Ileal Pouch-anal Anastomosis for Ulcerative Colitis: 30-year Analysis on Surgical Evolution and Patient Outcome

Overview

Journal BJS Open

Publisher Oxford University Press

Date 2025 Jan 22

PMID 39841130

Authors

Gabriele Bislenghi

Antonio Luberto

Wout De Coster

Leen van Langenhoven

Albert Wolthuis

Marc Ferrante

Severine Vermeire

Andre dHoore

Affiliations

Soon will be listed here.

Abstract

Background: Proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for patients with ulcerative colitis with medical refractory disease or dysplasia. The aim of this research was to describe the evolution of ileal pouch-anal anastomosis surgery and surgical outcomes over a three-decade interval in a high-volume referral centre.

Methods: All consecutive patients undergoing ileal pouch-anal anastomosis for ulcerative colitis between 1990 and 2022 at the University Hospitals of Leuven were retrospectively included. Patients were divided into three interval arms (interval A 1990-2000, interval B 2001-2010 and interval C 2011-2022). The primary outcomes of interest were anastomotic leakage at 30 days and pouch failure.

Results: Overall, 492 patients were included. The use of preoperative advanced therapies increased over time (P < 0.001). An increase in laparoscopic procedures (23.2% in interval A, 66.4% in interval B, 86.0% in interval C; P < 0.001) and a shift towards delayed ileal pouch-anal anastomosis (colectomy-first approach with delayed ileal pouch-anal anastomosis construction: 23.0% in interval A, 40.9% in interval B, 85.8% in interval C; P < 0.001) were observed. Anastomotic leakage rate decreased from 16.7% (interval A) to 8.4% (interval C) (P = 0.04). Delayed ileal pouch-anal anastomosis was the most relevant factor in limiting leakage (OR 0.49 (95% c.i. 0.27 to 0.87); P = 0.016). Median follow-up was 7.5 years (interquartile range 2.5-16). Cumulative pouch failure incidence was 8.2%, not significantly different between the three intervals (P = 0.580). Anastomotic leakage was the only significant risk factor for pouch failure (HR 2.82 (95% c.i. 1.29 to 6.20); P = 0.010).

Conclusion: Significant changes in the management of ulcerative colitis patients occurred. Despite the widespread use of advanced therapies and the expanded surgical indications, anastomotic leakage rate decreased over time. In the context of a delayed ileal pouch-anal anastomosis, diverting ileostomy could be avoided in selected cases. Anastomotic leakage remains the most relevant risk factor for pouch failure. Pouch failure incidence remained stable over the years.

Citing Articles

Transformational journey in ileo-pouch anal anastomosis surgery for ulcerative colitis.

Scaldaferri F, Sacchetti F BJS Open. 2025; 9(1).

PMID: 39907484 PMC: 11795663. DOI: 10.1093/bjsopen/zrae157.

References

Feinberg A, Lavryk O, Aiello A, Hull T, Steele S, Stocchi L . Conditional Survival After IPAA for Ulcerative and Indeterminate Colitis: Does Long-term Pouch Survival Improve or Worsen With Time?. Dis Colon Rectum. 2020; 63(7):927-933. DOI: 10.1097/DCR.0000000000001629. View

Heuthorst L, Harbech H, Snijder H, Mookhoek A, DHaens G, Vermeire S . Increased Proportion of Colorectal Cancer in Patients With Ulcerative Colitis Undergoing Surgery in the Netherlands. Am J Gastroenterol. 2023; 118(5):848-854. PMC: 10144357. DOI: 10.14309/ajg.0000000000002099. View

Gu J, Stocchi L, Ashburn J, Remzi F . Total abdominal colectomy vs. restorative total proctocolectomy as the initial approach to medically refractory ulcerative colitis. Int J Colorectal Dis. 2017; 32(8):1215-1222. DOI: 10.1007/s00384-017-2836-2. View

von Elm E, Altman D, Egger M, Pocock S, Gotzsche P, Vandenbroucke J . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007; 370(9596):1453-7. DOI: 10.1016/S0140-6736(07)61602-X. View

Beyer-Berjot L, Baumstarck K, Loubiere S, Vicaut E, Berdah S, Benoist S . Is diverting loop ileostomy necessary for completion proctectomy with ileal pouch-anal anastomosis? A multicenter randomized trial of the GETAID Chirurgie group (IDEAL trial): rationale and design (NCT03872271). BMC Surg. 2019; 19(1):192. PMC: 6909507. DOI: 10.1186/s12893-019-0657-7. View

