Pouch Patients Research Articles

Clinical approach to patients with an ileal pouch.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management.

Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch.

For over 40years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.

S788 Long-Term Use of Bile Acid Sequestrants to Improve Diarrhea and Abdominal Pain in IBD Patients With Ileoanal Pouch Anastomosis: A Tertiary Referral Center Experience

Introduction: Bile acid (BA) sequestrants are commonly used in IBD following ileocecal resection to treat bile acid malabsorption and associated abdominal pain and diarrhea. There is less experience with use of BA binders in IBD patients following colectomy and ileoanal pouch reconstruction. IBD ileoanal pouch patients frequently experience bouts of diarrhea and abdominal pain and have limited treatment options. We sought to characterize our institutional experience with BA sequestrants to treat abdominal pain and diarrhea in a large cohort of IBD ileoanal pouch patients with a focus on longterm therapy and improvement in patient reported outcomes. Methods: We analyzed a prospective, natural history registry of consented IBD patients followed at a tertiary center (2009-2022). Patients with ileoanal pouch reconstruction following colectomy were identified and individuals with > 2 years of follow up formed the study cohort. BA sequestrants included cholestyramine, colestipol and colesevelam. Patient reported outcomes of diarrhea and abdominal pain, recorded at the time of clinic encounters were organized, and mean scores before and after bile acid binder therapy were compared. Results: There were 132 ileoanal pouch patients with longterm followup (mean age 51.8 + 13.9 years; 42% F; 58% M). BA sequestrants were initiated in 93 individuals and 63 patients (68%) continued therapy for >2 years, forming the multiyear therapy group. Patterns of BA sequestrant use included 48% receiving one, 41% trialing two and 11% using all three agents. The most commonly prescribed were colesevelam (48 patients), cholestyramine (33 patients) and colestipol (22 patients) and switching between BA sequestrants was commonly due to insurance coverage. The mean number of stools per day improved following initiation of BA sequestrants (p< 0.001). Abdominal pain scores also improved with longterm BA sequestrant therapy (p=0.017). Patterns of healthcare utilization improved with longterm BA sequestrant therapy with a reduction in annual patterns of emergency room visits (p=0.007) and hospitalizations (p< 0.001). (Figure) Conclusion: A majority of IBD ileoanal pouch patients benefitted from BA sequestrant treatment, reducing number of bowel movements and abdominal pain over a >2 year period, with a parallel reduction in healthcare utilization. Formal trials of BA sequestrants in the longterm management of chronic ileoanal pouch symptoms in the IBD patient population are warranted.Figure 1.: Results before and after bile acid sequestrants.

Development and Validation of a Symptom-based Scoring System for Bowel Dysfunction After Ileoanal Pouch Reconstruction.

To utilize items identified as priorities by the Patient-Reported Outcomes after Pouch Surgery Delphi consensus study to create a validated tool for quantifying pouch function. The Patient-Reported Outcomes After Pouch Surgery Delphi consensus study identified 7 symptoms and 7 consequences as key domains for evaluating and analyzing ileoanal pouch function. Pouch patients were recruited at inflammatory bowel disease centers and via patient advocacy websites. They were administered a questionnaire-based survey eliciting responses regarding the frequency of a variety of bowel symptoms. Associations between items and quality of life were computed in a score generation cohort of 298 patients by logistic regression modeling. Individual score values were designated to items to create an additive score titled the "Ileoanal Pouch Syndrome Severity Score." Validity was tested in a subsequent cohort of 386 patients using receiver operating characteristic area under the curve. In addition, test-rest validity, convergent validity, and clinical validity were evaluated. After the determination of item weights, the range of possible scores was 0 to 145. Score ranges were then determined as cutoff values for "ileoanal pouch syndrome." The score was then validated on the second patient cohort, with a receiver operating characteristic area under the curve of 0.83. Importantly, worsening severity of Ileoanal Pouch Syndrome score significantly correlated with higher rates of poor quality of life. Lastly, the questionnaire was rigorously validated to show test-retest validity, convergent validity compared with other bowel function scores, and clinical validity. This study developed a patient-centered, clinically useful scoring system that can quantify the range and severity of symptoms experienced by ileoanal pouch patients and their correlation with quality of life.

Histologic Activity in an Endoscopically Normal-Appearing Pouch Predicts Future Risk of Pouchitis in Patients With Ulcerative Colitis.

