Current Treatment Options in Gastroenterology

, Volume 16, Issue 3, pp 275–288 | Cite as

Outcomes and Management of the Ileal Pouch-Anal Anastomosis in the Elderly

  • James Q. Zhou
  • Sean Michael Duenas
  • Tarik Kirat
  • Feza Remzi
  • Shannon ChangEmail author
Intractable Disease in the Elderly: When Conventional Therapy Fails (S Katz, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Intractable Disease in the Elderly: When Conventional Therapy Fails


Purpose of Review

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients undergoing colectomy to maintain intestinal continuity. Earlier studies have suggested that outcomes are worse in elderly patients who underwent IPAA. However, more recent reports have shown that IPAA outcomes in the elderly are comparable to younger patients. We review the recent medical literature regarding outcomes and treatments for common complications in elderly IPAA patients.

Recent Findings

Compared to younger patients, IPAA in the elderly is not associated with increased major surgical complications, but is associated with increased length of stay and re-admission rate for dehydration in older patients. Rates of fecal incontinence after IPAA were similar between younger and older patients. Sacral nerve stimulation has shown early promise as a possible treatment for fecal incontinence after IPAA, but more research is needed. Pouchitis is a common complication, and antibiotics remain first-line treatment options. Other treatment options include mesalamines, steroids, immunomodulators, and biologics. The efficacy of newer biologics such as vedolizumab and ustekinumab has been reported, but more data is needed.


IPAA is safe in the elderly with high self-reported patient satisfaction. However, the elderly IPAA patient warrants special consideration regarding outcomes and management.


Ileal pouch-anal anastomosis Pouchitis Elderly Fecal incontinence Biologics 


Compliance with Ethical Standards

Conflict of Interest

James Q. Zhou declares that he has no conflict of interest.

Sean Michael Duenas declares that he has no conflict of interest.

Tarik Kirat declares that he has no conflict of interest.

Feza Remzi declares that he has no conflict of interest.

