Background: Ileal pouch anal anastomosis (IPAA) after proctocolectomy for ulcerative colitis could be complicated by the prepouch ileitis (PI), a still unperceived condition which presents as an inflammation of the afferent limb of the pouch. Little is known about the onset of disease and the factors associated with more aggressive patterns and failure of treatments
Methods: From a prospectively mantained database of 1238 IPAA's performed in a single centre since 1985, all cases with a diagnosis PI were selected. Data concerning the outcomes of the IPAA, diagnosis and treatment of PI and long-term follow-up were compared between a subgroup of patients requiring surgery (SURG) or not (NOSURG) for the treatment of PI
Results: 59 patients (4.6% of IPAA) were included. 19 (32.2%) required surgery at some point. At the time of the IPAA a higher rate of extraintestinal diseases (27.8 vs 10%, p0.05) and ASA score 3 (21.4 vs 0%, p 0.01) were seen in SURG group. PI was diagnosed after 5 and 6.3 years from the IPAA in SURG and NOSURG groups (p 0.4). At diagnosis, SURG group had a higher rate of outlet obstruction (47.4 vs 2.7%). The endoscopy revealed a significantly higher rate of afferent limb stenosis (68.4 vs 33.3%, p 0.01) in the SURG group and of pouchitis (94.6 vs 68.4%, p 0.008) in the NOSURG one. SURG patients were more likely to receive steroids (77.8 vs 45.7%, p 0.02), anti TNF-alfa (44.4 vs 20%, p 0.05) than NOSURG patients, while a similar rate of patients had antibiotics, immunosuppressors or endoscopic treatment. Clinical and/or endoscopic response to antibiotics (0 vs 56.6%, p<0.001), steroids (7.1 vs 37.5%), immunosuppressors (0 vs 50%, p 0.02) or anti TNF-alfa (0 vs 50%, p 0.01) was significantly lower in SURG group. Only the endoscopic treatment had similar temporary success between groups (40 vs 66.6%, p 0.4).
In the SURG group, 10 partial ileal resections (52.6%), 4 ileostomies (21.1%), 2 pouch excisions (10.5%), 2 stricturoplasties (10.5%), 1 redo pouch (5.3%) were performed. The histological examination revealed Crohn's disease in 5 (31.2%) and non specific inflammation in 14 (68.8%) patients. Three (15.8%) patients had postoperative complications. After a median follow up time from PI diagnosis of 97 and 76 months (p 0.3), the 3, 5 and 10 year pouch failure rates in SURG and NOSURG groups were 12.2 vs 3.2%, 26.2 vs 4.2% and 45.3 vs 17.3%, respectively (p 0.007).
Conclusions: Prepouch ileitis occurs in about 5% of IPAA patients and is associated with Crohn's disease only in a minority of cases. A cospicuous rate of those patients require multiple medical and endoscopic treatments. Especially when a stricture persists, a lack of response to treatment usually leads to surgery and to a much higher chance of pouch failure.