Anal canal inflammation after ileal pouch-anal anastomosis. The need for treatment

Diagnosis and Management of Cuffitis: A Systematic Review

BACKGROUND

In patients with ulcerative colitis or familial adenomatous polyposis who develop neoplasia or fail medical therapy and require colectomy, restorative proctocolectomy with IPAA is often indicated. Although often well tolerated, IPAA can be complicated by cuffitis or inflammation of the remaining rectal cuff. Although much has been published on this subject, there is no clear and comprehensive synthesis of the literature regarding cuffitis.

METHODS

Our systematic literature review analyzes 34 articles to assess the frequency, cause, pathogenesis, diagnosis, classification, complications, and treatment of cuffitis.

RESULTS

Cuffitis occurs in an estimated 10.2% to 30.1% of pouch patients. Purported risk factors include rectal cuff length >2 cm, pouch-rectal anastomosis, stapled anastomosis, J-pouch configuration, 2- or 3-stage IPAA, preoperative Clostridium difficile infection, toxic megacolon, fulminant colitis, preoperative biologic use, medically refractory disease, immunomodulator/steroids use within 3 months of surgery, extraintestinal manifestations of IBD, and BMI <18.5 kg/m2 at the time of colectomy. Adverse consequences associated with cuffitis include decreased quality-of-life scores, increased risk for pouchitis, pouch failure, pouch excision, and pouch neoplasia.

CONCLUSIONS

Given the similarities between pouchitis and cuffitis, diagnosis and treatment of cuffitis should proceed according to the International Ileal Pouch Consortium guidelines. This review found that the majority of the current literature fails to distinguish between classic cuffitis (a form of reminant ulcerative proctitis) and nonclassic cuffitis (resulting from other causes). Further work is needed to distinguish the unique risk factors and endoscopic characteristics associated with each subtype, and further randomized clinical trials should be conducted to strengthen the evidence for treatment options.

Management of Pouch Neoplasia

BACKGROUND

Pouch neoplasia occurs following ileal pouch-anal anastomosis, with or without mucosectomy in ulcerative colitis and familiar adenomatous polyposis.

OBJECTIVES

This study aimed to review available literature and make recommendations regarding pouch neoplasia.

DATA SOURCES

Data were collected from specialty hospitals, and a literature review was conducted due to the lack of published large-scale studies. Recommendations for treatment were made based on the literature review and expert opinions.

STUDY SELECTION

Large-scale studies of pouch neoplasia were selected.

INTERVENTION

The intervention was studies with details of pouch neoplasia.

MAIN OUTCOME MEASURES

We aimed to identify the management modalities for pouch neoplasia based on the type.

RESULTS

Pouch neoplasia can occur in each component of the pouch-afferent limb, pouch body, cuff, and anal transitional zone. In patients with ulcerative colitis, pouch neoplasia is treated because colitis-associated neoplasia comprises a multifocal lesion, which most commonly involves the cuff and anal transitional zone. Close surveillance or endoscopic complete resection is optimal for low-grade dysplasia. For adenocarcinoma, high-grade dysplasia, and low-grade dysplasia with difficult complete resection, pouch excision is recommended. In familiar adenomatous polyposis patients with adenomas of the afferent limb or pouch body, endoscopic resection is optimal. Endoscopic resection is feasible for discrete adenoma in the cuff and anal transitional zone, and surgical excision is optimal for laterally spreading, extensive, large, or flat adenoma. For adenocarcinomas involving any component, pouch excision is recommended.

LIMITATIONS

Published large-scale studies were lacking because of disease rarity.

CONCLUSION

Pouch neoplasia occurs in each pouch component. In patients with ulcerative colitis, pouch excision is recommended for adenocarcinomas and high-grade dysplasia, whereas endoscopic intervention may be preferable to low-grade dysplasia. In familiar adenomatous polyposis patients, pouch excision is necessary for adenocarcinoma, and endoscopic resection or excisional surgery is optimal for adenoma.

Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis

Proctocolectomy with ileal pouch-anal anastomosis is the intervention of choice for ulcerative colitis and familial adenomatous polyposis requiring surgery. One of the long-term complications is pouch cancer, having a poor prognosis. The risk of high-grade dysplasia and cancer in the anal transitional zone and ileal pouch after 20 years is estimated to be 2 to 4.5% and 3 to 10% in ulcerative colitis and familial polyposis, respectively. The risk factors for ulcerative colitis are the presence of pre-operative dysplasia or cancer, disease duration > 10 years and severe villous atrophy. For familial polyposis, the risk factors are the number of pre-operative polyps > 1000, surgery with stapled anastomosis and the duration of follow-up. In the case of ulcerative colitis, a pouchoscopy should be performed annually if one of the following is present: dysplasia and cancer at surgery, primary sclerosing cholangitis, villous atrophy and active pouchitis (every 5 years without any of these factors). In the case of familial polyposis, endoscopy is recommended every year including chromoendoscopy. Even if anal transitional zone and ileal pouch cancers seldom occur following proctectomy for ulcerative colitis and familial adenomatous polyposis, the high mortality rate associated with this complication warrants endoscopic monitoring.

Treatment of pouchitis, Crohn's disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium

Pouchitis, Crohn's disease of the pouch, cuffitis, polyps, and extraintestinal manifestations of inflammatory bowel disease are common inflammatory disorders of the ileal pouch. Acute pouchitis is treated with oral antibiotics and chronic pouchitis often requires anti-inflammatory therapy, including the use of biologics. Aetiological factors for secondary pouchitis should be evaluated and managed accordingly. Crohn's disease of the pouch is usually treated with biologics and its stricturing and fistulising complications can be treated with endoscopy or surgery. The underlying cause of cuffitis determines treatment strategies. Endoscopic polypectomy is recommended for large, symptomatic inflammatory polyps and polyps in the cuff. The management principles of extraintestinal manifestations of inflammatory bowel disease in patients with pouches are similar to those in patients without pouches.

