Ileal pouch-anal anastomosis for ulcerative colitis: an Australian institution's experience.

Aim We report outcomes and evaluate patient factors and the impact of surgical evolution on outcomes in consecutive ulcerative colitis patients who had restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) at an Australian institution over 26 years. Methods Data including clinical characteristics, medical therapy pre-surgery and surgical outcomes were collected. We divided eligible patients into three period arms (period 1: 1990-1999; period 2: 2000-2009; period 3: 2010-2016). Outcomes of interest were IPAA leak and pouch failure. Results Two hundred and twelve patients were included. Median follow up was 50 months (interquartile range [IQR]: 17-120). Rates of early and late complications were 35% and 52% respectively. Early complications included wound infection (9.4%), pelvic sepsis (8%) and small bowel obstruction (6.6%) while late complications included small bowel obstruction (19%), anal stenosis (17%) and pouch fistula (13%). Overall, IPAA leak rate was 6.1% and pouch failure rate was 4.8%. Eighty three patients (42%) experienced pouchitis. Over time, we observed an increase in patient exposure to thiopurine (p=0.0025), cyclosporin (p=0.0002) and anti-tumour necrosis factor (p<0.00001) coupled with a shift to laparoscopic technique (p<0.00001), stapled IPAA (p<0.00001), J pouch configuration (p<0.00001), a modified two-stage procedure (p=0.00012) and a decline in defunctioning ileostomy rate at time of IPAA (p=0.00002). Apart from pouchitis, there was no significant difference in surgical and chronic inflammatory pouch outcomes with time. Conclusion Despite greater patient exposure to immunomodulatory and biologic therapy pre surgery coupled with a significant change in surgical techniques, surgical and chronic inflammatory pouch outcome rates have remained stable.