Rate Of Pouchitis Research Articles

Prediction of pouchitis after ileal pouch-anal anastomosis in patients with ulcerative colitis using artificial intelligence and deep learning.

Pouchitis is one of the major postoperative complications of ulcerative colitis (UC), and it is still difficult to predict the development of pouchitis after ileal pouch-anal anastomosis (IPAA) in UC patients. In this study, we examined whether a deep learning (DL) model could predict the development of pouchitis. UC patients who underwent two-stage restorative proctocolectomy with IPAA at Keio University Hospital were included in this retrospective analysis. The modified pouchitis disease activity index (mPDAI) was evaluated by the clinical and endoscopic findings. Pouchitis was defined as an mPDAI ≥ 5.860; endoscopic pouch images before ileostomy closure were collected. A convolutional neural network was used as the DL model, and the prediction rates of pouchitis after ileostomy closure were evaluated by fivefold cross-validation. A total of 43 patients were included (24 males and 19 females, mean age 39.2 ± 13.2years). Pouchitis occurred in 14 (33%) patients after ileostomy closure. In less than half of the patients, mPDAI scores matched before and after ileostomy closure. Most of patients whose mPDAI scores did not match before and after ileostomy closure had worse mPDAI scores after than before. The prediction rate of pouchitis calculated by the area under the curve using the DL model was 84%. Conversely, the prediction rate of pouchitis using mPDAI before ileostomy closure was 62%. The prediction rate of pouchitis using the DL model was more than 20% higher than that using mPDAI, suggesting the utility of the DL model as a prediction model for the development of pouchitis. It could also be used to determine early interventions for pouchitis.

Ileal pouch-anal anastomosis in the elderly: A systematic review and meta-analysis.

Despite good overall outcomes in most patients undergoing ileal pouch-anal anastomosis (IPAA), there is still hesitation about performing an IPAA in older patients due to the comorbidity burden and concern about incontinence. The aim of this work was to identify short- and long-term outcomes in older patinets undergoing IPAA to determine the perioperative safety and long-term functional success of IPAA in older patients. A literature search was performed for all publications on IPAA in adults aged ≥50years that reported short- and long-term outcomes. Data extraction included demographics, 30-day outcomes, long-term functional outcomes and pouch failure. Data were further separated by age group (50-65 and ≥65years). Outcomes were compared between age groups. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale. Of 1053 publications reviewed, 13 full papers were included in the analysis. The overall 30-day morbidity and mortality rates were 47.3% and 1.3%, respectively. Thirty-day postoperative rates of small bowel obstruction and pelvic sepsis were 7.6% and 9.9%, respectively. After a median follow-up time of 62months, rates of pouchitis, incontinence and pouch failure were 13.9%, 17.5% and 7.5%, respectively. There was no statically significant difference in rates of short- or long-term functional outcomes based on age 50-65 versus ≥65years. Increasing age did not increase the rate of short- or long-term outcomes, including pouch failure. These data suggest that the decision for IPAA construction should not be based on age alone.

Impact of paediatric onset primary sclerosing cholangitis on clinical course and outcome of inflammatory bowel disease: a case-control population-based study in Finland

Introduction and aim: The aim of this study was to investigate the outcome of a paediatric onset of inflammatory bowel disease (IBD) in a cohort of subjects with primary sclerosing cholangitis (PSC) and in a matched-age population-based control group without PSC.Methods: We identified 28 IBD-PSC cases (median age at IBD diagnosis 12.5 years, 25–75th: 10–16 years) and selected three IBD controls for each case matched for age and year of IBD diagnosis. All data regarding the gastrointestinal tract and liver were collected at diagnosis and at last follow-up (median 15 years).Results: At diagnosis the prevalence of pancolitis was similar between the groups (78% and 79%, respectively p = –.30), but histologic inflammation was milder in IBD-PSC (61% vs 30%, p = .06). At last follow-up (median age 29 years) pancolitis was less frequent (6% and 33%, respectively p = .04) and the remission higher (76% and 47%, respectively p = .08) in IBD-PSC patients than in IBD patients. Panproctolectomy (32% in IBD-PSC and 34% in IBD, p = 1.0) and the rate of pouchitis (62% and 70%, respectively p = .8) were similar.Conclusions: The outcome of paediatric onset IBD in patients with PSC in adulthood seems to be comparable to those with IBD only.

Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review.

Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the procedures of choice for restoration of intestinal continuity in ulcerative colitis or familial adenomatous polyposis. This systematic review aims to assess short-term postoperative and long-term functional outcomes in pediatric patients undergoing IPAA. A literature search was performed for all publications of pediatric IPAA in which short- and long-term outcomes were reported. Papers were excluded based on title, abstract, and full-length review. Data collection included patient demographics, medication use preoperatively, operative approach, 30-day postoperative outcomes, long-term functional outcomes (to maximal date of follow-up), and pouch failure rate. Outcomes were compared in those patients with and without perioperative corticosteroid exposure. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale as all studies were cohort studies. Of 710 records reviewed, 42 full papers were included in the analysis. Rates of superficial surgical site infection, pelvic sepsis, ileus, and small bowel obstruction at <30 days were 10%, 11%, 10%, and 14%, respectively. Rates of pouchitis, stricture, chronic fistula tract, incontinence, and pouch failure were 30%, 17%, 12%, 20%, and 8%, respectively, at 37-109 months of follow-up; incontinence was significantly higher in those exposed to corticosteroids preoperatively (52% vs 20%; P < 0.001). The median daytime, nighttime, and 24-hour stool frequency were 5.3, 1.4, and 5 bowel movements, respectively. IPAA is safe with good long-term functional outcomes in pediatric patients.

Preoperative Clostridium difficile Infection Does Not Affect Pouch Outcomes in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-anal Anastomosis.

The operation of choice for patients with chronic ulcerative colitis (CUC) is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis is the most common complication after IPAA. The incidence of Clostridium difficile infection (CDI) is higher in CUC patients than the general population and can lead to significant disease flares and higher rates of colectomy. We sought to determine the risk of pouchitis in patients with precolectomy CDI and 90-day postoperative IPAA complications. A retrospective case-control study was conducted on patients with CUC who underwent an IPAA between January 1, 2000 and January 10, 2015. The study cohort was comprised of patients diagnosed with CDI within 90 days before colectomy; patients with CUC without CDI comprised the control cohort. The primary outcome measure was the frequency of pouchitis after IPAA. Secondary outcomes included time to pouchitis, 90-day postoperative pouch morbidity: surgical site infection, hemorrhage, anastomotic leak, fistula formation, pouchitis treatment and response, and pouch failure requiring end-ileostomy or fecal diversion. Univariate and multivariable analysis was used to determine differences between CDI and non-CDI groups. Forty-eight case patients and 154 control patients were included. Patients with preoperative CDI were younger (P = 0.010), had higher rates of medically refractory disease (P = 0.002), and had greater use of biologic therapy (P = 0.046). The rate of pouchitis was 50.0% (n = 24) and 46.8% (n = 72) (P = 0.694) among patients with and without preoperative CDI, respectively. Patients with preoperative CDI who developed pouchitis post-IPAA were more likely to require medical management with an anti-TNFα (P = 0.042) and surgical management with end/diverting ileostomy (P = 0.042). Preoperative CDI was associated with higher rates of postoperative IPAA anastamotic or pouch strictures (P = 0.018). Multivariable analysis revealed primary sclerosing cholangitis (PSC) as the only variable associated with increased risk for pouchitis (OR 10.59; 95% CI, 3.07-51.08; P < 0.001). Preoperative CDI does not seem to be associated with an increased risk of pouchitis in patients with CUC.