The impact of histologic inflammation on subsequent risk of acute pouchitis in patients with ulcerative colitis (UC) has not been robustly examined. We examined the association between histologic inflammation in endoscopically normal-appearing ileal pouches in patients with UC with subsequent risk of antibiotic-responsive acute pouchitis. Among 163 study patients, 53% had histologic inflammation in an endoscopically normal-appearing ileal pouch. Histologic inflammation in the pouch was associated with an increased risk of pouchitis (24.1% vs 6.8%, adjusted odds ratio 4.41, 95% confidence interval 1.48-13.20). Histologic inflammation in an endoscopically normal pouch was associated with an increased risk of acute pouchitis.

Endoscopic Management of Adenomas in the Ileal Pouch and the Rectal Remnant after Surgical Treatment in Familial Adenomatous Polyposis.

In patients with familial adenomatous polyposis (FAP), adenomas and even carcinomas may develop in the rectal remnant and the ileal pouch after surgical treatment. The aim of this study was to evaluate the outcome of endoscopic management in patients with FAP. The main outcome measurements were the appearance of secondary cancer, complications, and the need for additional surgery. Thirty-four FAP patients with Kock’s continent ileostomy (Kock) (n = 3), ileorectal anastomosis (IRA) (n = 12), and ileal pouch-anal anastomosis (IPAA) (n = 19) were identified. The median follow-up period of endoscopic surveillance was 11.5 years for pouch patients (Kock + IPAA) and 21.7 years for IRA. Metachronous adenomas appeared in 32 patients (94.1%). In pouch patients, a total of 120 treatments were given to 20 patients, and 12 sessions of delayed bleeding (10%) occurred, which was significantly higher compared to IRA patients, with 0 sessions (p < 0.001). In IRA patients, a total of 169 treatments were given to 11 patients, with one case of perforation. No adenocarcinoma has developed since the start of endoscopic surveillance. Regular endoscopic surveillance and treatment are feasible and safe. However, in pouch patients, one must be cautious about delayed bleeding in the treatment of adenomas.

Pouch volvulus-why adhesions are not always the enemy.

Minimally invasive approaches to proctocolectomy with ileal pouch anal anastomosis have become the standard of care with one benefit being the reduced risk of adhesion-related complications. However, a lack of pouch adherence to the pelvis can lead to increased mobility as well as volvulization, placing pouch viability at risk. We aimed to describe our institutional experience with pouch volvulus. Patients who presented with pouch volvulus from 1983 to 2020 were identified through a search of our pelvic pouch registry and enterprise-wide electronic medical record. Pouch volvulus was defined as a reducible rotation of the J-pouch on its mesenteric axis with evidence of a properly oriented ileo-anal anastomosis. Patients with 'twisted pouches' were excluded. In total, 5760 patients underwent ileal pouch anal anastomosis from 1983 to 2020. Six patients (five women) were identified with a diagnosis of 'pouch volvulus' consistent with our definition. The six pouches were constructed utilizing laparoscopic techniques and the mean time from construction to volvulus was 2.36 years. All patients underwent urgent surgery, with a paucity of adhesions noted in five. Reduction and pouch pexy was performed in three and pouch excision in three, with immediate pouch reconstruction in two and end ileostomy creation in one. At a median follow-up of 9months, pouch survival was 50%. Pelvic pouches constructed using minimally invasive techniques may be at risk of volvulus due to reduced adhesion development. A high index of suspicion is warranted in pouch patients with obstructive symptomatology. CT imaging may be diagnostic, and prompt surgical intervention may facilitate pouch salvage.

