The first 2 authors contributed equally to the article.
Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis
Article first published online: 31 OCT 2007
Copyright © 2007 Crohn's & Colitis Foundation of America, Inc.
Inflammatory Bowel Diseases
Volume 14, Issue 1, pages 20–28, January 2008
How to Cite
Ferrante, M., Declerck, S., De Hertogh, G., Van Assche, G., Geboes, K., Rutgeerts, P., Penninckx, F., Vermeire, S. and D'Hoore, A. (2008), Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Inflamm Bowel Dis, 14: 20–28. doi: 10.1002/ibd.20278
- Issue published online: 10 DEC 2007
- Article first published online: 31 OCT 2007
- Manuscript Accepted: 3 AUG 2007
- Manuscript Received: 18 JUN 2007
- ulcerative colitis;
Background: During the course of their disease, about 30% of patients with ulcerative colitis (UC) will undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). We evaluated the outcome of IPAA in a Belgian referral center.
Methods: Clinical charts were reviewed for pre- and postoperative disease course, functional outcome, and complications in all patients with UC (n = 182) and indeterminate colitis (n = 2) who underwent IPAA in 1990–2004.
Results: Follow-up data were available in 173 out of 184 patients (67 female, median age at proctocolectomy 39.0 years). Median functional Öresland score 1 year after IPAA was 3 (range 0–11). Early postoperative complications were seen in 27% of patients. After a median (interquartile range) follow-up of 6.5 (3.4–9.9) years, 35% of patients developed septic and/or obstructive complications. Forty-six percent of patients developed at least 1 episode of pouchitis. Risk factors for pouchitis were the presence of extraintestinal manifestations (odds ratio [OR] 1.92 (1.23–3.01), P = 0.004) and younger age at proctocolectomy (P = 0.004). Chronic pouchitis was present in 33 patients and associated with extraintestinal manifestations (OR 2.93 (1.13–7.62), P = 0.027), backwash ileitis (OR 9.28 (1.71–50.49), P = 0.010), and length of follow-up (P = 0.004). Pouch failure occurred in 5% of patients.
Conclusions: Although proctocolectomy with IPAA surgery has a good functional outcome, postoperative complications, especially pouchitis, remain considerable in patients with UC.
(Inflamm Bowel Dis 2007)
Up to 30% of patients suffering from ulcerative colitis (UC) will ultimately need to undergo a total colectomy.1 The most frequent indications for colectomy include intractable disease and occurrence of dysplasia or cancer in case of long-standing colitis. A total proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgery of choice for the “definitive” management of UC since it avoids a permanent stoma while removing all diseased colonic mucosa.2
Although most patients report a marked improvement of their quality of life after pouch surgery,3–5 one of the most frequent long-term complications is the occurrence of pouchitis.6 The exact incidence of pouchitis following IPAA is unknown and figures vary significantly between studies (7–59%). Besides differences in length and type of follow-up, an important reason for this variation is a lack of universally accepted diagnostic criteria for pouchitis.7 From a clinical perspective, different types of pouchitis exist.8 Patients can present with a single episode of acute pouchitis, while others have acute relapsing pouchitis or a chronic unremitting course.
The etiology of pouchitis is not entirely understood yet. Bacterial overgrowth, altered balance of luminal bacteria, mucosal ischemia, nutritional deficiencies, lack of short-chain fatty acids, and fecal bile acids toxicity have all been suggested as possible etiological factors.7 Some authors suggest that pouchitis might be due to a missed diagnosis of Crohn's disease (CD) or a novel third form of inflammatory bowel disease (IBD).7
Apart from pouchitis, the postoperative phase can be troubled by several other complications, including pouch leakage, pelvic abscess, pouch fistula, small bowel obstruction, anastomotic stricture, postoperative bleeding, fecal incontinence, sexual dysfunction, and female infertility.9–16 A recent review of the literature on late small bowel obstruction after IPAA reported incidences of 9% at 30 days, 18% at 1 year, 27% at 5 years, and 31% at 10 years.17 However, 92.5% of these patients did not require a surgical intervention within 10 years after surgery.17 Incidences of pouch leakage and associated pelvic sepsis range from 5–14%.13, 18, 19 Mortality following IPAA is seen in less than 0.5% of patients.9, 13, 20
The primary aim of our study was to assess the outcome of restorative proctocolectomy with IPAA in patients with ulcerative colitis or IBD type unclassified (IBDU). We assessed postoperative complications (including pouchitis), functional outcome, and ultimate pouch failure. Furthermore, we wanted to identify predictors of bad outcome.
