Ileal Pouch Anal Anastomosis Works for Some Crohn's Patients


NEW YORK — Ileal pouch anal anastomosis has an unexpectedly good long-term retention rate in highly selected Crohn's disease patients, according to a single-center study of more than 200 patients.

The 10-year pouch retention rate was 85% or higher in patients diagnosed with Crohn's disease before or immediately after the procedure, and about 50% in those whose Crohn's diagnosis was delayed 3 months or more postoperatively.

Ileal pouch anal anastomosis (IPAA) surgery also won very high patient satisfaction marks from individuals with long-term pouch retention, Dr. Genevieve B. Melton reported at the annual meeting of the American Surgical Association.

IPAA is widely considered the procedure of choice in ulcerative colitis patients whose inflammatory bowel disease requires surgery. However, IPAA is a controversial treatment for Crohn's patients because of concerns that the pouch itself may develop active Crohn's disease, as well as a lack of long-term outcome data, said Dr. Melton of the Cleveland Clinic Foundation.

Dr. Melton reported on 204 Crohn's disease patients who underwent IPAA at the Cleveland Clinic. Just how cautious and selective the clinic's surgeons are is evident from the fact that these 204 were the only Crohn's disease patients in the clinic's database of nearly 2,900 inflammatory bowel disease patients on whom the procedure was performed.

Moreover, only 10% of the 204 patients were known to have Crohn's disease at the time IPAA was scheduled. Another 47% were diagnosed with Crohn's disease immediately after surgery, based on surgical pathology, while in 43% the diagnosis was delayed a median of 3 months postoperatively.

The overall 10-year pouch retention rate was 71%. It was 85% among patients with known Crohn's disease at the time of IPAA, 87% in those whose Crohn's was diagnosed immediately after surgery, and significantly worse (53%) in those with a delayed diagnosis.

In a multivariate analysis, pouch loss was associated with delayed diagnosis of Crohn's disease, abdominopelvic sepsis, and pouch-vaginal fistula, but not with extraintestinal disease manifestations, smoking, postoperative infliximab or corticosteroid therapy, or preoperative pathology, Dr. Melton said.

At follow-up, patients with pouch retention reported a median of seven bowel movements per day. In all, 72% reported perfect or near-perfect continence, and 68% reported rare or no urgency symptoms.

Postoperative manifestations of Crohn's disease were common. Perianal fistula, pouch-vaginal fistula, IPAA stricture, and pouchitis occurred in 11%–40% of patients without a delayed diagnosis of Crohn's disease and were two- to fourfold more common in those with delayed diagnosis.

Nonetheless, patients with a retained pouch at follow-up rated their quality of life as a median 9 out of a possible 10 and their happiness with the surgery as a 10.

“The functional outcomes aren't as good as for the pouch in ulcerative colitis patients, but one of the take-home messages of this study is that Crohn's patients are perhaps willing in some cases to accept less than perfect outcomes,” she said. “These patients—if they retain their pouch—are reporting a happiness with surgery of 10 out of 10.”

Why do patients with a delayed diagnosis of Crohn's disease do so much worse following IPAA? The answer is unknown, but it's likely they have a phenotypic variant of the disease that, over time, tends to include small-bowel and/or anal involvement, Dr. Melton said.

Audience members were eager to learn whether this study's results will prompt Cleveland Clinic surgeons, who are very experienced with IPAA, to suggest a large-scale broadening of the selection criteria for the procedure.

“We're reluctant to offer it to patients with known Crohn's disease,” Dr. Melton replied. Their current selection criteria include Crohn's disease confined to the colon with no anal, perianal, or small bowel involvement; stable disease for several years; and a thorough patient understanding of the risks of recurrence.

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