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Long-term follow-up after ileoanal pouch procedure

Algorithm for diagnosis, classification, and management of pouchitis

  • Original Contributions
  • Published:
Diseases of the Colon & Rectum

Abstract

PURPOSE: Inflammation of the ileoanal pouch (pouchitis) is one of the main complications after restorative proctocolectomy, yet its cause remains poorly understood. A standardized definition and diagnostic procedures in pouchitis are lacking. METHOD: We analyzed all cases of pouchitis occurring in a group of 308 patients (210 with ulcerative colitis, 98 with familial adenomatous polyposis) who took part in a prospective long-term follow-up program. The severity of pouchitis was measured using a pouchitis activity score (Heidelberg Pouchitis Activity Score). An algorithm for the classification and management of pouchitis was established which enables the clinician: 1) to determine theseverity of pouchitis, 2) to differentiate betweenprimary pouchitis and pouchitis caused by surgical complications (secondary pouchitis), and 3) to evaluate the course (acute vs. chronic (>3 months)). RESULTS: The median duration of follow-up was 48 (range, 13–119) months. At least one episode of pouchitis was diagnosed in 29 percent of patients with ulcerative colitis and in 2 percent of familial adenomatous polyposis patients. Secondary pouchitis occurred in 6 percent of ulcerative colitis patients and was cured by surgical treatment in 13 (87 percent) of 15 cases. Primary pouchitis was diagnosed in 23 percent of ulcerative colitis patients, including 6 percent of all ulcerative colitis patients with chronic primary pouchitis. The latter showed poor response to medical treatment. In one case multifocal high-grade dysplasia occurred. Histologic examination of the excised pouch identified a carcinoma originating from the ileal mucosa. CONCLUSIONS: Ulcerative colitis patients after restorative proctocolectomy face a high risk of developing pouchitis. The algorithm used in this study was highly efficient in identifying patients with a secondary pouchitis who require surgical treatment and patients with chronic primary pouchitis. For the latter, long-term surveillance seems mandatory because of the risk of malignant transformation of the pouch mucosa.

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References

  1. Williams NS. Restorative proctocolectomy is the first choice elective surgical treatment for ulcerative colitis. Br J Surg 1989;76:1109–10.

    PubMed  Google Scholar 

  2. Ambroze WL Jr, Dozois RR, Pemberton JH, Beart RW Jr, Ilstrup DM. Familial adenomatous polyposis: results following ileal pouch-anal anastomosis and ileorectostomy. Dis Colon Rectum 1992;35:12–5.

    PubMed  Google Scholar 

  3. Sandborn WJ. Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis, and treatment. Gastroenterology 1994;107:1856–60.

    PubMed  Google Scholar 

  4. Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF. Pouchitis after ileal pouch-anal anastomosis: a pouchitis disease activity index. Mayo Clin Proc 1994;69:409–15.

    PubMed  Google Scholar 

  5. Kühbacher T, Schreiber S, Runkel N. Pouchitis: pathophysiology and treatment. Int J Colorectal Dis 1998;13:196–207.

    Article  PubMed  Google Scholar 

  6. Romanos J, Samarasekera DN, Stebbing JF, Jewell DP, Kettlewell MG, Mortensen NJ. Outcome of 200 restorative proctocolectomy operations: the John Radcliffe Hospital Clinical experience. Br J Surg 1997;84:814–8.

    Article  PubMed  Google Scholar 

  7. Järvinen HJ, Luukkonen P. Experience with restorative protocolectomy in 201 patients. Ann Chir Gynaecol 1993;82:159–64.

    PubMed  Google Scholar 

  8. Salesmans JM, Nagengast FM, Lubbers EJ, Kuijpers JH. Postoperative long-term results of ileal pouch-anal anastomosis for ulcerative colitis and familial polyposis coli. Dig Dis Sci 1992;37:1882–9.

    Article  PubMed  Google Scholar 

  9. Rauh SM, Schoetz DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Pouchitis—is it a wastebasket diagnosis? Dis Colon Rectum 1991;34:685–9.

    PubMed  Google Scholar 

  10. Dozois RR, Kelly KA, Welling DR,et al. Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis. Ann Surg 1989;210:268–73.