MATERIALS AND METHODS
All patients who underwent a proctocolectomy with IPAA for UC or IBDU at the University Hospital Gasthuisberg in Leuven (tertiary referral center) between January 1990 and December 2004 were identified through the surgical database. A total of 184 consecutive patients (113 male/71 female; median (interquartile range, IQR) age at diagnosis 29.5 (23.8–38.8) years; median (IQR) age at proctocolectomy 39.0 (30.4–47.7) years) were identified.
Clinical charts of all patients were reviewed to trace clinical, endoscopic, and histologic characteristics, including gender, age at diagnosis, age at proctocolectomy, age at closure of ileostomy, duration of disease prior to proctocolectomy, duration of follow-up after closure of ileostomy, diagnosis prior to proctocolectomy, diagnosis after proctocolectomy, familial history, extraintestinal manifestations, smoking behavior, therapy at proctocolectomy, extent of disease, and presence of backwash ileitis prior to proctocolectomy. Surgical characteristics included type of surgery (laparoscopic versus laparotomy), type of anastomosis (stapled without mucosectomy versus handsewn with mucosectomy), type of pouch (J-pouch or S-pouch), number of stages (1-, 2-, or 3-stage surgery), and construction of the pouch at time of proctocolectomy.
The clinical charts were also reviewed to trace the occurrence of pouchitis and other postoperative complications. In case of absence of follow-up at our tertiary referral center in the last 6 months, we contacted the clinician (general practitioner or local gastroenterologist) following the patient.
Over the study period of 15 years, ileal-pouch anal surgery was performed by 4 experienced abdominal surgeons. Restorative proctocolectomy with IPAA was defined as a 1-, 2-, or 3-stage procedure. Importantly, the number of stages did not follow strict guidelines, but the surgical judgment was based on severity of colitis at the time of surgery and clinical condition of the patient. In general, pouch construction was not performed in the presence of risk factors that were identified to be related to leakage: a preoperative white blood cell count >10,000/μL, emergency surgery, or the combination of leucocytosis and preoperative corticosteroid dose equivalent to or more than 200 mg hydrocortisone over 24 hours.21
Follow-up data were obtained by standardized and regular outpatient visits: 1 early postoperative visit 6 weeks after closure of ileostomy, followed by 3-monthly visits up to 1 year and yearly visits thereafter, unless patients developed symptoms necessitating earlier visits. Follow-up visits included detailed history and clinical examination. If the clinician suspected pouchitis, an endoscopy was performed and biopsies were taken for histologic examination. The diagnosis of pouchitis was only made after confirmation on endoscopy and histological examination.
Functional outcome at 1 year after closure of ileostomy was assessed using the Öresland score (ranging from 0–15).22 Patients were asked about pad usage, presence of fecal seepage, and number of bowel movements during daytime or at night. Other questions concerned the presence of urgency, evacuation difficulties, peri-anal soreness, restriction of diet, need for medication, and any social handicap including any work restrictions. Score details are listed in Table 3.
|Number of bowel movements during daytime|
|Number of bowel movements at night|
|Soiling or seepage during daytime||1||4/117||3|
|Soiling or seepage at night||1||18/117||15|
|Protective pad during daytime||1||5/117||4|
|Protective pad at night||1||3/117||3|
|Medication (continuous or occasional)||1||41/117||35|
Postoperative complications were defined early if they occurred within 1 month after closure of ileostomy and late if they occurred thereafter. Early complications were grouped as septic complications (leakage, abscesses, fistula, etc.) and postoperative bleeding requiring a surgical revision. Prolonged ileus was not regarded as an early complication.
