Prevalence of ‘pouch failure’ of the ileoanal pouch in ulcerative colitis: a systematic review and meta-analysis

Background and aims The ileoanal pouch (IPAA) provides patients with ulcerative colitis (UC) that have not responded to medical therapy an option to retain bowel continuity and defecate without the need for a long-term stoma. Despite good functional outcomes, some pouches fail, requiring permanent diversion, pouchectomy, or a redo pouch. The incidence of pouch failure ranges between 2 and 15% in the literature. We conducted a systematic review and meta-analysis aiming to define the prevalence of pouch failure in patients with UC who have undergone IPAA using population-based studies. Methods We searched Embase, Embase classic and PubMed from 1978 to 31st of May 2021 to identify cross-sectional studies that reported the prevalence of pouch failure in adults (≥ 18 years of age) who underwent IPAA for UC. Results Twenty-six studies comprising 23,389 patients were analysed. With < 5 years of follow-up, the prevalence of pouch failure was 5% (95%CI 3–10%). With ≥ 5 but < 10 years of follow-up, the prevalence was 5% (95%CI 4–7%). This increased to 9% (95%CI 7–16%) with ≥ 10 years of follow-up. The overall prevalence of pouch failure was 6% (95%CI 5–8%). Conclusions The overall prevalence of pouch failure in patients over the age of 18 who have undergone restorative proctocolectomy in UC is 6%. These data are important for counselling patients considering this operation. Importantly, for those patients with UC being considered for a pouch, their disease course has often resulted in both physical and psychological morbidity and hence providing accurate expectations for these patients is vital.

P268 Ileal Pouch-Anal Anastomosis Complications and Pouch Failure: A Systematic Review and Meta-Analysis

Background Previous studies demonstrated wide variation in postoperative complication rates following ileal pouch-anal anastomosis (IPAA). This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Methods A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from 1 January 2010 to 6 May 2020. A meta-analysis was performed using a random effects model. The relationship between pouch-related complications and pouch failure was assessed using Spearman’s correlations. Results Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95%CI5.56–10.59) and 10.3% (95%CI7.24–14.30) for studies with a median follow-up of ≥5 years and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1–17%), pelvic sepsis (2–18%), fistula (1–30%), stricture (1–34%), pouchitis (11–61%) and Crohn’s disease of the pouch (0–18%). Pelvic sepsis (r=0.51, p&lt;0.05) and fistula (r=0.63, p&lt;0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r=0.77, p&lt;0.01). Conclusion Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to increased risk of pouch failure. Pouch survival may be improved through standardized assessment of anastomotic integrity for early identification and adequate management of anastomotic leaks.

Systematic Review and Meta-analysis of Outcomes After Ileal Pouch-anal Anastomosis in Primary Sclerosing Cholangitis and Ulcerative Colitis

Background The optimal restorative surgical management of patients with concomitant diagnoses of primary sclerosing cholangitis and ulcerative colitis [PSC-UC] who require colectomy is controversial, given that patients may have an increased risk for pouchitis after ileal pouch-anal anastomosis [IPAA]. We aimed to compare rates of pouchitis and pouch failure among patients with and without PSC by performing a systematic review and meta-analysis. Methods A systematic search performed through August 18, 2020, identified 12 studies that compared the rates of pouchitis [n = 11] and/or pouch failure [n = 6] among patients with PSC-UC and UC alone. We then performed a meta-analysis using random effects modelling to estimate the odds of developing any episodes of pouchitis or pouch failure. Results A total of 4108 patients underwent an ileal pouch-anal anastomosis after proctocolectomy for UC. Of these, 3799 [92%] were performed for UC alone and 309 [8%] were performed for PSC-UC. In a meta-analysis of 11 studies, patients with PSC-UC compared with UC alone were significantly more likely to develop any pouchitis (63% vs 30%, odds ratio [OR] 4.21, 95% confidence interval [CI] 2.86–6.18), chronic pouchitis [47% vs 15%, OR 6.37, 95% CI 3.41–11.9], and pouch failure [10% vs 7%, OR 1.85, 95% CI 1.08–3.17]. Conclusions Patients with PSC-UC were more likely to experience pouchitis and pouch failure than patients with UC alone. The risks of inflammatory complications after IPAA must be weighed against the potential complications with other surgical procedures, and future studies comparing outcomes among these procedures may inform decision making in this population.

