Proctocolectomy 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.

INCIDENTAL DYSPLASIA DURING TOTAL PROCTOCOLECTOMY WITH ILEOANAL POUCH: IS IT ASSOCIATED WITH WORSE OUTCOMES?

Patients with inflammatory bowel disease (IBD) are at increased risk of colorectal cancer. In cases of invisible or non-endoscopically resectable dysplasia found at colonoscopy, total proctocolectomy with ileal pouch anal anastomosis can be offered with good long-term oncological outcomes and pouch survival, however, little is known regarding cancer-related outcomes when dysplasia is found incidentally after surgery. We hypothesized incidental colorectal dysplasia is associated with worse oncologic outcomes compared to dysplasia diagnosed preoperatively.

Surgical Options for Appropriate Length of J-Pouch Construction for Better Outcomes and Long-term Quality of Life in Patients with Ulcerative Colitis after Ileal Pouch-Anal Anastomosis.

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is widely accepted as a radical surgery for refractory ulcerative colitis (UC). Definite results on the appropriate pouch length for an evaluation of the risk-to-benefit ratio regarding technical complications and long-term quality of life (QOL) are still scarce. Data on UC patients who underwent IPAA from 2008 to 2022 in four well-established pouch centers affiliated to China UC Pouch Center Union were collected. A total of 208 patients with a median follow-up time of 6.0 years (interquartile range, 2.3 to 9.0 years) were enrolled. The median lengths of the patients' short and long pouches were 14.0 cm (interquartile range, 14.0 to 15.0 cm) and 22.0 cm (interquartile range, 20.0 to 24.0 cm), respectively. Patients with a short J pouch configuration were less likely to achieve significantly improved long-term QOL (p=0.015) and were prone to develop late postoperative complications (p=0.042), such as increased defecation frequency (p=0.003) and pouchitis (p=0.035). A short ileal pouch was an independent risk factor for the development of late postoperative complications (odds ratio, 3.100; 95% confidence interval, 1.519 to 6.329; p=0.002) and impaired longterm QOL improvement (odds ratio, 2.221; 95% confidence interval, 1.218 to 4.050, p=0.009). The length of the J pouch was associated with the improvement in long-term QOL and the development of late post-IPAA complications. A long J pouch configuration could be a considerable surgical option for pouch construction.

Acute Severe Ulcerative Colitis Is Associated With an Increased Risk of Acute Pouchitis.

Pouchitis occurs in up to 80% of patients after total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) and has been associated with microbial and host-related immunological factors. We hypothesized that a more robust immune response at the time of colectomy, manifested by acute severe ulcerative colitis (ASUC), may be associated with subsequent acute pouchitis. This was a retrospective cohort analysis of all patients with UC or indeterminate colitis complicated by medically refractory disease or dysplasia who underwent TPC with IPAA at Mount Sinai Hospital between 2008 and 2017 and at least 1 subsequent pouchoscopy. Acute pouchitis was defined according to the Pouchitis Disease Activity Index. Cox regression was used to assess unadjusted relationships between hypothesized risk factors and acute pouchitis. A total of 416 patients met inclusion criteria. Of the 165 (39.7%) patients who underwent urgent colectomy, 77 (46.7%) were admitted with ASUC. Acute pouchitis occurred in 228 (54.8%) patients a median of 1.3 (interquartile range, 0.6-3.1) years after the final surgical stage. On multivariable analysis, ASUC (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.04-2.17) and a greater number of biologics precolectomy (HR, 1.57; 95% CI, 1.06-2.31) were associated with an increased probability of acute pouchitis, while older age at colectomy (HR, 0.98; 95% CI, 0.97-0.99) was associated with a decreased probability. Time to pouchitis was significantly less in patients admitted with ASUC compared with those not (P = .002). A severe UC disease phenotype at the time of colectomy was associated with an increased probability of acute pouchitis.

Focal Cancer in Colitis.