Late complications consisted of obstructive and persistent or new septic conditions. Pouchitis was analyzed separately and the diagnosis of pouchitis was based on typical clinical symptoms, in combination with a suggestive endoscopic image of inflammation of the pouch, confirmed by histology.7, 23 Symptoms included watery, sometimes bloody diarrhea, abdominal cramps, fecal urgency and tenesmus, general malaise, and fever. Typical endoscopy findings were characterized by hyperemic and/or hemorrhagic friable and granular mucosa with excessive mucopurulent areas and superficial erosions. Histologic examination showed acute inflammation including neutrophilic infiltration and mucosal ulceration in addition to chronic inflammation, including villous atrophy, crypt hyperplasia, and a chronic inflammatory cell infiltration.7, 8, 23 Pouchitis was further categorized as acute, acute relapsing, or chronic, as described previously.8 Pouchitis was considered acute if symptoms responded rapidly to medication and if the duration was less than 4 weeks. Starting from 3 or more acute episodes, pouchitis was defined as acute relapsing. Pouchitis was considered chronic if symptoms lasted for more than 4 weeks, despite standard therapy.8 One patient with early pouchectomy was excluded from the analyses of late postoperative complications.
Pouch failure was defined as the need for a permanent ileostomy with or without pouchectomy, in case of intractable symptoms or complications.
Demographic, clinical, and surgical parameters were compared between patients who did and did not develop complications during follow-up, using chi-square statistics, Fisher's Exact test, and Mann–Whitney U-tests. The cumulative incidence of pouchitis was estimated by means of Kaplan–Meier analysis. Multivariate backward Wald logistic regression and Cox proportional hazards model were performed to identify independent predictors of complications following IPAA.
All analyses were performed using SPSS 15.0 (Chicago, IL). The threshold for statistical significance was predefined as P < 0.05. For the multivariate analyses, all variables with P < 0.1 in univariate analysis were included.
We were unable to trace 11 out of 184 patients (5%) who had moved without leaving updated contact details. These patients, who all had UC, were excluded from further analysis. For the remaining patients the median (IQR) follow-up after closure of ileostomy was 6.5 (3.4–9.9) years.
Demographic and clinical characteristics of the 173 patients (67 female/106 male; median age at diagnosis 31.1 (23.8–39.0) years; median age at proctocolectomy 39.0 (30.4–47.7) years) are summarized in Table 1. These characteristics did not differ from those of the total cohort of 184 patients (data not shown).
|N = 173|
|Female/Male (%)||67/106 (39/61)|
|Median (IQR) age at diagnosis (years)||31.1 (23.8–39.0)|
|Median (IQR) disease duration prior to proctocolectomy (years)||5.1 (2.2–9.8)|
|Median (IQR) age at proctocolectomy (years)||39.0 (30.4–47.7)|
|Median (IQR) disease duration prior to closure of ileostomy (years)||5.5 (2.6–10.2)|
|Median (IQR) age at closure of ileostomy (years)||39.5 (31.3–48.0)|
|Median (IQR) follow-up after closure of ileostomy (years)||6.5 (3.4–9.9)|
|Diagnosis prior to proctocolectomya|
|Ulcerative colitis (%)||162/173 (94)|
|IBD unclassified (%)||11/173 (6)|
|Crohn's disease (%)||0/173 (0)|
|Diagnosis after proctocolectomya|
|Ulcerative colitis (%)||169/173 (99)|
|Indeterminate colitis (%)||2/173 (1)|
|Crohn's disease (%)||0/173 (0)|
|Indication for proctocolectomy|
|Intractable disease (%)||165/172 (96)|
