Endoscopic Phenotype of the J Pouch in Patients With Inflammatory Bowel Disease: A New Classification for Pouch Outcomes.

BACKGROUND & AIMS: Pouchitis is a common complication of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis who have undergone colectomy. Pouchitis has been considered a single entity despite a broad array of clinical and endoscopic patterns. We developed a novel classification system based on the pattern of inflammation observed in pouches and evaluated the contributing factors and prognosis of each phenotype. METHODS: We identified 426 patients (384 with ulcerative colitis) treated with proctocolectomy and IPAA who subsequently underwent pouchoscopies at the University of Chicago between June 1997 and December 2019. We retrospectively reviewed 1359 pouchoscopies and classified them into 7 main pouch phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted 6 months after ileostomy takedown. Logistic regression analysis was used to assess factors contributing to each phenotype. Pouch survival was estimated by the log-rank test and the Cox proportional hazards model. RESULTS: Significant contributing factors for afferent limb involvement were a body mass index of 25 or higher and hand-sewn anastomosis, for inlet involvement the significant contributing factor was male sex; for diffuse inflammation the significant contributing factors were extensive colitis and preoperative use of anti-tumor necrosis factor drugs, for cuffitis the significant contributing factors were stapled anastomosis and preoperative Clostridioides difficile infection. Inlet stenosis, diffuse inflammation, and cuffitis significantly increased the risk of pouch excision. Diffuse inflammation was associated independently with pouch excision (hazard ratio, 2.69; 95% CI, 1.34-5.41; P = .005). CONCLUSIONS: We describe 7 unique IPAA phenotypes with different contributing factors and outcomes, and propose a new classification system for pouch management and future interventional studies.

Histopathology of Colectomy Specimens Predicts Endoscopic Pouch Phenotype in Patients with Ulcerative Colitis.

BACKGROUND: The endoscopic appearance in patients with "pouchitis" after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be quite heterogenous. Patients with an endoscopic phenotype resembling Crohn's disease (CD) are at high risk of pouch loss. AIMS: We aimed to assess how the histopathology of colectomy specimens predicts endoscopic pouch phenotypes in UC. METHODS: We retrospectively assessed pouchoscopies from patients with UC who underwent IPAA and classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted ≥ 6 months from ileostomy takedown. We assessed the clinical and pathological data including deep, focal inflammation, granulomas, and terminal ileal involvement in the colectomy specimens. Logistic regression analysis was performed to identify contributing factors to each phenotype. RESULTS: This study included 1,203 pouchoscopies from 382 patients with UC. On multivariable analysis, deep inflammation was significantly associated with pouch fistulas (Odds ratio 3.27; 95% confidence interval 1.65-6.47; P = 0.0007). Of the 75 patients with deep inflammation, only two patients (2.7%) were diagnosed with CD based on pathology review. Terminal ileal involvement significantly increased the risk of afferent limb involvement (Odds ratio 2.96; 95% confidence interval 1.04-8.47; P = 0.04). There were no significant associations between other microscopic features and phenotypes. CONCLUSIONS: We identify histologic features of colectomy specimens in UC that predict subsequent pouch phenotypes. Particularly, deep inflammation in the resected colon was significantly associated with pouch fistulas, a pouch phenotype with poor prognosis.

Abnormal Pouchogram Predicts Pouch Failure Even in Asymptomatic Patients.

