Risk Factors For Pouch Failure Research Articles

IPAA in Known Preoperative Crohn's Disease: A Systematic Review.

Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure. This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease. A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews. The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected. Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology. The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate. Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified. This investigation was limited by the small number of studies with significant study heterogeneity. In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

Experience, Complications and Prognostic Factors of the Ileoanal Pouch in Ulcerative Colitis: An Observational Study

IntroductionIleoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure. MethodsA retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983 to 2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors. ResultsThe study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouchrelated fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years ( P < .01; HR: 5.55), handsewn anastomosis ( P < .01; HR: 3.78), pouch-vaginal ( P = .02; HR: 2.86), pelvic ( P < .01; HR: 5.17) and cutaneous P = .01; HR: 3.01) fistulae were the main pouch failure risk factors. ConclusionRestorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.

Experiencia, complicaciones y factores pronósticos con el reservorio anal en la colitis ulcerosa. Estudio observacional

IntroductionIleoanal pouch following restorative proctocolectomy is the treatment for ulcerative colitis after failed medical treatment. Our main aim was to evaluate early and late morbidity associated with restorative proctocolectomy. The secondary aim was to assess risk factors for pouch failure. MethodsA retrospective, observational, single-center study was performed. Patients who had undergone restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis from 1983-2015 were included. Early (<30 days) and late (>30 days) adverse events were analyzed. Pouch failure was defined as the need for pouch excision or when ileostomy closure could not be performed. Univariate and multivariate analyses were performed to assess pouch failure risk factors. ResultsThe study included 139 patients. One patient subsequently died in the early postoperative period. Mean follow-up was 23 years. Manual anastomoses were performed in 54 patients (39%). Early adverse events were found in 44 patients (32%), 15 of which (11%) had anastomotic fistula. Late adverse events were found in 90 patients (65%), and pouch-related fistulae (29%) were the most commonly found in this group. Pouch failure was identified in 42 patients (32%). In the multivariate analysis, age >50 years (p<0.01; HR: 5.55), handsewn anastomosis (p<0.01; HR: 3.78), pouch-vaginal (p=0.02; HR: 2.86), pelvic (p<0.01; HR: 5.17) and cutaneous p=0.01; HR: 3.01) fistulae were the main pouch failure risk factors. ConclusionRestorative proctocolectomy for a preoperative diagnosis of ulcerative colitis has high morbidity rates. Long-term outcomes could be improved if risk factors for failure are avoided.

Long-term follow up of ileal pouch anal anastomosis in a large cohort of pediatric and young adult patients with ulcerative colitis

AimThe study's aim is to determine long-term outcomes in a large cohort of pediatric and young adult patients who underwent proctocolectomy with ileal pouch anal anastomsis (IPAA) for ulcerative colitis (UC). MethodsPatients diagnosed with UC in childhood or adolescence (age≤21years) who underwent IPAA in childhood, adolescence, or young adulthood between 1982 and 1997 were contacted to determine pouch history, complications, and quality of life. ResultsData were obtained from 74 patients out of a previously reported cohort. Median age at diagnosis of UC was 15years and at surgery was 18years. Median follow-up was 20years. Complications during follow-up were pouchitis (45%), strictures (16%), fistulae (30%), obstruction (20%), and change of diagnosis to Crohn's (28%). Twenty-three percent reported no complications. Fourteen percent had pouch failure, with Crohn's and fistulae reported to be the most frequent complications. Seventy-nine percent reported being very satisfied at 20years follow-up. ConclusionTo our knowledge, this study represents the largest cohort with the longest follow-up of pediatric and young adult patients undergoing IPAA for UC. Change in diagnosis to Crohn's and development of fistulae are risk factors for pouch failure. Despite reported complications, IPAA remains an excellent option for pediatric patients with UC.