|Dysplasia/malignancy (%)||7/172 (4)|
|Familial history of IBD (%)||39/141 (28)|
|Extent of colitis prior to proctocolectomyb|
|Proctitis (%)||0/171 (0)|
|Left-sided colitis (%)||48/171 (28)|
|Extensive colitis (%)||123/171 (72)|
|Backwash ileitis prior to proctocolectomy (%)||8/134 (6)|
|Extra-intestinal manifestation prior to proctocolectomy (%)c||77/170 (45)|
|Smoking at proctocolectomy|
|Never (%)||62/131 (47)|
|Former (%)||50/131 (38)|
|Active (%)||19/131 (15)|
|Medication at proctocolectomy|
|Aminosalicylates (%)||84/169 (50)|
|Corticosteroids (%)||132/169 (78)|
|Azathioprine, 6-mercaptopurine (%)||64/169 (38)|
|Methotrexate (%)||3/169 (2)|
|Cyclosporine (%)||48/169 (28)|
|Infliximab (%)||3/169 (2)|
|Antibiotics (%)||27/169 (16)|
Prior to proctocolectomy, UC was diagnosed in 94% of the patients, based on clinical, radiological, endoscopical, and histological findings.24 The remaining 11 patients were classified as IBDU.25 In 9 of these patients the diagnosis of IBDU could be changed to UC after thorough examination of the resection specimen and previous biopsies. Postoperatively, 2 patients were diagnosed with indeterminate colitis (IC). None of the patients who underwent a proctocolectomy with IPAA had a pre- or perioperative diagnosis of CD.
The indication for proctocolectomy was intractable disease in 96% of the patients, including 10 patients with a toxic megacolon, 8 patients with a severe hemorrhage, and 1 patient with a symptomatic stricture. Three patients were operated for dysplasia, while 4 patients were diagnosed with a colonic malignancy. According to the Montreal classification, 72% of the patients had extensive colitis with mucosal inflammation beyond the splenic flexure.25 Eight patients had backwash ileitis. Seventy-seven patients (45%) experienced at least 1 extraintestinal manifestation (EIM) during the preoperative course of their disease. These included patients with peripheral arthritis (14%), spondylarthropathy (6%), arthralgia (21%), erythema nodosum (2%), pyoderma gangrenosum (1%), uveitis (1%), conjunctivitis (3%), (epi)scleritis (2%), primary sclerosing cholangitis (2%), aphtous stomatitis (3%), and trombo-embolic events (5%).
IPAA Surgery and Follow-up
Surgical characteristics are summarized in Table 2. Twenty-six patients (15%) underwent a 1-stage procedure, while 32 patients (18%) underwent a 3-stage procedure (subtotal colectomy first, followed by completion proctocolectomy and IPAA, and finally ileostomy closure). In 1 patient the ileostomy was never closed due to pouch necrosis 13 days after pouch construction. The remaining 115 patients (67%) underwent a 2-stage procedure. In 101 of these the pouch construction was performed at the time of proctocolectomy (first stage), while in the remaining 14 patients pouch construction was performed after prior subtotal colectomy. The ileostomy could be closed in all but 1 patient. The median (IQR) duration between proctocolectomy and closure of ileostomy was 11.7 (7.9–19.0) weeks.
|N = 173|
|Laparoscopic assisted surgery||77/173 (45)|
|Type of anastomosis|
|Stapled without mucosectomy (%)||165/173 (95)|
|Handsewn with mucosectomy (%)||7/173 (4)|
|No anastomosis (%)||1/173 (1)|
|Type of pouch|
|J-pouch (%)||169/173 (98)|
|S-pouch (%)||4/173 (2)|
|Number of stages|
|One-stage surgery (%)||26/173 (15)|
|Two-stage surgery (%)||115/173 (67)|
|Three-stage surgery (%)||32/173 (18)|
|Pouch construction at the time of proctocolectomy (%)||127/173 (73)|
Early Postoperative Complications
Within 1 month after closure of ileostomy, none of the 173 patients died, but 46 patients (27%) developed at least 1 complication.
