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P271 Ulcerative colitis patients undergoing pouch surgery due to non-refractory disease have a better outcome compared to those operated due to refractory inflammation

H. Yanai*1, S. Ben-Shachar2, L. Mlynarsky1, H. Tulchinsky3, I. Dotan1

1Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv, Israel, 2Tel Aviv Sourasky Medical Center affiliated to Sackler Faculty of Medicine, Tel Aviv University, Genetic Institute, Tel Aviv, Israel, 3Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Proctology Unit, Department of Surgery, Tel Aviv, Israel


Up to one-quarter of patients with ulcerative colitis (UC) may require total proctocolectomy with ileal pouch anal anastomosis (IPAA, pouch surgery) for either refractory disease or for dysplastic/neoplastic lesion(s) - non-refractory disease. Up to 60% of pouch patients may develop inflammation of the previously normal ileum, and in ~ a third the inflammatory process is chronic, i.e. chronic pouchitis (CP) or Crohn's-like disease of the pouch (CLDP). Predictors for a normal pouch (NP) phenotype are vague. We hypothesized that patients operated for non-refractory rather than refractory disease have better prognosis.


Adult UC patients, after pouch surgery, followed at a tertiary pouch clinic were recruited. Characteristics of patients with NP outcome, including demographic, inflammatory, serologic, and genetic markers (NOD2 InsC mutation; R702W/rs2066844) were analyzed and compared to those of patients who developed CP and CLDP (together defined as "pouchitis"). Patients with dual indication for surgery were excluded. Stepwise logistic regression was used to assess possible predictors.


Overall, 128 eligible pouch patients were identified: mean age 47.2 ± 15.6 years, females-45.3%, Ashkenazi Jewish- 45.3%, non smokers-71%, PSC- 3.9%. Fifty-three patients (41.1%) had a favorable outcome- a NP phenotype. Disease extent before pouch surgery was pancolitis in 58% and proctitis in 4.3%. Mean follow-up period was 136.1 ± 79.1 months. Family history of IBD was more prevalent in the pouchitis group compared with NP (41.9% vs. 21.2% respectively, p=0.021). BMI was decreased in pouchitis compared with NP (23.5 ± 4.6 vs. 25.5 ± 5.7 p<0.001, respectively). Patients who developed pouchitis were younger at the time of UC diagnosis, as well as at the time of operation, compared with patients who had a NP phenotype (mean age: 22.3 ± 11.1 vs. 27.9 ± 12.0 years, p=0.001, and 32.6 ± 14.6 vs. 41.3 ± 15.5 years, p= 0.007, respectively). Only 28 patients (18%) were operated for non-refractory disease, and most (69.6%) had a NP phenotype, in contrast to 35.5% NP phenotype in the refractory disease group (p=0.004). Inflammatory markers and serology were similarly distributed. NOD2 insC mutation was detected in 4 patients- all were operated for refractory disease and following surgery developed pouchitis (P=NS). Stepwise logistic regression revealed two significant predictors for a favorable outcome: surgery due to non-refractory disease, OR=3.73 (95%CI=1.339-10.393), and increased BMI OR=1.151 (95%CI=1.063-1.247).


UC patients undergoing pouch surgery due to non-refractory disease have better outcome compared with those operated due to refractory disease. This suggests different immunopathology and may affect therapeutic decisions.