Colectomy risk score predicts pouchitis in patients with ulcerative colitis

Risk stratification is required to improve the management of pouchitis with ulcerative colitis (UC) patients who undergo ileal pouch-anal anastomosis (IPAA). Recently, the colectomy risk score (CRS) has been used to assess UC severity and predict the need for surgery. We explored whether the CRS predicted pouchitis in patients with UC who underwent IPAA. This retrospective study included 168 UC patients who underwent IPAA. Pouchitis was diagnosed according to the pouchitis disease activity index. The primary endpoint was the cumulative incidence of pouchitis. The risk factors for pouchitis using preoperatively obtained data, including the CRS, were investigated. Based on their CRS, patients were assigned to low- (scores 0-3), intermediate- (scores 4-6), and high-risk (scores 7-9) groups. The incidence of pouchitis was estimated using the Kaplan-Meier curve. CRS validity was assessed using the Cox proportional hazards model. During the median 7.2 (interquartile range [IQR] 2.8-11.1) years' follow-up, 37 (28.5%) patients were diagnosed with pouchitis. Patients with pouchitis had significantly higher CRS than patients without pouchitis (median 7.0; IQR, 4.0-7.0 vs median 5.0; IQR, 3.0-7.0). The cumulative incidences of pouchitis in the low-, intermediate-, and high-risk groups were 10.3%, 18.3%, and 36.1% at 5 years, respectively. Thus, the incidence trended to increase significantly as CRS increased. Multivariate analysis revealed high-risk CRS status was an independent predictor of pouchitis (hazard ratio: 18.03; 95% confidence interval 1.55-210.05). CRS is useful in risk stratification for the development of subsequent pouchitis in patients with UC undergoing IPAA.

State-of-the-art surgery for ulcerative colitis

Ulcerative colitis (UC) is an autoimmune-mediated colitis which can present in varying degrees of severity and increases the individual’s risk of developing colon cancer. While first-line treatment for UC is medical management, surgical treatment may be necessary in up to 25–30% of patients. With an increasing armamentarium of biologic therapies, patients are presenting for surgery much later in their course, and careful understanding of the complex interplay of the disease, its management, and the patient’s overall health is necessary when considering he appropriate way in which to address their disease surgically. Surgery is generally a total proctocolectomy either with pelvic pouch reconstruction or permanent ileostomy; however, this may need to be spread across multiple procedures given the complexity of the surgery weighed against the overall state of the patient’s health. Minimally invasive surgery, employing either laparoscopic, robotic, or transanal laparoscopic approaches, is currently the preferred approach in the elective setting. There is also some emerging evidence that appendectomy may delay the progression of UC in some individuals. Those who treat these patients surgically must also be familiar with the numerous potential pitfalls of surgical intervention and have plans in place for managing problems such as pouchitis, cuffitis, and anastomotic complications.

Reporting Templates for MRI and Water-Soluble Contrast Enema in Patients With Ileal Pouch-Anal Anastomosis: Experience From a Large Referral Center

Ileal pouch-anal anastomosis (IPAA) surgery is the reference standard surgical procedure for treatment of ulcerative colitis and most patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of workup for pouch dysfunction. The purpose of this article is to propose structured reporting templates for MRI and water-soluble contrast enema (WSCE), based on our referral pouch center's experience, in patients who have undergone IPAA surgery. We review salient surgical technique, pouch anatomy, and imaging protocols, with an emphasis on a systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting templates for MRI and WSCE.

Initial experience with transanal proctectomy in children

BACKGROUND

The use of transanal proctectomy may have particular advantages for pediatric patients with small pelvic working space. We report short-term outcomes of transanal completion proctectomy (taCP) during surgery for inflammatory bowel disease.

METHODS

All patients (age≤19) underwent taCP from January 1, 2018 to December 31, 2019. Prior total abdominal colectomy (TAC) was performed using a single-incision technique. At operation, patients underwent single-incision laparoscopy with taCP. Patient demographics, pre and perioperative details, and postoperative complications were abstracted.

RESULTS

Seven patients (n = 6) with a median age of 18 years [Range: 13-19] were included in this initial series. All patients had a prior TAC with end-ileostomy with taCP occurring a median of 6 [Range: 3-89] months after TAC. Six of 7 had a diagnosis of ulcerative colitis (UC) while 1 patient had Crohn's colitis. For patients with UC, taCP was part of an ileal pouch-anal anastomosis with the majority (n = 4) proceeding as a modified-two stage and the remaining (n = 2) a three-stage approach. Single-incision laparoscopy through the prior ileostomy site was used in all IPAA patients. Median operative time was 226 [Range: 150-264] minutes with no conversions to more invasive technique. Median hospital length of stay (LOS) was 5 [Range: 2-8] days. In-hospital complications occurred in two patients who had watery diarrhea that prolonged LOS but resolved postdischarge. One patient was readmitted for bowel obstruction that resolved with placement of red rubber catheter at the ileostomy site. Of the 4 patients with a functioning ileal pouch, 1 patient reported 6-10 bowel movements per day, while 3 others reported ≤5 bowel movements per day. Half (n = 2) reported 1-2 nocturnal bowel movements at their first postoperative visit. No patients reported soiling or leakage, though one patient had a single episode of incontinence.

CONCLUSION

In this pilot series, transanal proctectomy was effective and safe. Future work should compare traditional MIS completion proctectomy to taCP for applications in pediatric inflammatory bowel disease.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

IV.

Surveillance pouchoscopy for dysplasia: Cleveland Clinic Ileoanal Pouch Anastomosis Database

BACKGROUND

No formal guidelines exist for surveillance pouchoscopy following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis.

METHODS

All adults who had previously had IPAA for ulcerative colitis, and underwent a pouchoscopy between 1 January 2010 and 1 January 2020, were included.

RESULTS

A total of 9398 pouchoscopy procedures were performed in 3672 patients. The majority of the examinations were diagnostic (8082, 86·0 per cent; 3260 patients) and the remainder were for routine surveillance (1316, 14·0 per cent; 412 patients). Thirteen patients (0·14 per cent of procedures) were found to have biopsy-proven neoplasia at the time of pouchoscopy; seven had low-grade dysplasia (LGD) (0·07 per cent; all located in the anal transition zone), none had high-grade dysplasia (HGD) and six (0·06 per cent) had invasive adenocarcinoma (4 in anal transition zone and 6 in pouch). Of the six patients with adenocarcinoma, four had neoplasia at the time of proctocolectomy (2 adenocarcinoma, 1 LGD, 1 HGD); all six were symptomatic with anal bleeding or pelvic pain at the time of pouchoscopy, had a negative surveillance pouchoscopy examination within 2 years of diagnosis of adenocarcinoma, had palpable masses on digital rectal examination, and had visible lesions at the time of pouchoscopy.

