic antibiotic-dependent pouchitis (CADP) was defined as more than 3 episodes of pouchitis per year or persistent symptoms requiring long-term antibiotics to maintain disease remission. Primary outcomes were endoscopic remission defined as complete mucosal healing of chronic pouchitis and pouch failure defined as the requirement of diverting loop ileostomy or pouch excision. Univariable and multivariable logistic regression analysis were used to identify risk factors of CARP. Results A total of 251 patients were included and 232 were analyzed (Male, 57.3%; Current smoker, 13.4%; Median age at surgery, 44 years; Disease duration at surgery, 4 years; Previous exposure to biologics/small molecules, 23.7%; Extra-intestinal manifestations, 8.2%; Preoperative cytomegalovirus infection, 19.4%). The most common cause of surgery was steroid refractoriness (50.9%), followed by dysplasia/colorectal cancer (26.7%). The median time from surgery to chronic pouchitis was 48 months (interquartile range 23.5–100.0). Among 74 patients (31.9%) with chronic pouchitis, 31 patients (13.4%) were CARP and 43 patients (18.5%) were CADP. The most frequent endoscopic phenotype according to Chicago classification was focal inflammation of the pouch in all groups (chronic pouchitis, 47.3%; CARP, 35.5%; CADP, 55.8%). Patients with CARP were less likely to have concomitant probiotics compared with CADP (29.0% vs 72.1%; p&amp;lt;0.01). Endoscopic remission rate in chronic pouchitis, CARP, and CADP were 14.9% (11/74), 9.7% (3/31), and 18.6% (8/43), respectively (Table 1). Pouch failure rate in chronic pouchitis, CARP, and CADP were 13.5% (10/74), 16.1% (5/31), and 11.6% (5/43), respectively (Table 1). In a multivariable analysis, current smoking status was positively associated with CARP development (OR: 3.56; 95% confidence interval 1.33–9.52; p=0.01). Conclusion Current smoker with UC who underwent IPAA had a higher risk of CARP. Concomitant use of probiotics was less likely to be associated with developing CARP.

Endoscopic management of ileal pouch-anal anastomosis strictures: meta-analysis and systematic literature review.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a common surgical procedure for ulcerative colitis and familial adenomatous polyposis. IPAA strictures are a known complication, often requiring surgical intervention. Endoscopic interventions offer a less invasive alternative, but their safety and efficacy remain uncertain. A comprehensive literature search was performed to identify pertinent studies. Outcomes assessed were technical success, clinical success (immediate and end of follow up), pouch failure rate and adverse events. Pooled estimates were calculated using random effects models with a 95% confidence interval. A total of 607 patients from 9 studies were included. Technical success, defined as the ability to pass the endoscope through the stricture, was achieved in 97.4% of patients. Immediate clinical success, defined as symptom improvement post-intervention, was seen in 44.5% of patients. Clinical success at the end of follow up was observed in 81.7% of patients. However, 6.8% of patients experienced pouch failure and ultimately 14.5% required surgical intervention for refractory strictures or complications. Endoscopic intervention-related serious adverse events occurred in 3.9% of patients, including perforation and major post-procedural bleeding. Endoscopic interventions for IPAA strictures demonstrate high technical success rates, providing a less invasive option for managing this complication. While clinical success rates immediately post-procedure and at end of follow up are promising, a significant proportion of patients ultimately require surgical intervention for pouch failure or refractory strictures.

Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn’s Disease: Experience of a Tertiary Center

BackgroundThe leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis. ObjectiveDetermine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn’s disease phenotype of the pouch. DesignRetrospective cohort study of a prospectively maintained, IRB-approved database. Settings/PatientsNinety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn’s-related perianal disease. InterventionsTwo hundred thirty-one operations for perianal or anovaginal fistula(s). Main Outcome and MeasuresHealing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure. ResultsOverall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m2. More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03–0.43, p = 0.001). Overall pouch failure rate was 12.1%. LimitationsRetrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset. ConclusionsPouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.

Population outcomes, trends and the future of pouch surgery for ulcerative colitis: a 19-year New South Wales data linkage study.

Ileal pouch-anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. A retrospective data linkage study of the NSW population over a 19-year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3-10.8%) and 10.6% (95% CI 8.0-13.1%) at 5- and 10-years, respectively. Increasing age and non-elective admission were associated with higher failure rates. One-third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three-quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration.

Predictors of pouch failure: A tertiary care inflammatory bowel disease centre experience.