Four patients needed a surgical reintervention for bleeding after proctocolectomy with or without pouch construction.
Forty-three patients (25%) presented an inflammatory complication. Minor anastomotic leaks requiring antibiotics with or without transanal drainage were seen in 18 patients, while pelvic abscesses and pouch fistula were seen in 25 patients (14%). In 10 patients the abscess required drainage, but none of these patients required a pouchectomy.
Early postoperative complications were not predicted by any of the clinical or surgical variables. In particular, early postoperative complications were similar in patients with and without perioperative use of corticosteroids or immunomodulators.
Functional Outcome at 1 Year
One year after closure of ileostomy, functional outcome was assessed in 117 patients. Some details necessary for calculating the Öresland score were missing in 56 patients. The median Öresland score was 3 (range 0–11). Ninety-one percent of patients had a functional Öresland score of 6 or less, which can be considered as a good pouch function. The functional data (together with the number of bowel movements during the day and at night) included in the Öresland score are shown in Table 3.
Late Postoperative Septic or Obstructive Complications
Late postoperative septic and/or obstructive complications were seen in 35% of 172 patients. In detail, septic and obstructive complications were seen in 24 and 45 patients, respectively, with 9 patients having both septic and obstructive complications.
As shown in Table 4, late septic and/or obstructive complications occurred more frequently in smokers (P = 0.019), patients who underwent an open procedure (P = 0.067), patients who underwent multistage surgery (P = 0.001), and patients with an older age at proctocolectomy (P = 0.044). Late septic complications tended to be more frequent in patients under corticosteroids at the time of IPAA surgery (P = 0.112). The perioperative diagnosis, the duration of follow-up, and the presence of early postoperative complications did not influence the occurrence of late septic and/or obstructive complications.
|Odds Ratio (95% CI) P-value||Odds Ratio (95% CI) P-value||Odds Ratio (95% CI) P-value|
|Active smoking at proctocolectomy||3.15 (1.17–8.54) P = 0.019||2.31 (0.73–7.34) P = 0.148||2.41 (0.88–6.61) P = 0.082|
|Laparoscopic assisted surgery||0.55 (0.29–1.05) P = 0.067||0.28 (0.10–0.79) P = 0.012||0.78 (0.39–1.56) P = 0.479|
|One-stage surgery||0.13 (0.03–0.56) P = 0.001||0.84 (0.78–0.90) P = 0.027||0.20 (0.05–0.89) P = 0.027|
|Under corticosteroids at proctocolectomy||2.28 (0.97–5.38) P = 0.055||3.31 (0.74–14.83) P = 0.112||1.41 (0.59–3.37) P = 0.436|
|Younger age at proctocolectomy||NA P = 0.044||NA P = 0.071||NA P = 0.126|
|Duration of follow-up after closure of ileostomy||NA P = 0.328||NA P = 0.077||NA P = 0.906|
In a multivariate analysis, factors associated with late septic and/or obstructive complications were older age at proctocolectomy (P = 0.017) and multistage surgery (odds ratio [OR] 6.54 (1.44–29.41), P = 0.015).
During a median (IQR) follow-up of 6.5 (3.4–9.9) years, 80 patients (46%) developed at least 1 episode of acute pouchitis (Fig. 1). The prevalence of pouchitis steadily increased over time, with cumulative incidence rates of 25%, 32%, 36%, 40%, and 45% at 1, 2, 3, 4, and 5 years, respectively.
Of all patients developing pouchitis, 32 (40%) developed fewer than 3 episodes of pouchitis during follow-up, 15 (19%) had acute relapsing pouchitis, and 33 (41%) developed chronic pouchitis.