    PubMed  Google Scholar 

  11. Luukkonen P, Järvinen H, Tanskanen M, Kahri M. Pouchitis—recurrence of the inflammatory bowel disease? Gut 1994;35:243–6.

    PubMed  Google Scholar 

  12. Keränen U, Luukkonen P, Järvinen H. Functional results after restorative protocolectomy complicated by pouchitis. Dis Colon Rectum 1997;40:764–9.

    Article  PubMed  Google Scholar 

  13. Svaninger G, Nordgren S, Oresland T, Hultén L. Incidence and characteristics of pouchitis in the Kock continent ileostomy and the pelvic pouch. Scand J Gastroenterol 1993;28:695–700.

    PubMed  Google Scholar 

  14. Nicholls RJ, Banerjee AK. Pouchitis: risk factors, etiology, and treatment. World J Surg 1998;22:347–51.

    Article  PubMed  Google Scholar 

  15. Schmidt MC, Lazenby AJ, Hendrickson RJ, Sitzmann JV. Preoperative terminal ileal and colonic resection histology predicts risk of pouchitis in patients after ileoanal pull-through procedure. Ann Surg 1998;227:654–62.

    Article  PubMed  Google Scholar 

  16. Fonkalsrud EW, Phillips JD. Reconstruction of malfunctioning ileoanal pouch procedures as an alternative to permanent ileostomy. Am J Surg 1990;160:245–51.

    PubMed  Google Scholar 

  17. Madden MV, Farthing MJ, Nicholls RJ. Inflammation in ileal reservoirs: ‘pouchitis.’ Gut 1990;31:247–9.

    PubMed  Google Scholar 

  18. Fozard BJ, Pemberton JH. Results of pouch surgery after ileo-anal anastomosis: the implications of pouchitis. World J Surg 1992;16:880–4.

    Article  PubMed  Google Scholar 

  19. Chaussade S, Denizot Y, Valleur P,et al. Presence of PAF-acether in stool of patients with pouch ileoanal anastomosis and pouchitis. Gastroenterology 1991;100:1509–14.

    PubMed  Google Scholar 

  20. Levin KE, Pemberton JH, Phillips SF, Zinsmeister AR, Pezim ME. Role of oxygen free radicals in the etiology of pouchitis. Dis Colon Rectum 1992;35:452–6.

    Article  PubMed  Google Scholar 

  21. Clausen MR, Tvede M, Mortensen PB. Short-chain fatty acids in pouch contents from patients with and without pouchitis after ileal pouch-anal anastomosis. Gastroenterology 1992;103:1144–53.

    PubMed  Google Scholar 

  22. Breuer NF, Rampton DS, Tammar A, Murphy GM, Dowling RH. Effect of colonic perfusion with sulfated and nonsulfated bile acids on mucosal structure and function in the rat. Gastroenterology 1983;84:969–77.

    PubMed  Google Scholar 

  23. Sandborn WJ, McLeod R, Jewell DP. Medical therapy for induction and maintenance of remission in pouchitis: a systematic review. Inflamm Bowel Dis 1999;5:33–9.

    PubMed  Google Scholar 

  24. Gionchetti P, Rizzello F, Venturi A,et al. Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis. Aliment Pharmacol Ther 1999;13:713–8.

    Article  PubMed  Google Scholar 

  25. Scott AD, Phillips RK. Ileitis and pouchitis after colectomy for ulcerative colitis. Br J Surg 1989;76:668–9.

    PubMed  Google Scholar 

  26. Fleshman JW, Cohen Z, McLeod RS, Stern H, Blair J. The ileal reservoir and ileoanal anastomosis procedure. Factors affecting technical and functional outcome. Dis Colon Rectum 1988;31:10–6.

    PubMed  Google Scholar 

  27. Fischer JE, Nussbaum MS, Martin LW,et al. The pull-through procedure: technical factors in influencing outcome, with emphasis on pouchitis. Surgery 1993;114:828–35.

    PubMed  Google Scholar 

  28. Galandiuk S, Scott NA, Dozois RR,et al. Ileal pouchanal anastomosis. Reoperation for pouch-related complications. Ann Surg 1990;212:446–54.