Rates of pouch failure after total proctocolectomy with ileal pouch-anal anastomosis (IPAA) range from 5% to 18%. There is little consistency across studies regarding the factors associated with failure, and most include patients who underwent IPAA in the pre-biologic era. Our aim was to analyse a cohort of patients who underwent IPAA in the biologic era at a large-volume inflammatory bowel disease institution to better determine preoperative, perioperative and postoperative factors associated with pouch failure. A retrospective cohort analysis was performed with data from an institutional review board approved prospective database with ulcerative colitis or unclassified inflammatory bowel disease patients who underwent total proctocolectomy with IPAA at Mount Sinai Hospital between 2008 and 2017. Preoperative, perioperative and postoperative data were collected and univariate and multivariate analyses were performed to identify factors associated with increased risk of pouch failure. Out of 664 patients included in the study, pouch failure occurred in 41 (6.2%) patients, a median of 23.3 months after final surgical stage. Of these, 17 (41.4%) underwent pouch excision and 24 (58.5%) had diverting ileostomies. The most common indications for pouch failure were Crohn's disease like pouch inflammation (CDLPI) (n = 17, 41.5%), chronic pouchitis (n = 6, 14.6%), chronic cuffitis (n = 5, 12.2%) and anastomotic stricture (n = 4, 9.8%). On multivariate analysis, pre-colectomy biologic use (hazard ratio [HR] 2.25, 95% CI 1.09-4.67), CDLPI (HR 3.18, 95% CI 1.49-6.76) and pouch revision (HR 2.59, 95% CI 1.26-5.32) were significantly associated with pouch failure. Pouch failure was significantly associated with CDLPI, preoperative biologic use and pouch revision; however, reassuringly it was not associated with postoperative complications.

Can preoperative CT/MR enterography preclude the development of Crohn's disease-like pouch complications in ulcerative colitis patients undergoing J pouch surgery?

We aimed to determine whether ulcerative colitis patients with preoperative negative computed tomography or magnetic resonance enterography (CTE/MRE) were less likely to develop Crohn's disease-like pouch complications (CDLPC) and establish risk factors and predictors for developing CDLPC. This was a single centre retrospective analysis of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU) who underwent total proctocolectomy with ileal J-pouch between January 2010 and December 2020. The study group comprised patients with negative preoperative CTE/MRE and the control group included patients operated without preoperative CTE/MRE. A total of 131 patients were divided into the negative CTE/MRE study group (76 [58%] patients) and control group (55 [42%] patients). There were no significant differences in incidence rates (21% vs. 23.6%, p = 0.83), time to developing CDLPC from ileostomy closure (22.3 vs. 23.8 months; p = 0.81), pouchitis rates (23.6% vs. 27.2%; p = 0.68), or pouch failure rates (5.2 vs. 7.2; p = 0.71). Multivariate Cox regression analysis showed backwash ileitis (HR 4.1; p = 0.03, CI: 1.1-15.1), severe pouchitis (HR 3.4; p = 0.039, CI: 1.0-10.9), and history of perianal disease (HR 3.4; p = 0.017, CI: 1.4-39.6) were independent predictors for CDLPC. Negative findings on MRE/CTE prior to J-pouch surgery in ulcerative colitis should be interpreted with caution as it is does not reliably exclude or predict development of CDLPC. These patients should be preoperatively counselled concerning the possibility of developing CDLPC regardless of lack of positive findings on preoperative CTE/MRE. Patients with backwash ileitis with a previous history of perianal disease should be informed of the potentially increased risk of developing such complications.

Incidence and causes of failure in various anatomical pouch designs 20years after surgical primary ileal-pouch anal anastomosis construction.

Since the introduction of ileo-pouch anal anastomosis (IPAA) surgery, various pouch designs have been applied. Recently, there has been renewed interest in creating larger pouch designs to reduce defecation frequency after pouch surgery. The aim of this study was to assess chronic pouch failure (PF) rates and causes in alternative S or septated (SP) pouches when compared to J pouches and B- shaped adaptations. This retrospective cohort study included patients that underwent primary IPAA construction surgery from 1978-2000. Pouch designs were subdivided in J and B (J/B), and larger pouches (S/SP). PF included need for a pouch excision, redo pouch procedure, revisional pouch surgery, or permanent ileostomy surgery. Outcomes of this study were incidence and causes for PF per pouch design group. Out of 200 patients who underwent IPAA surgery, 19 had an S/SP design and 181 had a J/B design. After a follow-up of 27.0 (IQR 23.3 - 29.0) years, 45/200 (22.5%) patients who underwent IPAA surgery between 1975-2000 developed PF. Some 78.9% of patients with an S/SP pouch developed PF, compared to 16.7% of patients with a J/B pouch (p < 0.01). Mechanical outlet issues occurred more often in S/SP pouches when compared to J/B (42.1% vs. 1.1%, p < 0.01), and were predominantly caused by septal- or pouch wall intussusception and efferent loop kinking (S-pouch). Despite an inevitable proportion of bias, the current study revealed that S/SP pouches were characterized by an increased PF incidence due to emptying problems after long-term follow-up when compared to J/B pouches. Constructing an S pouch or large septated reservoir at index surgery should therefore be questioned because of a shorter longevity.

