Faculty Bibliography

BACKGROUND: Ileal pouch rectal anastomosis (IPRA) is a possible alternative to permanent ileostomy when a short, normal-appearing rectal stump remains after total colectomy. Its outcomes in Crohn colitis (CC) patients have not been reported. STUDY DESIGN: CC patients who underwent IPRA from 1992 to 2004 were identified. Operative and morbidity data were collected. Functional outcomes and quality-of-life (QOL) data were obtained using a mailed questionnaire and compared with matched patients who underwent straight ileorectal anastomosis (SIRA). RESULTS: Twenty-three CC patients underwent IPRA. Perioperative complications included three pelvic septic fluid collections and five small bowel obstructions or ileus, and were treated nonoperatively. Twenty-two patients were available for longterm followup (median 98 months). Fourteen patients (64%) had disease recurrence. Two (9%) have lost a functioning anastomosis. Nine (41%) required additional operations. Matched SIRA patients had higher level of anastomosis (23.4 +/- 5.5 versus 9.0 +/- 4.1 cm above the dentate line; p < 0.0001). Bowel movement frequency (median 6.5/24 hours in both groups), incontinence, and urgency rates were similar. Nighttime seepage and pad usage were more frequent in IPRA. No differences were found in QOL parameters (Cleveland Global QOL score: 0.78 versus 0.73 [0 = worst, 1 = best], IPRA versus SIRA, respectively; p = 0.31). All patients with a functioning IPRA stated they would have their operation again if needed, and 94% would recommend it to others. CONCLUSIONS: IPRA offers durable preservation of bowel continuity and good function and QOL in selected CC patients who might otherwise require a permanent ileostomy.

PURPOSE: : This study evaluated outcomes of patients with abdominal salvage operations for failed ileal pouch-anal anastomosis. METHODS: : Patients undergoing laparotomy for ileoanal pouch salvage were reviewed from a prospectively maintained pouch database and records. RESULTS: : From 1983 to 2007, 241 abdominal reconstructions were performed. The median follow-up was 5 years (range, 0.04-20.8). Diagnoses before primary ileal pouch-anal anastomosis were ulcerative colitis in 187, familial adenomatous polyposis in 22, indeterminate colitis in 20, Crohn's disease in 9, and other in 3. The most common indications for salvage were fistula (n = 67), leak (n = 65), stricture (n = 42) pouch dysfunction (n = 40), pelvic abscess (n = 25). Seventy-one cases had a new pouch constructed. One hundred and seventy cases had the original pouch salvaged. Twenty-nine cases had either pouch excision or ileostomy without pouch excision the result of failure after reconstruction. To assess functional results and quality of life, patients with reconstruction were matched to those with a primary ileal pouch-anal anastomosis. Significantly higher proportions of patients with reconstruction reported seepage during daytime (P = 0.002), at night (P = 0.015), and daytime pad usage (P = 0.02). Other parameters and quality of life were similar between groups. CONCLUSIONS: : Repeat abdominal surgery was a good alternative for pouch failure. Functional and quality of life outcomes were encouraging.

OBJECTIVES: Autoimmune disorders (ADs) frequently coexist with inflammatory bowel disease. The aim of the study was to determine whether coexisting AD in patients with ileal pouches increases the risk for chronic antibiotic-refractory pouchitis (CARP) and other inflammatory conditions of the pouch. METHODS: A total of 622 patients seen in our Pouchitis Clinic were enrolled. We compared the prevalence of adverse outcomes of the pouch (including CARP, Crohn's disease of the pouch, and pouch failure) in patients with or without concurrent AD and assessed the factors for these adverse outcomes. RESULTS: There were seven pouch disease categories: normal (N=60), irritable pouch syndrome (N=112), active pouchitis (N=131), CARP (N=67), Crohn's disease (N=131), cuffitis (N=83), surgical complications (N=36), and anismus (N=2). The prevalence of AD in these pouch disease categories was 4.5%, 12.5%, 9.2%, 13.4%, 10.7%, 3.8%, 1.5%, and 0%, respectively. The presence of at least one AD at time of pouch surgery was shown to be associated with a twofold increase in the risk for CARP (hazard ratio=2.29; 95% CI: 1.52, 3.46; P<0.001) and for pouch-associated hospitalization (hazard ratio=2.39; 95% CI: 1.59, 3.58; P<0.001). The presence of AD was not associated with increased risk for irritable pouch syndrome, active pouchitis, Crohn's disease, cuffitis, surgical complications, or pouch failure. Patients with Crohn's disease of the pouch had a 2.42 times higher risk for pouch failure (P=0.042) than these without. Active smoking or a history of smoking was shown to be associated with an increased risk for pouch-associated hospitalization and pouch failure. CONCLUSIONS: AD appears to be associated with an increased risk for CARP, and the presence of the association between these AD and pouch disorders may stimulate further research on the link of these organ systems on an immunological basis.