CONCLUSION

Surveillance pouchoscopy is not recommended in asymptomatic patients because significant neoplasia following IPAA for ulcerative colitis is rare.

Inflammatory Pouch Conditions Are Common After Ileal Pouch Anal Anastomosis in Ulcerative Colitis Patients

BACKGROUND

Total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) is the gold standard surgery for ulcerative colitis (UC) patients with medically refractory disease. The aim of this study was to report the rates and risk factors of inflammatory pouch conditions.

METHODS

This was a retrospective review of UC or IBD unspecified (IBDU) patients who underwent TPC with IPAA for refractory disease or dysplasia between 2008 and 2017. Pouchoscopy data were used to calculate rates of inflammatory pouch conditions. Factors associated with outcomes in univariable analysis were investigated in multivariable analysis.

RESULTS

Of the 621 patients more than 18 years of age who underwent TPC with IPAA between January 2008 and December 2017, pouchoscopy data were available for 386 patients during a median follow-up period of 4 years. Acute pouchitis occurred in 205 patients (53%), 60 of whom (30%) progressed to chronic pouchitis. Cuffitis and Crohn's disease-like condition (CDLC) of the pouch occurred in 119 (30%) patients and 46 (12%) patients, respectively. In multivariable analysis, female sex was associated with a decreased risk of acute pouchitis, and pre-operative steroid use and medically refractory disease were associated with an increased risk; IBDU was associated with chronic pouchitis; rectal cuff length ≥2 cm and medically refractory disease were associated with cuffitis; age 45-54 at colectomy was associated with CDLC. Rates of pouch failure were similar in chronic pouchitis and CDLC patients treated with biologics and those who were not.

CONCLUSIONS

Inflammatory pouch conditions are common. Biologic use for chronic pouchitis and CDLC does not impact the rate of pouch failure.

Cuffitis: is an endoscopic approach possible?

Background  Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the reference surgical treatment for patients with ulcerative colitis (UC) refractory to medical treatment. One of the complications is leaving a strip of rectal mucosa which can be a cause of persistent inflammation or cuffitis. The objective of our study is to present an endoscopic approach for the treatment of cuffitis. Methods  This retrospective study included three patients who suffered from cuffitis after a proctocolectomy with IPAA for UC refractory to medical treatment. An endoscopic resection of the cuffitis was performed by the same operator. Two different techniques were used: hybrid endoscopic submucosal dissection (ESD) for one patient and mucosectomy with cap and resection for the two others. Results  The endoscopic treatment was performed successfully in all three patients. The only complication observed was rectal bleeding which did not require endoscopic revision. The three patients are now asymptomatic. Conclusion  Endoscopic treatment of cuffitis appears to be an interesting approach with few complications in the short term and good clinical efficacy.

A comprehensive review and update on ulcerative colitis. Dis Mon 2019;65:100851. [PMID: 30837080 DOI: 10.1016/j.disamonth.2019.02.004]

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.

SATB2 and Hep Par 1 Immunohistochemistry Is Helpful in Distinguishing Between Inflamed and Architecturally Altered Ileal Pouch and Rectal Cuff Mucosa

The management of patients with ulcerative colitis after proctocolectomy with ileal pouch-anal anastomosis includes independent histological assessments of inflammation in the ileal pouch and the rectal cuff. However, the distinction between pouchitis and cuffitis can be impeded both endoscopically and histologically by the combined effects of inflammation and regeneration. We investigated the use of 2 markers, hepatocyte paraffin 1 (Hep) and SATB2 (special AT-rich sequence-binding protein 2), which are expressed immunohistochemically in the small and large bowel epithelium, respectively, as ancillary methods to deal with this problem. Immunohistochemical staining was performed retrospectively on 20 consecutive pairs of post-ileal pouch-anal anastomosis biopsies with varying degrees of histological inflammation and architectural distortion, which had each been designated as "ileal pouch" or "rectal cuff" by the referring endoscopists. Expression was graded as focal (10% to 74% stained cells) or diffuse (75% to 100%). Among the ileal pouch biopsies, 20 (100%) expressed Hep either diffusely (75%) or focally (25%), whereas SATB2 staining was either negative in 15 (75%) or focal in 5 (25%), the latter group all expressing Hep diffusely. Among the rectal cuff biopsies, 14 expressed SATB2 diffusely. Of these, Hep was either negative in 11 (79%) or focally positive in 3 (21%), the latter group all expressing SATB2 diffusely. Six ostensibly rectal cuff biopsies (30%) expressed Hep diffusely and were negative for SATB2, suggesting endoscopic misidentification. None of the 40 biopsies expressed both markers diffusely. We conclude that in doubtful cases, diffuse expression of either Hep or SATB2 can be helpful in discriminating between ileal pouch and rectal cuff mucosa, respectively.

Outcome after ileal pouch-anal anastomosis in ulcerative colitis patients: experience during a 27-year period

BACKGROUND

No previous study describes the postoperative outcome and functional results after ileal pouch-anal anastomosis (IPAA), performed in ulcerative colitis by the same surgical team with the different anastomotic techniques adopted in a 27-year period.

METHODS

Prospectively, consecutive 333 ulcerative colitis patients operated adopting different IPAA techniques during the open surgery period 1984-2011 were enrolled. IPAA was performed using single stapling (SS) technique in 38 patients, double stapling (DS) technique in 235 patients (TIA stapler 42 patients, Endo-GIA 131 patients, Contour 62 patients) and handsewn IPAA in 60 patients.

RESULTS

Statistically different early and late complications were recorded among the different IPAA techniques. A lower frequency of daily and nocturnal defecations and a higher level of continence were observed in the DS-IPAA compared to handsewn IPAA. The distance between the anastomotic line and the anal verge was significantly lower in DS Endo-GIA or DS Contour groups than in the DS TIA and SS. In SS IPAA group, 31.6% developed cuffitis compared to 14.4% belonging to DS group, at a mean follow-up of 140.4 months.

CONCLUSIONS

Technical improvements changed the IPAA technique. Stapled IPAA is characterized by better functional outcome than handsewn IPAA. DS Endo-GIA and Contour IPAA are followed by lower risk of cuffitis.