Long-term outcomes and sex differences after restorative proctocolectomy in pediatric patients with ulcerative colitis

BackgroundRestorative proctocolectomy (RPC) for ulcerative colitis (UC) could result in a higher patient quality of life, avoiding frequent disease flares; however, pouch failures and pouch-related complications (PRCs) can develop. PurposeNo cohort studies have examined pouch failure and the differences between adult and pediatric patients or the sex differences in pediatric UC. Therefore, the pouch failure rates were compared between adults and pediatric patients, and pouch failure and PRCs in pediatric UC were evaluated. MethodsUC patients who underwent RPC between January 1987 and June 2014 at Hyogo College of Medicine were included. Patient background characteristics, PRCs, and pouch failure were reviewed. ResultsA total of 1347 adult UC patients and 90 (51 boys, 39 girls) pediatric UC patients were included in the study. The cumulative rate of pouch failure at 10years after RPC was significantly higher in pediatric UC (9.5%) than in adult UC (2.1%; p<0.01). In pediatric UC, the independent risk factors for pouch failure were pouchitis (hazard ratio (HR) 19.3) and anal fistula (HR 5.5). Although a sex difference was not seen in pouch failure, an independent risk factor for PRCs was being a girl (HR 2.5). ConclusionsPouch failure was more common in pediatric than in adult UC. PRCs after RPC were more common in girls in pediatric UC.

Functional and Manometric Outcomes after Redo-Ileal Pouch Anal Anastomosis in Patients with Ulcerative Colitis

Aim: To retrospectively analyze manometric findings in patients with ulcerative colitis who underwent redo-ileo anal anastomosis for pouch-related complications. Methods: Functional and anal manometric parameters were analyzed before, immediately after, and 6 months after the procedure in 17 patients who underwent redo-ileo anal anastomosis between 2001 and 2012. Results: Of the 17 patients, 13 showed stoma closure and 9 have maintained gastrointestinal continuity with functional pouches. Manometric findings were similar before and immediately after redo-ileo anal anastomosis, including length of high-pressure zone (p = 0.11) and maximum resting and (p = 0.060) squeezing (p = 0.69) pressures, but maximum resting pressure improved significantly 6 months later (p = 0.021). Univariate analysis showed that ulcerative colitis duration <3 years before ileo anal anastomosis (p = 0.0073), interval between pouch-related complications and ileo anal anastomosis <2 years (p = 0.040), and persistent abscess before diversion ileostomy (p = 0.0024) were significant risk factors for pouch failure after redo-ileo anal anastomosis. Conclusions: Although maximum resting pressure was significantly reduced 3 months after redo-ileo anal anastomosis, it returned to preoperative levels after 6 months. The length of the high-pressure zone and the maximum squeezing pressure were not affected by this procedure.

Do Clinical Characteristics of de Novo Pouch Crohn’s Disease After Restorative Proctocolectomy Affect Ileal Pouch Retention?

Data on the association between ileal pouch retention and clinical characteristics of pouch Crohn's disease developing after restorative proctocolectomy for ulcerative colitis are still limited. The aim of this study was to identify whether clinical features of pouch Crohn's disease are associated with pouch retention. The study was conducted in a tertiary referral center. All patients diagnosed with clinically active pouch Crohn's disease during follow-up after IPAA for ulcerative colitis or indeterminate colitis were identified from an ileal pouch registry. The definition of early vs late diagnosis was based on the median time interval to diagnosis of Crohn's disease after pouch creation. The associations between pouch retention and the clinical features and treatments of pouch Crohn's disease were analyzed. The long-term pouch retention rate was estimated by using the Kaplan-Meier method. Multivariate logistic regression was used to analyze independent factors for pouch failure. From 1993 to 2009, a total of 65 (28 males) patients developed de novo pouch Crohn's disease during a mean 7.9 years of follow-up after pouch creation. The overall pouch retention rate was 57%. The median time from pouch creation to pouch Crohn's disease diagnosis was 3.6 years. Univariate analysis demonstrated that early diagnosis of pouch Crohn's disease, disease location, and clinical manifestations at the time of diagnosis were associated with pouch outcomes, whereas medical therapy or perianal surgery was not. Multivariate analysis showed that fistula at the time of diagnosis (OR = 17.5, p = 0.002) and early diagnosis (OR = 5.70, p = 0.011) were independent risk factors for pouch failure, whereas afferent limb disease was associated with pouch retention (OR = 0.07, p = 0.018). The retrospective nature of this study and referral bias were limitations. Disease characteristics of de novo pouch Crohn's disease heavily influence pouch retention. The interval from pouch construction, fistulizing disease, and disease location can be used as prognostic indicators when ileal pouch Crohn's disease is diagnosed.

