EP792 - Ileal Pouch Anal Anastmosis Outcomes Among Patients with Primary Sclerosing Cholangitis

Image or Table (Do Not add text here):

Purpose/Background: Primary sclerosing cholangitis (PSC) is a progressive biliary disease that can affect patients with ulcerative colitis (UC). While Ileal pouch anal anastomosis (IPAA) is the surgery of choice for patients with UC, previous reports have demonstrated worse outcomes among patients with concomitant PSC than those with UC alone. We reviewed the long-term outcomes for patients who underwent IPAA surgery with a diagnosis of PSC and UC at our institution.

Methods/Interventions: All IPAA procedures performed at our institution between 1982-2022 were identified from our prospectively maintained IBD-surgery database. Inclusion criteria were a confirmed diagnosis of PSC, either before or after IPAA surgery, and age greater than 18. Paper and electronic records were reviewed. In addition, we sent functional surveys to all PSC-UC patients, as well as a UC-only control group. Our primary outcome was pouch failure (defined as pouch excision or permanent diversion). Secondary outcomes were the rate of pouchitis, antibiotic therapy, biological treatment for pouchitis, pouch function, COREFO functional score, and PROMIS QOL score.

Results/Outcomes: 60 patients were identified with a confirmed diagnosis of PSC who underwent IPAA surgery. Median age at the time of IPAA surgery was 39 years, and 26 were female (43%). Median follow-up time was 14 years. 15 (25%) of patients required at least one liver transplant; 10 of whom had IPAA surgery after, and 5 patients before, their first liver transplant. Pouch failure occurred in 5 (8.3%) patients with PSC. 28 PSC patients responded to our survey (median time from IPAA surgery was 9 years). Among the survey respondents, pouchitis was common with 85% reporting a history of pouchitis (vs. 52% of UC-only controls, p=0.01), with 6 patients (21%) on antibiotics currently and 3 patients (10%) on biologic therapy.
Compared to the 52 controls with UC-alone, patients with PSC had similar stools per day, urgency, incontinence (both major and minor), evacuation difficulties, and perianal pain. In addition, they reported similar rates of anti-diarrheal use, protective pad use, and the need for a restricted diet (see Table 1). However, patients with PSC had a higher rate of nocturnal stools (59% reported 2+ BMs/night, vs. 36% in controls, p=0.035). The COREFO score among those with PSC was comparable to those with UC-alone (median 57 vs 55, p=0.53). The reported QOL was also similar between those with PSC and those with UC-alone (median PROMIS score of 37 vs. 36, p=0.72).

Conclusion/Discussion: Although PSC patients undergoing IPAA have higher rates of pouchitis and greater nocturnal stools, the rate of pouch failure (8%) is comparable to those with UC-alone (~10% at 10 years). In addition, IPAA functional outcomes, COREFO score, and QOL are similar between those with PSC and those with UC-alone.
Our study results suggest that PSC patients undergoing IPAA surgery have similar long-term functional outcomes as those with UC-alone, despite the higher risk of pouchitis. Further research is required to investigate the relationship between PSC and pouchitis.