Outcomes of salvage surgery for ileal pouch complications and dysfunctions. the experience of a referral centre and review of literature

BACKGROUND AND AIMS

Failure rates of restorative proctocolectomy with ileo pouch-anal anastomosis (IPAA) range between 3.5 and 15%. Salvage surgery aims to preserve the pouch and transanal evacuation. We report our experience with salvage, review the outcomes of revisional pouch surgery, and propose a classification of pouch dysfunction.

METHODS

We collected data on patients undergoing pouch salvage surgery between 1987 and 2014 at our hospital. Pre- and post-salvage functional data were assessed. Function at the 3-year follow-up was compared with that of matched IPAA controls (study patients:controls, 1:3).

RESULTS

Considering only patients who underwent primary IPAA at our centre (n = 31), 5-year failure was higher after salvage compared with primary IPAA (28.8 vs 5.7% log rank test, p = 0.005). Overall, we included 39 patients, with eight additional patients who received primary IPAA elsewhere, undergoing 46 procedures. Most patients had a J-pouch (74.4%) and needed salvage for septic complications. A transperineal approach was used in 22 patients, whereas 17 underwent abdominal salvage, with 77.3 and 64.7% success rates, respectively. Minor surgery was effective but required repeated procedures. Overall failure was 28.2% at a median follow-up of 42 (1-153) months. A significant decrease in bowel frequency (p = 0.021) and rate of urgency (p = 0.009) was observed at the 3-year follow-up after salvage in 25 patients available for comparison. Functional results after major salvage procedures were poorer compared with healthy IPAA controls (p = 0.003).

CONCLUSIONS

Salvage surgery is effective and safe in experienced teams, but the 5-year failure rate is higher after salvage than after successful primary pouch surgery. Sepsis brings about a higher risk of failure compared with mechanical causes of dysfunction.

Treatment strategy for preventing pouchitis as a postoperative complication of ulcerative colitis: the significance of the management of cuffitis

PURPOSE

The aim of this study was to examine the risk factors for and to evaluate strategies for preventing pouchitis as a postoperative complication of ulcerative colitis (UC).

METHODS

A total of 119 cases of UC in which restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) was performed at our institution between 2000 and 2012 was investigated; nine patients in whom it was impossible to close the ileostomy due to an intractable anal fistula or pelvic abscess were excluded.

RESULTS

The cumulative risk of developing pouchitis 5 years after IPAA with stoma closure was 31.0%. Significant relationships with pouchitis were found for the surgical indication (p = 0.0126) and surgical method (p = 0.0214). A significant correlation was found between pouchitis and cuffitis. Pouchitis was significantly more common in the cases with cuffitis than in those without (p = 0.0002). There was also a significantly different cumulative incidence observed between the cases with and without cuffitis (p < 0.0001). In addition, pouchitis had a greater tendency to recur in the cases with cuffitis than in those without (p = 0.2730).

CONCLUSION

The cumulative incidence rate of pouchitis was 10.6% at 1 year, 15.1% at 2 years and 31.0% at 5 years. Controlling cuffitis is important to prevent pouchitis.

Clinical course of cuffitis in ulcerative colitis patients with restorative proctocolectomy and ileal pouch-anal anastomoses

BACKGROUND

Cuffitis, considered a form of reminiscent ulcerative colitis (UC), is one of the common complications of ileal pouch-anal anastomosis (IPAA) and its disease course has not been systematically characterized. The aim was to examine the disease course of cuffitis in a large historical cohort.

METHODS

All patients with cuffitis diagnosed based on a combined evaluation of symptom and pouch endoscopy at the initial visit to our Pouchitis Clinic were included. Pouch patients with diagnoses other than cuffitis served as controls. Patients with familial adenomatous polyposis were excluded.

RESULTS

A total of 120 patients with cuffitis were included. The control group consisted of 811 patients (normal pouch, n = 85; irritable pouch syndrome, n = 155; acute pouchitis, n = 170; chronic pouchitis, n = 128; Crohn's disease [CD] of the pouch, n = 185; and surgical complications, n = 88). After a median follow-up of 6 years (interquartile range: 3-10 years) after pouch construction, there were 40 (33.3%) having 5-aminosalicylate (5-ASA)/steroid-responsive cuffitis; 22 (18.3%) having 5-ASA/steroid-dependent cuffitis, and 58 (48.4%) developing 5-ASA/steroid-refractory cuffitis. Further investigation of the 58 patients with refractory cuffitis showed that 19 (32.8%) had CD of the pouch and 14 (24.1%) had surgical complications including fistulae and anastomotic sinuses. There were 16 (13.3%) cuffitis patients who developed pouch failure during the follow-up period.

CONCLUSIONS

Cuffitis may represent a spectrum of diseases. In patients with refractory cuffitis, a diagnosis of CD or surgery-associated anal transitional zone complications should be considered.

Postoperative defecatory function of an ileal pouch-anal anastomosis after a restorative proctocolectomy for ulcerative colitis: evaluation using fecoflowmetry

An ileal pouch is usually reconstructed as an alternative to a neorectum after a total proctocolectomy for ulcerative colitis (UC). However, the real defecatory function of an ileal pouch is uncertain. This study was designed to analyze the functional and clinical outcomes after a proctocolectomy and ileal pouch-anal anastomosis (IPAA) for UC using fecoflowmetry (FFM). Sixteen patients who underwent IPAA for UC between 1990 and 2005 were studied. They were evaluated by FFM, together with Kelly's clinical score (KCS), and anorectal manometric assessments were also performed. FFM showed that the fecoflow pattern (FFP) of 14 patients (87%) was the block type and of 2 patients (13%) was the segmental type. The clinical score and tolerance volume showed no improvement 1 year or more after IPAA. However, the value of the maximum fecal stream flow rate (Fmax) improved with time. FFM shows that the defecatory function improved after IPAA, and it may therefore contribute to a good long-term outcome after the surgery.

Perioperative complications in inflammatory bowel disease

Almost 50% of patients with inflammatory bowel disease (IBD) will undergo surgery for their disease at some stage of its clinical course. Complications seen following surgery may occur early or late in the postoperative period. Patient factors, including active inflammatory disease, malnutrition, and use of immunosuppressant medications, make these patients a challenging surgical group and at increased risk for surgical complications. The purpose of this review is to characterize the complications that are commonly seen following surgery in patients with IBD and to discuss the surgical and patient factors that may influence their development.