Geltzeiler C, Lu K, Diggs B, Deveney K, Keyashian K, Herzig D . Initial surgical management of ulcerative colitis in the biologic era. Dis Colon Rectum. 2014; 57(12):1358-63. DOI: 10.1097/DCR.0000000000000236. View

Bislenghi G, Martin-Perez B, Fieuws S, Wolthuis A, DHoore A . Increasing experience of modified two-stage transanal ileal pouch-anal anastomosis for therapy refractory ulcerative colitis. What have we learned? A retrospective analysis on 75 consecutive cases at a tertiary referral hospital. Colorectal Dis. 2020; 23(1):74-83. DOI: 10.1111/codi.15231. View

Giddings H, Ng K, Solomon M, Steffens D, Van Buskirk J, Young J . Reducing rate of total colectomies for ulcerative colitis but higher morbidity in the biologic era: an 18-year linked data study from New South Wales Australia. ANZ J Surg. 2023; 93(12):2928-2938. DOI: 10.1111/ans.18713. View

de Lacy F, Keller D, Martin-Perez B, Emile S, Chand M, Spinelli A . The current state of the transanal approach to the ileal pouch-anal anastomosis. Surg Endosc. 2019; 33(5):1368-1375. DOI: 10.1007/s00464-019-06674-5. View

10.

Fazio V, Ziv Y, Church J, Oakley J, Lavery I, Milsom J . Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg. 1995; 222(2):120-7. PMC: 1234769. DOI: 10.1097/00000658-199508000-00003. View

11.

Miller-Ocuin J, Dietz D . The Evolution of Pelvic Pouch Surgery: Optimal Pouch Design for an Ileal Pouch Anal Anastomosis. Clin Colon Rectal Surg. 2023; 35(6):453-457. PMC: 9797272. DOI: 10.1055/s-0042-1758135. View

12.

Sahami S, Buskens C, Fadok T, Tanis P, de Buck van Overstraeten A, Wolthuis A . Defunctioning Ileostomy is not Associated with Reduced Leakage in Proctocolectomy and Ileal Pouch Anastomosis Surgeries for IBD. J Crohns Colitis. 2015; 10(7):779-85. DOI: 10.1093/ecco-jcc/jjv201. View

13.

Ali U, Keus F, Heikens J, Bemelman W, Berdah S, Gooszen H . Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis. Cochrane Database Syst Rev. 2009; (1):CD006267. DOI: 10.1002/14651858.CD006267.pub2. View

14.

Bach S, Mortensen N . Revolution and evolution: 30 years of ileoanal pouch surgery. Inflamm Bowel Dis. 2006; 12(2):131-45. DOI: 10.1097/01.MIB.0000197547.80558.59. View

15.

Dayton M, Larsen K . Outcome of pouch-related complications after ileal pouch-anal anastomosis. Am J Surg. 1997; 174(6):728-31; discussion 731-2. DOI: 10.1016/s0002-9610(97)00188-8. View

16.

Bikhchandani J, Polites S, Wagie A, Habermann E, Cima R . National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis. Dis Colon Rectum. 2015; 58(2):199-204. DOI: 10.1097/DCR.0000000000000282. View

17.

Remzi F, Lavryk O, Ashburn J, Hull T, Lavery I, Dietz D . Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care. Colorectal Dis. 2017; 19(11):1003-1012. DOI: 10.1111/codi.13699. View

18.

Gu J, Remzi F, Shen B, Vogel J, Kiran R . Operative strategy modifies risk of pouch-related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α therapy. Dis Colon Rectum. 2013; 56(11):1243-52. DOI: 10.1097/DCR.0b013e3182a0e702. View

19.

Mark-Christensen A, Kjaer M, Ganesalingam S, Qvist N, Thorlacius-Ussing O, Rosenberg J . Increasing Incidence of Pelvic Sepsis Following Ileal Pouch-Anal Anastomosis for Ulcerative Colitis in Denmark: A Nationwide Cohort Study. Dis Colon Rectum. 2019; 62(8):965-971. DOI: 10.1097/DCR.0000000000001404. View

20.

de Buck van Overstraeten A, Wolthuis A, DHoore A . Transanal completion proctectomy after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis: a modified single stapled technique. Colorectal Dis. 2016; 18(4):O141-4. DOI: 10.1111/codi.13292. View