Colorectal cancer (CRC) is a known complication of inflammatory bowel disease (IBD). Widely accepted guidelines recommend that patients with ulcerative colitis diagnosed with CRC undergo total proctocolectomy with or without ileal pouch-anal anastomosis, and that patients with Crohn's disease and CRC undergo either total colectomy or proctocolectomy. These approaches are ideal for preventing synchronous and metachronous cancer, minimizing risk of refractory colitis requiring reoperation, and is the appropriate treatment for the vast majority of patients with IBD who are diagnosed with CRC and require surgical intervention. Segmental colectomy, however, may be considered in select patients with IBD and CRC, specifically in elderly patients with short disease duration, in patients with mild colitis identified preoperatively, in patients with high operative risk and prohibitive comorbidities, and in patients whose CRC appears to be sporadic as opposed to colitis-associated. Patients undergoing segmental resection must be closely surveilled postoperatively for dysplasia, recurrent cancer, and refractory colitis.

Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses

While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce. We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes. Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10. Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA. IV.

A104 INVISIBLE COLONIC MALIGNANCY AND POSSIBLE IDIOSYNCRATIC DRUG-INDUCED LIVER INJURY FROM VEDOLIZUMAB IN A PATIENT WITH ULCERATIVE COLITIS, PRIMARY SCLEROSING CHOLANGITIS AND AUTOIMMUNE HEPATITIS OVERLAP SYNDROME

Abstract Background Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract. Due to an increased risk of developing colorectal cancer, regular surveillance for dysplastic lesions via colonoscopy is recommended. Invisible dysplasia is the abnormal development of cells noted on pathology with no visible lesion seen during colonoscopy. Primary sclerosing cholangitis (PSC) is an immune-mediated liver disease leading to progressive stricturing and fibrosis of the bile ducts. There is significant association between PSC and IBD, as up to 80% of patients with PSC having underlying IBD. Drug induced liver injury (DILI) is a common cause of acute liver failure in most Western countries. Most cases of DILI are self-limited, with resolution of laboratory and clinical findings after cessation of the offending agent. Purpose To describe a case of invisible colonic malignancy and possible idiosyncratic drug-induced liver injury from vedolizumab (VDZ) in a patient with ulcerative colitis (UC), PSC and autoimmune hepatitis (AIH) overlap syndrome. Method Patient consent was obtained. Information from electronic records was extracted, including admission notes and procedural reports. A literature review was performed using Pubmed. Result(s) A 32-year-old Caucasian female with UC on VDZ with PSC and AIH had multiple colonoscopies performed demonstrating multifocal low-grade dysplasia. However, she remained resistant to surgery. She presented to clinic with tea-coloured urine, fatigue, and scleral icterus. Investigations revealed conjugated hyperbilirubinemia with elevation in hepatocellular liver enzymes. Imaging was consistent with large duct PSC, and liver biopsy showed grade 2 chronic hepatitis raising the possibility of large bile duct obstruction. She underwent liver transplant assessment and VDZ was held. Her bilirubin and liver enzymes recovered. Given multiple colonoscopies showing multifocal dysplastic changes and the patient declining other biologics, she would ultimately undergo total proctocolectomy with end ileostomy. Pathology demonstrated mucinous adenocarcinoma with a signet ring component. Conclusion(s) Both mucinous adenocarcinoma and signet ring carcinoma are more aggressive malignancies associated with poor prognosis. Found more often in younger patients, they are often diagnosed in later stages with lymphovascular invasion. Here, there was no evidence of metastases in any of the 40 lymph nodes examined, which indicated more favourable prognosis. The mechanism by which VDZ potentially causes liver injury is unknown. Multiple therapies for PSC-AIH overlap and IBD were entertained as causative agents. However, significant improvement in clinical symptoms and serologic parameters following cessation of VDZ was temporally suggestive. This case simultaneously highlights the importance of both timely colectomy in IBD patients with high-risk features during surveillance and early recognition and cessation of potential causative medications which induce liver injury. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Long-term Prognostic Impact of Metachronous Rectal Cancer in Patients With Familial Adenomatous Polyposis: A Single-center Retrospective Study.

