Crohn’s colitis patients can be offerred an ileoanal pouch Feza H. Remzi, MD, FACS,FASCRS, FTSS ( Hon) Chairman Department of Colorectal Surgery Rupert B. Turnbull Jr., MD Chair Professor of Surgery Digestive Disease Institute Cleveland Clinic Cleveland, OH

Disclosures None

“If one can accept and live happily with a permanent ileostomy, trying to convince him/her to have an ileoanal pouch is a great disservice”

Surgical therapy for Crohn’s colitis Extent of disease is an important consideration in determining the extent of bowel resection in Crohn’s disease (CD) Based on the rectal involvement of Crohn’s colitis (CC), following procedures can be performed after a total procto /colectomy An end ileostomy A straight ileosigmoid or ileorectal anastomosis An ileal pouch- anal anastomosis (IPAA) An ileal pouch-rectal anastomosis (IPRA

Ileal pouch for Crohn’s colitis An ileal pouch-rectal anastomosis (IPRA)

Short rectal stump Extensive colonic involvement Distal rectal sparing Near total proctocolectomy (TAC + proximal proctectomy) straight IRA permanent end ileostomy ileal pouch/rectal anastomosis IPRA

Cleveland Clinic Experince N=23 patients IPRA was associated with low perioperative morbidity. Crohn’s disease recurred in most patients after IPRA. Gastrointestinal continuity was established in 91% in 8 years follow-up. Functional outcome and quality of life scores are good and comparable to straight ileorectal and ileosigmoid anastomosis. IPRA is associated with high satisfaction rates with surgery, similar to SIRA. Kariv et al JACS 2003

Conclusions When Crohn’s proctocolitis necessitates total colectomy and the length of the rectal stump precludes straight IRA, Ileal Pouch-Rectal Anastomosis can be considered a viable alternative to permanent diversion. IPRA offers good long term functional results and quality of life.

Ileal pouch for Crohn’s colitis An ileal pouch- anal anastomosis (IPAA)

Results over 4000 IPAA Patients Cleveland Clinic Experience 97% patients said that they would undergo surgery again 97.4% patients stated that they would be willing to recommend surgery to other patients

Ileal pouch for Crohn’s colitis Ideal indication Limited CD in the colorectum Preoperative pathologic confirmation of diagnosis No history of anoperineal CD No evidence of anoperineal CD involvement No evidence of small-bowel involvement by CD Panis et al. Lancet 1996.

Ileal pouch for Crohn’s colitis indication CD in the colorectum Preoperative pathologic confirmation of diagnosis ???????? Limited evidence of anoperineal CD involvement; excluding rectovaginal fistula No gross evidence of small-bowel involvement by CD

Ileal pouch for Crohn’s colitis Intentional IPAA creation, in patients who had prior colectomy confirming the diagnosis = Preop Patients undergoing two stage IPAA with apparent MUC or IndC and diagnosed with CD on the basis of postoperative histopathology = Postop Diagnosed with CD months or years after their surgery on the basis of subsequent clinical course or histopathology = Delayed diagnosis Melton et al. Ann Surg 2008

Predictors of pouch failure Factor Hazard ratio (95% CI) P value Age <30 yr 1.3 (0.8-3.1) 0.26 Delayed CD diagnosis 2.6 (1.1-6.5) 0.03 Mouth ulcer 1.9 (0.7-3.8) 0.17 3-stage IPAA 1.2 (0.8-1.8) 0.36 Prior anal fissure 1.5 (0.9-2.5) 0.13 Postoperative pouch-vaginal fistula 2.8 (1.3-6.4) 0.01 Postoperative perianal fistula 1.3 (0.6-2.6) 0.56 Pelvic sepsis 9.7(3.4-27.3) 0.0001 Melton et al. Ann Surg 2008

Crohn’s and IPAA Cleveland Clinic Experience 204 patients, with median F/U 7.4 years Preoperative diagnosis N=20 10% Postoperative diagnosis N=97 47% Delayed diagnosis N=87 43% Pouch retention rate 71 % ( 10 years) Delayed diagnosis , pouchvaginal fistula and postoperative sepsis were associated with higher failure rates Melton Ann Surg 2008

Cleveland Clinic Experience 10 years pouch survival rates Preoperative diagnosis N=20 10% 85 % Postoperative diagnosis N=97 47% 87 % Delayed diagnosis N=87 43% 53 % Pouch retention rate 71 % ( 10 years) Melton Ann Surg 2008

Survival of IPAA in patients with CD Melton et al. Ann Surg 2008

Survival of IPAA in patients with CD Intentional CD (solid thin line), incidental CD pouch (dotted line), delayed diagnosis (solid thick line) Melton et al. Ann Surg 2008

Ileal pouch for Crohn’s colitis Carefully selected patients with CD undergoing primary restorative proctocolectomy with ileal pouch-anal anastomosis have low pouch loss and favorable functional results Patients with presumed ulcerative colitis or indeterminate colitis diagnosed with CD from operative histopathology can expect similar good results Outcomes in patients with delayed diagnosis are worse but approximately half retain their pouch at 10 years with good functional outcome

Ileal pouch for Crohn’s colitis For patients, with good anal sphincter function and associated morbidity, facing definitive end-ileostomy An ileal pouch can be a reasonable alternative keeping continence and gastrointestioanal tract continuity, even for a good period of time

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