Restorative proctocolectomy with ileal pouch-anal anastomosis in elderly patients - is advanced age a contraindication?

AimWe aimed to determine pouch function and retention rate for restorative proctocolectomy with ileal pouch‐anal anastomosis (IPAA) for ulcerative colitis (UC) in elderly patients.MethodsWe identified patients over 50 years old subjected to IPAA for confirmed pathological UC from 1980 until 2016. Patients were grouped according to age: 50–59, 60–69 and 70+ years. Short and long‐term outcomes and quality of life (QOL) were compared among the groups.ResultsSix hundred and one patients were identified (399 (66.4%) between 50–59 181 (30.1%) between 60–69, and 21 (3.5%) over 70 years of age). More males were in the 70+ arm, and more two‐stage procedures were performed in this group. Wound infection increased with age (P = 0.023). There was a trend of more fistula and pouchitis in the 70+ patients (P = 0.052 and P = 0.055, respectively). Pouch failure rate increased with age, and it was statistically significant in the 70+ cohort (P = 0.015). Multivariate stepwise logistic regression showed that pelvic sepsis (HR 4.8 (95% CI 1.5–15.4), P = 0.009), fistula (HR 6.0 (95% CI 1.7–21.5), and mucosectomy with handsewn anastomosis (HR 4.5 (95% CI 1.4–14.7)), were independently associated with pouch failure. No difference was observed in the QOL among the groups, but pouch function was better for patients younger than 60 years.ConclusionIn elderly patients with UC, IPAA may be offered with reasonable functional outcomes, and ileal pouch retention rates, as an alternative to the permanent stoma. Stapled anastomosis increases the chance of pouch retention and should be recommended as long as the distal rectum does not carry dysplasia.

P346 Chronic pouch failure rates after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis

Abstract Background During restorative (completion) proctectomy and Ileal pouch-anal anastomosis (IPAA), rectal dissection can be performed in either the total meso-rectal excision (TME) plane with anterolateral exception, or as a full close rectal dissection (CRD). CRD showed lower postoperative morbidity and better short-term quality of life (QOL) when compared to TME. We aimed to compare the incidence of chronic pouch failure (PF) in patients undergoing TME or CRD during proctectomy followed by IPAA for inflammatory bowel diseases (IBD). Methods This mono-centre retrospective cohort study included consecutive patients who underwent IPAA surgery for UC from January, 2002 to October, 2017 in a tertiary IBD referral centre. Outcomes of this study were chronic pouch failure (PF) rates and PF-free survival between patients who underwent CRD and TME. Chronic PF was defined as a pouch-related complication occurring &amp;lt;, 3 months after IPAA surgery requiring pouch-redo surgery, -excision or definitive ileostomy without excision. PF-free survival was defined as months between date of functional pouch and date of surgical PF. Multivariable cox- regression was used to determine whether CRD as dissection type had impact on PF-free survival, when compared to TME. (Chronic) anastomotic ileal pouch-anal leakage and fistula were also included in analyses as confounding factors, which is in line with available literature1. Results Out of, 293 patients that underwent pouch surgery, 123 (42.0%) had a proctectomy in the CRD plane, and, 170 (58.0%) in the TME plane. As the median operation year for CRD was, 9 years later (2006 vs, 2015), a significantly shorter postoperative follow-up for CRD patients was reported (74 vs, 172 months, p&amp;lt;0.01). PF occurred in, 27 (9.2%) patients, of which six (4.9%) underwent CRD and, 21 (12.4%) underwent TME (p=0.03). Both the mean PF-free survival in months (162 vs, 195, p=0.31) and PF-free survival rate after, 36 months (98.1% vs, 92.1%) were comparable among patients who underwent CRD and TME (Figure, 1, p=0.31). CRD was not associated with developing chronic PF (Odds ratio = 0.96, CI, 95%:, 0.35–2.61) after multivariable cox-regression analysis. Figure, 1. PF-free survival curve for patients who underwent CRD (red) and TME (blue) Conclusion In the current study, we did not observe a significant difference in chronic PF after either CRD or TME. Although data on long-term functional outcomes and QOL are necessary to draw final conclusions, results of this study suggest that long-term outcomes of CRD were comparable to outcomes after TME. As an earlier study concluded CRD is beneficial when it comes to postoperative morbidity and short-term QOL, surgeons should consider performing close rectal dissection during IPAA surgery for IBD.

