Topic: C. Clinical GI
Long-term Outcomes with Ileal Pouch-Anal Anastomosis and Crohn’s Disease: Pouch Retention, Implications of Delayed Diagnosis, and Use in Highly Selected Patients
Genevieve B Melton1, Victor W Fazio1, Ravi P Kiran1, Jin He1, Ian C Lavery1, Bo Shen2, Jean- Paul Achkar2, Feza H Remzi1
1Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH;2Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, OH
OBJECTIVE(S): While considered the procedure of choice in ulcerative colitis, ileal pouch-anal anastomosis (IPAA) is controversial in Crohn’s disease (CD). There is little data on long-term outcomes following IPAA in CD.
METHODS: Data for CD patients were assessed from a prospectively maintained IPAA database. Time to diagnosis and pouch retention were analyzed using Kaplan-Meier curves. Clinicopathologic factors associated with pouch retention were evaluated with log-rank test and Cox proportional hazards model.
RESULTS: Two-hundred and four CD patients (108 female, median age 33 years) with primary IPAA had median follow-up 89(range 4-278) months. CD diagnosis was ‘early’ (before IPAA (n=20,10%) or immediately after IPAA from operative histopathology (n=97,48%)), or ‘delayed’ at median 36 (range 3-233) months after IPAA (from histopathology (n=32,16%) or clinical evaluation (n=55,27%)). Overall 10-year retention rate was 71%(early diagnosis 87%, delayed diagnosis 53%). Absolute pouch loss was worse with delayed diagnosis (49% vs.15%,p<0.0001). On multivariate analysis, pouch loss was associated with delayed diagnosis (p=0.03), pouch-vaginal fistula (p=0.01), and pelvic sepsis (p=0.0001) but not smoking, preoperative pathology, postoperative Infliximab or steroids, or extra-intestinal manifestations. Patients with retained IPAA at follow-up had near-perfect/perfect continence (72%), rare/no urgency (68%) with median daily bowel movements 7 (range 2-20). Median quality of life, health, energy, and happiness were 9, 9, 8, and 10 of 10 respectively.
CONCLUSIONS: Carefully selected patients with Crohn’s disease undergoing IPAA have low pouch loss and favorable functional results. Outcomes in patients with delayed diagnosis are worse but most retain their pouch at ten years with good functional outcome.