Surgical Outcomes and Quality of Life in Young Patients After Ileoanal Anastomosis for Ulcerative Colitis

BACKGROUND Pediatric ulcerative colitis (UC) that is resistant to medical therapy is managed surgically with a colectomy and ileal pouch anal anastomosis. Family and patient concerns including quality of life (QoL), bowel function, and surgical complications may factor heavily in the decision to proceed with surgical intervention. OBJECTIVE We aim to investigate the QoL, bowel habits, and operative outcomes of younger (≤11 years old) compared with older patients with pediatric UC after surgical intervention. METHODS Medical records of patients with UC after colectomy with ileoanal reconstruction (2002–2013) at our institution were reviewed. Patients/parents completed a QoL (ranging from 0 = best to 10 = worst, assessing physical, social, and psychological aspects), bowel habit, and disease course questionnaire and then compared younger (age ≤ 11 years, n = 26) with older (age > 11 years, n = 38) patients. Data were analyzed by t test or Fisher’s exact test, expressed as mean ± SEM with significance of p ≤ .05. RESULTS The mean age at colectomy was 7.04 ± 0.63 versus 14.71 ± 0.32 years in the two groups. Follow-up (months) was similar between groups (younger: 19.03 ± 5.36 vs. older: 14.31 ± 2.65, p = .391). Questionnaire return rate was high (71%). Both age groups expressed a significant and similar improvement in QoL after surgery (6.76 ± 0.56 to 2.05 ± 0.39 in younger cohort and 7.32 ± 0.33 to 2.6 ± 0.379 in older cohort). Specific variables assessed including energy level, pain, limitations, effect on family, diet restrictions, missed school, appearance, happiness, and missed social events were all significantly improved (p < 0.001) following surgery in both the younger and older cohorts. Patients had a significant reduction in stooling frequency compared to pre-colectomy in younger (12.89 ± 1.86 to 4.61 ± 0.47, p < 0.001) and older (14.74 ± 1.91 to 5.04 ± 0.29, p < 0.001) patients. Rate of pouchitis was similar between younger (23.8%) and older (29.4%) patients, as was post-operative small bowel obstruction 19% vs 24% respectively. Dehydration was slightly increased in the younger population, 15% vs 5%. Anastomotic leak (7.7% vs 10.5%) and stricture (11.5% vs 21.1%) rates were reduced in younger patients. CONCLUSIONS A colectomy with ileoanal anastomosis for younger children (≤11 years old) with UC is without increased complications relative to older patients, even a slightly decreased anastomotic stricture and leak rate, and offers similar improvement in quality of life and stooling patterns.

Quality of life, continence and frequency of pouchitis following laparoscopic versus open colectomy and ileal pouch-anal anastomosis: an Irish perspective.

This study aims to assess quality of life outcomes, continence, rates of pouchitis and predictors of pouchitis for patients undergoing laparoscopic versus open three-stage ileal pouch-anal anastomosis (IPAA) surgery in our institution. Forty-two patients having had three-stage (IPAA) surgery were identified. One was excluded as they had undergone pouchectomy. A postal questionnaire followed by telephone contact was undertaken. The questionnaire was based on The Gastrointestinal Quality of Life Index (GIQLI) and Wexner/Cleveland Clinic Faecal Incontinence Symptom Severity Scoring Systems. Our aim was to assess morbidity, quality of life, incidence of pouchitis and continence following restorative panproctocolectomy and IPAA. Thirty-five patients completed the response. The median age at colectomy of our patient population was 32 years. 57 % were male and 43 % were female. 54.3 % of cases were carried out laparoscopically. 8/19 patients who had laparoscopic surgery had pouchitis (42.1 %) versus 9/16 patients who had open surgery (56.3 %). The median Wexner score was 0. Nine patients (25.7 %) had a GIQLI score that was within or above the range reported for healthy controls. The rate of complications was 31.7 % for emergency cases and 25.7 % for elective cases. The rate of pouchitis in this group was 48.5 %. Overall pelvic sepsis rate was 12.8 %. Ileal pouch-anal anastomosis is a successful and well-tolerated procedure with 94 % of patients opting to have the surgery again. Preliminary results do not show any significant difference in the incidence of pouchitis following laparoscopic surgery.