Diagnosis and management of dysplasia and cancer of the ileal pouch in patients with underlying inflammatory bowel disease

Approximately 30% of the patients with ulcerative colitis (UC) would ultimately require colectomy for medically refractory UC or UC-associated neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for these patients. However, this procedure does not completely abolish the risk for neoplasia of the pouch. The main risk factor for pouch neoplasia is a preoperative diagnosis of UC-associated dysplasia or cancer. Although the natural history and prognosis of pouch dysplasia are not clear, mortality associated with pouch cancer, once diagnosed, appears to be high. Conversely, not all pouch neoplasia follows the chronic inflammation-dysplasia-cancer sequence, which makes pouch endoscopy with biopsy, the current gold standard for surveillance, challenging. In addition, the findings that pouch neoplasia is not common and that pouch endoscopy still misses dysplasia lead to controversy on the need and time interval of routine endoscopic surveillance. However, based on reports in the literature and their own experience, the authors recommend surveillance endoscopy to be performed in patients at risk, such as those with a precolectomy diagnosis of UC-associated neoplasia. This review appraises issues in the prevalence and incidence, risk factors, technical aspects of pouch construction, clinical and pathological features, natural history, surveillance examination, diagnosis, and management of pouch neoplasia.

Complications of ileoanal pouches

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical therapy of choice for patients with chronic ulcerative colitis and the majority of patients with familial adenomatous polyposis. It restores gastrointestinal continuity, re-establishes transanal defecation, and avoids a permanent stoma. Although this technically demanding procedure is associated with low mortality rates, it is frequently accompanied by early and late complications. This article will review these complications and discuss the interventions that are needed to provide appropriate treatment.

Guide to endoscopy of the ileo-anal pouch following restorative proctocolectomy with ileal pouch-anal anastomosis; indications, technique, and management of common findings

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the surgical procedure of choice for patients with ulcerative colitis (UC). It is also performed in selected patients with familial adenomatous polyposis (FAP). A significant proportion of patients will develop pouch dysfunction. Flexible pouchoscopy is the most important initial investigation in patients with dysfunction. It is also important in UC and FAP surveillance. The aim is to provide gastroenterologists with a clear understanding of the technique, indications, and diagnostic pitfalls when investigating RPC patients with flexible pouchoscopy. Flexible pouchoscopy for the investigation of RPC patients with pouch dysfunction has a high diagnostic yield, with most causes of pouch dysfunction identifiable during this procedure. The risk of developing dysplasia following RPC is low. Surveillance pouchoscopy is only recommended in those with FAP, those with a previous history of dysplasia or carcinoma, primary sclerosing cholangitis, those with a retained rectal cuff, and those with Type C histological changes. Flexible pouchoscopy is a useful first-line investigation in patients with pouch dysfunction. It can be performed without sedation and has a high diagnostic yield; it is also important as part of surveillance in FAP and selected UC patients.

Anal transition zone in the surgical management of ulcerative colitis

Preservation of the anal transition zone has long been a significant source of controversy in the surgical management of ulcerative colitis. The two techniques for restorative proctocolectomy and ileal pouch anal anastomosis (RPC IPAA) in common practice are a stapled anastomosis and a handsewn anastomosis; these techniques differ in the amount of remaining rectal mucosa and therefore the presence of the anal transition zone following surgery. Each technique has advantages and disadvantages in long-term functional outcomes, operative and postoperative complications, and risk of neoplasia. Therefore, we propose a selective approach to performing a stapled RPC IPAA based on the presence of dysplasia in the preoperative endoscopic evaluation.

Ileal pouch dysfunction: diagnosis and management

Restorative proctocol ectomy is the elective surgical procedure of choice for most patients who have ulcerative colitis or familial adenomatous polyposis. This major advance has offered an alternative to permanent ileostomy in these patients.

Cost-effectiveness of quantitative fecal lactoferrin assay for diagnosis of symptomatic patients with ileal pouch-anal anastomosis

BACKGROUND AND AIMS

To assess cost-effectiveness of fecal lactoferrin (FL) as the initial diagnostic approach to symptomatic patients with ileal pouch-anal anastomosis (IPAA).

METHODS

Four competing strategies [empiric metronidazole therapy (txMTZ), initial pouch endoscopy with biopsy (testBiop), initial FL assay followed by metronidazole therapy (testFL+MTZ), and initial FL assay followed by pouch endoscopy and biopsy (testFL+Biop)] were modeled in a decision tree.

RESULTS

In the base-case, the average cost per patient was $241 for testFL+MTZ, $251 for txMTZ, $405 for testFL+Biop, and $431 for testBiop. The testBiop strategy had greater effectiveness compared with txMTZ but at an incremental cost of $158 per day. The txMTZ strategy was slightly more costly and minimally more effective than testFL+MTZ with an incremental cost effectiveness of just over $12 per day. However, the testFL+MTZ strategy was associated with a 31% absolute reduction in antibiotic exposure compared with the txMTZ strategy.

CONCLUSIONS

Compared with empiric metronidazole therapy, FL before treatment with metronidazole is less costly with less exposure to antibiotics and less need for endoscopy, with only marginal decrease in effectiveness.

Comprehensive pouch clinic concept for follow-up of patients after ileal pouch anal anastomosis: report of 3 years' experience in a tertiary referral center

BACKGROUND

We designed and evaluated a novel concept in enhancing postoperative care of patients following restorative proctocolectomy (RPC) for ulcerative colitis (UC) and determined the risk factors, incidence, and nature of RPC-associated complications in this population.

METHODS

The study cohort consisted of consecutive UC patients post-RPC attending a comprehensive pouch clinic run by a gastroenterologist and a colorectal surgeon in a tertiary care medical center (from January 2003 to December 2005). Data were collected on their medical history, physical examination, laboratory tests, pouch endoscopy and biopsies, and anonymous in-house patient satisfaction questionnaires mailed to the first 90 patients. Assessment was also done on data regarding risk factors, incidence, and nature of RPC-associated complications.