V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY Victoria Maxon and Alvin Goh Victoria MaxonVictoria Maxon More articles by this author and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video aims to provide a step-by-step approach for robot-assisted repair of benign distal ureteroenteric strictures (UES) following radical cystectomy (RC). METHODS: We demonstrate the feasibility and safety of robotic repair through three clinical scenarios after different forms of diversion and open primary surgery. UES repair is performed in the setting of an open RC and neobladder (NB), an open Indiana pouch and a repeat repair after RC and ileal conduit (IC). The RC/IC and Indiana pouch patients were placed in the modified lateral position with right side up. Port placement was directed at the right lower quadrant. The RC/NB patient was placed in the supine position and port placement was similar to that of RC. The operation consists of extensive lysis of adhesions, mobilization of the diversion and ureter, identification of the UES, excision of ureteral scar tissue and spatulation, assessment of ureteral perfusion using indocyanine green (ICG) fluorescence and the creation of a tension-free and watertight anastomosis. RESULTS: All cases were completed successfully without the need for open conversion. There were no intraoperative complications. Operative times ranged from 174-273 minutes. Estimated blood loss ranged from 10-50ml. Patients were discharged on postoperative day 1. No major complications occurred within 90 days of discharge. Renal function remained stable in all three patients at 6 weeks postoperatively. Patients were followed with functional renal imaging at 3 months postoperatively. CONCLUSIONS: Robot-assisted repair of UES is feasible and safe, even in the setting of extensive prior open abdominal surgery. This is the ideal approach for UES repair because it requires less mobilization of surrounding structures, allows for intraoperative ureteral assessment with ICG fluorescence and can successfully create a tension-free and watertight anastomosis. Our patients recovered quickly and without complications. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e369 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Victoria Maxon More articles by this author Alvin Goh More articles by this author Expand All Advertisement PDF downloadLoading ...

Early and Midterm Complications of the Continent Catheterizable Indiana Pouch Urinary Diversion: A 7-year Experience

To describe the most recent 7 year experience with 137 Indiana pouch patients at a single institution and provide data on complications with this type of urinary diversion during the first postoperative year. We queried our bladder cancer database to identify all patients who underwent cystectomy with continent catheterizable urinary reservoir between 2012 and 2018. Pre-, intra-, and postoperative data were collected. Complications were stratified into early (within 90 days) and midterm (90-365 days). The primary outcomes were postoperative complications, and overall and cancer-specific mortality. A total of 137 patients underwent open cystectomy with Indiana pouch creation. Of these, 93% were radical cystectomies. On average, the operation took 422 minutes. There were 53 (39%) patients who experienced any type of complication during the first postoperative year (Clavien II-V). Twenty-five patients (18.2%) readmitted in the early postoperative period vs 18 (13.1%) patients midterm. There were 10 (7.3%) patients that required early reoperation and 11 (8%) in the midterm period. The overall mortality rate was 1.5% early and 3.7% midterm, with the majority of the mortality rate attributed to cancer progression (85.7%). Patients undergoing continent catheterizable reservoir urinary diversion appear to have comparable complication rates to other urinary diversions published in the literature. At high-volume urologic institutions, Indiana Pouch creation is a suitable option for select patients desiring a continent diversion.

The Effect of the Crohn's Disease Exclusion Diet on Patients With Pouch Inflammation: An Interventional Pilot Study

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis.1 Unfortunately, pouch inflammation (ie, pouchitis) is reported in up to 72% of pouch patients.1,2.

A Retrospective Cohort Study of Implantable Pulse Generator Surgical Site Infections After Deep Brain Stimulation Surgery With an Antibacterial Envelope

IntroductionDeep brain stimulation (DBS) surgery is an established treatment for many patients with neurologic disease, and a common complication of DBS is surgical site infection (SSI). In 2016, neurosurgeons at our institution began enclosing implantable pulse generators (IPGs) within fully absorbable, antibacterial envelopes in patients who underwent initial DBS implantation. We sought to determine whether the use of antibacterial envelopes reduced IPG-related SSIs. Materials and MethodsWe performed a retrospective chart review of all adult patients who underwent initial DBS implantation at Stanford Hospital between November 14, 2012, and November 9, 2020. Operative details, perioperative antibiotics, comorbidities, and postoperative complications were extracted for all patients. Univariate and multivariate logistic regression were used to identify factors associated with SSIs within three months of surgery, and interrupted time-series analysis was performed to assess whether the departmental adoption of the antibacterial envelope led to a reduction in IPG SSIs. ResultsOf 344 patients who underwent initial IPG implantation with the antibacterial envelope, one developed an SSI within three months of surgery (0.3%), compared with six of 204 patients (2.9%) who underwent the same procedure without the antibacterial envelope (odds ratio: 0.10, 95% CI: 0.01–0.80, p = 0.031). Univariate logistic regression revealed that the antibacterial envelope and 2000-mg intravenous cefazolin perioperatively were associated with reduced SSI risk, whereas no other factors reached statistical significance. After adjusting for comorbidities, no association remained statistically significant. Interrupted time-series analysis showed a reduction in SSIs after 2016, but the effect was not significant. ConclusionsThe adoption of antibacterial envelopes was found to reduce IPG SSIs at the univariate level, but this association did not remain significant after controlling for confounding variables including perioperative antibiotic administration. Although encouraging, this study does not conclusively establish that the use of antibacterial pouches in patients who underwent initial DBS implantation reduces the incidence of IPG SSIs. Future prospective studies that control for confounding variables are necessary to determine the efficacy of antibacterial envelopes in reducing post-DBS infections at the IPG site before clear recommendations can be made.

