Ileorectal Anastomosis versus Ileal Pouch-Anal Anastomosis for the Surgical Treatment of Ulcerative Colitis: A Markov Decision Analysis.

BACKGROUND Ileorectal anastomosis in patients with ulcerative colitis results in decreased postoperative morbidity and better functional outcome but leads to increased risk for rectal cancer compared to ileal pouch-anal anastomosis. OBJECTIVE To compare ileorectal anastomosis with ileal pouch-anal anastomosis in ulcerative colitis, using a decision model. DESIGN A Markov simulation model was designed to simulate clinical events of ileorectal anastomosis and ileal pouch-anal anastomosis over a time horizon of 40 years with time cycles of 1 year. All probabilities and utilities were derived from observational studies, identified after a systematic literature search using MEDLINE. Primary outcomes were life years and quality-adjusted life years. Deterministic and probabilistic sensitivity analyses were performed. SETTINGS A decision model using Markov simulation was designed. PATIENTS The base case was a 35-year-old patient with ulcerative colitis and relatively preserved rectum. MAIN OUTCOMES MEASURES The primary outcome measure were (quality-adjusted) life years. RESULTS The model resulted in lower life years (36.22 vs 37.02) and higher quality-adjusted life years (33.42 vs 31.57) for ileorectal anastomosis. This was confirmed after probabilistic sensitivity analysis. The model was sensitive to the utility of ileorectal anastomosis, ileal pouch-anal anastomosis and end-ileostomy. A higher proportion of IRA patients will develop rectal cancer (7.6% vs 3.2%) and 43.5% of all ileorectal anastomosis patients will end with an ileostomy as opposed to 23.0% of all ileal pouch-anal anastomosis patients. LIMITATIONS The study was limited by characteristics inherent to modeling studies, including assumptions necessary to build the model, data input based on best available but often limited evidence and unavoidable extra- and interpolation of data. CONCLUSIONS Ileorectal anastomosis was the preferred treatment option when quality-adjusted life years was the outcome, with higher life years for ileal pouch-anal anastomosis. This model highlights that both surgical strategies are useful in ulcerative colitis patients with relatively spared rectum. See Video Abstract at http://links.lww.com/DCR/B249.