Surgical Outcome of Ileal Pouch—Anal Anastomosis When Used Intentionally for Well-Defined Crohnʼs Disease

Abstract

Background Crohn’s disease (CD) is considered a contraindication to ileal pouch—anal anastomosis (IPAA). In this study, we compare outcomes of CD and ulcerative colitis (UC) patients undergoing IPAA. Methods Patients were considered to have CD before surgery based on a history of small bowel disease, perianal disease, noncrypt-associated granuloma, or pretreatment skip colonic lesions. Patients were prospectively assessed for pouchitis or CD. Postoperative CD (pouch inflammation into the afferent limb or pouch fistula) or pouch failure (need for permanent diversion) were assessed. Preoperative serum was assayed for IBD-associated antibodies using enzyme-linked immunosorbent assay (ELISA). Results Seventeen patients with preoperative CD were identified. Seven (41%) patients developed postoperative recurrent CD in the afferent limb (n = 3) or pouch fistulizing disease (n = 4). One patient (6%) required pouch excision. The incidence of postoperative CD was higher (P = 0.002) in preoperative CD patients (41%) than UC patients (11%). There was no significant difference in pouchitis or pouch failure. There was also no significant difference in any preoperative clinical feature between patients with or without postoperative CD. Afferent limb inflammation developed in three (50%) of the six patients with pANCA+/OmpC− expression compared to none of the 11 patients without this serologic profile (P = 0.03). Conclusions Although the intentional use of IPAA in CD has a higher incidence of postoperative disease vs. UC patients, there was no significant difference in pouch failure. Demographics, clinical features, and serologic factors do not predict outcome of CD patients undergoing IPAA. IBD serology may identify the phenotype manifestation of postoperative recurrent CD.

The surgical treatment of inflammatory bowel disease-associated dysplasia

“…Although recent studies have shown no difference in pouch failure between CD and UC patients, this study was conducted on CD patients who had a preoperative diagnosis of UC and then received the CD diagnosis postoperatively after developing signs of CD, such as anal or pouch fistuli. Such patients are probably very different than those who are known preoperatively to have CD, and who have a significant IPAA failure rate overall [56].…”

Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn’s Colitis

“…Crohn's colitis was defined by patients who had idiopathic, chronic inflammation limited to the colon, with at least two of the following: non-crypt-associated granulomas, noncontinuous areas of inflammation (''skip lesions'') in the colon, and clinical history consistent with CD [10]. Medically refractory disease was defined as ongoing evidence of clinically and histologically active colitis after optimization or intolerance to medical therapy.…”

“…[9] Probability of long-term remission off meds 0.779 0.65-0.95 Ref. [10], expert opinion Probability of short-term remission, then recurrent CD requiring dual therapy 0.04 0.01-0.12 Expert opinion…”

“…[9,10] Probability of short-term CD remission followed by death 0.001 0-0.002 Ref. [9] Probability of short-term CD remission followed by recurrent medically refractory CD requiring pouch resection 0.03 0-0.10 Ref.…”

“…Meanwhile, long-term surgical outcomes in patients with indeterminate colitis undergoing colectomy with IPAA are similar to patients with ulcerative colitis (UC) [9]. Additionally, in carefully selected patients with Crohn's colitis without small bowel or perianal disease, IPAA has been shown to produce good outcomes and similar complication rates compared to colectomy with permanent EI in large, high-volume, single-center studies [10,11]. Still, guidelines for the surgical management of colonic CD recommend colectomy with EI and hesitate to endorse IPAA due to overall increased rates of pouch failure in patients with Crohn's disease [12][13][14].…”