Comparable Pouch Retention Rate Between Pediatric and Adult Patients After Restorative Proctocolectomy and Ileal Pouches

We compared long-term outcomes between adult and pediatric patients with inflammatory bowel disease (IBD) who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. We performed a retrospective study that analyzed data from consecutive patients with ileal pouches who presented to the subspecialty Pouch Center at the Cleveland Clinic from 2002-2011. Pouch outcomes of 104 pediatric patients (having pouch surgery at age <18 years; 53 male) were compared with those of 1135 adults (having pouch surgery at an age 18 years or older; 632 male). Pediatric patients had a shorter duration from time of IBD diagnosis to colectomy than adult patients. Fewer pediatric than adult patients had a history of smoking, concomitant extraintestinal manifestations, or dysplasia as the indication for colectomy. However, pediatric patients had higher rates of pouch procedure-related complications, postoperative pouch-associated hospitalization, and postoperative use of anti-tumor necrosis factor (TNF) agents. In multivariate analysis, risk factors for pouch failure included preoperative use of anti-TNF agents (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.05-3.13; P = .032), postoperative use of anti-TNF agents (HR, 2.07; 95% CI, 1.31-3.27; P = .002), Crohn's disease of the pouch (HR, 2.21; 95% CI, 1.28-3.82; P = .005), pouch procedure-related complications (HR, 2.68; 95% CI, 1.55-4.64; P < .001), and postoperative pouch-associated hospitalization (HR, 25.20; 95% CI, 14.44-43.97; P < .001). Being a pediatric patient was not significantly associated with pouch failure in univariate or multivariate analyses (HR, 0.6; 95% CI, 0.32-1.16; P = .13). On the basis of an analysis of patients with IBD who underwent restorative proctocolectomy and presented at a subspecialized Pouch Center, patients who had the surgery at a pediatric age tend to have a higher incidence of postoperative pouch complications than adults. However, long-term rates of pouch retention were comparable.

Pediatric and Adult Patients Had a Similar Pouch Survival Rate after Restorative Proctocolectomy

There were limited data in the literature on the long-term pouch outcomes in children who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The aim of this study was to compare long-term pouch outcomes in pediatric and adult patients. Consecutive inflammatory bowel disease (IBD) patients with ileal pouches seen in our Pouchitis Clinic from 2002-2012 were studied. The pouch outcome in pediatric patients was evaluated in comparison with adults by both univariate and multivariate analyses. All eligible patients were included into the study (N = 1,289), of whom 108 (8.4%) were pediatric patients (<18 years). Male accounted for 50.9% of pediatric patients and 55.5% of adults. Pediatric patients had a younger age at the time of IBD diagnosis and pouch construction and a shorter duration from IBD diagnosis to colectomy. Fewer pediatric patients had a history of smoking (9.3% vs. 20.7%, P = 0.004), concomitant extra-intestinal manifestations (21.5% vs. 39.1%, P<0.001), and dysplasia as the indication for colectomy (0.9% vs. 13.6%, P<0.001) than the adults. On the other hand, pediatric patients had higher rates of pouch surgery-associated complications (21.3% vs. 13.9%, P = 0.036), postoperative pouch-associated hospitalization (25.9% vs. 13.4%, P<0.001) and postoperative use of anti-TNF biologics (16.7% vs. 7.9%, P = 0.002) than the adults. Pouch failed in 100 patients (7.8%) after a mean follow-up of 10.6±6.8 years, including 13 (12.0%) in the pediatric group and 87 (7.4%) in the adult group (P = 0.082). Risk factors for pouch failure in the multivariate analysis included preoperative use of anti-TNF biologics, postoperative use of anti-TNF biologics, Crohn's disease of pouch, pouch surgery-related complications and postoperative pouch-associated hospitalization. However, pediatric patients were not found to be significantly associated with pouch failure in neither the univariate nor multivariate analyses, with a hazard ratio of 0.67 (95% confidence interval: 0.36-1.24, P = 0.2) from the multivariate analysis. Pediatric patients suffered from a higher incidence of postoperative pouch complications than adults; however the long-term pouch retention rates were comparable.