To evaluate the risk factors and long-term prognosis of metachronous rectal cancer in the remnant rectum of patients with familial adenomatous polyposis (FAP). Sixty-five patients (49 families) who underwent prophylactic surgery, including bowel resection, for FAP between January 1976 and August 2022 at Hamamatsu University Hospital were included and divided into two groups based on the presence of metachronous rectal cancer. Risk factors for metachronous rectal cancer development were analysed in cases treated with total colectomy with ileorectal anastomosis (IRA) and stapled total proctocolectomy with ileal pouch anal anastomosis (IPAA) (IRA, n=22; stapled IPAA n=20; total, n=42). The median surveillance period was 169 months. Twelve patients developed metachronous rectal cancer (IRA, n=5; stapled IPAA, n=7), of which six with advanced cancer died. Patients who temporarily dropped out of surveillance were significantly more likely to have metachronous rectal cancer (metachronous vs. non-metachronous rectal cancer: 33.3% vs. 1.9%, p<0.01). The mean duration of surveillance suspension was 87.8 months. Cox regression analysis revealed that temporary surveillance drop-out independently affected the risk (p=0.04). The overall survival associated with metachronous rectal cancer was 83.3% at 1 year and 41.7% at 5 years. Overall survival was significantly worse in advanced cancer than in early cancer cases (p<0.01). Temporary drop-out from surveillance was a risk factor for metachronous rectal cancer development, and advanced cancer had a poor prognosis. Continuous surveillance of patients with FAP, without temporary drop-out, is strongly recommended.

A Case of a Beta-Catenin-Activated Hepatic Adenoma in a Male Patient With Familial Adenomatous Polyposis

Hepatocellular adenoma is a benign liver tumor often diagnosed incidentally in women of reproductive age who are taking oral contraceptives. In this study, we present a unique case of an 18-year-old man with known familial adenomatous polyposis who presented with sepsis in the setting of a recent total proctocolectomy and was incidentally found to have multiple large hepatic lesions. A biopsy of a liver lesion confirmed the diagnosis of a beta-catenin-activated hepatic adenoma. To the best of our knowledge, this is the first known case of beta-catenin-activated hepatic adenoma in a patient with a known familial adenomatous polyposis mutation. Beta-catenin is one of the many subtypes of hepatocellular adenomas, which carries a high risk of malignant transformation.

Comparison of The Toronto IBD Global Endoscopic Reporting (TIGER) score, Mayo endoscopic score (MES), and ulcerative colitis endoscopic index of severity (UCEIS) in predicting the need for ileal pouch–anal anastomosis in patients with ulcerative colitis

Total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) has been accepted as a radical surgery for refractory ulcerative colitis (UC). We aimed to assess the predictive value of several novel and widely used endoscopic core systems, The Toronto IBD Global Endoscopic Reporting (TIGER) score, Mayo endoscopic score (MES), and ulcerative colitis endoscopic index of severity (UCEIS) in guiding the need for IPAA. Data on patients with UC from June 1986 and June 2022 at our institute were collected. The endoscopic evaluation was recorded according to the first colonoscopy after hospitalization. Primary outcome was the need for IPAA during admission and follow-up. A total of 313 patients with a median follow-up time and a median TIGER score of 12.0years (interquartile range (IQR): 6.0-17.0) and 212.0 (IQR: 7.0-327.0) were enrolled. IPAA was conducted in 110 (35.1%) patients, which significantly improved the long-term quality of life. TIGER score had the biggest area under the receiver-operating characteristic curve of 0.810 with a sensitivity of 75.0% and specificity of 87.1% at the cut-off value of 315 (p < 0.001). TIGER score ≥ 315 was an independent risk factor with the highest odds ratio for the need for IPAA and associated with the shortest IPAA-free survival time compared with UCEIS and MES. TIGER score was superior to UCEIS and MES in predicting the need for IPAA. For colorectal surgeons, three or more segments with moderate-to-severe endoscopic activity should be considered as a threshold value for decision-making for IPAA.

