1. Crohn’s Colitis Patients Should Never Be Offered an Ileoanal Pouch Asher Kornbluth, MD Clinical Professor of Medicine The Henry D. Janowitz Division of Gastroenterology The Icahn School of Medicine at Mount Sinai

2. Last Year’s Debate: 22 year old, Severe UC Failing 5 Days IV Steroids Their Position: Infliximab 5 mg/kg and subtotal colectomy if no improvement in 5 days

3. My Prior Debates: 22 year old, Severe UC Failing 5 Days IV Steroids Bedside Commode Start Kosher Diet

4. To Make

5. It Fair

6. For Our

7. Surgeon Friends

8. I’ll Try

9. To Speak

10. Slowly

11. And with only

12. 1 or

13. Maybe 2

14. Syllables

15. Per

16. Word

17. Problems with Pouches in Patients with Crohn’s disease The problem of symptoms The problem of local complications The problem of major complications The problem of pouch failure and excision

18. Problems with Pouches in Patients with Crohn’s disease The problem of symptoms The problem of local complications The problem of major complications The problem of pouch failure and excision

19. Increased symptoms in Crohn’s disease pouches Shen B, Am J Gastro 2005; 100: 93- 104

20. Increased symptoms in patients with pre- op perineal disease Richard et al, Dis Colon Rectum, 1997

21. Problems with Pouches in Patients with Crohn’s disease The problem of symptoms The problem of local complications The problem of major complications The problem of pouch failure and excision

24. Pouch Fistula in Crohn’s disease Shen, et al CGH 2008

25. Perianal complications in patients with pre-op Crohn’s disease Richard et al, Dis Colon Rectum, 1997

26. Fistula – Free Survival Analysis: IC-UC vs. IC-Crohn’s disease/Crohn’s disease Tekkis PP, et al. Colorectal Disease 2005; 7: 218

27. Problems with Pouches in Patients with Crohn’s disease The problem of symptoms The problem of local complications The problem of major complications The problem of pouch failure and excision

28. Meta Analysis: Major Complications of the Pouch in Patients with Crohn’s disease

29. Meta Analysis of Crohn’s disease pouch outcomes: Highest quality series Reese GE, et al. Dis Colon Rectum 2007; 50:239

30. Meta Analysis of Crohn’s disease pouch outcomes: More Recent Series Reese GE, et al. Dis Colon Rectum 2007; 50:239

31. Meta Analysis of Crohn’s disease pouch outcomes: Most experienced surgeons Reese GE, et al. Dis Colon Rectum 2007; 50:239

32. Problems with Pouches in Patients with Crohn’s disease The problem of symptoms The problem of local complications The problem of major complications The problem of pouch failure and excision

33. Pouch Failure Rate: Crohn’s disease vs. UC Brown CR, et al. Dis Colon Rectum 2005; 48: 1542

34. Pouch Survival: IC-UC vs. IC- Crohn’s disease, or CD Tekkis PP, et al. Colorectal Disease 2005; 7: 218

35. Risk factors for pouch failure: The Cleveland Clinic experience Fazio VW, et al. Ann Surgery 2003; 4:238

36. Planned Ileoanal Pouches for Crohn’s disease: Conclusions Pre-operative diagnosis of Crohn’s disease increases postoperative complications –Pouch fistula –Pelvic sepsis –Pouch failure! Multivariate analysis controlling for other variables likewise predict pre-op Crohn’s disease as predictor of increased pouch failure rate Increased incidence of poor outcomes in Crohn’s disease pouches are more common even in the most experienced centers

37. Thank You For Your Attention