Fate of the pouch in 151 pediatric patients after ileal pouch anal anastomosis

Abstract

Background/purpose: Ileal pouch anal anastomosis (IPAA) offers many pediatric patients a surgical cure for mucosal ulcerative colitis (MUC) with preservation of anal continence. However, some patients incur serious problems after surgery including chronic pouchitis and pouch failure. The goal of this study is to identify clinical and pathologic factors that are associated with an adverse outcome of IPAA.

Methods: A retrospective analysis of outcome was performed in 151 consecutive patients < or = 21 years of age who underwent IPAA with a mean follow-up of 7.24 years (range, 2 to 15 years). Patients were categorized into 4 outcome groups: A, no pouchitis; B, mild, acute pouchitis; C, chronic refractory pouchitis; and D, pouch failure. Pairwise comparisons were used to test the association between the groups and clinical and pathologic variables including age, sex, duration of symptoms, perianal disease, colonoscopic histology, terminal ileitis, operation type, staged versus unstaged IPAA, colonic specimen histology, early postoperative complications defined as less than 31 days postsurgery, late postoperative complications defined as 31 or more days postsurgery, and pouch fistulae. Crohn's disease as a definitive diagnosis and indeterminant colitis, a histologic diagnosis, also were tested for association with the above variables and outcome groups.

Results: One hundred and fifty-one pediatric patients underwent IPAA utilizing mucosectomy and hand-sewn S or J (n = 44) and stapled J or S-W anastomosis (n = 107) with 0% mortality rate and outcome as follows: group A, n = 54; group B, n = 73; group C, n = 11; group D, n = 13. Variables strongly associated with poor outcome, groups C and D, were duration of symptoms (P =.03), perianal disease (P =.03), late complications (P <.001), pouch fistulae (P <.001), and Crohn's disease (P <.0001). Furthermore, Crohn's disease was associated strongly with female gender (P =.01), perianal disease (P =.004), early (P =.006) and late (P <.001) complications, and pouch fistula (P <.001). The findings of indeterminant colitis, terminal ileitis, and early postoperative complications did not show significant differences between the 4 outcome groups.

Conclusions: Crohn's disease appears to be an important determinant of postoperative complications, chronic pouchitis, and pouch failure and occurred in 15% of the authors' patients after IPAA. Indeterminant colitis and the intraoperative findings of terminal ileitis are not associated with Crohn's disease or adverse outcome after IPAA in pediatric patients. Operation type and stage do not alter the clinical course after IPAA in pediatric patients.