Shannon Chang declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978;2:85–8.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Shen B. Pouchitis: what every gastroenterologist needs to know. Clin Gastroenterol Hepatol. 2013;11(12):1538–49. Scholar
  3. 3.
    •• Chang S, Shen B, Remzi F. When not to pouch: important considerations for patient selection for ileal pouch-anal anastomosis. Gastroenterology & Hepatology. 2017;13(8):466–75. Comprehensive overview of important patient selection criteria for IPAA.Google Scholar
  4. 4.
    Nimmons D, Limdi JK. Elderly patients and inflammatory bowel disease. World J Gastrointest Pharmacol Ther. 2016;7(1):51–65. Scholar
  5. 5.
    Cosnes J, Gower-Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology. 2011;140(6):1785–94. Scholar
  6. 6.
    Katz S, Pardi DS. Inflammatory bowel disease of the elderly: frequently asked questions (FAQs). Am J Gastroenterol. 2011;106(11):1889–97. Scholar
  7. 7.
    Gisbert JP, Chaparro M. Systematic review with meta-analysis: inflammatory bowel disease in the elderly. Aliment Pharmacol Ther. 2014;39(5):459–77. Scholar
  8. 8.
    •• Ananthakrishnan AN, Donaldson T, Lasch K, Yajnik V. Management of inflammatory bowel disease in the elderly patient: challenges and opportunities. Inflamm Bowel Dis. 2017;23(6):882–93. Overview of IPAA and treatment options for IBD.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Farouk R, Pemberton JH, Wolff BG, Dozois RR, Browning S, Larson D. Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis. Ann Surg. 2000;231(6):919–26. Scholar
  10. 10.
    Pellino G, Sciaudone G, Candilio G, Camerlingo A, Marcellinaro R, Rocco F, et al. Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly. BMC Surg. 2013;13(Suppl 2):S9. Scholar
  11. 11.
    Cohen JL, Strong SA, Hyman NH, Buie WD, Dunn GD, Ko CY, et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2005;48(11):1997–2009. Scholar
  12. 12.
    Magro F, Gionchetti P, Eliakim R, Ardizzone S, Armuzzi A, Barreiro-de Acosta M, et al. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders. J Crohns Colitis. 2017;11(6):649–70. Scholar
  13. 13.
    Lightner AL, Mathis KL, Dozois EJ, Hahnsloser D, Loftus EV Jr, Raffals LE, et al. Results at up to 30 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Inflamm Bowel Dis. 2017;23(5):781–90. Scholar
  14. 14.
    Ross H, Steele SR, Varma M, Dykes S, Clima R, Buie WD, et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2014;57(1):5–22. Scholar
  15. 15.
    • Ananthakrishnan AN, Shi HY, Tang W, Law CC, Sung JJ, Chan FK, et al. Systematic review and meta-analysis: phenotype and clinical outcomes of older-onset inflammatory bowel disease. J Crohns Colitis. 2016;10(10):1224–36. Comprehensive overview of outcomes in older-onset IBD. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Delaney CP, Fazio VW, Remzi FH, Hammel J, Church JM, Hull TL, et al. Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg. 2003;238(2):221–8. Scholar
  17. 17.
    • Colombo F, Sahami S, de Buck Van Overstraeten A, Tulchinsky H, Mege D, Dotan I, et al. Restorative proctocolectomy in elderly IBD patients: a multicentre comparative study on safety and efficacy. J Crohns Colitis. 2017;11(6):671–9. Multicenter, retrospective study assessing safety of IPAA in elderly.PubMedCrossRefGoogle Scholar
  18. 18.
    Pinto RA, Canedo J, Murad-Regadas S, Regadas SF, Weiss EG, Wexner SD. Ileal pouch-anal anastomosis in elderly patients: is there a difference in morbidity compared with younger patients? Color Dis. 2011;13(2):177–83. Scholar
  19. 19.
    Bollegala N, Jackson TD, Nguyen GC. Increased postoperative mortality and complications among elderly patients with inflammatory bowel diseases: an analysis of the National Surgical Quality Improvement Program Cohort. Clin Gastroenterol Hepatol. 2016;14(9):1274–81. Scholar
  20. 20.
    Kaplan GG, Hubbard J, Panaccione R, Shaheen AAM, Quan H, Nguyen GC, et al. Risk of comorbidities on postoperative outcomes in patients with inflammatory bowel disease. Arch Surg. 2011;146(8):959–64. Scholar
  21. 21.
    Cohan JN, Bacchetti P, Varma MG, Finlayson E. Outcomes after ileoanal pouch surgery in frail and older adults. J Surg Res. 2015;198(2):327–33. Scholar