RESULTS

A total of 120 UC patients with a functioning pouch visited the clinic: mean age 37 years, range 13-75; 57 males; mean disease duration 11 years; mean follow-up 65 months. Of the 55 patients who responded to the questionnaire, 48 (87%) felt that the comprehensive clinic significantly improved the quality of their care. The major complications were pouchitis (52%), extraintestinal manifestations, pouch-related fistula, and mechanical dysfunction. The risk factors for the development of pouchitis were time since surgery, >1-stage surgery, and reason for surgery (acute exacerbation/intractable disease more than dysplasia/cancer); the latter was the only independent risk factor.

CONCLUSIONS

The pouch clinic concept significantly enhanced patient satisfaction. The most common RPC-associated complication was pouchitis. Risk factors for developing pouchitis were duration since operation, >1-stage operation, and indication for surgery.

Review article: restorative proctocolectomy, indications, management of complications and follow-up--a guide for gastroenterologists

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for the majority of patients with ulcerative colitis who require surgery. Over 2500 patients in the UK have undergone restorative proctocolectomy. It is now increasingly being performed in district general hospitals as well as in specialist inflammatory bowel disease units. Gastroenterologists are increasingly involved in the management of patients following restorative proctocolectomy.

AIM

To provide gastroenterologists with a clear understanding of the investigation and evidence-based management of complications and the aftercare required in patients who have undergone restorative proctocolectomy.

RESULTS

Following restorative proctocolectomy, most patients have an excellent long-term functional outcome. Pouchitis, pelvic sepsis and poor function are the most common causes of failure. The development of cancer is rare; nevertheless, long-term follow-up is required.

CONCLUSIONS

The investigation and management of patients who develop complications require a multidisciplinary team approach to optimize the outcome. Protocols are suggested for investigation and management of patients with complications and for long-term cancer surveillance.

Preservation of the anal transition zone in ulcerative colitis. Long-term effects on defecatory function

INTRODUCTION

The anal transition zone (ATZ) after ileal pouch anal anastomosis (IPAA) for ulcerative colitis is considered at risk for dysplasia and persistent or recurrent disease activity. The long-term fate of the ATZ and the effects of histologic changes on defecatory function are not well-known.

METHODS

To evaluate the inflammatory and preneoplastic changes of the ATZ in patients without preoperative dysplasia, yearly biopsies of the ATZ were obtained and functional results recorded on a questionnaire/diary. Histologic changes were correlated with simultaneous assessment of defecatory function.

RESULTS

Between 1992 and 2006, 225 patients underwent a stapled IPAA. A total of 238 successful biopsies of the ATZ were performed. There was no dysplasia found. Acute inflammation was noted in 4.6%, chronic inflammation in 84.9%, and normal mucosa in 10.5% of cases. Patients with chronic inflammation reported an average of 6.2+/-1.7 bowel movements/day and 93.2% of them were able to delay a bowel movement for at least 30 min. The presence of chronic ATZ inflammation did not seem to have a negative impact on function, with 96.1% of patients reporting perfect continence, and only 5.3% using protective pads.

CONCLUSIONS

Preservation of the ATZ in selected patients is safe and offers excellent long-term functional results. New onset dysplasia was not noted. Chronic inflammation had limited clinical impact. Presence of ATZ inflammation in a total of 89.5% of patients warrants life-long surveillance with biopsies.

Use of a monoclonal antibody to sucrase-isomaltase for evaluation of the columnar cuff after stapled restorative proctocolectomy

PURPOSE

Restorative proctocolectomy with a double-stapled pouch-anal anastomosis retains a cuff of diseased columnar mucosa (columnar cuff) in the upper anal canal that may require biopsy. Biopsying this can be difficult and colonic phenotypic change in the pouch can lead to errors interpreting the histology. This study was designed to investigate the use of a monoclonal antibody to sucrase-isomaltase for differentiating ileal pouch from columnar cuff mucosa. Then, by using this antibody, the ability to accurately take and report biopsies from the anal canal was examined.

METHODS

The technique of staining for sucrase-isomaltase was developed. From 113 patients who had a double-stapled pouch-anal anastomosis, 467 formalin-fixed biopsies and 177 fresh-frozen biopsies were taken from the ileal pouch, columnar cuff, or anal transitional zone. Biopsies were stained with a monoclonal antibody to sucrase-isomaltase, and fixed biopsies were routinely reported after staining with hematoxylin and eosin.

RESULTS

A monoclonal antibody to sucrase-isomaltase reliably discriminated between ileal from rectal mucosa. A biopsy of columnar cuff mucosa as reported by routine histology was obtained during 72 percent of attempted outpatient examinations. Sucrase-isomaltase staining of reported columnar cuff biopsies showed that biopsies were of pouch rather than columnar cuff in 4.4 percent (95 percent confidence interval, 2-8) of outpatient examinations.

CONCLUSIONS

The monoclonal antibody to sucrase-isomaltase used in this study may have a clinical role when interpreting columnar cuff biopsies from patients being investigated for pouch dysfunction, or in patients having surveillance biopsies to exclude neoplasia in the columnar cuff.

Ileal pouch surgery for ulcerative colitis

Ulcerative colitis (UC) is a relapsing and remitting disease characterised by chronic mucosal and submucosal inflammation of the colon and rectum. Treatment may vary depending upon the extent and severity of inflammation. Broadly speaking medical treatments aim to induce and then maintain remission. Surgery is indicated for inflammatory disease that is refractory to medical treatment or in cases of neoplastic transformation. Approximately 25% of patients with UC ultimately require colectomy. Ileal pouch-anal anastomosis (IPAA) has become the standard of care for patients with ulcerative colitis who ultimately require colectomy. This review will examine indications for IPAA, patient selection, technical aspects of surgery, management of complications and long term outcome following this procedure.

Should ileal pouch-anal anastomosis include mucosectomy?

OBJECTIVE

Debate exists as to the benefits of performing mucosectomy as part of pouch surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Whilst mucosectomy results in a more complete removal of diseased mucosa, this benefit may be at the price of poorer function. We examined these issues.

METHOD

Using Medline, Embase, Ovid and Cochrane database searches papers were identified relating to the outcome following pouch surgery with and without mucosectomy. Potential reasons for functional problems were investigated, as were rates of 'cuffitis', dysplasia, polyposis and cancer in the ileal pouch and anal canal.