Pediatric and Adult Patients Had a Similar Pouch Survival Rate After Restorative Proctocolectomy

There were limited data in the literature on the long-term pouch outcomes in children who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The aim of this study was to compare long-term pouch outcomes in pediatric and adult patients. Consecutive inflammatory bowel disease (IBD) patients with ileal pouches seen in our Pouchitis Clinic from 2002-2012 were studied. The pouch outcome in pediatric patients was evaluated in comparison with adults by both univariate and multivariate analyses. All eligible patients were included into the study (N = 1,289), of whom 108 (8.4%) were pediatric patients (<18 years). Male accounted for 50.9% of pediatric patients and 55.5% of adults. Pediatric patients had a younger age at the time of IBD diagnosis and pouch construction and a shorter duration from IBD diagnosis to colectomy. Fewer pediatric patients had a history of smoking (9.3% vs. 20.7%, P = 0.004), concomitant extra-intestinal manifestations (21.5% vs. 39.1%, P < 0.001), and dysplasia as the indication for colectomy (0.9% vs. 13.6%, P < 0.001) than the adults. On the other hand, pediatric patients had higher rates of pouch surgery-associated complications (21.3% vs. 13.9%, P = 0.036), postoperative pouch-associated hospitalization (25.9% vs. 13.4%, P < 0.001) and postoperative use of anti-TNF biologics (16.7% vs. 7.9%, P = 0.002) than the adults. Pouch failed in 100 patients (7.8%) after a mean follow-up of 10.6±6.8 years, including 13(12.0%) in the pediatric group and 87 (7.4%) in the adult group (P = 0.082). Risk factors for pouch failure in the multivariate analysis included preoperative use of anti-TNF biologics, postoperative use of anti-TNF biologics, Crohn's disease of pouch, pouch surgery-related complications and postoperative pouch-associated hospitalization. However, pediatric patients were not found to be significantly associated with pouch failure in neither the univariate nor multivariate analyses, with a hazard ratio of 0.67 (95% confidence interval: 0.36-1.24, P = 0.2) from the multivariate analysis. Pediatric patients suffered from a higher incidence of postoperative pouch complications than adults; however the long-term pouch retention rates were comparable.

Prognostic Modeling of Preoperative Risk Factors of Pouch Failure

The prospect of pouch failure needs to be considered when evaluating the management strategy for patients who may be candidates for an ileo anal pouch. An ability to predict the likelihood and timing of failure preoperatively may influence surgical decision making. The aim of this study was to define a preoperative prognostic model for ileoanal pouch failure. A novel random forest methodology was used to evaluate the prognostic significance of 21 preoperative potential risk factors for pouch failure. A forest of 3000 random survival trees was grown to estimate pouch failure for each patient and to identify important risk factors that maximize survival prediction. This study took place at a tertiary referral department at a major academic medical center. Patients undergoing an ileoanal pouch at this institution between 1983 and 2008 were included. The primary outcome measured was pouch survival. Between 1983 and 2008, 3754 patients underwent ileoanal pouch. Type of resection (total proctocolectomy vs completion proctectomy), type of anastomosis (stapled vs mucosectomy), patient diagnosis (mucosal ulcerative colitis and others vs Crohn's disease) and diagnosis of diabetes had the strongest effect on pouch survival. Predicted survival was worse for completion proctectomy (HR, 1.44; 95% CI, 1.08-1.93), Crohn's disease (HR, 2.37; 95% CI, 1.48-3.79), handsewn anastomosis (HR, 1.72; 95% CI, 1.23-2.42), and diabetes (HR, 2.31; 95% CI, 1.25-4.24). Pouch survival was worse for the oldest group of patients. This study was limited by its retrospective nature. Random forest techniques applied to a large number of patients undergoing the ileoanal pouch identify factors associated with pouch failure. Attention directed at these factors may improve outcomes for these patients.

Efficacy and safety of endoscopic treatment of ileal pouch strictures

Endoscopic management of ileal pouch strictures has not been systemically studied. The aim was to evaluate endoscopic balloon therapy of pouch strictures in inflammatory bowel disease (IBD) patients with ileal pouches and to identify risk factors for pouch failure for those patients. Consecutive IBD patients with pouches from the Pouchitis Clinic who underwent nonfluoroscopy-guided outpatient endoscopic therapy were studied. The location, number, degree (range 0-3), and length of strictures and balloon size were documented. Efficacy and safety were evaluated with univariate and multivariate analyses. A total of 150 patients with pouch strictures were studied. Stricture locations were at the pouch inlet (n = 96), outlet (n = 73), afferent limb (n = 33), and pouch body (n = 2). A cumulative of 646 strictures were endoscopically dilated, with a total of 406 pouchoscopies. The median stricture score was 1 (interquartile range [IQR] 1-2); the median stricture length was 1 (IQR 0.5-1.25) cm, and the median balloon size was 20 (IQR 18-20) mm. Of 406 therapeutic endoscopies performed, there were two perforations (0.46%) and four transfusion-required bleeding (0.98%). The 5-, 10-, and 25-year pouch retention rates were 97%, 90.6%, and 85.9%, respectively. In a median follow-up of 9.6 (IQR 6-17) years, 131 patients (87.3%) were able to retain their pouches. The number of strictures and underlying diagnosis were independent risk factors for pouch failure in the Cox regression model. Endoscopic treatment of pouch stricture appears to be efficacious and generally safe to perform in experienced hands. Underlying diagnosis of Crohn's disease of the pouch and surgery-related strictures and multiple strictures were the risk factors for pouch failure.

