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J Crohns Colitis. 2019 Aug 14. pii: jjz146. doi: 10.1093/ecco-jcc/jjz146. [Epub ahead of print]

Long-term bowel function and fate of the ileal pouch after restorative proctocolectomy in patients with Crohn's disease. A systematic review with meta-analysis and metaregression.

Author information

1
Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy.
2
Section of Statistic, Department of Mental Health and Public Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy.
3
Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.
4
Department of Surgery and Cancer, Imperial College, London, UK.

Abstract

BACKGROUND AND AIMS:

Debate exists on whether IPAA can be safely offered to patients diagnosed with CD. Aim was to assess the outcome of ileal pouch anal anastomosis (IPAA) for Crohn's disease (CD) vs ulcerative colitis (UC).

METHODS:

PRISMA/MOOSE-compliant meta-analysis. Studies published between 1993 and 2018 were retrieved. Primary endpoints included complications. Secondary endpoints included functional outcome. The time of CD diagnosis was considered(intentional vs incidental IPAA).

RESULTS:

Eleven studies comprising 6770 patients(CD=352, UC=6418) were included, with 44-120 months of follow-up. Pouch fistulae were more common in CD (CDvs.UC; OR 6.08; P=0.0003,GRADE+++), as were strictures (OR 1.82; P=0.02,GRADE+++) and failure (OR 5.27; P<0.0001,GRADE++++). Compared with UC, postoperative CD diagnosis was associated with much higher risk of fistulae(OR 6.23; P=0.006,GRADE+++) and failure(OR 8.53; P<0.0001,GRADE++++) than intentional IPAA in CD(fistula:OR 4.17; P=0.04,GRADE+++; failure:OR 2.48; P=0.009,GRADE++++). Age at surgery was positively associated with failure in CD(P=0.007). Obstruction was more common after intentional IPAA for CD. The risk of pouchitis did not differ between CD and UC(OR 1.07, P=0.76,GRADE+++). CD patients were at higher risk of seepage (OR 2.27; P = 0.010,GRADE++).

CONCLUSIONS:

Patients with CD have 5-fold higher risk of failure, and 2-fold risk of strictures after IPAA compared with UC. The risk is much higher if diagnosis was performed after IPAA. Function in those who retain the pouch seemed similar to that of patients with UC. CD does not increase the risk of pouchitis. IPAA could be offered to a selected population of CD patients after proper preoperative counselling.(PROSPERO registry 116811).

KEYWORDS:

IPAA; crohn’s disease; ileoanal pouch; pouch; restorative proctocolectomy; ulcerative colitis

PMID:
31412119
DOI:
10.1093/ecco-jcc/jjz146

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