In univariate analysis, pouchitis was associated with younger age at diagnosis, younger age at proctocolectomy, younger age at closure of ileostomy, and presence of EIM prior to proctocolectomy (Table 5). In contrast, the risk of pouchitis was not associated with length of follow-up after proctocolectomy, perioperative diagnosis, gender, familial history of IBD, duration and extent of disease prior to proctocolectomy, presence of backwash ileitis, indication of surgery, smoking behavior, or therapy at time of proctocolectomy. Pouch reconstruction at the time of proctocolectomy (first stage) tended to be associated with pouchitis (80% versus 68%, P = 0.086). None of the other surgical characteristics were associated with pouchitis.
|No Pouchitis||Pouchitis||Odds Ratio (95% CI)||P-value|
|Female||39/92 (42%)||28/80 (35%)||0.73 (0.39–1.36)||0.321|
|Median (IQR) age at diagnosis (years)||33.6 (24.6–43.2)||27.8 (21.4–34.8)||0.005|
|Median (IQR) disease duration Prior to PC (years)||5.2 (2.2–9.3)||5.1 (2.0–10.0)||0.842|
|Median (IQR) age at PC (years)||41.6 (33.8–49.9)||35.5 (28.1–43.7)||0.003|
|Median (IQR) disease duration Prior to ileostomy (years)||5.5 (2.6–10.1)||5.3 (2.4–10.2)||0.962|
|Median (IQR) age at closure of Ileostomy (years)||42.1 (34.0–50.6)||35.5 (28.4–44.1)||0.002|
|Median (IQR) follow-up after Closure of ileostomy (years)||6.5 (2.9–9.8)||6.4 (3.8–10.5)||0.304|
|Preoperative diagnosis of IBDU||4/92 (4%)||7/80 (9%)||0.47 (0.13–1.68)||0.350|
|Perioperative diagnosis of IC||1/92 (1%)||1/80 (1%)||0.86 (0.05–14.11)||1.000|
|Familial history of IBD||16/72 (22%)||23/68 (34%)||1.79 (0.85–3.78)||0.126|
|Extensive colitis||63/90 (70%)||60/80 (75%)||1.29 (0.65–2.53)||0.467|
|Backwash ileitis||2/66 (3%)||6/67 (9%)||3.15 (0.61–16.20)||0.274|
|EIM prior to PC||34/91 (37%)||43/79 (54%)||2.00 (1.08–3.70)||0.026|
|Smoking prior to Proctocolectomy||36/66 (55%)||33/64 (52%)||0.89 (0.45–1.77)||0.733|
|Active smoking at Proctocolectomy||9/66 (14%)||10/64 (16%)||1.17 (0.44–3.11)||0.748|
|Proctocolectomy for Dysplasia/malignancy||3/92 (3%)||4/79 (5%)||1.58 (0.34–7.29)||0.705|
|Medication at PC|
|5-ASA||40/91 (44%)||44/77 (57%)||1.70 (0.92–3.14)||0.089|
|Corticosteroids||73/91 (80%)||59/77 (77%)||0.81 (0.39–1.69)||0.571|
|AZA, 6-MP||36/91 (40%)||28/77 (36%)||0.87 (0.47–1.63)||0.671|
|Methotrexate||1/91 (1%)||2/77 (3%)||2.40 (0.21–26.99)||0.594|
|Cyclosporine||26/91 (29%)||22/77 (29%)||1.00 (0.51–1.96)||1.000|
|Infliximab||3/91 (3%)||0/77 (0%)||0.53 (0.46–0.62)||0.251|
|Antibiotics||17/91 (19%)||10/77 (13%)||0.65 (0.28–1.52)||0.317|
|Laparoscopic assisted PC||43/92 (47%)||34/80 (43%)||0.84 (0.46–1.54)||0.645|
|Handsewn anastomosis||3/91 (3%)||3/80 (4%)||1.14 (0.22–5.81)||1.000|
|S-pouch||1/92 (1%)||3/80 (4%)||3.55 (0.36–34.78)||0.339|
|One-stage surgery||15/92 (16%)||11/80 (14%)||0.82 (0.35–1.90)||0.641|
|Pouch construction at PC||63/92 (68%)||64/80 (80%)||1.84 (0.91–3.72)||0.086|
Looking at pouchitis-free survival, patients without EIM had their first episode of pouchitis significantly later compared to patients with these features (Fig. 2; LogRank: P = 0.011, Breslow: P = 0.006). We were not able to attribute these findings to any particular extraintestinal manifestations, probably due to the small number of patients in each subgroup of EIM. We do note, however, that 3 out of 4 patients with primary sclerosing cholangitis (PSC) developed pouchitis within 2 years after closure of ileostomy.