BACKGROUND: Anastomotic complications after restorative total proctocolectomy with IPAA for ulcerative colitis alter functional outcomes and quality of life and may lead to pouch failure. Routine contrast enema of the pouch assesses anastomotic integrity before ileostomy reversal, but its clinical use is challenged. OBJECTIVE: The purpose of this research was to assess the relationship among preoperative clinical characteristics, abnormal pouchography, and long-term pouch complications. DESIGN: This was a retrospective chart review. SETTINGS: The study was conducted at a tertiary care center between 2000 and 2010. PATIENTS: Ulcerative colitis patients with IPAA undergoing pouchography before ileostomy closure were included. MAIN OUTCOME MEASURES: Patient demographics, incidence of pouch-related complications, and findings on pouchogram were recorded. Primary outcome was pouch failure, defined as excision or permanent diversion of the ileoanal pouch. Independent predictors of pouch failure were determined by multivariate regression. RESULTS: A total of 262 patients with ulcerative colitis were included. Contrast extravasation was seen in 27 patients (10.3%): 14 (51.9%) were clinically asymptomatic at the time of pouchogram. Six (22.2%) of 27 patients with extravasation developed pouch failure despite normalization of the pouchogram before ileostomy closure. Forty patients (15.3%) were found to have pouch-anal anastomotic stenosis; only 1 developed pouch failure. Pre-IPAA serum albumin and hemoglobin levels were inversely associated with contrast extravasation (serum albumin: OR = 0.42; hemoglobin: OR = 0.77; p < 0.05). Contrast extravasation was associated with delayed takedown operation (average = 67 d), increased risk (OR = 5.25; p < 0.01), and shorter time (median = 32.0 vs 72.5 mo; HR = 5.88; p < 0.05) to pouch failure, as well as increased risk of pouch-related complications (p < 0.05). LIMITATIONS: The study was limited by its retrospective nature and small number of patients who developed pouch failure. CONCLUSIONS: Pouchography before ileostomy takedown is useful in identifying patients with ulcerative colitis at risk for postoperative complications. Radiologic resolution of IPAA-related leak does not reliably predict healing; caution is warranted in this subgroup. See Video Abstract at http://links.lww.com/DCR/A818.

A Comparative Analysis of Clinical Symptoms and Modified Pouchitis Disease Activity Index Among Endoscopic Phenotypes of the J Pouch in Patients With Inflammatory Bowel Disease.

Background: The modified pouchitis disease activity index (mPDAI) based on clinical symptoms and endoscopic findings is used to diagnose pouchitis, but validated instruments to monitor pouchitis are still lacking. We recently established an endoscopic classification that described 7 endoscopic phenotypes with different outcomes. We assessed symptoms and compared mPDAIs among phenotypes in inflammatory bowel disease (IBD). Methods: We retrospectively reviewed pouchoscopies and classified them into 7 main phenotypes: normal (n = 25), afferent limb (AL) involvement (n = 4), inlet involvement (n = 14), diffuse (n = 7), focal inflammation of the pouch body (n = 25), cuffitis (n = 18), and pouch-related fistulas (n = 10) with a single phenotype were included. Complete-case analysis was conducted. Results: One hundred and three IBD patients were included. The median mPDAI was 0 (IQR 0-1.0) in patients with a normal pouch. Among inflammatory phenotypes, the highest median mPDAI was 4.0 (IQR 2.25-4.75) in cuffitis, followed by 3.0 (IQR 2.5-4.0) in diffuse inflammation, 2.5 (IQR 1.25-4.0) in inlet involvement, 2.5 (IQR 2.0-3.5) in AL involvement, 2.0 (IQR 1.0-3.0) in focal inflammation, and 1.0 (IQR 0.25-2.0) in the fistula phenotype. Perianal symptoms were frequently observed in pouch-related fistulas (8/10, 80%) and cuffitis (13/15, 87%). Among patients with cuffitis, all had incomplete emptying (6/6, 100%). Conclusions: We correlated the mPDAI with the endoscopic phenotypes and described the limited utility of symptoms in distinguishing between inflammatory phenotypes. Further studies are warranted to understand which symptoms should be monitored for each phenotype and whether mPDAI can be minimized after pouch normalization.

Endoscopic Normalization and Transition of J-Pouch Phenotypes Over Time in Patients With Inflammatory Bowel Disease.