    PubMed  Google Scholar 

  29. Belliveau P, Trudel J, Vasilevsky CA, Stein B, Gordon PH. Ileoanal anastomosis with reservoirs: complications and long-term results. Can J Surg 1999;42:345–52.

    PubMed  Google Scholar 

  30. Gullberg K, Stahlberg D, Liljeqvist L,et al. Neoplastic transformation of the pelvic pouch mucosa in patients with ulcerative colitis. Gastroenterology 1997;112:1487–92.

    PubMed  Google Scholar 

  31. Stern H, Walfisch S, Mullen B, McLeod R, Cohen Z. Cancer in an ileoanal reservoir: a new late complication? Gut 1990;31:473–5.

    PubMed  Google Scholar 

  32. Vieth M, Grunewald M, Niemeyer C, Stolte M. Adenocarcinoma in an ileal pouch after prior protocolectomy for carcinoma in a patient with ulcerative pancolitis. Virchows Arch 1998;433:281–4.

    Article  PubMed  Google Scholar 

  33. Veress B, Reinholt FP, Lindquist K, Löfberg R, Liljeqvist L. Long-term histomorphological surveillance of the pelvic ileal pouch: dysplasia develops in a subgroup of patients. Gastroenterology 1995;109:1090–7.

    Article  PubMed  Google Scholar 

  34. Moskowitz RL, Shepherd NA, Nicholls RJ. An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal reservoir. Int J Colorectal Dis 1986;1:167–74.

    Article  PubMed  Google Scholar 

  35. De Silva HJ, Millard PR, Kettlewell M, Mortensen NJ, Prince C, Jewell DP. Mucosal characteristics of pelvic ileal pouches. Gut 1991;32:61–5.

    PubMed  Google Scholar 

  36. Meagher AP, Farouk R, Dozois RR, Kelly DA, Pemberton JH. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 1998;85:800–3.

    Article  PubMed  Google Scholar 

  37. Fazio VW, Ziv Y, Church JM,et al. Ileal pouch-anal anastomosis complications and function in 1005 patients. Ann Surg 1995;222:120–7.

    PubMed  Google Scholar 

  38. Michelassi F, Stella M, Block GE. Prospective assessment of functional results after ileal J pouch-anal restorative protocolectomy. Arch Surg 1993;128:889–95.

    PubMed  Google Scholar 

  39. Lohmuller JL, Pemberton JH, Dozois RR, Ilstrup D, van Heerden J. Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis. Ann Surg 1990;211:622–9.

    PubMed  Google Scholar 

  40. Tytgat GN, van Deventer SJ. Pouchitis. Int J Colorectal Dis 1988;3:226–8.

    Article  PubMed  Google Scholar 

  41. Cox CL, Butts DR, Roberts MP, Wessels RA, Bailey HR. Development of invasive adenocarcinoma in a long-standing Kock continent ileostomy: report of a case. Dis Colon Rectum 1997;40:500–3.

    PubMed  Google Scholar 

  42. Shepherd NA. The pelvic ileal reservoir: apocalypse later? Patients need monitoring for the long term effects of reservoir construction. BMJ 1990;301:886–7.

    PubMed  Google Scholar 

  43. Thoeni RF, Fell SC, Engelstad B, Schrock TB. Ileoanal pouches: comparison of CT, scintigraphy, and contrast enemas for diagnosing surgical complications. AJR Am J Roentgenol 1990;154:73–8.

    PubMed  Google Scholar 

  44. Di Febo G, Miglioli M, Lauri. Aet al. Endoscopic assessment of acute inflammation of the ileal reservoir after restorative ileo-anal anastomosis. Gastrointest Endosc 1990;36:6–9.

    PubMed  Google Scholar 

  45. Setti Carraro P, Talbot IC, Nicholls RJ. Patterns of distribution of endoscopic and histological changes in the ileal reservoir after restorative proctocolectomy for ulcerative colitis. A long-term follow-up study. Int J Colorectal Dis 1998;13:103–7.