OBJECTIVES: Bone mineral density (BMD) can be adversely affected by the chronic nature of inflammatory bowel disease. Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with ulcerative colitis (UC) who require proctocolectomy. There are few data on BMD in UC patients with IPAA. The aim of the study was to assess the prevalence and risk factors associated with low BMD in UC patients after IPAA. METHODS: A total of 327 eligible patients with UC and IPAA from the Pouchitis Clinic were enrolled. Dual-energy X-ray absorptiometry was performed. Patients were classified as having normal or low BMD, based on the criteria by the International Society for Clinical Densitometry. A total of 39 demographic and clinical variables were evaluated with logistic regression models. RESULTS: Of 327 patients with a median of 4 years after IPAA, 105 (32.1%) had low BMD. Fragility fracture was documented in 11 patients (10.5%) in the low BMD group and in 13 of 222 patients (5.9%) in the normal BMD group (P=0.14). In the multivariable analysis, covariate-adjusted factors associated with a low BMD were advanced age (odds ratio (OR) =1.64 per 5 years; 95% CI, 1.44-1.87), low body mass index (OR=0.43 per 5 kg/m(2); 95% CI, 0.30-0.62), and non-use of daily calcium supplement (OR=0.53; 95% CI, 0.29-0.96). Pouch-associated factors were not found to be significantly associated with the bone loss. CONCLUSIONS: Low BMD was common in patients with UC, even after colectomy and IPAA. Low BMD in this patient population was associated with certain risk factors, some of which may be modifiable.

BACKGROUND: Inflammatory and noninflammatory complications of ileal pouch-anal anastomosis (IPAA) are common after restorative proctocolectomy of ulcerative colitis (UC). Some of the patients can have upper gastrointestinal pathology. The diagnostic role of esophagogastroduodenoscopy (EGD) in these patients has not been evaluated. The aim was to estimate the prevalence of upper gastrointestinal (GI) diseases detected by EGD and to assess factors associated with the abnormal EGD findings. METHODS: IPAA patients with underlying inflammatory bowel disease undergoing diagnostic EGD were recruited from a subspecialty pouchitis clinic. Diagnostic yield and incidental findings of EGD were evaluated. Twenty-three variables were evaluated including age, gender, UC duration, IPAA duration, the Pouchitis Disease Activity Index scores, pouch type, pre-IPAA diagnosis, and disease category of the pouch. Univariate and multivariate analyses were performed; stepwise selection with 0.35 and 0.10 as entry and exit criteria. RESULTS: Sixty-six patients undergoing EGD were enrolled in the study, of whom 64 (97%) patients had a concomitant pouch endoscopy. Indications for EGD include anemia, upper abdominal pain, weight loss, nausea and vomiting, and persistent diarrhea refractory to antibiotic therapy. Seventeen patients (25.8%) had a conclusive diagnosis and 14 (21.2%) had incidental findings, on EGD. The most common abnormal findings on EGD were Crohn's disease 12%), peptic ulcer disease (3%), gastritis/duodenitis on histology (11%), Candida esophagitis (3%), and arteriovenous malformations (3%). In multivariate analysis, factors associated with a conclusive EGD diagnosis were a high Pouchitis Disease Activity Index endoscopy score of the afferent limb (odds ratio [OR] = 1.8; 95% confidence interval [CI]: 1.09, 2.9; P = 0.02) and pouch types other than original J pouch (OR = 5.9; 95% CI: 1.08, 32.2; P = 0.041). CONCLUSIONS: EGD evaluation can yield valuable diagnostic information in selected symptomatic patients with IPAA.

