1. Crohn’s colitis patients can be offerred an ileoanal pouch
Feza H. Remzi, MD, FACS,FASCRS, FTSS ( Hon)
Chairman
Department of Colorectal Surgery
Rupert B. Turnbull Jr., MD Chair
Professor of Surgery
Digestive Disease Institute
Cleveland Clinic
Cleveland, OH

2. Disclosures
None

3. “If one can accept and live happily with a permanent ileostomy, trying to convince him/her to have an ileoanal pouch is a great disservice”

4. Surgical therapy for Crohn’s colitis
Extent of disease is an important consideration in determining the extent of bowel resection in Crohn’s disease (CD)
Based on the rectal involvement of Crohn’s colitis (CC), following procedures can be performed after a total procto /colectomy
An end ileostomy
A straight ileosigmoid or ileorectal anastomosis
An ileal pouch- anal anastomosis (IPAA)
An ileal pouch-rectal anastomosis (IPRA

5. Ileal pouch for Crohn’s colitis
An ileal pouch-rectal anastomosis (IPRA)

6. Short rectal stump Extensive colonic involvement Distal rectal sparing
Near total proctocolectomy
(TAC + proximal proctectomy)
straight IRA
permanent end ileostomy
ileal pouch/rectal anastomosis IPRA

7. Cleveland Clinic Experince N=23 patients
IPRA was associated with low perioperative morbidity.
Crohn’s disease recurred in most patients after IPRA.
Gastrointestinal continuity was established in 91% in 8 years follow-up.
Functional outcome and quality of life scores are good and comparable to straight ileorectal and ileosigmoid anastomosis.
IPRA is associated with high satisfaction rates with surgery, similar to SIRA.
Kariv et al JACS 2003

8. Conclusions
When Crohn’s proctocolitis necessitates total colectomy and the length of the rectal stump precludes straight IRA, Ileal Pouch-Rectal Anastomosis can be considered a viable alternative to permanent diversion.
IPRA offers good long term functional results and quality of life.

9. Ileal pouch for Crohn’s colitis
An ileal pouch- anal anastomosis (IPAA)

11. Results over 4000 IPAA Patients Cleveland Clinic Experience
97% patients said that they would undergo surgery again
97.4% patients stated that they would be willing to recommend surgery to other patients

12. Ileal pouch for Crohn’s colitis Ideal indication
Limited CD in the colorectum
Preoperative pathologic confirmation of diagnosis
No history of anoperineal CD
No evidence of anoperineal CD involvement
No evidence of small-bowel involvement by CD
Panis et al. Lancet 1996.

13. Ileal pouch for Crohn’s colitis indication
CD in the colorectum
Preoperative pathologic confirmation of diagnosis ????????
Limited evidence of anoperineal CD involvement; excluding rectovaginal fistula
No gross evidence of small-bowel involvement by CD

17. Ileal pouch for Crohn’s colitis
Intentional IPAA creation, in patients who had prior colectomy confirming the diagnosis = Preop
Patients undergoing two stage IPAA with apparent MUC or IndC and diagnosed with CD on the basis of postoperative histopathology = Postop
Diagnosed with CD months or years after their surgery on the basis of subsequent clinical course or histopathology = Delayed diagnosis
Melton et al. Ann Surg 2008

18. Predictors of pouch failure
Factor
Hazard ratio (95% CI)
P value
Age <30 yr
1.3 ( )
0.26
Delayed CD diagnosis
2.6 ( )
0.03
Mouth ulcer
1.9 ( )
0.17
3-stage IPAA
1.2 ( )
0.36
Prior anal fissure
1.5 ( )
0.13
Postoperative pouch-vaginal fistula
2.8 ( )
0.01
Postoperative perianal fistula
1.3 ( )
0.56
Pelvic sepsis
9.7( )
0.0001
Melton et al. Ann Surg 2008

19. Crohn’s and IPAA Cleveland Clinic Experience
204 patients, with median F/U 7.4 years
Preoperative diagnosis N= %
Postoperative diagnosis N= %
Delayed diagnosis N= %
Pouch retention rate 71 % ( 10 years)
Delayed diagnosis , pouchvaginal fistula and postoperative sepsis were associated with higher failure rates
Melton Ann Surg 2008

20. Cleveland Clinic Experience 10 years pouch survival rates
Preoperative diagnosis N= % %
Postoperative diagnosis N= % 87 %
Delayed diagnosis N= % 53 %
Pouch retention rate 71 % ( 10 years)
Melton Ann Surg 2008

21. Survival of IPAA in patients with CD
Melton et al. Ann Surg 2008

22. Survival of IPAA in patients with CD
Intentional CD (solid thin line), incidental CD pouch (dotted line), delayed diagnosis (solid thick line)
Melton et al. Ann Surg 2008

23. Ileal pouch for Crohn’s colitis
Carefully selected patients with CD undergoing primary restorative proctocolectomy with ileal pouch-anal anastomosis have low pouch loss and favorable functional results
Patients with presumed ulcerative colitis or indeterminate colitis diagnosed with CD from operative histopathology can expect similar good results
Outcomes in patients with delayed diagnosis are worse but approximately half retain their pouch at 10 years with good functional outcome

24. Ileal pouch for Crohn’s colitis
For patients, with good anal sphincter function and associated morbidity, facing definitive end-ileostomy
An ileal pouch can be a reasonable alternative keeping continence and gastrointestioanal tract continuity, even for a good period of time

25. None
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