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Background

Ileal pouch anal anastomosis (IPAA) after colectomy has been an accepted surgical procedure for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia or cancer, or familial adenomatous polyposis. Overall rate of pouch failure was reported to be less than 5% at 5 years follow up. IPAA in Crohn's colitis is still controversial due to increased risk of post-operative disease recurrence. Recent data do not show any increased risk of pouch failure in Crohn's disease (CD) patients. However, little is known about the association of pre-operative radiation with pouch failure.

Methods

Not applicable for case reports.

Results

Case 1: A 35 year old Caucasian female diagnosed with severe ileo-colonic CD at age 12 treated with intermittent prednisone use for about 12 years eventually went into clinical and endoscopic remission for 8 years after starting on infliximab. Colonoscopy for cancer surveillance (now 20 yr from her CD diagnosis) revealed a polypoid rectal adenocarcinoma with quiescent disease in the remainder of the colon. She started neo-adjuvant chemotherapy with radiation therapy, subsequently underwent total colectomy with ileostomy, and later reversal of ostomy with IPAA. Pouchoscopy for rectal bleeding revealed chronic pouchitis. Due to antibodies against infliximab, adalimumab and 6-mercaptopurine was started which brought her into remission for 1 year until she presented with severe left lower quadrant abdominal pain. She underwent diverting ileostomy for findings of a large intra-abdominal abscess in this area on imaging. Repeat pouchoscopy showed severe disease activity in the pouch consistent with chronic active pouchitis with a possible component of radiation pouchitis, but ileum on ileoscopy looked normal. She was deemed to have pouch failure underwent resection and permanent ileostomy.

Case 2: A 74 year old Caucasian male, with a past history significant for radiation therapy for prostate cancer 1 year prior, was diagnosed with UC pancolitis at age 70 and started treatment on infliximab. Due to continued symptoms and severe inflammation on repeat colonoscopy 6 months later, he underwent total proctocolectomy with subsequent IPAA. He did well for 9 months off medical therapy but developed severe lower abdominal pain and bloody diarrhea. Pouchoscopy revealed severe ulceration with friability in the pouch and in scattered areas of the ileum proximally changing his diagnosis to CD. Pathology was consistent with chronic active ileitis and chronic active pouchitis. Patient was started on antibiotics and vedolizumab. His symptoms persisted and hence underwent successful pouch removal and permanent ileostomy.

Conclusions

Pouch failure is defined as a nonfunctioning pouch at or prior to 12 months after IPAA. Post-operative radiation has been associated with poor pouch outcomes. One study has reported association of pelvic radiation administered prior to IPAA with poor surgical outcomes but did not achieve statistical significance on simple analysis. Our case series does suggest that pre-operative radiation is associated with pouch failure although larger studies are needed to confirm this. This should be an important consideration in the decision for surgery in a patient undergoing colectomy and possible IPAA in the setting of prior pelvic radiation therapy.

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Copyright © 2017 Crohn's & Colitis Foundation of America, Inc.
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