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P206 Demographic data and therapy before proctocolectomy with ileal pouch-anal anastomosis are associated with long-term pouch outcomes: A report from the epi-IIRN

J. Ollech1, S. Harel2, K. Yadgar1, N. Asayag2, A. Cahan3, N. Lederman4, E. Matz5, R. Balicer6, B. Feldman6, I. Brufman6, Z. Haklai7, D. Turner2, I. Dotan1, epi-IIRN

1Department of Gastroenterology, Rabin Medical Center, Petach Tikva, Israel, 2Institute of Pediatric Gastroenterology and Nutrition, Shaare Tzedek Medical Center, Jerusalem, Israel, 3Maccabi Health Services, Tel-Aviv, Israel, 4Medical Division, Meuhedet Sick Fund, Tel-Aviv, Israel, 5Leumit Health Fund, Leumit Health Fund, Tel-Aviv, Israel, 6Clalit Health Services, Clalit Research Institute, Tel-Aviv, Israel, 7Ministry of Health, Jerusalem, Israel

Background

Up to 25% of patients with ulcerative colitis (UC) may undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis may occur in 50–70% of patients, and ~30% may develop chronic pouchitis (CP) or Crohn’s-like disease of the pouch (CLDP). We aimed to identify predictors for the development of CP or CLDP during a long follow-up period.

Methods

Patients followed prospectively at the pouch clinic at Rabin Medical Center, were cross-referenced with data from the validated epiIIRN cohort which includes all IBD patients in Israel (n = 45 074). All patients had at least one year of follow-up since ileal continuity (i.e., ileostomy closure after pouch formation). CP was defined as an active flare of pouchitis for >4 weeks and being treated with antibiotics or anti-inflammatory therapy, or >4 episodes of acute pouchitis/year. CLDP was defined as having one or more of the following: pouch-related fistula (>1 year after ileostomy closure), inflammation of the afferent limb, or fibrostenotic disease of the pouch. For the analysis, the cohort was further categorised into favourable pouch outcomes (sustained normal pouch, acute pouchitis) vs. unfavourable pouch outcomes (CP, CLDP or pouch failure). Logistic regression included gender, age, previous therapies, disease duration before pouch surgery, surgical technique and number of previous non-IBD related abdominal operations.

Results

We included 182 patients (55% females; median age at IPAA: 32 years (IQR 23–45); median disease duration until pouch surgery 6 years (3–11); two-staged surgery 69%). The median follow up time was 14 years (IQR 7–22). Before surgery, 37% of patients had been exposed to immunomodulators (either thiopurines or methotrexate), 24% were exposed to anti-TNF therapy and 5% were previously treated with vedolizumab. An unfavourable pouch phenotype was noted in 48% of patients. On multivariate logistic regression, anti-TNF therapy and older age at pouch surgery were associated with decreased odds of an unfavourable pouch outcome (OR 0.3 95% CI 0.11–0.69, p = 0.007 and OR 0.96 95% CI 0.93–0.98, p = 0.005, respectively).

Conclusion

Therapy of UC with an anti-TNF and older age were associated with a favourable pouch outcome. These may be surrogates for patients with longer follow up as well as indication for IPAA. Such factors should be taken into consideration in clinical decision making.