RESULTS

The available evidence suggests that performing a mucosectomy leads to a worse functional outcome. Meta-analysis suggested that nighttime seepage of stool and resting and squeeze pressure were worse after mucosectomy. The most likely reason for functional impairment following pouch surgery was the degree of anal manipulation. Mucosectomy does seem to confer benefit in terms of disease control but this benefit does not reach statistical significance.

CONCLUSION

Stapled anastomosis avoiding mucosectomy is the approach of choice for ileal pouch anal anastomosis because this leads to superior functional outcome. Performing mucosectomy results in some clinical benefits in terms of lower rates of inflammation and dysplasia in the retained mucosa in UC patients and lower rates of cuff polyposis in FAP patients. However, on the basis of available evidence mucosectomy is only indicated in those cases where the patient is at a high risk of disease in the retained rectal cuff.

Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis

OBJECTIVE

Restorative proctocolectomy (RPC) with or without mucosectomy is the treatment of choice for most patients with ulcerative colitis (UC) requiring surgery. The ileal mucosa in the reservoir and the anorectal columnar epithelium below the ileo-anal anastomosis are at risk of neoplastic transformation.

METHOD

The literature has been reviewed to identify patients developing this complication and an attempt has been made to develop a rational follow-up policy based on the data available.

RESULTS

Dysplasia in the ileal reservoir is rare. It is associated with histological type C changes, sclerosing cholangitis and unremitting pouchitis in the ileal mucosa and to the presence of sclerosing cholangitis. Nine patients who have developed adenocarcinoma in the residual anorectal mucosa and seven in the reservoir have been reported in the literature. A further hitherto unreported patient treated by the authors brings the total to 17 patients. Twelve of these had histopathological data on either dysplasia or carcinoma in the original operative specimen. The time intervals from the onset of UC and from the RPC to the development of cancer were 120-528 (median 246) and 16-216 (median 60) months respectively. Cancer appeared to be related to the duration of disease rather than to the interval from RPC. In all the reported patients the interval from the onset of UC was 10 years.

CONCLUSION

Based on these data a surveillance programme should begin at 10 years from the onset of disease. Patients with dysplasia or carcinoma in the original specimen, those with type C ileal mucosal changes and patients with sclerosing cholangitis should be selected for surveillance. This will involve multiple biopsies of the ileal reservoir and the anorectal mucosa below the ileo-anal anastomosis.

Diagnosis and treatment of ileal pouch diseases in patients with underlying ulcerative colitis

Ileal pouch-anal anastomosis (IPAA) after total proctocolectomy is the surgical treatment of choice for ulcerative colitis (UC) patients with medically refractory disease or dysplasia. IPAA significantly improves quality of life in UC patients who require surgery. However, certain inflammatory and noninflammatory diseases can develop after the surgery, including pouchitis, Crohn's disease (CD) of the pouch, cuffitis, and irritable pouch syndrome. The cause and pathogenesis of these disease conditions of IPAA are largely unknown. Accurate diagnosis and classification are important for appropriate management.

Revolution and evolution: 30 years of ileoanal pouch surgery

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

Clinical approach to diseases of ileal pouch-anal anastomosis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for ulcerative colitis (UC) patients with medically refractory disease or dysplasia. IPAA significantly improves quality of life in UC patients who require surgery. However, certain inflammatory and noninflammatory diseases can develop after the surgery, including pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome. The etiology and pathogenesis of these disease conditions of IPAA are largely unknown. Accurate diagnosis and classification are important for appropriate management. Endoscopic evaluation is the most important tool for the diagnosis and differential diagnosis.

Practice parameters for the surgical treatment of ulcerative colitis

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Pouchitis: a spectrum of diseases

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis patients who require surgery. Pouchitis is the most common long-term complication after IPAA. Patients with pouchitis represent a heterogeneous group in terms of pathogenesis, clinical presentation, disease course, and prognosis, suggesting a wide range of disease mechanisms. Before the diagnosis of pouchitis is made, other inflammatory and non-inflammatory disease conditions, such as Crohn's disease, cuffitis, and irritable pouch syndrome, should be ruled out. Pouch endoscopy is the most important tool for diagnosis and differential diagnosis. Accurate diagnosis and classification are essential for appropriate management. Although the majority of patients with pouchitis respond to antibiotic therapy, a subset of these patients cannot achieve remission by means of antibiotics and thus require anti-inflammatory or immunosuppressive treatment.

Persistence of high CD40 and CD40L expression after restorative proctocolectomy for ulcerative colitis

AIM: To focus on the role of CD40 and CD40L in their pathogenesis.

METHODS: We analyzed by immunohistochemistry the CD40 and CD40L expression in the pouch mucosa of 28 patients who had undergone RPC for UC, in the terminal ileum of 6 patients with UC and 11 healthy subjects. We also examined by flow cytometry the expression of CD40 by B lymphocytes and monocytes in the peripheral blood of 20 pouch patients, 15 UC patients and 11 healthy controls.

RESULTS: Ileal pouch mucosa leukocytes presented a significantly higher expression of CD40 and CD40L as compared to controls. This alteration correlated with pouchitis, but was also present in the healthy pouch and in the terminal ileum of UC patients. CD40 expression of peripheral B lymphocytes was significantly higher in patients with UC and pouch, respect to controls. Increased CD40 levels in blood B cells of pouch patients correlated with the presence of spondyloarthropathy, but not with pouchitis, or inflammatory indices.

CONCLUSION: High CD40 expression in the ileal pouch mucosa could be implied in the pathogenesis of pouchitis following proctocolectomy for UC, whereas its increased levels on peripheral blood B lymphocytes are associated with the presence of extraintestinal manifestations.

Salvage reoperation for complications after ileal pouch-anal anastomosis

BACKGROUND

Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis.

METHODS

Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients.

RESULTS

A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent.

CONCLUSION

Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.