Surgical management of colonic perforation due to ulcerative colitis: report of a case

Surgical treatment of ulcerative colitis (UC) is indicated electively in failure of medical therapy and development of malignancy and dysplasia in long standing cases and acutely in fulminant colitis, perforation, bleeding, obstruction or in toxic megacolon. The surgical procedure in the past used to be total proctocolectomy with permanent ileostomy with its attendant psychological, social, physical, and sexual problems. With the advent of ileal pouch–anal anastomosis (IPAA) patients with UC can have a good quality of life without fear of having the permanent ileostomy. The advancement of minimally access surgery has added a new wing to the surgical armamentarium in coping the postoperative recovery, body image, sexual dysfunction etc. Laparoscopic surgery appeals to patients undergoing IPAA because they are generally young and hope to gain the potential benefit of reduced disability, more rapid recovery, and a better body image as a result of more cosmetic incisions. Depending upon the clinical presentation patient may require two or three stage procedure.

Rectal Cancer and Radiation in Colitis.

Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer. When IBD patients develop a rectal cancer, this should be treated with the same oncological principles and guidelines as the general population. Rectal cancer treatment includes surgery, chemotherapy, and radiation therapy (RT). Many IBD patients will require a total proctocolectomy with an ileal-pouch anal anastomosis (IPAA) and others, restoration of intestinal continuity may not be feasible or advisable. The literature is scarce regarding outcomes of IPAA after RT. In the present review, we will summarize the evidence regarding RT toxicity in IBD patients and review surgical strategies and outcomes of IPAA after RT.

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.

DOP70 Crohn’s Disease Like Inflammation of The Pouch is a Distinct Type of Pouchitis

Abstract Background Pouchitis occurs in up to 80% of patients with ulcerative colitis (UC) after total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA). The pathogenesis of pouchitis is unclear, but is thought to involve a complex interaction between the microbiome and mucosal immune system. To examine the underlying pathophysiological mechanisms of pouchitis, the present study aims to simultaneously define immuno-histological and microbial parameters associated with different pouch phenotypes. Methods Endoscopic biopsies from the pre-pouch ileum (PI) and the pouch body (PB) were obtained from 51 subjects age&amp;gt;18 who underwent TPC with IPAA, n=48 for UC and n=3 for familial adenomatous polyposis (FAP). Mucosal mononuclear cells (MMC) were isolated from the intra-epithelial compartment (IEC) and lamina propria (LP) and examined for lymphoid, myeloid and innate immune subsets by multiparameter flow-cytometry (FC). Histological sections were examined by two pathologists, blinded to clinical identifiers and scored for inflammatory parameters that included neutrophilic activity, lymphoplasmacytic infiltration, eosinophilia, villous atrophy and submucosal fibrosis. Metagenomic sequencing of stool was performed and analyzed for microbial beta and alpha diversity. Results IPAA subjects were classified into the following phenotypes: normal pouch (NP) n=15 (29.4%), acute pouchitis (AP) n=9 (17.6%), chronic antibiotic dependent pouchitis (CADP) n=9 (17.6%), Crohn’s disease like pouch inflammation (CDLPI) n=15 (29.4%), and FAP NP n=3 (5.9%). Among subjects with NP, the PB had a higher frequency of naïve-CD4+ and CD8+ T cells, central memory- CD4+ T cells, and naïve B cells and a lower frequency of homeostatic IELs relative to the PI (Fig. 1A). Immune remodeling of the PB was further confirmed on histology that demonstrated increased lymphoid aggregates and decreased IELs. Subjects with CDLPI had significantly higher levels of inflammation, chronicity, and lymphoid aggregates but decreased IELs in the PI than NP or AP patients (Fig. 1B and 1C). In contrast to immune parameters, the composition of the microbiota in non-inflamed UC pouches was more similar to inflamed UC pouches than to FAP pouches. Alpha diversity and genus relative abundance differences between UC and FAP pouch stool samples were not statistically significant (Fig. 1D). Conclusion CDLPI represents a distinct entity of pouchitis that is associated with heightened levels of chronic inflammation relative to AP despite similarities in microbiota.

