Inflammation of the rectal remnant endangers the outcome of ileal pouch-anal anastomosis: a case–control study

Abstract

Background Inflammation of the rectal remnant may affect the postoperative outcome of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). We aimed to determine the extent of inflammation in the anastomotic area during IPAA and to investigate the impact of proctitis on postoperative complications and long-term outcomes. Methods Three hundred thirty-four UC patients with primary IPAA were included in this retrospective case–control study. The histopathologic degree of inflammation in the anastomotic area was graded into three stages of no proctitis (“NOP”), mild to medium proctitis (“MIP”), and severe proctitis (“SEP”). Preoperative risk factors, 30-day morbidity, and follow-up data were assessed. Kaplan–Meier analysis was performed in the event of pouch failure. Results The prevalence of proctitis was high (MIP 40.4%, and SEP 42.8%). During follow-up, the incidence of complications was highest among SEP: resulting in re-intervention (n = 40; 28.2%, p = 0.017), pouchitis (n = 36; 25.2%, p < 0.01), and pouch failure (n = 32; 22.4%, p = 0.032). The time interval to pouch failure was 5.0 (4.0–6.9) years among NOP, and 1.2 (0.5–2.3) years in SEP (p = 0.036). ASA 3, pouchitis, and pouch fistula were independent risk factors for pouch failure. Conclusion Proctitis at the time of IPAA is common. A high degree of inflammation is associated with poor long-term outcomes, an effect that declines over time. In addition, a higher degree of proctitis leads to earlier pouch failure.

Review of long‐term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease

“…Of the included 49 studies, all but six were single centre retrospective studies. Other studies included were multicentre retrospective, 10,11 multicentre cross‐sectional, 7,12 multicentre case–control, 13 single centre case–control 14 and single centre cross‐sectional 15 . Sample sizes of included studies range from 31 to 3672 (median = 282) across 13 countries with a mean follow‐up time of 8.6 years.…”

“…Surgical complications (pelvic sepsis 4,14,25 and anastomotic leak 17,30,34 ) are most frequently associated with increased pouch failure rates. Thus, IAPP should be performed in high-volume tertiary centres with specialized pouch surgeons to prevent surgical complications and their sequela.…”

“…Reported pouch failure incidence ranged from 1.6% to 18.9% (median 6.9%, IQR: 4.8-10.8%) with a mean follow-up time of 9.9 years. 4,6,7,11,14,16,17,22,24,[26][27][28][29][30][31][32][33][34][35]…”

Impact of the body mass index on the retention of the anorectal mucosa after double-stapled ileal pouch-anal anastomosis for ulcerative colitis

“…In the present study, the high anastomosis group had a mean anterior wall of 3.5 cm and posterior wall of 2.1 cm, while the low anastomosis group had an anterior wall of 1.7 cm and posterior wall of 0.9 cm, suggesting that the difference in mucosal length between the two groups was not that great. Alternatively, the fact that inflammation of the cuff was seen in 28% of cases even in the low anastomosis group may indicate that, within a certain range of retained mucosal length, the severity of inflammation of the cuff is determined by the disease activity in individual cases, not by the mucosal length [ 20 ]. There is no doubt that the risk of tumor development increases with a longer retained mucosa.…”

Ileo-Anal Pouch Anastomosis and New Remedial Approaches for Ulcerative Colitis: A Review Article

“…Poor long-term outcomes are linked to high levels of inflammation; however, this effect fades over time. Additionally, a higher proctitis level causes pouch failure to occur earlier [ 24 ].…”