Pre-Pouch Ileitis is Associated with Development of Crohn’s Disease-Like Complications and Pouch Failure

Background and Aims It is unclear whether pre-pouch ileitis heralds an aggressive inflammatory pouch disease in patients with ileal-pouch anal anastomosis (IPAA). We compared outcomes of patients with pouchitis and concomitant pre-pouch ileitis to those with pouchitis alone. Methods Patients undergoing IPAA surgery for inflammatory bowel disease who subsequently developed pouchitis with concomitant pre-pouch ileitis (pre-pouch ileitis group) were matched by year of IPAA surgery and pre-operative diagnosis (ulcerative colitis or inflammatory bowel disease-unclassified) with patients who developed pouchitis alone (pouchitis group). Primary outcomes were development of Crohn’s disease (CD)-like complications (non-anastomotic strictures or perianal disease &gt;6 months after ileostomy closure) and pouch failure. Secondary outcomes were need for surgical/endoscopic interventions and immunosuppressive therapy. Log-rank test was used to compare outcome-free survival and Cox regression was performed to identify predictors of outcomes. Results There were 66 patients in each group. CD-like complications and pouch failure developed in 36.4% and 7.6% patients in pre-pouch ileitis group and 10.6% and 1.5% in pouchitis group, respectively. CD-like complications-free survival (log-rank p=0.0002) and pouch failure-free survival (log-rank p=0.046) were significantly lower in the pre-pouch ileitis group. Pre-pouch ileitis group had a higher risk of requiring surgical/endoscopic interventions (log-rank p=0.0005) and immunosuppressive therapy (log-rank p&lt;0.0001). Pre-pouch ileitis was independently associated with an increased risk of CD-like complications (HR 3.8; p=0.0007), need for surgical/endoscopic interventions (HR 4.1; p=0.002) and immunosuppressive therapy (HR 5.0; p=0.0002). Conclusions Pre-pouch ileitis is associated with a higher risk of complicated disease and pouch failure than pouchitis. It should be considered a feature of CD.

Pouch failures following restorative proctocolectomy in ulcerative colitis

Purpose Restorative proctocolectomy (RPC) is the most common operation in ulcerative colitis. Nevertheless, permanent ileostomy will sometimes be unavoidable. The aim was to evaluate the reasons for pouch failure and early morbidity after pouch excision. Methods The number and the reasons for pouch failures were analysed in patients undergoing RPC 1985-2016. Results Out of 491 RPC patients, 53 experienced pouch failure (10 women, 43 men); 52 out of 53 underwent pouch excision. The cumulative risk for excision at 5, 10 and 20 years was 5.6, 9.4 and 15.5%, respectively. The reasons for failure included septic events such as fistula in 12 (23%), chronic pouchitis in 11 (21%) and leakage in 8 (15%) patients. Functional reasons for pouch failure were recorded as poor function in 16 (30%), incontinence in 12 (23%) and stricture in 12 (23%) patients. Multiple causes for pouch failure were recorded for individual patients. Seven cases of Crohn’s disease were found among the failure cases: two before pouch excision and five after. Altogether, 15 Crohn’s disease diagnoses were set in the RPC cohort, giving a percentage of 47% of pouch failure in this disorder. A complication occurred in 23 (44%) patients within 30 days after surgery; 16 were mild (Clavien-Dindo grades I–II). Conclusions Eleven percent of RPC patients suffered pouch failure: more men than women. The reasons were multiple. Crohn’s disease created a risk of failure, but a half of these patients maintained the pouch. Morbidity after pouch excision was moderate, but in most cases slight.