  22. 22.
    •• Ramage L, Qiu S, Georgiou P, Tekkis P, Tan E. Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review. Int J Color Dis. 2016;31(3):481–92. Comprehensive analysis of functional outcomes of IPAA in elderly patients with different age cutoffs.CrossRefGoogle Scholar
  23. 23.
    Bauer JJ, Gorfine SR. Complications of restorative proctocolectomy with ileal pouch-anal anastomosis. Mount Sinai Expert Guides: Gastroenterology. Chichester: John Wiley & Songs, Ltd; 2015.Google Scholar
  24. 24.
    Chapman JR, Larson DW, Wolff BG, Dozois EJ, Cima RR, Pemberton JH, et al. Ileal pouch-anal anastomosis. Does age at the time of surgery affect outcome? Arch Surg. 2005;140:534–40.CrossRefPubMedGoogle Scholar
  25. 25.
    Bach SP, Mortensen NJM. Revolution and evolution: 30 years of ileoanal pouch surgery. Inflamm Bowel Dis. 2006;12(2):131–45. Scholar
  26. 26.
    Gearhart SL, Hull TL, Schroeder T, Church J, Floruta C. Sphincter defects are not associated with long-term incontinence following ileal pouch-anal anastomosis. Dis Colon Rectum. 2005;48(7):1410–5. Scholar
  27. 27.
    Dayton MT, Larsen KR. Should older patients undergo ileal pouch-anal anastomosis? Am J Surg. 1996;172:444–8.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Wasmuth HH, Trano G, Midtgard TM, Wibe A, Endreseth BH, Myrvold HE. Long-term function after ileal pouch-anal anastomosis—function does not deteriorate with time. Color Dis. 2010;12(10 Online):e283–90. Scholar
  29. 29.
    Kiran RP, El-Gazzaz G, Remzi FH, Church JM, Lavery IC, Hammel J, et al. Influence of age at ileoanal pouch creation on long-term changes in functional outcomes. Color Dis. 2011;13(2):184–90. Scholar
  30. 30.
    Hahnloser D, Pemberton JH, Wolff BG, Larson DR, Crownhart BS, Dozois RR. The effect of ageing on function and quality of life in ileal pouch patients. Trans Meet Am Surg Assoc. 2004;122:213–221.
  31. 31.
    Kirat HT, Remzi FH, Kiran RP, Fazio VW. Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery. 2009;146(4):723–9; discussion 9-30. Scholar
  32. 32.
    •• Kong E, Nikolaou S, Qiu S, Pellino G, Tekkis P, Kontovounisios C. A systematic review of sacral nerve stimulation for faecal incontinence following ileal pouch anal anastomosis. Updat Surg. 2017;70:1–5. Comprehensive analysis of all currently available literature on SNS for treatment fecal incontinence after IPAA.CrossRefGoogle Scholar
  33. 33.
    Meurette G, Wong M, Paye F, Parc Y, Tiret E, Lehur PA. Sacral nerve stimulation for the treatment of faecal incontinence after ileal pouch anal anastomosis. Color Dis. 2011;13(7):e182–3. Scholar
  34. 34.
    Lebas A, Rogosnitzky M, Chater C, Colombel JF, Nachury M, Cortot A, et al. Efficacy of sacral nerve stimulation for poor functional results of J-pouch ileoanal anastomosis. Tech Coloproctol. 2014;18(4):355–60. Scholar
  35. 35.
    Mege D, Meurette G, Vitton V, Leroi AM, Bridoux V, Zerbib P, et al. Sacral nerve stimulation can alleviate symptoms of bowel dysfunction after colorectal resections. Color Dis. 2017;19(8):756–63. Scholar
  36. 36.
    Wall GC, Schirmer LL, Anliker LE, Tigges AE. Pharmacotherapy for acute pouchitis. Ann Pharmacother. 2011;45(9):1127–37. Scholar
  37. 37.
    Lipman JM, Kiran RP, Shen B, Remzi F, Fazio VW. Perioperative factors during ileal pouch-anal anastomosis predict pouchitis. Dis Colon Rectum. 2011;54(3):311–7. Scholar
  38. 38.
    Hata K, Ishihara S, Nozawa H, Kawai K, Kiyomatsu T, Tanaka T, et al. Pouchitis after ileal pouch-anal anastomosis in ulcerative colitis: diagnosis, management, risk factors, and incidence. Dig Endosc. 2017;29(1):26–34. Scholar
  39. 39.
    Shen B, Achkar J-P, Lashner BA, Ormsby AH, Remzi FH, Brzezinski A, et al. A randomized clinical trial of ciprofloxacin and metronidazole to treat acute pouchitis. Inflamm Bowel Dis. 2001;7(4):301–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Isaacs KL, Sandler RS, Abreu M, Picco MF, Hanauer SB, Bickston SJ, et al. Rifaximin for the treatment of active pouchitis: a randomized, double-blind, placebo-controlled pilot study. Inflamm Bowel Dis. 2007;13(10):1250–5. Scholar
  41. 41.