In a Cox proportional hazards model the presence of EIM (54% versus 37%, OR 1.92 (1.23–3.01), P = 0.004) and young age at proctocolectomy (35.5 (28.1–43.7) years versus 41.6 (33.8–49.9) years, P = 0.004) were the only independent factors associated with pouchitis.
In univariate analysis, chronic pouchitis was more frequently diagnosed in patients with backwash ileitis (63% versus 19%, OR 7.01 (1.57–31.40), P = 0.012), in patients with perioperative use of aminosalicylates (26% versus 12%, OR 2.63 (1.16–5.96), P = 0.018), in patients with extraintestinal manifestations (27% versus 13%, OR 2.53 (1.15–5.56), P = 0.018), and in patients who underwent laparotomy (26% versus 10%, OR 3.08 (1.30–7.30), P = 0.008). The incidence of chronic pouchitis increased with length of follow-up (P = 0.001). In a multivariate analysis, independent risk factors for the development of chronic pouchitis were length of follow-up (P = 0.004), the presence of backwash ileitis (OR 9.28 (1.71–50.49), P = 0.010), and the presence of EIM (OR 2.93 (1.13–7.62), P = 0.027).
Pouch Failure and Death
During follow-up, we noted 9 pouch failures in our cohort of 173 patients (5%). One patient needed early pouchectomy because of pouch necrosis. In 1 patient the pouch needed to be removed 3 years after initial pouch surgery due to chronic intractable pouchitis. Persistent pouch fistula led to pouch failure in 6 patients. Three of these patients needed pouchectomy. Finally, in 1 patient the pouch had to be removed because of repeated pouch outlet obstructions. None of the recorded clinical or surgical variables was associated with pouch failure.
Four patients died during follow-up. From the 4 patients who received a proctocolectomy because of a malignancy, 2 died due to advanced metastatic colorectal cancer after 6 months and after 5 years, respectively. One patient died of multiorgan failure of unknown cause 3 years after IPAA surgery. One patient died of acute myeloid leukemia 4 years after IPAA surgery.
In this study a review of 182 consecutive patients with IBD who underwent IPAA surgery between 1990 and 2004 was undertaken. Follow-up data were available in 173 patients (171 patients with UC, 2 patients with IC). We were especially interested in postoperative complications (including pouchitis), pouch failure, and functional outcome.
The main limitations of this study were its retrospective character, the lack of data on severity of ulcerative colitis prior to surgery, and the lack of data on postoperative sexual dysfunction.
Most patients were satisfied with the pouch function at 1 year after surgery. The overall functional outcome of pouch surgery was good, with a median (IQR) Öresland score of 3 (2–4) in our cohort. The Öresland score could only be calculated in 68% of our 173 patients. However, this probably did not bias our results, since almost all our patients were still in follow-up after 1 year and only some details necessary for calculating the Öresland score were missing in 56 patients.
Another important topic, beyond the scope of this study, is the increased frequency of sexual dysfunction and infertility after pouch surgery.15, 16 Direct questions should be addressed to the postoperative patients in order to get a clear estimation of the incidence of these complications. In our retrospective study, we were not able to get a reliable estimation of these complications.
The early and late postoperative complication rates found in our study were 27% and 35%, respectively. These complication rates are in agreement with previous studies.5, 6, 9, 26 However, different length of follow-up in each of these studies makes it more difficult to compare late postoperative complications.
