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PREDICTORS OF POOR BOWEL FUNCTION FOLLOWING ILEAL-POUCH ANAL ANASTOMOSIS: RESULTS FROM THE UNITED STATES ILEAL POUCH-ANAL ANASTOMOSIS (TULIP) STUDY
Jesse Zuckerman
*2, Anthony de Buck van Overstraeten
1, Gil Melmed
2, William Conan Mustain
3, Jeffrey S. Scow
4, Katerina Wells
5, Mary Otterson
6, James Ogilvie
7, Lilianna Bordeianou
8, Stefan D. Holubar
9, Steven D. Wexner
10, Phillip Fleshner
2, Karen Zaghiyan
21Surgery, University of Toronto, Toronto, ON, Canada; 2Cedars-Sinai Medical Center, Los Angeles, CA; 3Mercy Clinic Colon and Rectal Surgery, Oklahoma City, OK; 4Penn State Health Milton S Hershey Medical Center, Hershey, PA; 5Baylor Scott & White Health, Dallas, TX; 6Medical College of Wisconsin, Milwaukee, WI; 7Corewell Health West Michigan, Grand Rapids, MI; 8Massachusetts General Hospital, Boston, MA; 9Cleveland Clinic, Cleveland, OH; 10Cleveland Clinic Florida, Weston, FL
Objective:
Patients with UC and IBD-U will often undergo ileal pouch-anal anastomosis (IPAA) after colectomy to restore intestinal continuity. We explored predictors of bowel function post-IPAA using a multicenter prospective database of functional outcomes.
Methods:
UC or IBD-U patients undergoing IPAA between 2018 and 2022 across North American centers were enrolled prospectively. We evaluated patient-reported outcomes of bowel function using the COREFO questionnaire, a validated measure of function after colorectal surgery. Baseline demographics and function were obtained before colectomy. We evaluated operative data, postoperative outcomes, and functional measures at 3, 6, and 12 months after ileostomy closure. We explored potential predictors of mean bowel function trajectories over time using longitudinal mixed models, accounting for repeated outcomes. Factors were included in models if they had potential to associate with post-IPAA bowel function based on previous data and clinical rationale.
Results:
There were 203 patients included; mean age was 35.8±13.4 and 59% were male. Most patients had UC (95%) with refractory disease the most common surgical indication (91%). Fifty-seven patients (28%) had subtotal colectomy without eventual IPAA; the rest had either 2-stage (n=21; 14%) or 3-stage (n=125; 86%) IPAA. Nine patients (6%) did not have their ileostomy closed at one year post-IPAA. There were 118 patients included for longitudinal analysis. Bowel function improved (COREFO mean 50.6±18.8 at baseline to 24.3±17.7 at 12 months, p<0.0001), as did underlying domains of frequency, social impact, stool-related aspects, and incontinence; this remained significant when adjusting for other patient and surgical factors. We also found an association between the surgical indication and bowel function – bowel function was on average 17.4 points higher for patients undergoing IPAA for refractory disease relative to those with dysplasia or cancer (p = 0.0003). Nevertheless, in analyzing individual trajectories of these two groups, patients with refractory disease had worse bowel function at baseline but greatly improved over time (mean 53.7±16.8 at baseline to 24.1±17.8 at 12 months), whereas patients with dysplasia/cancer have slightly worse bowel function over time (mean 22.03±17.8 at baseline to 28.0±17.8 at 12 months).
Conclusions:
We observed significant improvement in bowel function over time in patients who underwent IPAA for UC or IBD-U. Importantly, however, surgical indication appeared to affect patients’ functional trajectory in the first year after restoration of intestinal continuity: patients with refractory colitis experienced significantly improved bowel function and patients with dysplasia or cancer had slightly worse function. These results can guide pre-operative counselling and help set appropriate patient expectations.
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