    Shen B, Remzi FH, Lopez AR, Queener E. Rifaximin for maintenance therapy in antibiotic-dependent pouchitis. BMC Gastroenterol. 2008;8:26. Scholar
  42. 42.
    Singh S, Stroud AM, Holubar SD, Sandborn WJ, Pardi DS. Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst Rev. 2015;11:CD001176. Scholar
  43. 43.
    John E, Katz K, Saxena M, Chokhavatia S, Katz S. Management of inflammatory bowel disease in the elderly. Curr Treat Options Gastroenterol. 2016;14(3):285–304. Scholar
  44. 44.
    Scaioli E, Sartini A, Liverani E, Digby RJ, Ugolini G, Rosati G, et al. Sulfasalazine in prevention of pouchitis after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Dig Dis Sci. 2017;62(4):1016–24. Scholar
  45. 45.
    Gisbert JP, Gonzalez-Lama Y, Mate J. 5-Aminosalicylates and renal function in inflammatory bowel disease: a systematic review. Inflamm Bowel Dis. 2007;13(5):629–38. Scholar
  46. 46.
    Gionchetti P, Rizzello F, Poggioli G, Pierangeli F, Laureti S, Morselli C, et al. Oral budesonide in the treatment of chronic refractory pouchitis. Aliment Pharmacol Ther. 2007;25(10):1231–6. Scholar
  47. 47.
    Sambuelli A, Boerr L, Negreira S, Gil A, Camartino G, Huernos S, et al. Budesonide enema in pouchitis—a double-blind, double-dummy controlled trial. Aliment Pharmacol Ther. 2002;16(1):27–34.CrossRefPubMedGoogle Scholar
  48. 48.
    Gionchetti P, Calabrese C, Calafiore A, Pratico C, Poggioli G, Laureti S, et al. Oral beclomethasone dipropionate in chronic refractory pouchitis. J Crohns Colitis. 2014;8(7):649–53. Scholar
  49. 49.
    Botoman VA, Bonner GF, Botoman DA. Management of inflammatory bowel disease. Am Fam Physician. 1998;57(1):57–68.PubMedGoogle Scholar
  50. 50.
    Tsironi E, Hadjidakis D, Mallas E, Tzathas C, Karamanolis DG, Ladas SD. Comparison of T- and Z-score in identifying risk factors of osteoporosis in inflammatory bowel disease patients. J Musculoskelet Neuronal Interact. 2008;8(1):79–84.PubMedGoogle Scholar
  51. 51.
    Tornatore KM, Logue G, Venuto RC, Davis PJ. Cortisol pharmacodynamics after methylprednisolone administration in young and elderly males. J Clin Pharmacol. 1997;37:304–11.CrossRefPubMedGoogle Scholar
  52. 52.
    Brown ES, Chandler PA. Mood and cognitive changes during systemic corticosteroid therapy. Prim Care Companion J Clin Psychiatry. 2001;3(1):17–21.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Juneja M, Baidoo L, Schwartz MB, Barrie A 3rd, Regueiro M, Dunn M, et al. Geriatric inflammatory bowel disease: phenotypic presentation, treatment patterns, nutritional status, outcomes, and comorbidity. Dig Dis Sci. 2012;57(9):2408–15. Scholar
  54. 54.
    Dharmasiri S, Johnson H, McLaughlin S, Weaver S. Azathioprine in the elderly—is it tolerated and safe? J Crohns Colitis. 2014;8(Supplement 1):S1. Scholar
  55. 55.
    Toruner M, Loftus EV Jr, Harmsen WS, Zinsmeister AR, Orenstein R, Sandborn WJ, et al. Risk factors for opportunistic infections in patients with inflammatory bowel disease. Gastroenterology. 2008;134(4):929–36. Scholar
  56. 56.
    Naganuma M, Kunisaki R, Yoshimura N, Takeuchi Y, Watanabe M. A prospective analysis of the incidence of and risk factors for opportunistic infections in patients with inflammatory bowel disease. J Gastroenterol. 2013;48(5):595–600. Scholar
  57. 57.
    Beaugerie L, Brousse N, Bouvier AM, Colombel JF, Lemann M. Lymphoproliferative disorders in patients receiving thiopurines for inflammatory bowel disease: a prospective observational cohort study. Lancet. 2009;374(9701):1617–25. CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Khan N, Abbas AM, Lichtenstein GR, Loftus EV Jr, Bazzano LA. Risk of lymphoma in patients with ulcerative colitis treated with thiopurines: a nationwide retrospective cohort study. Gastroenterology. 2013;145(5):1007–15 e3. Scholar
  59. 59.
    Abbas AM, Almukhtar RM, Loftus EV Jr, Lichtenstein GR, Khan N. Risk of melanoma and non-melanoma skin cancer in ulcerative colitis patients treated with thiopurines: a nationwide retrospective cohort. Am J Gastroenterol. 2014;109(11):1781–93. Scholar
  60. 60.