BACKGROUND: Crohn's disease (CD) of the pouch can occur in patients with restorative proctocolectomy and ileal pouch-anal anastomosis originally performed for a preoperative diagnosis of ulcerative colitis (UC). CD of the pouch was often observed in patients with a family history of CD. The purpose was to determine whether the family history of CD increased the risk for CD of the pouch in patients who underwent restorative proctocolectomy. METHODS: A total of 558 eligible patients seen in the Pouchitis Clinic were enrolled, including 116 patients with CD of the pouch and 442 patients with a normal pouch or other pouch disorders. Demographic and clinical variables were included in the study. Multivariable logistic regression analyses were performed. RESULTS: The adjusted multivariate logistic analyses revealed that the risk for CD of the pouch was increased in patients with a family history of CD, with an odds ratio (OR) of 3.22 (95% confidence interval [CI] 1.56-6.67), or with a first-degree relative with CD (OR = 4.18, 95% CI, 1.48-11.8), or with a greater number of family members with CD (OR = 2.00 per family member, 95% CI, 1.19-3.37), adjusting for age, gender, smoking status, duration of IBD, duration of having a pouch, and a preoperation diagnosis of indeterminate colitis or CD. In addition, patients of younger age and longer duration of having a pouch had a higher risk for CD of the pouch. A diagnosis of CD of the pouch was associated with a poor outcome, with a greater than 5-fold estimated increased odds of pouch failure (OR = 5.58, 95% CI, 2.74-11.4). CONCLUSIONS: The presence of a family history of CD is associated with an increased risk for CD of the pouch, which in turn has a high risk for pouch failure.

PURPOSE/OBJECTIVE:Little data exist regarding infliximab use in surgical decision making and postoperative complications in ulcerative colitis. Our goals were to determine the rate of postoperative complications in infliximab-treated ulcerative colitis patients undergoing restorative proctocolectomy and to determine whether three-stage procedures are more often necessary. METHODS:We studied a group of infliximab-treated patients and matched control subjects who underwent two-stage restorative proctocolectomy between 2000 and 2006. Postoperative complications were compared. In addition, the rate of three-stage procedures was compared between all infliximab- and noninfliximab-treated patients. RESULTS:A total of 523 restorative proctocolectomies were performed. In the infliximab group, there were 46 two-stage and 39 three-stage procedures. Covariate-adjusted odds of early complication for the infliximab group was 3.54 times that of controls (P = 0.004; 95 percent confidence interval (CI), 1.51-8.31). The odds of sepsis were 13.8 times greater (P = 0.011; 95 percent CI, 1.82-105) and the odds of late complication were 2.19 times greater (P = 0.08; 95 percent CI, 0.91-5.28) for infliximab. The odds of requirement for three-stage procedures was 2.07 times greater in the infliximab group (P = 0.011; 95 percent CI, 1.18-3.63). CONCLUSIONS:Infliximab increases the risk of postoperative complications after restorative proctocolectomy and has altered the surgical approach to ulcerative colitis. Potential benefits of infliximab should be balanced against these risks.

OBJECTIVE: To assess long-term outcomes after ileal pouch-anal anastomosis (IPAA) in Crohn's disease (CD). SUMMARY BACKGROUND DATA: Although considered the procedure of choice in ulcerative colitis, performance of ileal pouch-anal anastomosis (IPAA) is controversial in CD. METHODS: CD patients were identified from a prospectively maintained IPAA database. Time-to-diagnosis and pouch retention rates were analyzed using Kaplan-Meier curves. Demographic, clinical, and pathologic 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, and median follow-up 7.4 years) with primary IPAA were included. CD diagnosis was before IPAA (intentional) in 20(10%), from postoperative histopathology (incidental) in 97(47%) or made in a delayed fashion at median 36 months after IPAA in 87(43%). Overall 10-year pouch retention was 71%. On multivariate analysis, pouch loss was associated with delayed diagnosis (P = 0.03, hazard ratio [HR] 2.6 (95% confidence interval [CI] 1.1-6.5)), pouch-vaginal fistula (P = 0.01, HR 2.8 (95% CI 1.3-6.4)), and pelvic sepsis (P = 0.0001, HR 9.7(95% CI 3.4-27.3)). 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 overall quality of life, quality of health, level of energy, and happiness with surgery were 9, 9, 8, and 10 of 10, respectively. CONCLUSIONS: For CD patients with IPAA, when the diagnosis is established preoperatively or immediately following surgery, pouch loss rates are low and functional results are favorable. Outcomes in patients with delayed diagnosis are worse but half retain their pouch at 10 years with good functional outcomes.