What Can an Aging Pouch Tell Us? Outcomes of Ileoanal Pouches Over 20 Years Old

Abstract

BACKGROUND:Little is known about the long-term functional outcomes of restorative proctocolectomy. OBJECTIVE:The aim of this study was to examine ileoanal pouch outcomes 20 and 30 years postoperatively.DESIGN: This is a retrospective case series. SETTING:This study was conducted at a tertiary care referral center. PATIENTS:Patients who underwent restorative proctocolectomy between 1980 and 1994 were identified.Those with ≥20 years of in-person follow-up were included. MAIN OUTCOMES MEASURES:Pouch function, pouchitis, anal stricture, and pouch failure rates were analyzed.RESULTS: A total of 203 patients had ≥20 years of follow-up. Of those, 71 had ≥30 years of follow-up. Initial diagnoses included ulcerative colitis (83%), indeterminate colitis (9%), familial adenomatous polyposis (4%), and Crohn's disease (3%). Twenty-one percent of those with ulcerative or indeterminate colitis later transitioned to Crohn's disease. Mean daily stool frequency was 7 (IQR 6-8), 38% experienced seepage, 31% had anal stenosis, 47% experienced pouchitis, and 18% had pouch failure. Over time, stool frequency increased in 41% of patients, stayed the same in 43%, and decreased in 16%.Patients older than 50 years at the time of construction had more daily bowel movements (median 8 vs 6; p = 0.02) and more seepage (77% vs 35%; p = 0.005) than those younger than 50 years. Patients with Crohn's disease had higher stool frequency (median 8 vs 6; p < 0.001) and higher rates of anal stenosis (44% vs 26%; p = 0.02), pouchitis (70% vs 40%; p < 0.001), and pouch failure (38% vs 12%; p < 0.001) compared to non-Crohn's patients. Patients with ≥30 years of follow-up had similar function as those with 20-30 years of follow-up.LIMITATIONS: This was a retrospective, single-institution study. Only 35% of pouches created during the study period had >20 years of follow-up. CONCLUSIONS:Most patients maintain reasonably good function and retain their pouches after 20 years. Over time, stool frequency and seepage increase. Older age and Crohn's disease are associated with worse outcomes. See Video Abstract at http://links.lww.com/DCR/B801. ¿QUÉ NOS DICE UN RESERVORIO A LARGO PLAZO? RESULTADOS DE LOS RESERVORIOS ILEOANALES MAYORES DE 20 AÑOSANTECEDENTES: se sabe poco sobre los resultados funcionales a largo plazo de la proctocolectomía restauradora.OBJETIVO: El objetivo de este estudio fue examinar los resultados del reservorio ileoanal 20 y 30 años después de la operación.DISEÑO: Serie de casos retrospectiva.ENTORNO CLÍNICO: Centro de referencia de atención terciaria PACIENTES: Se identificaron pacientes que se sometieron a proctocolectomía restauradora entre 1980 y 1994. Se incluyeron aquellos con ≥20 años de seguimiento en persona.

Review of long‐term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease

“…Variable follow‐up durations may result in ‘ageing’ pouches influencing results, whereby studies with long follow‐up times have increased complication rates, as evidenced by Hashavia et al 18 . and Beresneva et al 27 . where an increased incidence of chronic pouchitis and pouch failure were seen respectively.…”

“…All but one of the included studies are retrospective and heterogeneity across studies is high with respect to disease phenotype, underlying type of IBD, surgical indication (emergency vs. elective) and technique. Variable follow-up durations may result in 'ageing' pouches influencing results, whereby studies with long follow-up times have increased complication rates, as evidenced by Hashavia et al 18 and Beresneva et al 27 where an increased incidence of chronic pouchitis and pouch failure were seen respectively. Additionally, all but five of the included studies were single centre cohorts which may also affect results and reproducibility.…”

“…Reported pouch failure incidence ranged from 1.6% to 18.9% (median 6.9%, IQR: 4.8-10.8%) with a mean follow-up time of 9.9 years. 4,6,7,11,14,16,17,22,24,[26][27][28][29][30][31][32][33][34][35]…”

“…Twenty-three risk factors across 16 studies were significantly associated with pouch failure upon multivariate analysis. The most frequently documented were a final pathology of CD, 4,11,27,50 perioperative pelvic sepsis 4,29,31 and anastomotic leak. 17,30,34 Fourteen risk factors across 10 studies were significantly associated with chronic pouchitis on multivariate analysis.…”