BACKGROUND: Patients with inflammatory bowel disease (IBD) who undergo proctocolectomy with ileal pouch-anal anastomosis may develop pouchitis. We previously proposed a novel endoscopic classification of pouchitis describing 7 phenotypes with differing outcomes. This study assessed phenotype transitions over time. METHODS: We classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb (AL) involvement, (3) inlet (IL) involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch-related fistulas noted more than 6 months after ileostomy takedown. Among 2 endoscopic phenotypes, the phenotype that was first identified was defined as the primary phenotype, and the phenotype observed later was defined as the subsequent phenotype. RESULTS: We retrospectively reviewed 1359 pouchoscopies from 426 patients (90% preoperative diagnosis of ulcerative colitis). The frequency of primary phenotype was 31% for AL involvement, 42% for IL involvement, 28% for diffuse inflammation, 72% for focal inflammation, 45% for cuffitis, 18% for pouch-related fistulas, and 28% for normal pouch. The most common subsequent phenotype was focal inflammation (64.8%), followed by IL involvement (38.6%), cuffitis (37.8%), AL involvement (25.6%), diffuse inflammation (23.8%), normal pouch (22.8%), and pouch-related fistulas (11.9%). Subsequent diffuse inflammation, pouch-related fistulas, and AL or IL stenoses significantly increased the pouch excision risk. Patients who achieved subsequent normal pouch were less likely to have pouch excision than those who did not (8.1% vs 15.7%; P = .15). CONCLUSIONS: Pouch phenotype and the risk of pouch loss can change over time. In patients with pouch inflammation, subsequent pouch normalization is feasible and associated with favorable outcome.

Endoscopic pouch phenotypes can change over time and subsequent development of diffuse inflammation, pouch-related fistulas, and afferent limb/inlet stenoses significantly worsen pouch outcomes. In patients with pouch inflammation, subsequent pouch normalization is feasible and associated with favorable outcomes.

Preoperative infliximab therapy does not increase morbidity and mortality after laparoscopic resection for inflammatory bowel disease.

BACKGROUND: The impact of infliximab on the postoperative course of patients with IBD is under debate. OBJECTIVE: The aim of this study was to evaluate the influence of infliximab on perioperative outcomes in patients undergoing elective laparoscopic resection for IBD. DESIGN: This study is a retrospective analysis of a prospectively collected, institutional review board-approved database. SETTING, PATIENTS, INTERVENTIONS: Patients undergoing laparoscopic resection on preoperative infliximab (infliximab group) were compared with patients who did not receive infliximab (noninfliximab group). MAIN OUTCOME MEASURES: The short-term and long-term morbidity and mortality rates were assessed. RESULTS: Elective laparoscopic resection for IBD was performed on 518 patients from January 2004 through June 2011; 142 patients were treated with infliximab preoperatively. Both groups had similar demographics, type and severity of IBD, comorbidities, and type of surgery. A significantly higher number of patients in the infliximab group had been on aggressive medical therapy to control symptoms of IBD during the month preceding surgery, including steroids (73.9 vs 58.8%, p = 0.002) and immunosuppressors (32.4 vs 20.5%, p = 0.006). Operative time and blood loss were similar (p = 0.50 and p = 0.34). Intraoperative complication rate was 2.1% in both groups. No significant differences were observed in terms of the conversion rate to laparotomy (6.3% vs 9.3%, p = 0.36), overall 30-day postoperative morbidity (p = 0.93), or mortality (p = 0.61). The rates of anastomotic leak (2.1% vs 1.3%, p = 0.81), infections (12% vs 11.2%, p = 0.92), and thrombotic complications (3.5% vs 5.6%, p = 0.46) were similar. Subgroup analyses confirmed similar rates of overall, infectious, and thrombotic complications regardless of whether patients had ulcerative colitis or Crohn's disease. LIMITATIONS: This study is subject to the limitations of a retrospective design. CONCLUSIONS: Infliximab is not associated with increased rates of postoperative complications after laparoscopic resection.

Outcomes of Ileoanal Pouch Anastomosis in Pediatric Ulcerative Colitis Are Worse in the Modern Era: A Time Trend Analysis Outcomes Following Ileal Pouch-Anal Anastomosis in Pediatric Ulcerative Colitis.