    •• Huguet M, Pereira B, Goutte M, Goutorbe F, Dubois A, Bommelaer G, et al. Systematic review with meta-analysis: anti-TNF therapy in refractory pouchitis and Crohn’s disease-like complications of the pouch after ileal pouch-anal anastomosis following colectomy for ulcerative colitis. Inflamm Bowel Dis. 2018;24(2):261–8. Meta-analysis of studies assessing role of biologics for treatment of pouchitis.CrossRefPubMedGoogle Scholar
  61. 61.
    Segal JP, Ding NS, Worley G, McLaughlin S, Preston S, Faiz OD, et al. Systematic review with meta-analysis: the management of chronic refractory pouchitis with an evidence-based treatment algorithm. Aliment Pharmacol Ther. 2017;45(5):581–92. Scholar
  62. 62.
    Herfarth HH, Long MD, Isaacs KL. Use of biologics in pouchitis: a systematic review. J Clin Gastroenterol. 2015;49(8):647–54. Scholar
  63. 63.
    Calabrese C, Gionchetti P, Rizzello F, Liguori G, Gabusi V, Tambasco R, et al. Short-term treatment with infliximab in chronic refractory pouchitis and ileitis. Aliment Pharmacol Ther. 2008;27(9):759–64. Scholar
  64. 64.
    Molnar T, Farkas K, Nagy F, Wittmann T. Successful use of infliximab for treating fistulizing pouchitis with severe extraintestinal manifestation: a case report. Inflamm Bowel Dis. 2008;14(12):1752–3. Scholar
  65. 65.
    Yeates J, Rashid M. Successful long-term use of infliximab in refractory pouchitis in an adolescent. Gastroenterol Res Pract. 2010;2010:860394. Scholar
  66. 66.
    Akitake R, Nakase H, Tamaoki M, Ueno S, Mikami S, Chiba T. Modulation of Th1/Th2 balance by infliximab rescues postoperative occurrence of small-intestinal inflammation associated with ulcerative colitis. Dig Dis Sci. 2010;55(6):1781–4.CrossRefPubMedGoogle Scholar
  67. 67.
    Axelrad J, Bernheim O, Colombel JF, Malerba S, Ananthakrishnan A, Yajnik V, et al. Risk of new or recurrent cancer in patients with inflammatory bowel disease and previous cancer exposed to immunosuppressive and anti-tumor necrosis factor agents. Clin Gastroenterol Hepatol. 2016;14(1):58–64. Scholar
  68. 68.
    Bar F, Kuhbacher T, Dietrich NA, Krause T, Stallmach A, Teich N, et al. Vedolizumab in the treatment of chronic, antibiotic-dependent or refractory pouchitis. Aliment Pharmacol Ther. 2017;47:581–7. Scholar
  69. 69.
    Philpott J, Ashburn J, Shen B. Efficacy of vedolizumab in patients with antibiotic and anti-tumor necrosis alpha refractory pouchitis. Inflamm Bowel Dis. 2017;23(1):E5–6. Scholar
  70. 70.
    Schmid M, Frick JS, Malek N, Goetz M. Successful treatment of pouchitis with vedolizumab, but not fecal microbiota transfer (FMT), after proctocolectomy in ulcerative colitis. Int J Color Dis. 2017;32(4):597–8. Scholar
  71. 71.
    Coletta M, Paroni M, Caprioli F. Successful treatment with vedolizumab in a patient with chronic refractory pouchitis and primary sclerosing cholangitis. J Crohns Colitis. 2017;11(12):1507–8. Scholar
  72. 72.
    Mir F, Yousef MH, Partyka EK, Tahan V. Successful treatment of chronic refractory pouchitis with vedolizumab. Int J Color Dis. 2017;32(10):1517–8. Scholar
  73. 73.
    Bethge J, Meffert S, Ellrichmann M, Conrad C, Nikolaus S, Schreiber S. Combination therapy with vedolizumab and etanercept in a patient with pouchitis and spondylarthritis. BMJ Open Gastroenterol. 2017;4(1):e000127. Scholar
  74. 74.
    Tran-Minh ML, Allez M, Gornet JM. Successful treatment with ustekinumab for chronic refractory pouchitis. J Crohns Colitis. 2017;11(9):1156. Scholar
  75. 75.
    Peter J, Zeitz J, Stallmach A. Ustekinumab rescue therapy in a patient with chronic refractory pouchitis. J Crohns Colitis. 2018;
  76. 76.
    Pellino G, Sciaudone G, Candilio G, De Fatico GS, Landino I, Canonico S, et al. Restorative proctocolectomy with ileal pouch-anal anastomosis is safe and effective in selected very elderly patients suffering from ulcerative colitis. Int J Surg. 2014;12(Suppl 2):S56–S9. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • James Q. Zhou
    • 1
  • Sean Michael Duenas
    • 1
  • Tarik Kirat
    • 2
  • Feza Remzi
    • 2
  • Shannon Chang
    • 3
    Email author
  1. 1.Department of Internal MedicineNew York University Langone HealthNew YorkUSA
  2. 2.Division of Colorectal SurgeryNew York University Langone HealthNew YorkUSA
  3. 3.Division of Colorectal SurgeryNew York University Langone HealthNew YorkUSA

Personalised recommendations