Indications for Proctocolectomy and Surgical Outcomes in Patients with Inflammatory Bowel Disease and Primary Sclerosing Cholangitis

Purpose: Inflammatory bowel disease associated with primary sclerosing cholangitis (PSC-IBD) may represent a distinct phenotype of IBD. PSC-IBD carries an increased risk of dysplasia and colorectal cancer as well. The unique natural history of PSC-IBD may be reflected in indications for proctocolectomy and surgical outcomes in these patients. This study characterizes a group of patients with PSC-IBD who underwent colectomy and compares them to matched patients with UC alone. Methods: Patients with IBD who underwent proctocolectomy with ileal pouch-anal anastomosis (IPAA) at St. Louis University from 1995–2005 were identified retrospectively. Cases were required to have PSC confirmed by cholangiography. Controls with UC alone were matched for sex, year of first visit, and duration of IBD prior to first visit (two per case). Results: Five patients with PSC-IBD who underwent colectomy/IPAA were identified and matched with ten controls. There was no difference between the groups in time to colectomy following the diagnosis of IBD. Dysplasia was an indication for colectomy in 3/5 patients with PSC-IBD, compared to none of the controls. Refractory disease was an indication for colectomy in 3/5 cases and 10/10 controls. There was no significant difference in rates of pouchitis between the groups. The percentage of patients alive at most recent follow-up was lower in the PSC-IBD group. Both deaths in the PSC-IBD group were from sepsis. Interestingly, among patients with PSC, the presence of backwash ileitis appeared to increase the risk of colectomy. Conclusions: Dysplasia is a more common indication for colectomy in patients with PSC-IBD. This is true despite a high prevalence of pancolitis in both groups and a similar time to colectomy, suggesting that colitis in PSC-IBD is associated with an increased risk for dysplasia. PSC-IBD patients may also have higher morbidity following colectomy. Backwash ileitis appears to be risk factor for colectomy in patients with PSC.Table

LETTERS TO THE EDITOR

Although the etiology of pouchitis after ileal pouch-anal anastomosis (IPAA) is unknown, its manifestations resemble those of nonspecific inflammatory bowel disease, including, anecdotally, the apparent ability to evoke extraintestinal manifestations (EIM) of inflammatory bowel disease (IBD). Our aim was to determine in what manner pouchitis and EIMs were associated. The computerized records of 819 consecutive patients who underwent IPAA between January 1981 and December 1988 were reviewed. Eighty-five patients were excluded (because of incomplete follow-up, death, or permanent ileostomy). Follow-up of the remaining 734 patients was complete (mean, 41 months). The mean age was 32 years and the ratio of men to women was 1:1. Ileal pouch-anal anastomosis was performed for chronic ulcerative colitis in 91% of patients and for familial adenomatous polyposis in 9%. Pouchitis occurred in 31% of chronic ulcerative colitis patients and 6% of familial adenomatous polyposis patients (p less than 0.01). The mean time to first occurrence was 17 months. Pouchitis recurred in 61% of patients at risk. Patients with preoperative and postoperative EIMs had significantly higher rates of pouchitis than did patients without EIMs (39% preoperative EIMs versus 26% with no EIMs, p less than 0.001; 53% postoperative EIMs versus 25% with no EIMs, p less than 0.001). Of patients with pouchitis in whom EIMs resolved after IPAA but then recurred (n = 12), EIMs recurred when pouchitis occurred and abated when pouchitis was treated in seven patients. We concluded that pouchitis occurred frequently after IPAA and that patients with EIMs were at higher risk of developing pouchitis than were patients who never had EIMs. Furthermore some patients experienced a temporal relationship between flares of EIMs and pouchitis. These results imply that pouchitis may be a novel manifestation of inflammatory bowel disease persisting after operation.