P458 Low adherence to Mediterranean diet is associated with increased adipose tissue in patients with ulcerative colitis (UC) after pouch surgery: a cross sectional study

Abstract Background Obesity [body mass index (BMI) ≥30 kg/m2 ] prevalence in patients with inflammatory bowel diseases (IBD) ranges between 15-40%. Dual-energy x-ray absorptiometry (DEXA) is the gold standard for body composition evaluation. Patients with ulcerative colitis (UC) who undergo total proctocolectomy and pouch surgery may develop small bowel inflammation (pouchitis) resembling Crohn's disease (CD). We aimed to assess body composition of patients with UC-pouch and potential risk factors for high adiposity. Methods Patients with UC-pouch ages 18-50 were recruited. Adipose tissue was assessed by DEXA (increased adipose tissue defined as &amp;gt; 26% male, &amp;gt;31% female), sarcopenia- assessed by hand-grip (defined as &amp;lt;30 kg male, &amp;lt;20 kg female). Clinical data, biochemical and inflammatory markers documented, Mediterranean diet adherence assessed by the Israeli Mediterranean diet (I-MEDAS) questionnaire. Results Recruited patients: 30: male/female 14/16; median age 45 (IQR 31-51.7) years; median BMI 23.2 (IQR 21-26.5); median pouch age 17 (IQR 10-25) years. One patient was obese (BMI ≥ 30 kg/m2) and seven-overweight (BMI 25-29.9 kg/m2). Median fat percentage 34.7 (IQR 30.1-39.7); 23/30 (76.6%) had increased adipose tissue. 14/30 (46%) patients were defined as normal weight obesity- normal BMI with increased adipose tissue. In univariate analysis comparing males to females, age and I-MEDAS score were comparable. Females were less physically active (p=0.028), had lower BMI (p=0.043), and higher rates of elevated adipose tissue (p=0.002). In multivariate analysis adherence to the Mediterranean diet was associated with lower adipose tissue regardless of sex and BMI (p&amp;lt;0.001). Sarcopenia was found in 1 (3.33%) female patient. Conclusion Patients with UC-pouch are at risk for "Normal-weight obesity", an uprising health concern, having increased adipose tissue regardless of BMI and sarcopenia. Adherence to the Mediterranean diet is inversely associated with increased adiposity, and may be used to modify adiposity in patients with UC after pouch surgery, irrespectively of BMI.

P449 Minimally invasive IPAA in UC: Preliminary results from a referral center

Abstract Background Minimally invasive approaches in performing restaurative total proctocolectomy in Ulcerative Colitis(UC) have been increasingly adopted. In particular, the robotic approach could be used with more benefits in proctectomy with ileal pouch anal anastomosis (IPAA). In fact, the robotic device seems to potentially overcome all the limitations found in laparoscopic and conventional open surgery. The aim of our study was to compare and evaluate early and late functional postoperative outcomes and complications after IPAA, performed with open, laparoscopic and robotic techniques in UC patients. Methods At our institution, 397 UC patients who underwent restorative proctocolectomy with IPAA during the period 1986-2022, consecutively treated either with open surgery, laparoscopic or robotic techniques were enrolled. The incidence of early (&amp;lt;30 days) and late (&amp;gt;30 days) postoperative complications (intestinal occlusion, haematoma/wound infection, anastomotic dehiscence), hospital stay and an assessment about continence, autonomic nerve damage, incidence of pouchitis and cuffitis was evaluated. Results About the 397 patients, 344 underwent conventional open IPAA, 31 laparoscopically and 22 robotically. Comparable early and late postoperative surgical complications were recorded among the different techniques [early and late complications respectively 24/53 (45,2%) and 146/344(42,4%)] in minimally invasive and open groups. Minimally invasive surgery showed a better outcome regarding wound infections [0/53 (0%)], anastomotic dehiscence and reduced length of stay but open surgery demonstrated a better result on early and late intestinal occlusion [8/53 (15%)vs 22/344 (6,39%)] and anastomotic stenosis [5/53 (9,43%) vs 15/344 (4,36%)]. Lastly, the rate of cuffitis was higher in open surgery than in the minimally invasive group [(3/53 (5,66%) vs 46/344(13,37%)] and within these, robotic approach seems to show better results compared to laparoscopy. Conclusion UC patients undergoing IPAA could benefit from a minimally invasive surgical approach. Our experience confirms that robotics seems to be related to hopeful outcomes both in the short and long term period, even if more studies are needed to refine the promising results.