BACKGROUND: Despite significant differences in surgical outcomes between pediatric and adult patients with ulcerative colitis (UC) undergoing colectomy, counseling on pediatric outcomes has largely been guided by data from adults. We compared differences in pouch survival between pediatric and adult patients who underwent total proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: This was a retrospective single-center study of patients with UC treated with IPAA who subsequently underwent pouchoscopy between 1980 and 2019. Data were collected via electronic medical records. We stratified the study population based on age at IPAA. Differences between groups were assessed using t tests and chi-square tests. Kaplan-Meier curves were used to compare survival probabilities. Differences between groups were assessed using a log-rank test. RESULTS: We identified 53 patients with UC who underwent IPAA before 19 years of age and 329 patients with UC who underwent IPAA at or after 19 years of age. Subjects who underwent IPAA as children were more likely to require anti-tumor nerosis factor (TNF) postcolectomy compared with adults (41.5% vs 25.8%; P < .05). Kaplan-Meier estimates revealed that pediatric patients who underwent IPAA in the last 10 years had a 5-year pouch survival probability that was 28% lower than that of those who underwent surgery in the 1990s or 2000s (72% vs 100%; P < .001). Further, children who underwent IPAA and received anti-TNF therapies precolectomy had the most rapid progression to pouch failure when compared with anti-TNF-naive children and with adults who were either exposed or naive precolectomy (P < .05). CONCLUSIONS: There are lower rates of pouch survival for children with UC who underwent IPAA following the uptake of anti-TNF therapy compared with both historical pediatric control subjects and contemporary adults.

Ileal pouch­anal anastomosis is the most common surgical approach for patients with ulcerative colitis undergoing total proctocolectomy. Outcomes are informed by heterogeneous adult data cohorts often predating anti-tumor necrosis factor uptake. We find that for children in the modern era pouch loss occurs at higher rates.

Minimally invasive pouch surgery for ulcerative colitis: is there a benefit in staging?

BACKGROUND: With the introduction of biologic agents, medical and surgical management of ulcerative colitis has been associated with significant morbidity. A staged surgical approach is advocated to obviate the risks of infectious complication and consequent poor pouch function. OBJECTIVE: The aim of this study was to analyze the outcomes of our selective staged approaches in patients with ulcerative colitis who were undergoing laparoscopic pouch surgery. DESIGN: Consecutive patients with ulcerative colitis referred for laparoscopic surgical treatment between 2002 and 2008 were included in the study. Data were prospectively collected. Patients were divided into 2 groups: a 3-stage group, initial laparoscopic abdominal colectomy followed by pouch surgery with a diverting loop ileostomy, and a 2-stage group, laparoscopic pouch surgery with a diverting loop ileostomy at the initial operation. RESULTS: Of the 118 patients eligible for the study, 68 were in the 2-stage group and 50 were in the 3-stage group. Patients were more likely to have been receiving aggressive medical therapy in the 3-stage group than in the 2-stage group: 43% vs 16% (P = .01) receiving anti-tumor necrosis factor therapy and 96% vs 67% (P = .04) receiving systemic corticosteroids. Although overall complication rates were similar between groups (P = .4), infectious complications were higher in the 2-stage group (38.2% vs 21%, P < .05). CONCLUSIONS: In our practice, we have selectively applied a 3-stage laparoscopic surgical approach to restorative proctocolectomy in patients with ulcerative colitis who are receiving aggressive medical therapy in an attempt to minimize perioperative complications. This strategy appears efficacious, and short-term outcomes compare favorably with those following a 2-stage approach.

Laparoscopy or conventional open surgery for patients with ileocolonic Crohn's disease? A prospective study.

BACKGROUND: Crohn's patients have been considered challenging laparoscopic candidates. The aim of this study was to analyze the short-term and long-term outcomes of laparoscopic and open surgery in consecutive patients with ileocolonic Crohn's disease. METHODS: Patients were enrolled prospectively but not randomized between August 2002 and October 2006. Patients and disease-specific characteristics, intraoperative variables, and short-term and long-term postoperative outcomes were analyzed. RESULTS: Overall, 146 consecutive patients were included in the study: 59 in the laparoscopic operation group and 87 in the open operation group. Laparoscopic patients were younger (P = .001), with a lower body mass index (BMI) (P = .008). Operative time was similar between the 2 groups. Blood loss was less in the laparoscopic group (P = .012), and postoperative blood transfusions were administered only to patients in the open group. Narcotic requirement, which was expressed as days on the IV narcotics and as morphine equivalent, was less in the laparoscopic group (P = .01). Duration of stay was less in the laparoscopic group, 5.5 versus 7.0 days, (P = .001). Using step-wise multiple regression analysis, the use of laparoscopic operation was associated with a lesser hospital stay (P < .05). Complication rates were similar, which included 1 anastomotic leak that required reoperation in each group. At a median follow-up of 19 months, there have been no disease recurrences. CONCLUSIONS: In selected patients, laparoscopy leads to a faster recovery without increasing morbidity and without compromising remission. It should be considered a safe and effective alternative to open operation.

