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P541 Intestinal failure: a rare but significant outcome of restorative proctocolectomy

Segal J., Oke S., Clark S., Hart A.

St Mark's Hospital, Department of Gastroenterology, Harrow, United Kingdom

Background

Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) removes the entire colon & rectum, while preserving the anal sphincter, maintaining intestinal continuity1–4. RPC-IPAA is offered to patients with ulcerative colitis (UC) refractory to treatment or associated with dysplasia, and some patients with familial adenomatous polyposis (FAP). Complications are well described, but intestinal failure (IF) requiring parenteral support (PS) is an uncommon complication of this surgery that carries with it significant morbidity & mortality. We report of the complication of IF as a complication of RPC-IPAA.

Methods

Adult patients with RPC-IPAA as an underlying cause of IF who were treated at our institution, were identified between 1/1/1998 & 1/1/2016. Information on complications, small intestinal length & pathophysiological causes of IF were recorded7. Date & cause of death were also recorded. Comparison was made with other patients who had received PS for IF at the same unit during the same time period. Patients were excluded if RPC-IPAA was not a direct cause of IF, or if the cause of the IF was due to malignancy.

Results

Of 807 in the IF database, 35 were identified with a RPC-IPAA and met the inclusion criteria. There were 13 male patients in the pouch group with IF. The pouch was formed for UC in 26, FAP in 6, & other reasons in 3. The pathophysiological classification of IF was short bowel in 49% (n=17), mechanical obstruction in 29% (n=10), intestinal fistulae in 14% (n=5), intestinal dysmotility in 6% (n=2) & small bowel mucosal disease in 3% (n=1). Survival was 96% at 1 year and 75% at, 5 years. This compared to 76% & 48% respectively in the non-pouch group (p=0.02).

IF was a potentially avoidable complication in three patients (9%) with a pouch.

Two developed IF due to short bowel after index pouch formation (residual small bowel length of 50–100cm). One patient underwent a pouch originally for ulcerative colitis but developed IF due to small bowel Crohn's disease with no prior small bowel imaging prior to pouch formation was documented.

Figure 1. Survival pouches with IF vs non pouches with IF.

Conclusion

IF is a rare complication of RPC-IPAA surgery, but carries with it a high disease burden. Our data has shown that survival is better in RPC-IPAA patients compared to patients who have IF for other conditions. We recommend documenting the pre and post-operative bowel length, with appropriate pre-operative imaging of the small bowel as standard practice in RPC-IPAA surgery.