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P220 Current practices in Ileal pouch surveillance for ulcerative colitis patients in Three London IBD referral centres

Kabir M.1, Morgan S.*1, Samaan M.A.2, Forsyth K.2, Segal J.P.3,4, Elkady S.3,5, Arenaza A.P.Z.3, Kok K.1, Seward E.1, Vega R.1, Di Caro S.1, Westcott E.6, Mehta S.1, Rahman F.1, McCartney S.1, Bloom S.L.1, Northover M.6, Darakhshan A.6, Williams A.6, Anderson S.2, Sanderson J.2, Hart A.3,4, Irving P.M.2

1University College London, Gastroenterology, London, United Kingdom 2Guy's & St Thomas' Hospital, Gastroenterology, London, United Kingdom 3St Mark's Hospital, IBD, London, United Kingdom 4Imperial College, London, United Kingdom 5University of Alexandria, Alexandria, Egypt 6Guy's & St Thomas' Hospital, Surgery, London, United Kingdom

Background

There are no universally accepted guidelines regarding surveillance of IBD patients after ileal pouch-anal anastomosis (IPAA). The British Society of Gastroenterologists suggests “considering” pouchoscopy and biopsy but accepts “there is no clear evidence that surveillance is beneficial and thus it cannot be strongly recommended”. Nonetheless, a recent study of the self-reported practice patterns of US clinicians showed a majority (79%) felt that surveillance was indeed necessary.

We aimed to assess how frequently pouch surveillance is being carried out at our centres. We also evaluated the approaches used for pouchoscopy and the use of endoscopic biopsies.

Methods

The records of 177 patients who underwent IPAA for IBD at three London IBD referral centres (Guy's & St Thomas', University College London and St Mark's Hospitals) were reviewed. Patients with Crohn's disease and those with less than 1 year post-surgical follow-up were excluded.

Data regarding the endoscopic follow-up of the remaining 126 patients was collected retrospectively. Fisher's exact (categorical data) and signed rank sum (continuous data) tests were used.

Results

Table 1. Demographic and surgery related details

Characteristicn=126
Gender, male:female72:54 (58%:42%)
Median age at time of colectomy (range), years35 (16–64)
Median duration since completion of pouch surgery (range), years8.2 (1.3–13.4)
Indication for colectomy
 Acute severe UC49 (39%)
 Chronic active UC49 (39%)
 Colorectal cancer7 (5%)
 High-grade dysplasia5 (4%)
 Unknown16 (13%)

15/126 (12%) had never undergone pouchoscopy for any indication. Of the 111 who had, the median interval between completion of pouch surgery and first pouchoscopy was 1.3 years (0.2–6.4). Median number of pouchoscopies was 3 (0–11), carried out at a median frequency of every 2.4 years (0.9–8.1). Two rectal cuff cancers were found.

59/126 (47%) had never undergone pouchoscopy solely for surveillance. Duration since completion of pouch surgery, specialty of supervising clinician and a history of pouchitis did not significantly effect rates of surveillance.

Table 2. Comparison of surveillance vs non-surveillance groups

Figure 1. Documentation of pouch regions examined and biopsied at pouchoscopy.

Conclusion

Our results demonstrate a wide variation in endoscopic surveillance of UC-IPAA patients, even amongst experienced clinicians. Some patients underwent several pouchoscopies for surveillance, whereas others had none. Surveillance rates did not seem to be risk factors related. In addition, pouchoscopy could be considered incomplete in a significant proportion of patients with no description of the pre-pouch ileum or rectal cuff/anal transition zone.