Risk factors for pouch failure in patients with different phenotypes of Crohnʼs disease of the pouch

Crohn's disease (CD) of the pouch is one of the leading causes of pouch failure in patients with restorative proctocolectomy. Risk factors for pouch failure in these patients are yet to be identified. The aim of the study was to assess risk factors associated with pouch failure in patients with CD of the pouch. All patients with a confirmed diagnosis of CD of the pouch in the Pouchitis Clinic between 2002 and 2007 were evaluated. Patients with familial adenomatous polyposis, normal pouches, pouchitis, cuffitis, surgical complications, and other diseased pouch conditions were excluded. Pouch failure was defined as the requirement for a permanent diversion or pouch resection. Demographic and clinical factors were studied with univariable and multivariable analyses. A total of 137 patients with CD of the pouch were included. Twenty-two patients (16%) developed pouch failure a median of 6 years after ileostomy takedown. Four of 50 patients (8.0%) with inflammatory CD, 4 of 30 (13.3%) with fibrostenotic CD, and 14 of 57 (24.6%) with fistulizing CD had pouch failure. A Kaplan-Meier plot for time to pouch failure by CD phenotype showed a trend toward association (P = 0.054) in patients with fistulizing CD. Adjusting for age, smoking status, and the use of immunomodulators or biologics, fistulizing CD was not found to be significantly associated with a higher hazard for pouch failure. Younger age, being an ex-smoker, and the use of immunomodulators or biologics were found to increase the hazard of pouch failure. Younger age, being an ex-smoker, and the requirement for immunomodulators or biologics were associated with pouch failure. The identification of these risk factors may help delineate the natural history of CD of the pouch and shed light on proper clinical management and prognosis.

ILEAL POUCH-ANAL ANASTOMOSIS IN CHILDREN WITH ULCERATIVE COLITIS: LONG-TERM FOLLOW-UP

37 The study is a retrospective review of all patients less than 22 years of age with Ulcerative Colitis (UC) who had colectomy and ileal pouch-anal anastomosis (IPAA) between 1982-1996. The purpose of the review was to evaluate the long-term outcome of IPAA in children with UC. Demographic, preoperative and surgical data were abstracted from the medical records and quality of life information was obtained from patient interviews. 176 children and adolescents were identified during the study period with a median age of 15 years. Follow-up data was available in 158 patients. The principal indication for surgery was intractable symptoms despite vigorous medical therapy. Median follow-up was 7 years. Small bowel obstruction was the most common early complication occurred in 20 patients (12.8%); 65% of them required surgical intervention. Late complications included pouchitis in 95 (60%) patients and pelvic infection in 40 (25%). The cumulative risk for pouchitis was up to 60% at 7 years compared to 15% at 2 years in our initial survey. Twenty-three patients had chronic pouchitis (14.5%); 6 patients had their pouch removed. The long-term surgical failure rate was 9.4% occurred in 15 patients. They had end-ileostomy with excision or permanent bypass of the pouch. Eleven patients were diagnosed as Crohn's disease on the basis of further small bowel disease or recurrent fistula who had functioning pouch but on immunosuppressive therapy. 77% of patients were "very satisfied" with their surgical outcome compared to 92% in our initial survey. In conclusion, IPAA is still an effective surgical procedure for patients with UC who are unresponsive to conventional medical therapy. There is an increased risk of pouchitis, surgical failure and more frequent diagnosis of Crohn's disease with longer follow-up. Chronic pouchitis and recurrent pelvic infection were risk factors for pouch failure. These issues should be clearly discussed with patients preoperatively before considering pelvic pouch surgery.