Predictors of pouchitis after ileal pouch-anal anastomosis: A retrospective review

PURPOSE: The primary end point of this study was to determine the risk factors that predict chronic pouchitis in those patients having ileal pouch-anal anastomosis. METHODS: A total of 237 patients with ulcerative colitis and undergoing ileal pouch-anal anastomosis by one surgeon at Oregon Health & Science University from 1993 to 2003 were evaluated. Data were gathered via retrospective chart reviews and by a questionnaire administered by telephone in 2004. Patients were excluded if there was less than one-year follow-up documented in the chart or they could not be contacted by telephone (n=62), postoperative diagnosis of Crohn's disease (n=3), failed ileoanal procedure (n=1), and one-stage ileal pouch-anal anastomosis (n=3), leaving 167 patients for evaluation. Patients were defined as having chronic pouchitis (> 3 episodes of pouchitis) or no pouchitis (<= 3 episodes of pouchitis). Potential risk factors included number of operations used to perform ileal pouch-anal anastomosis, fulminant ulcerative colitis with two-stage operation, duration of diverting ileostomy after pouch formation, primary sclerosing cholangitis, other extraintestinal manifestations of ulcerative colitis, preoperative liver function tests, duration of ulcerative colitis, and the occurrence of postoperative complications. Initial univariate analysis was performed on all risk factors. Multivariate analysis was performed on all univariate risk factors with P values < 0.2. RESULTS: The prevalence of chronic pouchitis in our population was 46 percent. The following variables were identified during univariate analysis and entered into a multivariate model: preoperative serum albumin (P=0.07), PSC (P=0.126), duration of diverting ileostomy (P=0.111), fulminant ulcerative colitis with two-stage operation, (P=0.051), the presence of postoperative complications (P=0.031), and the type of postoperative complications (anastomotic complications, P=0.013). Patients who did not undergo diverting ileostomy at the time of their ileal pouch-anal anastomosis trended toward a lower likelihood of developing chronic pouchitis (P=0.06). Multivariate analysis showed that patients with postoperative complications (53 percent, P=0.042), specifically anastomotic complications, were more likely to develop chronic pouchitis (P=0.005). Eight percent of patients had primary sclerosing cholangitis and 11 percent of patients had at least one extraintestinal manifestation of ulcerative colitis. Patients with primary sclerosing cholangitis were not more likely to develop chronic pouchitis (P=0.168). Patients with extraintestinal manifestations also were not more likely to develop chronic pouchitis (P=0.273). CONCLUSIONS: Chronic pouchitis is a frequent complication after ileal pouch-anal anastomosis. In this study patients with primary sclerosing cholangitis or other extraintestinal manifestations of ulcerative colitis were not more likely to develop chronic pouchitis. Patients with postoperative complications, specifically anastomotic complications after ileal pouch-anal anastomosis, were more likely to develop chronic pouchitis and may benefit from early strategies to prevent pouchitis.