SSAT - the Presence of Abdominal Hernia Is Associated With Adverse Outcomes of the Ileal Pouch

Back to 2015 Annual Meeting Program

the Presence of Abdominal Hernia Is Associated With Adverse Outcomes of the Ileal Pouch
Ganglei Liu^*², Feza H. Remzi², Luca Stocchi², Hermann Kessler², Bo Shen¹

¹Gastroenterology-A31, Cleveland Clinic, Cleveland, OH; ²Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH

Background: There are no published studies on the impact of abdominal hernia developed after restorative proctocolectomy on the outcome of the ileal pouch. Our aim was to evaluate the effect of abdominal hernia on the outcomes of the ileal pouches in patients with underlying inflammatory bowel disease (IBD).
Methods: We evaluated all eligible pouch patients with post-operatively developed abdominal hernia from our prospectively maintained Pouchitis Registry between 2002 and 2014. The control group (N = 123) were patients with no abdominal hernia randomly selected from the Pouchitis Registry with a case to control ratio of 1 to 3. Patients with pre-colectomy abdominal hernia or pre- or post- colectomy inguinal hernia were excluded. All patients were regularly followed up at the Pouch Clinic for at least 1 year. Demographic and clinical factors, were assessed with univariable and multivariable analysis for adverse pouch outcomes (chronic pouchitis, Crohn's disease of the pouch, newly diagnosed pouch sinus and post-operative pouch-related hospitalization (beyond 30 days after pouch surgery), and pouch failure.
Results: Out of 1,564 patients in the registry, 208 (13.3%) were found to develop new abdominal hernia after pouch construction. A total of 41 patients met the inclusion criteria (the study group), with 21 (51.2%) undergoing hernia repair surgery. There were 36 patients (87.8%) with incisional hernia, 3(7.3%) with parastomal hernia, and 2 (4.9%) with both. Among the 21 patients with hernia repair, 13 (61.9%) had mesh and 8 (38.1%) had no mesh. The duration from the pouch construction to the latest visit was 8.8 ±5.5 years for the whole patient cohort. The patients were older and had a higher body mass index than controls (41.6 ± 12.1 vs. 35.9 ± 12.6 years, p=0.012; 28.7 ± 5.5 vs. 24.9 ± 4.5, p<0.01, respectively). The prevalence of adverse pouch outcomes was similar between the two groups (Table 1). Independent factors associated with pouch failure on multivariable analysis were abdominal hernia (hazard ratio [HR] = 6.019, 95% confidence interval [CI] = 1.623-22.314, p=0.007) and pre-operative biological therapy (HR = 21.181, 95% CI = 3.712-120.871, p=0.001) (Table2). There were no statistical differences in adverse pouch outcomes among patients with abdominal hernia with or without surgical repair.
Conclusions: The newly developed abdominal hernia after ileal pouch-anal anastomosis is associated with a higher risk for pouch failure. Patients with de novo abdominal hernia should be monitored closely for pouch dysfunction and preventive measures may be beneficial for pouch survival.

Table 1. Comparisons of demographic, clinical factors, and pouch outcomes

Characteristic Pouch patients with Abdominal Hernia
N=41
Pouch patients without Abdominal Hernia
N=123
P value Characteristic Pouch patients with Abdominal Hernia
N=41
Pouch patients without Abdominal Hernia
N=123
P value
Male, n (%) 23 (56.1%) 65 (52.8%) 0.718 Significant comorbidities 5(12.2%) 12(9.8%) 0.657
Age at pouch construction, years 41.6 ± 12.1 35.9 ± 12.6 0.012 Surgical complications after pouch 11(26.8%) 22(17.9%) 0.216
Caucasian, n (%) 40 (97.6%) 117 (95.1%) 0.681 •Pre-Chronic pouchitis 1(2.4%) 3(2.4%) 1.000
Smoking, n (%) 0.080 •Pre-Active pouchitis 10(24.4%) 29(23.6%) 0.916
None 28(68.3%) 102(82.9%) •Pre-Chronic cuffitis 5(12.2%) 23(18.7%) 0.338
Ex-smoker 8(19.5%) 16(13.0%) •Pre-CD of the pouch 2(4.9%) 8(6.5%) 1.000
Active smoker 5(12.2%) 5(4.1%) •Pre-Combined chronic pouch inflammation 8(19.5%) 30(24.4%) 0.521
Family history of IBD 6(14.6%) 27(22.0%) 0.312 •Pre-Acute cuffitis 2(4.9%) 16(13.0%) 0.247
BMI at latest visit 28.7 ± 5.5 24.9 ± 4.5 <0.001 •Pre-Irritable pouch syndrome 1(2.4%) 4(3.3%) 1.000
Autoimmune disease 4(9.8%) 15(12.2%) 0.785 Pre-op biological therapy 5(12.2%) 25(20.3%) 0.244
Toxic megacolon 5(12.2%) 13(10.6%) 0.773 Post-op immunomodulator 6(14.6%) 11(8.9%) 0.301
Primary sclerosing cholangitis 3(7.3%) 4(3.3%) 0.368 Post-op biological therapy 1(2.4%) 10(8.1%) 0.294
Extensive colitis 39(95.1%) 115(93.5%) 1.000 Chronic NSAID Use 1(2.4%) 10(8.1%) 0.294
Extraintestinal manifestations 16(39.0%) 52(42.3%) 0.714 Duration from pouch construction to last visit 8.2 ± 4.8 9.0 ± 5.8 0.445
Liver transplantation 1(4.9%) 2(0.8%) 0.155 *Post-Chronic pouchitis 9(22.0%) 25(20.3%) 0.824
Pre-pouch diagnosis 1.000 *Post-Active pouchitis 6(14.6%) 19(15.4%) 0.900
UC 39(95.1%) 114(92.7%) *Post-Chronic cuffitis 2(4.9%) 3(2.4%) 0.600
Indeterminate colitis 2(4.9%) 7(5.7%) *Post-CD of the pouch 7(17.1%) 22(17.9%) 0.906
CD 0(0%) 2(1.6%) *Post-Combined chronic pouch inflammation 17(41.5%) 50(40.7%) 0.927
Stage of the pouch 0.108 *Post- acute cuffitis 1(2.4%) 1(0.8%) 0.439
1 0(0%) 6(4.9%) *Post-irritable pouch syndrome 9(22.0%) 14(11.4%) 0.091
2 28(68.3%) 94(76.4%) New anastomotic sinus 4(9.8%) 4(3.3%) 0.108
3 12(29.3%) 18(14.6%) Post-op pouch related-hospitalization 6(14.6%) 11(8.9%) 0.301
4 or redo 1(2.4%) 5(4.1%)
J pouch 41(100%) 119(96.7%) 0.573

•Pre : diagnosed at the first Pouch Clinic visit
*Post : diagnosed at the latest Pouch Clinic visit

Table 2. Multivariate Analysis of Risk Factors Associated with Pouch Failure

Characteristic Pouch Failure
Hazard Ratio(95% Confidence Interval) P value
Surgical complications after pouch 2.964(0.779-11.279) 0.111
Pre-op anti-TNF biological therapy (yes versus no) 21.181(3.712-120.871) 0.001
Abdominal hernia (yes versus no) 6.019(1.623-22.314) 0.007

Back to 2015 Annual Meeting Program