P0406 Complications after ileal pouch-anal anastomosis in patients with Ulcerative Colitis and primary sclerosing cholangitis
Authors: Simonič J , Simonič P , Bislenghi G , D’Hoore A , Verstockt B , Ferrante M , Vermeire S , Sabino J 
Published: January 2025

Abstract

Background
Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a common treatment approach for patients with primary sclerosing cholangitis (PSC) and medically refractory ulcerative colitis (UC) or colorectal dysplasia. Patients with PSC-UC are more likely to experience pouchitis, chronic pouchitis and pouch failure than patients with UC alone (1, 2). The aim of retrospective study is to compare rates of pouch complications and need for biologics in UC IPAA patients with and without PSC.

Methods
We performed a retrospective cohort study of patients who underwent IPAA surgery between March 2015 and February 2024 at our tertiary referral centre. According to the internal hospital protocol, pouchoscopies and clinical examination were performed 1, 3, 6, and 12 months after restoration of the faecal stream. Demographics, comorbidities, pouchitis frequency (as by clinician assessment), laboratory tests and medication use were collected from the electronic medical records and compared between groups for the first year following IPAA surgery, and at last follow-up. Descriptive and univariate analyses was performed. Fisher’s exact test was used to compare frequency of pouch complications (pouchitis, need for biologics and pouch failure) between PSC-UC and UC group.

Results
In our cohort there were 186 patients with UC that underwent IPAA surgery, among them 14 (7.5%) with concomitant PSC. After a similar follow-up between both groups (p=0.99), patients with PSC-UC compared with UC only were more likely to develop pouchitis at any given timepoint, month 1 (n=173: 14.3% vs 10.7 %, p=0.65), month 3 (n=149: 36.4% vs 16.7 %, p=0.11), month 6 (n=154: 25% vs 22.5%, p=1.0), month 12 (n=144: 41.7% vs 18.9%, p=0.13). By month 12, 92.9% of PSC-UC patients had developed pouchitis compared to 61.0% in the UC only group (n= 178, RR 1.52, 95% confidence interval (CI) 0.19-11.92, p=0.02) Fig 1. After a median follow-up of 24 months, the need for biologics in PSC-UC group tended to be higher (n=163: 30.8% vs 12.7%, RR 2.43, 95% confidence interval (CI) 0.68-8.66, p=0.09). Pouch failure tended to occur more frequent in the PSC-UC group (n= 163: 7.7% vs 4.0%, RR 1.92, 95% confidence interval (CI) 0.21-17.31, p=0.45).

Conclusion
Percentage of patients with at least one episode of pouchitis in the first year after IPAA surgery was significantly higher in UC-PSC group. Additionally, patients with PSC-UC after IPAA surgery appear to be at higher risk for pouch complications, such as pouchitis, the need for biologics and pouch failure, however statistical significance was not achieved due to a low sample size in UC-PSC group.

References
(1)Barnes EL, Holubar SD, Herfarth HH. Systematic review and meta-analysis of outcomes after ileal pouch-anal anastomosis in primary sclerosing cholangitis and ulcerative colitis. J Crohns Colitis. 2021;15(8):1272-1278. doi:10.1093/ecco-jcc/jjab025
(2)Quinn KP, Urquhart SA, Janssens LP, Lennon RJ, Chedid VG, Raffals LE. Primary sclerosing cholangitis-associated pouchitis: A distinct clinical phenotype. Clin Gastroenterol Hepatol. 2022;20(5): e964-e973. doi: 10.1016/j.cgh.2021.02.006