    Article  PubMed  Google Scholar 

  46. O'Connel, Rankin, Weiland LH, Kelly KA. Enteric bacteriology absorption, morphology and emptying after ileal pouch-anal anastomosis. Br J Surg 1986;73:909–14.

    PubMed  Google Scholar 

  47. Luukkonen P, Valtonen V, Sivonen A, Sipponen P, Järvinen H. Fecal bacteriology and reservoir ileitis in patients operated on for ulcerative colitis. Dis Colon Rectum 1988;31:864–7.

    PubMed  Google Scholar 

  48. Setti Carraro P, Talbot IC, Nicholls RJ. Longterm appraisal of the histological appearances of the ileal reservoir mucosa after restorative protocolectomy for ulcerative colitis. Gut 1994;35:1721–7.

    PubMed  Google Scholar 

  49. Stallmach A, Moser C, Hero-Gross R,et al. Pattern of mucosal adaptation in acute and chronic pouchitis. Dis Colon Rectum 1999;42:1311–7.

    Article  PubMed  Google Scholar 

  50. Hurst RD, Chung TP, Rubin M, Michelassi F. The implications of acute pouchitis on the long-term functional results after restorative protocolectomy. Inflamm Bowel Dis 1998;4:280–4.

    PubMed  Google Scholar 

  51. Libicher M, Scharf J, Wunsch S, Stern J, Düx M, Kauffmann G. MRI of pouch-related fistulas in ulcerative colitis after restorative proctocolectomy. J Comput Assist Tomogr 1998;22:664–8.

    Article  PubMed  Google Scholar 

  52. Hrung JM, Levine MS, Rombeau JL, Rubesin SE, Laufer I. Total protocolectomy and ileoanal pouch: the role of contrast studies for evaluating postoperative leaks. Abdom Imaging 1998;23:375–9.

    Article  PubMed  Google Scholar 

  53. Kmiot WA, Williams MR, Keighley MR. Pouchitis following colectomy and ileal reservoir construction for familial adenomatous polyposis. Br J Surg 1990;77:1283.

    PubMed  Google Scholar 

  54. Hurst RD, Molinar M, Chung TP, Rubin M, Michelassi F. Prospective study of the incidence, timing and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy. Arch Surg 1996;131:497–502.

    PubMed  Google Scholar 

  55. Sandborn WJ, Landers CJ, Tremaine WJ, Targan SR. Antineutrophil cytoplasmic antibody correlates with chronic pouchitis after ileal pouch-anal anastomosis. Am J Gastroenterol 1995;90:740–7.

    PubMed  Google Scholar 

  56. Becker JM, Raymond JL. Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases. Ann Surg 1986;204:375–83.

    PubMed  Google Scholar 

  57. Van Duijvendijk P, Slors FM, Taat CW, Oosterveld P, Vasen HF. Functional outcome after colectomy and ileorectal anastomosis compared with proctocolectomy and ileal pouch-anal anastomosis in familial adenomatous polyposis. Ann Surg 1999;230:648–54.

    Article  PubMed  Google Scholar 

  58. Kartheuser AH, Pare R, Penna CP,et al. Ileal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: a ten-year experience. Surgery 1996;119:615–23.

    PubMed  Google Scholar 

  59. Penna C, Dozois RR, Tremaine W,et al. Pouchitis after ileal pouch anal anastomosis for chronic ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis. Gut 1996;38:234–9.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Pathology, University of Heidelberg, Heidelberg, Germany

    F. Autschbach M.D. & T. Uehlein

  2. Department of Surgery, University of Heidelberg, Kirschnerstrasse 1, 69120, Heidelberg, Germany

    U. A. Heuschen M.D., E. H. Allemeyer M.D., A. M. Zöllinger M.D., G. Heuschen M.D., Ch. Herfarth M.D. & J. Stern M.D.

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  1. U. A. Heuschen M.D.
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  2. F. Autschbach M.D.
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Heuschen, U.A., Autschbach, F., Allemeyer, E.H. et al. Long-term follow-up after ileoanal pouch procedure. Dis Colon Rectum 44, 487–499 (2001). https://doi.org/10.1007/BF02234320

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