In a multivariate analysis we found that both older age at proctocolectomy and 1-stage surgery were associated with a reduced risk for late septic and/or obstructive complications. The first finding further strengthens the recommendation of also performing IPAA surgery in older patients.3 The protective role of 1-stage surgery is probably related to a selection of patients undergoing such a procedure. In our clinic we prefer to perform a temporary ileostomy, but carefully selected patients can undergo 1-stage proctocolectomy with IPAA construction without an increase of septic postoperative complications.27, 28
During a median (IQR) follow-up of 6.5 (3.4–9.9) years, 46% of 172 patients developed at least 1 episode of pouchitis. Interestingly, within the first year after closure of ileostomy 25% of the patients encountered a pouchitis episode, but the cumulative incidence of pouchitis increased with longer follow-up. The incidence of pouchitis in our cohort did not differ from the literature, in particular when studies with a similar length of follow-up were compared.13, 14, 29, 30 This finding confirms that, although the major goal of proctocolectomy in patients with UC is to prevent recurrence of inflammation, a large number of patients will eventually develop pouchitis.
In the past, several investigators reported that most of the pouchitis episodes occur only once in a patient and can be treated successfully with antibiotics, with chronic pouchitis in only 5% of the patients.31, 32 In contrast, we observed that 60% of the patients with pouchitis developed acute relapsing or chronic pouchitis. However, one should always bear in mind that different investigators might have used different diagnostic criteria, different stratification of pouchitis, and different intensity and duration of follow-up.33 In this perspective, we showed that duration of follow-up was associated with occurrence of chronic pouchitis.
In a multivariate analysis, patients developing pouchitis during follow-up were significantly younger at closure of ileostomy and more often had preoperative extraintestinal IBD manifestations. In larger published cohorts, age at surgery has never been described as a risk factor for pouchitis.33, 34 In accordance with our study, several studies have highlighted the association between the presence of extraintestinal manifestations and pouchitis.29, 31, 33–36 In our study the presence of extraintestinal manifestations was also associated with the development of chronic pouchitis. The previously reported association with primary sclerosing cholangitis, in particular,31 was not confirmed in our study, but there were only 4 patients with PSC. Three out of these 4 patients with PSC developed pouchitis within 2 years after proctocolectomy.
Some studies have found an increased incidence of pouchitis following IPAA for extensive ulcerative colitis.35, 37, 38 In accordance with other trials,9, 33 we could not find such an association. Furthermore, backwash ileitis was not associated with occurrence of pouchitis overall, in contrast with an earlier report,38 but we did find an association with evolution toward chronic pouchitis.
Several investigators also reported an influence of smoking on pouchitis rates.33, 36, 39 In our study we did not find an influence of former or active cigarette smoking. The higher incidence of pouchitis in patients with a familial history of IBD or proctocolectomy for dysplasia reported by Shen et al33 could not be replicated in our cohort either. Finally, perioperative diagnosis and surgical characteristics did not influence pouchitis rates.
During a median (IQR) follow-up of 6.5 (3.4–9.9) years, 9 patients (5%) needed permanent ileostomy because of pouch failure. The pouch failure rate in our cohort is in agreement with previously reported Anglo-American cohorts.10, 20 Our cohort was too small to establish any risk factor for pouch failure.
One year after IPAA surgery, the overall functional outcome was good. In the early postoperative phase, 27% of patients developed a complication, but none of the patients died. During a median follow-up of 6.5 years, late septic or obstructive complications were seen in 35% of the patients, especially in those who underwent multistage surgery. Pouch failure requiring definitive ileostomy was seen in 5%. Forty-six percent of patients developed at least 1 pouchitis episode. Young age at proctocolectomy and the presence of extraintestinal manifestations prior to proctocolectomy were independently associated with pouchitis during follow-up. Two-thirds of the pouchitis patients developed acute relapsing or chronic disease, with an increase over time. Chronic pouchitis was seen more in patients with backwash ileitis and patients with extraintestinal manifestations.
- 25Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol. 2005; 19(Suppl A): 5–36., , , et al.