Preservation of the anal transition zone in ulcerative colitis. Long-term effects on defecatory function.

INTRODUCTION: The anal transition zone (ATZ) after ileal pouch anal anastomosis (IPAA) for ulcerative colitis is considered at risk for dysplasia and persistent or recurrent disease activity. The long-term fate of the ATZ and the effects of histologic changes on defecatory function are not well-known. METHODS: To evaluate the inflammatory and preneoplastic changes of the ATZ in patients without preoperative dysplasia, yearly biopsies of the ATZ were obtained and functional results recorded on a questionnaire/diary. Histologic changes were correlated with simultaneous assessment of defecatory function. RESULTS: Between 1992 and 2006, 225 patients underwent a stapled IPAA. A total of 238 successful biopsies of the ATZ were performed. There was no dysplasia found. Acute inflammation was noted in 4.6%, chronic inflammation in 84.9%, and normal mucosa in 10.5% of cases. Patients with chronic inflammation reported an average of 6.2+/-1.7 bowel movements/day and 93.2% of them were able to delay a bowel movement for at least 30 min. The presence of chronic ATZ inflammation did not seem to have a negative impact on function, with 96.1% of patients reporting perfect continence, and only 5.3% using protective pads. CONCLUSIONS: Preservation of the ATZ in selected patients is safe and offers excellent long-term functional results. New onset dysplasia was not noted. Chronic inflammation had limited clinical impact. Presence of ATZ inflammation in a total of 89.5% of patients warrants life-long surveillance with biopsies.

Does morbid obesity change outcomes after laparoscopic surgery for inflammatory bowel disease? Review of 626 consecutive cases.

BACKGROUND: Little is known about the impact of obesity on morbidity in patients with inflammatory bowel disease (IBD) who are undergoing laparoscopic resections. The aim of this study was to evaluate outcomes in a consecutive series of normal weight (NW), overweight (OW), and obese (OB) patients undergoing elective laparoscopic colorectal surgery for IBD. STUDY DESIGN: This study is a retrospective analysis of a prospectively collected, Institutional Review Board-approved IBD database. RESULTS: Laparoscopic colorectal resection was performed in 626 patients (335 NW, 206 OW, and 85 OB) between August 2002 and December 2011. Operative time and blood loss were significantly higher in the OW and OB groups compared with the NW group (p = 0.001 and p < 0.001). No differences were observed in terms of intraoperative blood transfusions (p = 0.738) or complications (p = 0.196). The OW and OB groups had a significantly higher conversion rate (p = 0.049 and p = 0.037) and a longer incision compared with the NW group (p = 0.002 and p < 0.001). Obesity was an independent predictor of conversion to open surgery. No significant differences between groups were observed in terms of overall 30-day postoperative morbidity (p = 0.294) and mortality (p = 0.796). Long-term complications occurred in 6.3% NW, 7.3% OW, and 4.7% OB patients (p = 0.676). Incisional hernias were more common in the OB group compared with the NW group (p = 0.020). On multivariate analysis, obesity was not an independent risk factor for either early or late postoperative complications. CONCLUSIONS: Obesity increases the complexity of laparoscopic resections in IBD with higher blood loss, operative time, and conversion rates, without worsening outcomes.

Laparoscopic colectomy for Crohn's colitis. A large prospective comparative study.

