PREOPERATIVE WIRELESS CAPSULE ENDOSCOPY DOES NOT PREDICT LONG-TERM ADVERSE OUTCOMES AFTER ILEAL-POUCH ANAL ANASTOMOSIS
Adam Truong*1, Karen Zaghiyan2, Phillip Fleshner2
1Surgery, Cedars-Sinai Medical Center, Los Angeles, CA; 2Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is the standard operative approach for ulcerative colitis (UC) patients requiring surgery for medically refractory disease or dysplasia. Despite excellent long-term outcomes, pouchitis or de novo Crohn's disease (CD) may occur after IPAA. It seems intuitive that the presence of small bowel mucosal inflammation before surgery would be an important predictor of these adverse outcomes after surgery, however little is known however regarding the utility of small bowel evaluation with wireless capsule endoscopy (WCE) before IPAA. The aim of this study was to assess the value of preoperative WCE in predicting adverse outcomes in UC patients undergoing IPAA.
METHODS: All UC patients undergoing IPAA between February 2002 to November 2018 were identified from a prospective registry database at a single inflammatory bowel disease referral center. WCE was defined as abnormal if there were erosions, ulcers, strictures or erythema. Abnormal WCE alone, without other clinical manifestations, was not sufficient for the diagnosis of CD or inflammatory bowel disease unclassified (IBDU), both of which were excluded. Adverse outcomes were assessed prospectively and included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent/resistant), or de novo CD (5 or more mucosal ulcers proximal to the ileal pouch, pouch fistula, or perianal complication 3 months after ileostomy closure). A p-value less than 0.05 was considered statistically significant.
RESULTS: The study cohort of 126 patients had a median age of 40 (range; 7-75) years and included 53 (42%) males. WCE was abnormal in 19 (15%) patients (2 with an area of small bowel erythema, 2 with an area of erosion, 11 with a single ulcer, and 4 with multiple ulcers). Baseline demographic and disease characteristics were similar between the normal and abnormal WCE groups. After a median follow-up of 30 (range; 3-195) months following stoma closure, adverse outcomes included AP (n=21;17%), CP (n=4;3%), and de novo CD (n=16;13%). There was no significant difference in adverse outcomes between normal versus abnormal WCE for AP (19% vs 5%;p=0.15), CP (3% vs 5%;p=0.57) or de novo CD (12% vs 16%,p=0.66). Kaplan-Meier analysis similarly showed no correlation between WCE findings and time to development of any adverse pouch complication (p=0.77).
CONCLUSION: In this largest to date prospective series investigating the value of preoperative WCE in UC, we showed that the majority (85%) of tests were normal. We also found that long-term outcomes of IPAA were not significantly different between UC patients who had abnormal compared to normal preoperative WCE. There appears to be little value in performing preoperative WCE in UC patients about to undergo IPAA.
Adverse Outcomes by Wireless Capsule Endoscopy Results
| N | No Pouchitis | Acute Pouchitis | Chronic Pouchitis | De Novo Crohn's Disease | |
| WCE - | 107 | 71 (66%) | 20 (19%) | 3 (3%) | 13 (12%) |
| WCE + | 19 | 14 (74%) | 1 (5%) | 1 (5%) | 3 (16%) |
| P-Value | 0.147 | 0.570 | 0.660 |
Row percentages are displayed. WCE: Wireless capsule endoscopy. -/+: Normal/Abnormal.
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