P568 Patients with ulcerative colitis after pouch surgery are at risk for low spinal bone mineral density: a cross sectional study

Abstract Background Low bone mineral density (BMD) is prevalent in patients with inflammatory bowel diseases (IBD), specifically Crohn’s disease (CD) due to multiple factors including active inflammation, use of corticosteroids, surgeries and nutritional deficiencies. Patients with ulcerative colitis (UC) who undergo total proctocolectomy and pouch surgery may develop small bowel inflammation (pouchitis) resembling CD. Data regarding their BMD are scarce. We assessed low BMD rates and risk factors in these patientsץ Methods Patients with UC-pouch ages 18-50 without BMD assessment in the past 5 years were recruited. BMD was assessed by dual-energy x-ray absorptiometry (DEXA). Clinical data, biochemical and inflammatory markers were detected and dietary patterns were assessed using validated questionnaires. Results Patients recruited-30: male/female 14/16; Median age 45 (IQR 31-51.7) years; median BMI 23.2 (IQR 21-26.5); median IBD duration 23 (IQR 15-30) years; median pouch age 17 (IQR 10-25) years. Low BMD detected in 16/30 (53.3%): 6/30 (20%) osteoporosis,10/30 (33.3%) osteopenia. Low L1-L4 T-scores correlated with younger age, lower BMI and shorter disease duration (p= 0.001; p= 0.001; p= 0.023, respectively). In univariate analysis patients with low and normal BMD were comparable in age, gender, BMI, smoking, past and current medical treatment. In multivariate analysis younger age and lower BMI remained significant (age SE= 0.22, β 0.422 p=0.043, BMI SE=0.06, β=0.531 p=0.006) independently of sex, years since IBD diagnosis, and smoking. Dietary patterns were comparable (p=0.715). Conclusion Abnormally low BMD was prevalent in over half of patients with UC-Pouch. Interestingly younger age and lower BMI were risk factors for low spinal BMD. Dietary patterns did not account for the findings. BMD should be routinely assessed in patients with UC-pouch and intervention to correct abnormally low BMD should be planned.

INCIDENTAL DYSPLASIA DURING TOTAL PROCTOCOLECTOMY WITH ILEOANAL POUCH: IS IT ASSOCIATED WITH WORSE OUTCOMES?