INTRODUCTION: The purpose of this study was to compare short-term outcomes of laparoscopic (LC) vs open colectomy (OC) in patients with Crohn's colitis. MATERIALS AND METHODS: We collected data on all patients undergoing colectomy for primary or recurrent Crohn's disease confined to the colon from July 2002 to August 2008. Patient and disease-specific characteristics and perioperative and short-term postoperative outcomes were prospectively collected and analyzed. RESULTS: A total of 125 patients underwent colectomy during the study period, 55 (44%) LC. There were six conversions (10.9%). Median operative time was shorter in the LC group (212 min, interquartile range (IQR) 180-315 LC vs 286 min, IQR 231-387 OC, p = 0.032). Estimated blood loss was less for the LC group (100 ml, IQR 90-250 LC vs 250 ml, IQR 100-400 OC, p = 0.002). Earlier return of bowel function was noted in the LC group (3 days vs 4 days, OC). Length of post-op stay was shorter in the LC group (6 days, IQR 5-8 vs 8 days, IQR 6-10 OC, p = 0.001). There was one death in the OC group. Postoperative complications occurred in eight (14.5%) LC patients vs 16 (22.9%) OC. Disease recurrence rate was 16%, 10.9% LC and 20% OC, respectively. CONCLUSIONS: Laparoscopic colectomy is a safe and effective technique in the hands of experienced surgeons. Benefits of laparoscopic colectomy in Crohn's disease include reduced operative blood loss, quicker return of bowel function, and shorter hospital length of stay.

Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis: a comparative observational study on long-term functional results.

PURPOSE: Long-term results after laparoscopic ileal pouch anal anastomosis (IPAA) have not been thoroughly evaluated. Our study prospectively compares short- and long-term outcomes of laparoscopic and open IPAA. METHODS: Between October 2002 and November 2007, 73 laparoscopic and 106 open IPAA patients were enrolled. Patient- and disease-specific characteristics and short- and long-term outcomes were prospectively collected. RESULTS: There were no differences in demographics, treatment, indication, duration of surgery, and diversion between groups. Laparoscopic patients had faster return of flatus (p = 0.008), faster assumption of a liquid diet (p < 0.001), and less blood loss (p = 0.026). While complications were similar, the incidence of incisional hernias was lower in the laparoscopic group (p = 0.011). Mean follow-up was 24.8 months. Average number of bowel movements was 6.8 +/- 2.8/day for laparoscopy and 6.3 +/- 1.7 for open (p = 0.058). Overall, 68.4% of patients were fully continent at 1 year, up to 83.7% long term without differences between groups. Other indicators of defecatory function and quality of life remain similar overtime. CONCLUSIONS: Laparoscopic IPAA confers excellent functional results. Most patients are fully continent and have an average of six bowel movements/day. When present, minor incontinence improves over time. Laparoscopy mirrors the results of open IPAA and is a valuable alternative to open surgery.

Chronic inflammatory changes in the anal transition zone after stapled ileal pouch-anal anastomosis: is mucosectomy a superior alternative?

BACKGROUND: Chronic inflammation (CI) is commonly found in the anal transition zone (ATZ) after stapled ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Yet, its impact on defecatory function and the need for a complete mucosectomy has not been completely elucidated. This study aims to evaluate the long-term functional outcomes of patients with CI of the ATZ after stapled IPAA in comparison with mucosectomy patients. METHODS: Between June 1987 and November 2007, 66 UC patients were found to have CI of the ATZ after stapled IPAA and were compared with 228 UC patients who underwent mucosectomy with hand-sewn (HS) IPAA. Patients were mailed a questionnaire to assess defecatory function and quality of life. Data were analyzed prospectively. RESULTS: No differences were observed in age, sex, number, or consistency of bowel movements (BMs) between groups. Complete continence was reported by 90.3% of CI and 66.8% of HS patients (P < .001). The CI group also had a significantly lower rate of major incontinence (P < .001). Functional parameters in favor of the CI group included the ability to discriminate between gas and stool (P < .001), the use of protective pads during both the day and the night (P < .001), dietary modifications in the timing of meals (P < .001) and type of food (P = .005), and the presence of perianal rash (P = .019). In the CI group, more patients rated their quality of life as improved from before the operation (P < .001). CONCLUSIONS: Preservation of the ATZ, even in presence of persistent inflammation, confers improved continence, better functional outcomes, and superior quality of life.