Nurse-led surveillance of ileoanal pouch patients post-stoma reversal: outcomes at 12-month review.

Restorative proctocolectomy with pouch anal anastomosis is the accepted treatment for suitable patients with ulcerative colitis, yet surveillance following stoma reversal remains contentious and involves several issues. While most patients are discharged from routine follow-up between 6 weeks and 3 months, some remain on surveillance pathways indefinitely. A high volume of patients require advice for many months or years after the stoma has been reversed, with the burden of surveillance on consultant-led clinics. Nurse-led follow-up after restorative proctocolectomy has been recognised for decades but has not been validated. This study reports the first protocol-based pathway for nurse-led follow-up. Using validated questionnaires, suitable pouch patients were followed up in nurse-led clinics over a 12-month period then sent an online survey to report on the service they received. Overall, most patients were satisfied with the nurse-led follow-up; however, further engagement and investment in the workforce and infrastructure is required to offer sustainable services.

Surgery for pouch inflow limb-related complications: Crohn's disease or something else?

A total proctocolectomy with subsequent creation of an ileal-pouch, such as a J-pouch or a Kock pouch, has been the most common surgery performed for ulcerative colitis (UC). A small portion of these patients will develop complications with the inflow limb into the pouch requiring operative intervention. The objective was to establish a better understanding as to the pathological mechanism by which these pouch inflow limb problems develop. This was a retrospective cohort study conducted at a single tertiary care inflammatory bowel disease (IBD) center. A database was created of all the patients who underwent pouch-related procedures, following completion of their original pouch, between 2006 and 2018. The patients requiring operative resection for inflow limb complications were identified among this cohort. Operative and pathological data were collected. One hundred seventy-eight UC patients underwent surgeries on their pouches between 2006 and 2018. Sixteen patients required operative resection for inflow limb problems. Reoperations for inflow limb problems included inflow limb resection with pouch excision (n = 4) and inflow limb resection with pouch revision (n = 12). The pathology findings of the inflow limb were consistent with Crohn's disease in 9 patients (56%). Two other patients (total 69%) were eventually diagnosed with Crohn's disease due to other pathological specimens or perianal pathology. The remaining patients had chronic, non-specific enteritis/serositis. A small proportion of pouch patients will eventually require surgery for inflow limb complications. Among these, there was a high rate of Crohn's disease of the inflow limb and overall change in diagnosis to Crohn's disease (Plietz et al. inOfficial Journal of the American College of Gastroenterology | ACG 114:S453,2019).

Identification of gut microbiome and transcriptome changes in ulcerative colitis and pouchitis

Background Pouchitis is the common postoperative complication of ulcerative colitis (UC) and is also considered as inflammatory bowel disease. The aim was to investigate the microbiological and transcriptional differences between the two illnesses. Methods Eighty-five participants were enrolled (37 UC, 15 healthy UC pouches, 15 pouchitis and 18 healthy volunteers) and stool samples were collected. Microbial populations were analyzed by pyrosequencing of 16S ribosomal DNA. Furthermore, transcriptome data of 119 UC and 28 pouch patients were obtained from two data sets for bioinformatics analysis. Results The results of gut microbiota community analysis showed that with aggravation of UC, intestinal microorganisms were characterized by a gradual decreased in diversity and numbers of butyrate-producing bacteria and Bacteroides. Besides, in addition to the decrease of probiotics, the proliferation of Escherichia–Shigella and Ruminococcus gnavus was observed in pouchitis which is related to multiple infection pathways. The function enrichment of differential expression genes and hub genes, as well as the immunological condition was shown to be distinct using transcriptome bioinformatics analysis between UC and pouchitis. A stronger immune response occurs in UC and may be associated with high expression of tumor necrosis factor and interleukin, while multiple hub genes such as CDK1 in pouchitis are associated with cell cycle regulation. Conclusions The characteristics of gut microbiota disturbance and transcriptome alteration in UC and pouchitis are different. Our findings suggested that pouchitis may have a unique pathogenesis which was separated from UC.