Comprehensive evaluation of inflammatory and noninflammatory sequelae of ileal pouch-anal anastomoses

BACKGROUND AND AIMS

Ileal pouch-anal anastomosis (IPAA) improves quality of life (QOL) for ulcerative colitis patients who require surgery. Crohn's disease (CD) of the pouch, pouchitis, cuffitis, and irritable pouch syndrome (IPS) have an adverse impact on physical and psychological well-being, which can compromise the gain in QOL after the surgery. Their clinical, endoscopic, and histologic features have not been fully characterized. The aim of this study was to compare demographic, clinical, endoscopic, and histologic features between CD of the pouch, pouchitis, cuffitis, IPS, and normal pouches. METHODS We enrolled 124 patients: normal pouches (N = 26), CD of the pouch (N = 23), pouchitis (N = 22), cuffitis (N = 21), and IPS (N = 32). Symptomatology, endoscopy, histology, and the Cleveland Global QOL and the Irritable Bowel Syndrome-QOL scores were compared among the groups.

RESULTS

Univariate analysis of demographic and clinical data showed a possible association between NSAID use and pouchitis, extraintestinal manifestation and cuffitis, and antidepressant use and IPS. There were no differences in the Pouchitis Disease Activity Index symptom scores between the disease groups, with an exception of bleeding, which occurred almost exclusively in cuffitis. Endoscopy was useful in discriminating between CD of the pouch, pouchitis, cuffitis, and normal pouches or IPS. Patients with diseased IPAA had worse QOL scores.

CONCLUSIONS

Symptoms largely overlapped among the disease groups of IPAA. Endoscopy is valuable for diagnosis. Inflammatory or noninflammatory sequelae of IPAA adversely affected patients' QOL.

Treatment of rectal cuff inflammation (cuffitis) in patients with ulcerative colitis following restorative proctocolectomy and ileal pouch-anal anastomosis

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice in the majority of patients with ulcerative colitis (UC) who require surgery. To ease the construction of the IPAA and improve functional outcome by minimizing sphincter related stretch injury, a stapling technique is being commonly used in the pouch-anal anastomosis. Despite its advantages, the procedure normally leaves a 1-2 cm of anal transitional zone or rectal cuff, which is susceptible to recurrence of residual UC or cuffitis. Cuffitis can cause symptoms mimicking pouchitis.

AIM

To conduct an open-labeled trial of topical mesalamine in patients with cuffitis.

METHODS

We treated 14 consecutive patients with cuffitis by giving mesalamine suppositories 500 mg b.i.d. (mean 3.2 months, range 1-9 months). The Cuffitis Activity Index (adapted from the Pouchitis Disease Activity Index) scores and improvement in symptoms of bloody bowel movements and arthralgias were measured as primary and secondary outcomes.

RESULTS

All patients had surgery for medically refractory UC. There were significant reductions in the total Cuffitis Activity Index scores after the therapy (11.93 +/- 3.17 vs 6.21 +/- 3.19, p < 0.001). Symptom (3.24 +/- 1.28 vs 1.79 +/- 1.31), endoscopy (3.14 +/- 1.29 vs 1.00 +/- 1.52), and histology (4.93 +/- 1.77 vs 3.57 +/- 1.39) scores each were significantly reduced (p < 0.05). Ninety-two percent of patients with bloody bowel movements and 70% of patients with arthralgias improved after the therapy. No systemic or topical adverse effects were reported.

CONCLUSION

Topical mesalamine appears well tolerated and effective in treating patients with cuffitis, with improvement in symptom as well as endoscopic and histologic inflammation.

Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis

BACKGROUND & AIMS

Increased stool frequency, urgency, and abdominal pain in patients with ileal pouch-anal anastomosis (IPAA) may be due to inflammatory conditions, including pouchitis, cuffitis, or Crohn's disease or noninflammatory conditions such as irritable pouch syndrome. Distinction among these entities requires pouch endoscopy and biopsy. Noninvasive means of diagnosis are preferable.

METHODS

Sixty consecutive subjects with IPAA for inflammatory bowel disease had measurements of fecal lactoferrin and alpha1-antitrypsin and underwent pouch endoscopy with biopsy, with calculation of the pouchitis disease activity index in a prospective cross-sectional study.

RESULTS

Symptomatic patients with an inflammatory condition had significantly higher fecal lactoferrin concentrations (median, 176.0 microg/mL, interquartile range [IQR] 79.0-450.8) compared with those with a noninflammatory condition (median, 4.8 microg/mL; IQR, 1.2-11.0) or those who were asymptomatic (median, 7.8 microg/mL; IQR, 1.4-12.9), P < 0.001. At a cutoff level of 7 microg/mL, fecal lactoferrin could distinguish patients with irritable pouch syndrome from those with pouchitis, cuffitis, or Crohn's disease with a sensitivity of 100% and specificity of 85%. Fecal alpha1-antitrypsin was not able to distinguish symptomatic patients with and without an inflammatory condition.

CONCLUSIONS

Fecal lactoferrin can serve as a sensitive and noninvasive initial screening test in an algorithm for evaluation of symptomatic patients with IPAA. If fecal lactoferrin levels are low (<7 microg/mL), IPS can be diagnosed. If fecal lactoferrin levels are high, pouch endoscopy with biopsy is warranted to distinguish among different causes of inflammation. Longitudinal studies are needed to define better the role of this test in the management of patients with IPAA.

Patients with extraintestinal manifestations have a higher risk of developing pouchitis in ulcerative colitis: multivariate analysis

BACKGROUND

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) have been the surgical treatments of choice for ulcerative colitis (UC). However, the IPAA is sometimes complicated with pouchitis. Furthermore, the cumulative risk and risk factors for developing pouchitis in patients with UC undergoing IPAA have not been reported in any Asian population. The aim of our study is to clarify the cumulative risk and risk factors for developing pouchitis in Japanese patients with UC undergoing IPAA.

METHODS

Fifty-eight patients with UC undergoing IPAA were retrospectively evaluated for the presence of pouchitis, gender, age of onset, history of smoking, presence of extraintestinal manifestations (EIMs) and type of operation. The diagnosis of pouchitis was based on the pouchitis disease activity index. The cumulative risk and risk factors for developing pouchitis were assessed.

RESULTS

The cumulative risks for developing pouchitis at 1 and 5 years were 9.0% and 14.4%, respectively. The estimated risks of pouchitis at 5 years was 48.1% in patients with EIMs and 4.6% in those without. Both univariate and multivariate analyses revealed that the presence of EIMs is a significant risk factor (hazard ratio 16.85, 95% confidence interval 3.12-91.00; P=0.001).

CONCLUSIONS

The presence of EIMs is a significant risk factor for the development of pouchitis in Japanese patients with UC undergoing IPAA.