摘要
PURPOSE: Recent studies have suggested that a subset of patients with Crohn’s colitis may have a favorable outcome after ileal pouch-anal anastomosis and have advocated elective ileal pouch anal anastomosis in selected patients with Crohn’s disease. We have not offered ileal pouch anal anastomosis to patients with known Crohn’s disease, but because of the overlap in clinical presentation of ulcerative colitis and inde terminate colitis, some patients receiving an ileal pouch-anal anastomosis are subsequently found to have Crohn’s disease. We review our experience with these patients to identify potential preoperative predictors of ultimate pouch failur e. METHODS: Patients with a final diagnosis of Crohns disease were identified from an ileal pouch anal anastomosis registry. These patients are followed pros pectively. Preoperative and postoperative clinical and pathologic characteristic s were evaluated as predictors of outcome. Median (range) values are listed. RES ULTS: Thirty two (18 females) patients (4.1 percent) with a final diagnosis of Crohn’s disease were identified from a registry of 790 ileal pouch anal anasto mosis patients (1980-2002). Patients underwent ileal pouch anal anastomosis in two stages (11 patients) or three stages (21 patients). The preoperative diagno sis was ulcerative colitis in 24 patients and indeterminate colitis in 8 patient s. Median follow up was 153 (range, 13-231) months. The median time from ileal pouch anal anastomosis to diagnosis of Crohns disease was 19 (range, 0-188) months. Complications occurred in 93 percent, including perineal abscess/fistul a (63 percent), pouchitis (50 percent), and anal stricture (38 percent). Pouch f ailure (excision or current diversion) occurred in nine patients (29 percent) at a median of 66 (range, 6-187) months. Two of these 9 patients had preoperative anal disease (not significant). Comparing patients with failed pouches (n=9) to patients with functioning pouches (n=23), post ileal pouch anal anastomosis p erineal abscess (67 vs. 26 percent, P=0.05) and pouch fistula (89 vs. 30 percent , P=0.01) were more commonly associated with pouch failure. Preoperative clinica l, endoscopie, and pathologic features were not predictive of pouch failure or p atient outcome. For those with a functional pouch, 50 percent have been or are c urrently on medication to treat active Crohns disease. This group had six bowe l movements in 24 (range, 3-10) hours, with leakage in 60 percent and pad usage in 45 percent. CONCLUSIONS: Patients who undergo ileal pouch anal anastomosis and are subsequently found to have Crohns disease experience significant morbi dity. Preoperative characteristics, including the presence of anal disease, were not predictive of subsequent pouch failure. We choose not to recommend the rout ine application of ileal pouch anal anastomosis in any subset of patients with known Crohns disease.
PURPOSE: Recent studies have suggested that a subset of patients with Crohn's colitis may have a favorable outcome after ileal pouch-anal anastomosis and have advocated elective ileal pouch anal anastomosis in selected patients with Crohn's disease. We have not offered ileal pouch anal anastomosis to patients with known Crohn's disease, but because of the overlap in clinical presentation of ulcerative colitis and inde terminate colitis, some patients receiving an ileal pouch-anal anastomosis are subsequently found to have Crohn's disease. We review our experience with these patients to identify potential preoperative predictors of ultimate pouch failur e. METHODS: Patients with a final diagnosis of Crohns disease were identified from an ileal pouch anal anastomosis registry. These patients are followed pros pectively. Preoperative and postoperative clinical and pathologic characteristic s were evaluated as predictors of outcome. Median (range) values are listed. RES ULTS: Thirty two (18 females) patients (4.1 percent) with a final diagnosis of Crohn's disease were identified from a registry of 790 ileal pouch anal anasto mosis patients (1980-2002). Patients underwent ileal pouch anal anastomosis in two stages (11 patients) or three stages (21 patients). The preoperative diagno sis was ulcerative colitis in 24 patients and indeterminate colitis in 8 patient s. Median follow up was 153 (range, 13-231) months. The median time from ileal pouch anal anastomosis to diagnosis of Crohns disease was 19 (range, 0-188) months. Complications occurred in 93 percent, including perineal abscess/fistul a (63 percent), pouchitis (50 percent), and anal stricture (38 percent). Pouch f ailure (excision or current diversion) occurred in nine patients (29 percent) at a median of 66 (range, 6-187) months. Two of these 9 patients had preoperative anal disease (not significant). Comparing patients with failed pouches (n=9) to patients with functioning pouches (n=23), post ileal pouch anal anastomosis p erineal abscess (67 vs. 26 percent, P=0.05) and pouch fistula (89 vs. 30 percent , P=0.01) were more commonly associated with pouch failure. Preoperative clinica l, endoscopie, and pathologic features were not predictive of pouch failure or p atient outcome. For those with a functional pouch, 50 percent have been or are c urrently on medication to treat active Crohns disease. This group had six bowe l movements in 24 (range, 3-10) hours, with leakage in 60 percent and pad usage in 45 percent. CONCLUSIONS: Patients who undergo ileal pouch anal anastomosis and are subsequently found to have Crohns disease experience significant morbi dity. Preoperative characteristics, including the presence of anal disease, were not predictive of subsequent pouch failure. We choose not to recommend the rout ine application of ileal pouch anal anastomosis in any subset of patients with known Crohns disease.