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

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

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

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

P323 The Crohn’s Disease Exclusion Diet (CDED) for pouch inflammation: an interventional pilot study

Abstract Background Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with UC. Unfortunately, pouchitis is a common condition, reported in up to, 72% of pouch patients. Pouchitis pathogenesis is not entirely clear and has similarities to that of Crohn’s disease (CD), given the de-novo inflammation of the small intestine, the microbial dysbiosis and the occurrence of a penetrating phenotype. The Crohn’s Disease Exclusion Diet (CDED) has demonstrated its efficacy in improving clinical and biochemical parameters of intestinal inflammation in CD. Therefore, we aimed to examine whether the CDED may be effective for the treatment of active pouchitis. Methods A non-controlled, open-label, interventional pilot trial. Active pouchitis patients were recruited at the comprehensive pouch clinic of the Tel Aviv Medical Center (TLVMC), a tertiary center. Patients were treated with the CDED (phases, 1–3) for, 24 weeks, underwent, 5 clinic visits (weeks, 0, 3, 6, 12 and, 24) which included physician assessment and monitoring [clinical pouch disease activity index (cPDAI) sub score evaluation], dietary evaluation and guidance, inflammatory biomarkers evaluation, and collection of biologic samples. Patients underwent three pouchoscopy procedures (baseline, end of phase, 2 and end of phase, 3) for assessment of endoscopic and histologic disease activity. The primary endpoint of the study was week-6 clinical remission (cPDAI subscore≥2). Results Fifteen patients (mean age, 42.6±11.2, 3 males, mean pouch age, 14.7±10.7 years) with pouchitis were recruited (Crohn’s like disease of the pouch, n=5; chronic pouchitis, n=4; acute pouchitis, n=3; recurrent acute pouchitis, n=3). Nine patients completed the study protocol and were evaluated throughout, 24 weeks, while six patients were withdrawn: four due to exacerbation requiring antibiotics, and two due to bowel obstruction. No other adverse events were noted. Clinical remission was achieved by, 66.7% of the study population at week, 6 by per-protocol analysis, and was maintained by, 60.0% at week, 12. Modified PDAI (mPDAI) decreased at week, 12 compared to baseline (8.0 vs., 5.0, P=0.027), with an improvement in the median number of defecations per day (24h) (12.5 vs., 7.0, P=0.003), and night (2.5 vs., 1.0, P=0.018). CRP and fecal calprotectin decreased compared to baseline (11.1±5.2 vs, 6.0±4.0, P=0.007, and, 697±680 vs, 497±483, P=0.607). Among patients who achieved clinical remission at week, 6, 80% maintained remission at week, 12 (P=0.025). Conclusion This pilot study demonstrates that CDED is a beneficial and safe therapeutic dietary intervention for pouchitis. Larger controlled trials should be performed in this population.

Prevalence of pouchitis in both ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis.

Pouchitis is a clinically significant complication of ileal pouch-anal anastomosis with its prevalence varying in the literature. Pouchitis is thought to occur more commonly in patients with ulcerative colitis (UC) than in patients with familial adenomatous polyposis (FAP). We conducted a systematic review with meta-analysis of all published literature to report the prevalence of pouchitis in all pouch patients as well as specifically in UC and FAP. We also investigated the prevalence of acute and chronic pouchitis in UC and FAP. A meta-analysis was conducted bysearching theEmbase,Embase Classic and PubMed databases between 1978 and 2021 exploring the prevalence of pouchitis in UC and FAP. We then performed a random effects modelin order to find the pooled prevalence of pouchitis and used odds ratios to report differences in the prevalence of pouchitis in UC and FAP. Fifty-nine full papers and conference abstracts were included in the meta-analysis comprising 18117 patients with UC and 860 with FAP. The prevalence of pouchitis in UC was 0.32 (95% CI 0.27-0.37) and in FAP was found to be 0.06 (95% CI 0.03-0.15). The odds ratio of pouchitis in UC patients compared with FAP patients was 4.95 (95% CI 3.17-7.72, P<0.0001). Our findings support the consensus that the prevalence of pouchitis is higher in UC than in FAP. More significantly our findings suggest that the true prevalence of pouchitis is higher than commonly reported in the literature. This literature may help counsel patients prior to undergoing restorative proctocolectomy.