Abstract BACKGROUND Patients with inflammatory bowel disease (IBD) are at increased risk of colorectal cancer. In cases of invisible or non-endoscopically resectable dysplasia found at colonoscopy, total proctocolectomy with ileal pouch anal anastomosis can be offered with good long-term oncological outcomes and pouch survival, however, little is known regarding cancer-related outcomes when dysplasia is found incidentally after surgery. We hypothesized incidental colorectal dysplasia is associated with worse oncologic outcomes compared to dysplasia diagnosed preoperatively. METHODS Using our prospectively collected pouch registry, we identified patients who had a) preoperative dysplasia or b) dysplasia found only after colectomy. Patients with cancer preoperatively or after colectomy were excluded. Included patients were divided into three groups: ONLYPRE (+preoperative biopsy, negative final pathology), PREFINAL (+preoperative biopsy and final pathology), and ONLYFINAL (negative preoperative biopsy, +final pathology. Long-term pouch survival in the three groups was assessed with survival analysis. RESULTS In total, 517 patients were included: ONLYPRE = 125 (24%), PREFINAL = 254 (49%), ONLYFINAL = 137 (26%). Overall, the median age at IPAA was 46 (IQR 36 - 62) and 33% were female. The preoperative diagnosis was ulcerative colitis in 91% cases. No demographic differences were observed between the groups. In patients with a positive preoperative biopsy, the concordance between preoperative biopsy and final pathology was 49% (Figure 1a). After a median follow-up of 12 years (IQR 3 – 21), there were no differences in overall, disease-free or pouch survival between groups (Figure 1b, c, d). Cancer/dysplasia developed in 11 patients: 3 (2%) in the ONLYPRE, 5 (2%) in the PREPOST, and 3 (2%) in the ONLYPOST group (Table 1). Oncologically, one required redo pouch (ONLYPRE group), while 4 required pouch excision: 1 (1%) In ONLYPRE, 1 (0.5%) in the PREPOST, and 2 (2%) in the ONLYPOST group (p = 0.24). Only one cancer-related death occurred in the entire cohort (ONLYPRE group). Disease-free survival at 10 years was 98% for ONLYPRE, 98% for PREPOST, and 98% for ONLYPOST (p = 0.968). Pouch survival at 10 years was 96% for ONLYPRE, 99% for PREPOST, and 97% for ONLYPOST (p = 0.236). CONCLUSION An ileoanal pouch in the setting of IBD-associated dysplasia, regardless of when it is diagnosed, confers exceptionally good long-term outcomes. The incidental finding of dysplasia during proctocolectomy does not seem to be associated with worsened outcomes compared to preoperatively diagnosed dysplasia.

Managing ulcerative colitis after surgery.

Management of ulcerative colitis after surgery suggested by guidelines (total proctocolectomy with ileal-pouch anal anastomosis) is a big challenge for physicians because patients who believed that their disease had been cured started experiencing very uncomfortable symptoms repeatedly. A high number of patients develop episodes of pouchitis, which is a non-specific inflammation of the pouch whose etiology is unknown. Antibiotics are the elective treatment for acute pouchitis, but regarding chronic pouchitis, this condition is very complicated to treat due to the absence of well-designed specific studies for this group of patients. Antibiotics, budesonide, and biological therapies are some of the recommended drugs for these patients, but despite their use, some need a permanent ileostomy.

Associations between Pouchitis and Fecal Calprotectin after Restorative Proctocolectomy in Patients with Ulcerative Colitis

Introduction: Recently, fecal calprotectin has been identified and used as an assessment tool for the confirmation of disease activity in ulcerative colitis. Although a meta-analysis suggested the usefulness of fecal calprotectin for the assessment of pouchitis, the number of participants was still insufficient. Therefore, we prospectively measured fecal calprotectin levels during pouchoscopy and analyzed their associations with pouchitis. Methods: Patients who underwent pouchoscopy after total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis were included. Fecal samples were collected for the measurement of calprotectin during pouchoscopy. Patients either with or without suspicious pouchitis were included. Pouchitis was defined as a modified pouchitis disease activity index (m-PDAI) score of ≥5. The associations between the development of pouchitis and the m-PDAI score and fecal calprotectin and serum markers, including C-related protein, albumin, and white blood cells, were assessed. Results: A total of 170 patients were included. Seventy-two patients were diagnosed with pouchitis with an m-PDAI score of 7.3 ± 1.5. The values of fecal calprotectin were 1,500 ± 1,544 μg/g in patients with pouchitis and 259 ± 402 μg/g in patients without pouchitis (p < 0.01). The correlation coefficient between calprotectin and the m-PDAI score was significant (r² = 0.279, p < 0.001). The cutoff value of fecal calprotectin in receiver operating characteristic analysis was 246 μg/g (area under curve 0.85, sensitivity 83.9%, specificity 71.0%). Fecal samples were able to be collected from 6 patients. The levels of fecal calprotectin significantly decreased from 2,101.3 ± 880.3 μg/g to 284.2 ± 96.9 μg/g in response to the treatment. Conclusions: Elevated fecal calprotectin appeared to be significantly correlated with pouchitis. We should consider the alteration of this marker during treatments in further studies.