Indeterminate Colitis - Update on Treatment Options.

Indeterminate colitis (IC) is described in approximately 5–15% of patients with inflammatory bowel disease (IBD). It usually reflects a difficulty or lack of clarity in distinguishing between ulcerative colitis (UC) and Crohn’s disease (CD) on biopsy or colectomy specimens. The diagnostic difficulty may explain the variability in the reported prevalence and incidence of IC. Clinically, most IC patients tend to evolve over time to a definite diagnosis of either UC or CD. IC has also been interchangeably described as inflammatory bowel disease unclassified (IBDU). This review offers an overview of the available limited literature on the conventional medical and surgical treatments for IC. In contrast to the numerous studies on the medical management of UC and CD, there are very few data from dedicated controlled trials on the treatment of IC. The natural evolution of IC more closely mimics UC. Regarding medical options for treatment, most patients diagnosed with IC are treated similarly to UC, and treatment choices are based on disease severity. Others are managed similarly to CD if there are features suggestive of CD, including fissures, skin tags, or rectal sparing. In medically refractory IC, surgical treatment options are limited and include total proctocolectomy (TPC) and ileal pouch–anal anastomosis (IPAA), with its associated risk factors and complications. Post-surgical complications and pouch failure rates were historically thought to be more common in IC patients, but recent meta-analyses reveal similar rates between UC and IC patients. Future therapies in IBD are focused on known mechanisms in the disease pathways of UC and CD. Owing to the lack of IC-specific studies, clinicians have traditionally and historically extrapolated the data to IC patients based on their symptomatology, clinical course, and endoscopic findings.

Staged Approaches to Restorative Proctocolectomy with Ileoanal Pouch—When and Why?

Restorative proctocolectomy (RPC) with ileal pouch anal-anastomosis (IPAA) is commonly performed for patients with ulcerative colitis, familial adenomatous polyposis, and selected phenotypes of Crohn's disease (CD). Due to concerns about the effects of surgical complications on pouch functional outcomes, debate remains surrounding when and whether RPC with IPAA should be performed in a staged manner. Particularly debated are the timings of the IPAA, whether it is constructed at time of the proctocolectomy and whether to utilize temporary fecal diversion with a loop ileostomy. RPC with IPAA can be performed in one, two, or three stages, with each stage typically separated by 3-6 months. Proponents of a staged approach argue that poor pouch function, which is often a result of IPAA complications, including leak and infection, can be difficult to overcome and mandate additional, major surgeries, and that staging pouch creation and pairing with a protective ileostomy reduce those complications. However, subjecting patients to multiple surgeries and prolonging their time with an ileostomy present unique risks as well. Surgeons' experience and preference and patient characteristics need to be considered when determining operative planning. Highly selected patients with CD can be considered for RPC with IPAA, although with an acknowledgment of inherently higher pouch failure rates. Understanding the short- and long-term consequences of RPC with IPAA construction can help surgeons determine the appropriate approach.

Ileal Pouch-anal Anastomosis Complications and Pouch Failure: A systematic review and meta-analysis.

This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure. Previous studies demonstrated wide variation in postoperative complication rates following IPAA. A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman's correlations. Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56-10.59) and 10.3% (95% confidence intervals: 7.24-14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1-17%), pelvic sepsis (2-18%), fistula (1-30%), stricture (1-34%), pouchitis (11-61%), and Crohn's disease of the pouch (0-18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01). The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak. This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to an increased risk of pouch failure.

P268 Ileal Pouch-Anal Anastomosis Complications and Pouch Failure: A Systematic Review and Meta-Analysis

Abstract Background Previous studies demonstrated wide variation in postoperative complication rates following ileal pouch-anal anastomosis (IPAA). This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Methods A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from 1 January 2010 to 6 May 2020. A meta-analysis was performed using a random effects model. The relationship between pouch-related complications and pouch failure was assessed using Spearman’s correlations. Results Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95%CI5.56–10.59) and 10.3% (95%CI7.24–14.30) for studies with a median follow-up of ≥5 years and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1–17%), pelvic sepsis (2–18%), fistula (1–30%), stricture (1–34%), pouchitis (11–61%) and Crohn’s disease of the pouch (0–18%). Pelvic sepsis (r=0.51, p&amp;lt;0.05) and fistula (r=0.63, p&amp;lt;0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r=0.77, p&amp;lt;0.01). Conclusion Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to increased risk of pouch failure. Pouch survival may be improved through standardized assessment of anastomotic integrity for early identification and adequate management of anastomotic leaks.