S726 A Comparative Analysis of the Modified Pouchitis Disease Activity Index and the Endoscopic Phenotypes of the J Pouch in Patients With Inflammatory Bowel Disease

S726 A Comparative Analysis of the Modified Pouchitis Disease Activity Index and the Endoscopic Phenotypes of the J Pouch in Patients With Inflammatory Bowel Disease

Perianal Fistula After Ileoanal Pouch in Patients With Ulcerative Colitis: A Review of 475 Patients Operated on at a Major IBD Center

Ileoanal pouch anastomosis is the surgical treatment of choice for patients with intractable ulcerative colitis. Perianal disease is a feature that is often present in Crohn's disease and infrequently in ulcerative colitis. The aim of this study is to identify the incidence and factors associated with the development of postoperative perianal fistula in patients undergoing ileoanal pouch anastomosis for ulcerative colitis. A prospectively collected database at the time of surgery with subsequent follow-up was utilized. The study was conducted at a high-volume single institution. We studied a series of 475 consecutive patients with preoperative diagnosis of ulcerative colitis who underwent ileoanal pouch anastomosis. The incidence of postoperative perianal fistula and the factors correlating with its development were primary outcome measures of the study. The overall number of patients developing perianal fistulas was 44 of 475 (9%). Eleven patients with perianal fistula (25%) required return to ileostomy, of which 7 had pouch excision. Patients who developed a postoperative perianal fistula had a younger age at the onset of disease, had a lower age at index surgery, and were more likely to be subsequently classified as indeterminate colitis or Crohn's disease. Patients developing perianal fistulas were also more likely to develop partial dehiscence or stricture of the ileoanal anastomosis. This study spans nearly 40 years during which the surgical procedure evolved. Young age at the onset of disease, lower age at surgery, and postoperative diagnosis of Crohn's disease and indeterminate colitis were the factors correlating with perianal fistulas. Delayed healing of the ileoanal anastomosis with partial separation and/or stricture also correlated with the onset of perianal fistulas. The severity of rectal inflammation at the time of surgery or the presence of stapled versus handsewn anastomosis did not correlate with the development of perianal fistulas. See Video Abstract at http://links.lww.com/DCR/B705. ANTECEDENTES:El reservorio ileoanal es el tratamiento quirúrgico de elección para los pacientes con colitis ulcerativa intratable. La enfermedad perianal es una característica que a menudo está presente en la enfermedad de Crohn y con poca frecuencia en la colitis ulcerativa.OBJETIVO:El objetivo del estudio es identificar la incidencia y los factores asociados con el desarrollo de fístula perianal posoperatoria en pacientes sometidos a reservorio ileoanal por colitis ulcerativa.DISEÑO:Base de datos recopilada prospectivamente en el momento de la cirugía con seguimiento subsecuente.ENTORNO CLÍNICO:El estudio se llevó a cabo en una única institución de gran volumen.PACIENTES:Estudiamos una serie de 475 pacientes consecutivos con diagnóstico preoperatorio de colitis ulcerativa a los que se les realizó reservorio ileoanal.PRINCIPALES MEDIDAS DE VALORACIÓN:La incidencia de fístula perianal posoperatoria y los factores que se correlacionan con su desarrollo fueron las principales medidas de resultado del estudio.RESULTADOS:El número total de pacientes que desarrollaron fístulas perianales fue 44 de 475 (9%). Once pacientes con fístula perianal (25%) requirieron volver a la ileostomía, de los cuales 7 tuvieron resección del reservorio. Los pacientes que desarrollaron fístula perianal posoperatoria tenían edad más temprana al inicio de la enfermedad, menor edad en el momento de la cirugía inicial y tenían más probabilidades de ser clasificados posteriormente como colitis indeterminada o enfermedad de Crohn. Los pacientes que desarrollaron fístulas perianales también fueron más propensos a desarrollar dehiscencia parcial o estenosis de la anastomosis ileoanal.LIMITACIONES:Este estudio abarca casi 40 años durante los cuales ha evolucionado el procedimiento quirúrgico.CONCLUSIONES:Edad temprana al inicio de la enfermedad, menor edad al momento de la cirugía, diagnóstico postoperatorio de enfermedad de Crohn y colitis indeterminada fueron los factores que se correlacionaron con las fístulas perianales. El retraso en la cicatrización de la anastomosis ileoanal con separación parcial y/o estenosis también se correlacionó con la aparición de fístulas perianales. La gravedad de la inflamación rectal en el momento de la cirugía o la presencia de anastomosis con grapas versus anastomosis manual no se correlacionó con el desarrollo de fístulas perianales. Consulte Video Resumen en http://links.lww.com/DCR/B705.