QS107 - What is the long-term retention and functional outcomes of ileal pouch anal anastomosis

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Purpose/Background: Functional outcomes after ileal pouch-anal anastomosis (IPAA) procedure are highly variable and may change over time. Pelvic floor and pouch physiologic function following IPAA is poorly understood. This study aims to assess long-term patient-reported IPAA function and compare those outcomes to objective measurements of pouch and pelvic floor function.

Methods/Interventions: We performed a cross-sectional observational study of adults who underwent IPAA between 1981 and 2023 and are currently followed at a single academic tertiary care center. Bowel function and symptom severity was evaluated with the Ileoanal Pouch Syndrome Severity Index (IPSS) score questionnaire, and a subset also underwent anorectal manometry during their follow-up visits. Patients were stratified based on pouch age at the time of most recent follow-up ( < 10 years, 10-30 years, >30 years). Bowel function and anorectal manometry were compared across groups.

Results/Outcomes: 150 patients were included, 39 of whom also underwent anorectal manometry. Mean follow-up after IPAA creation was 25 years (+/- 12 years). Patients whose pouch was created over 30 years ago were younger at the time of surgery than those whose pouches were created more recently (mean 29 +/- 7 years vs 43 +/- 13, p< 0.01). Compared to pouches < 10 years old, pouches >30 years old had a lower mean number of stools per 24 hours (mean 7 +/- 3 vs 9 +/- 3, p = 0.05) as well as fewer nighttime bowel movements (mean 1.5 +/- 1 vs 2 +/- 1, p = 0.03). Pouches over 30 years old also had more anal strictures (39% vs. 7%, p< 0.01) and pouchitis (62% vs 9%, p< 0.01) compared to pouches < 10 years old. However, fecal incontinence, seepage, urgency, frequency, and incomplete emptying were similar across all groups.
Anorectal manometry revealed that IPAA patients had lower resting pressure, squeeze increment, endurance, and average strain compared to normal values, but higher than average squeeze pressures. Manometry values were generally lower in older pouches compared to younger pouches, with the most pronounced reduction observed in males. Despite the decline in anal manometry values with pouch age, no difference in IPSS scores were observed amongst the three pouch age groups. Logistic regression did not identify any significant factors associated with incontinence, stoma formation, or the mean number of bowel movements.

Conclusion/Discussion: Pouchitis and anal strictures were more common in J-pouches over 30 years old. The higher prevalence of stricture in this population is likely due to the change in technique from hand sewn anastomosis to double staple method. However, patient-reported functional outcomes remained consistent, regardless of pouch age. Although anorectal manometry suggested diminished anorectal strength and endurance in patients with older pouches, this did not appear to correlate with patient-reported functional outcomes. This suggests that patients adapt to their J-pouch in other ways and highlights the complexity of anorectal physiology over time. Additional studies are needed to better understand predictors of poor function following the IPAA procedure.