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P134 Long-term bowel function and fate of the ileal pouch after restorative proctocolectomy in patients with Crohn’s disease: a systematic review and meta-analysis

G. Pellino*1, D. Vinci1, G. Signoriello2, C. Kontovounisios3, S. Canonico1, F. Selvaggi1, G. Sciaudone1

1Universitá della Campania, Colorectal Surgery, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, Naples, Italy, 2Università della Campania Luigi Vanvitelli, Section of Statistic, Department of Mental Health and Public Medicine, Naples, Italy, 3Royal Marsden Hospital and Imperial College London, Unit of Colorectal Surgery, Royal Marsden Hospital, London, UK

Background

Debate exists on whether restorative proctocolectomy with ileal pouch anal anastomosis (RPC) can be safely offered to patients diagnosed with Crohn’s disease (CD). Few studies have been published on the topic. Our aim was to systematically review the literature for study reporting on RPC in CD compared with patients who underwent the procedure for ulcerative colitis (UC).

Methods

This is a Cochrane Collaboration QUORUM-compliant meta-analysis. All studies published between 1993 and 2018 were evaluated for inclusion. Only studies comparing the outcome of RPC in CD and UC and with more than 2 years of follow-up were included. In the event of studies from the same Centre, only the most recent or the one with more complete data were included. Two screeners performed the literature screening and review (GuS and DV); discrepancies were addressed by agreement with a third screener (GiS). Searches were performed on PubMed, EMBASE, Ovid and Cochrane Database (last search 19 October 2018). Primary endpoints included complications. Secondary endpoints included functional outcome (PROSPERO registry 116811).

Results

Eleven studies comprising 6770 patients (CD = 352, UC = 6418) were included in the quantitative analysis. Follow-up ranged between 44 and 120 months. Preoperative diagnosis of CD was made in 30% of patients. Pouch fistulae were more common in CD patients (CD vs. UC; OR 5.62; 95% CI, 2.01–15.76, p = 0.001), as well as strictures (CD vs. UC; OR 1.83; 95% CI, 1.13–2.97, p = 0.015) and failure (CD vs. UC; OR 5.33; 95% CI, 2.60–10.61, p > 0.001). Heterogeneity was acceptable in the analysis of strictures (I2 = 36%), whereas it was high in fistulae and failure (I2 = 85% and 72%, respectively). Pelvic sepsis and bowel obstruction were more common in CD, but they did not reach statistical significance. Interestingly, there was no significant difference in the incidence of pouchitis between CD and UC (OR 1.07, p > 0.05). In patients who preserved their pouch, there were no differences in terms of incontinence, urgency and use of pads; however, CD patients were at higher risk of seepage (CD vs. UC; OR 2.28; 95% CI, 1.22-4.26; p = 0.010, I2 = 34%).

Forest plot of failure (up) and pouchitis (down). Description in the text.

Conclusion

Patients with CD have 5-fold higher risk of fistulae and failure, and 2-fold risk of strictures after RPC compared with UC. However, in those who retain the pouch function might be similar to that of patients with UC. CD does not increase the risk of pouchitis. RPC could be offered to a very selected population of patients with CD, motivated not to have a definitive stoma, and after proper preoperative counselling.