Abstract: Ileal pouch–anal anastomosis (IPAA) is the preferred surgical treatment for patients who undergo colectomy and wish to avoid a permanent ileostomy. The overall outcomes are positive, with an improved quality of life and stable long-term pouch retention. However, certain conditions or disease states may be at a higher risk of pouch dysfunction or failure. For example, obese patients have an increased risk for postoperative complications. In addition, women with a history of obstetric complications and elderly patients with a history of sphincter damage or dysfunction may be at an increased risk for postoperative incontinence, although quality-of-life indices do not necessarily correlate with incontinence scores. Advanced age itself is not a contraindication to pouch surgery, and elderly patients can be considered for IPAA based on individual functionality and comorbidities. Pelvic radiation may lead to pouch dysfunction. Finally, patients with Crohn’s disease and indeterminate colitis may have increased complications with IPAA, but highly specific patient selection leads to good rates of pouch retention. This article examines several clinical scenarios that require careful thought prior to consider-ing IPAA.
Ileal pouch–anal anastomosis (IPAA, also referred to as pouch) has been the preferred surgical treatment for the majority of patients requiring colectomy who have ulcerative colitis (UC) and familial adenomatous polyposis since the procedure was first reported in 1978.1,2 Select patients with indeterminate colitis (IC) or Crohn’s disease (CD) may also undergo IPAA.3 IPAA is typically created in a 2- or 3-stage procedure, although 1-stage procedures are also offered.4 A main advantage of IPAA is the preservation of traditional bowel evacuation and the avoidance of a permanent ileostomy.
Most patients undergoing IPAA report good to excellent quality of life after surgery5-8 and would undergo the operation again.9,10 On average, patients report a median of 6 bowel movements per day after IPAA.5,9,11 IPAA patients have better outcomes in terms of body image compared to patients with ileostomies.12 Moreover, IPAA has been reported to have little to no impact on the patient’s professional or social life.5 Overall pouch function is reported to be stable over time, with multiple studies evaluating outcomes up to 30 years or more after IPAA.5,6,8,13,14
Although there are excellent outcomes for the majority of patients undergoing IPAA, a minority of patients experience postoperative complications such as fecal incontinence, pouchitis, and CD. Patients with persistent pouch dysfunction have a suboptimal quality of life and are at an increased risk for pouch failure, which can be defined as the need for pouch excision and end ileostomy, diverting ileostomy for a prolonged period of time, or permanent diversion.15 Overall long-term pouch failure rates range from 4.4% to 8.5%.16-18 To maximize the likelihood of successful long-term pouch outcomes, thoughtful patient selection is essential. This article discusses several clinical scenarios requiring careful consideration prior to IPAA, including obesity, sphincter dysfunction or damage, advanced age, radiation therapy, and CD or IC.
Obesity
There is a worldwide obesity epidemic. In obese patients in general, surgery is frequently more technically challenging, often necessitating longer operation times.19,20 Although patients with inflammatory bowel disease (IBD) may frequently be malnourished and underweight, there are increasing numbers of obese patients with IBD.21 Obesity, defined as a body mass index of 30 or higher, has been associated with multiple post-IPAA complications.20,22,23 Klos and colleagues reported
significantly increased complications after IPAA, including incisional hernias (relative risk [RR], 2.21), any pouch complication (RR, 1.96), anastomotic/pouch strictures (RR, 2.77), and inflammatory pouch complications (RR, 2.61).23 The construction of IPAA in obese patients has also been associated with a longer operation time,20,22 a prolonged inpatient stay,22 and a higher risk for wound infection and anastomotic leak.10
However, obesity is not a complete contraindication to pouch surgery even though the condition increases the likelihood of complications after IPAA. Performing the procedure in obese patients is more technically challenging due to bulky mesentery and difficult intraabdominal and pelvic exposure.10,23 Because IPAA is elective, it is advisable to encourage weight loss in obese patients prior to scheduling the procedure to promote optimal outcomes.
Sphincter Dysfunction or Damage
One of the benefits of IPAA is the ability to maintain anal sphincter function and preserve the normal route of evacuation. Both the internal anal sphincter (involuntary sphincter) and the external anal sphincter (voluntary sphincter) play important roles in the maintenance of continence. Intuitively, a decreased resting anal sphincter pressure in IPAA patients increases the risk of fecal incontinence.24-26 Approximately 25% to 30% of pouch patients experience either major fecal incontinence or minor seepage.24,27 The incidence of severe fecal incontinence ranges from 6% to 8%.5,11 Nocturnal incontinence is more common than daytime incontinence.24,28 Pouch patients with fecal incontinence report a decreased quality of life compared with continent pouch patients.29,30
IPAA can result in sphincter damage. The resting anal sphincter pressure in patients after IPAA is lower than in patients who have not undergone surgery (Table 1).31-34 The prevailing explanation for decreased anal sphincter pressure after IPAA has been attributed to damage to the internal and external anal sphincter during surgery, possibly from anal dilation and manipulation or mucosectomy.28 Patients with stapled anastomoses have been noted to have less seepage and incontinence compared to patients with hand-sewn anastomoses.35
Part of the sphincter damage and dysfunction after IPAA may be reversible. In a small study of pediatric patients after IPAA, all patients had some soiling in the first 6 months after surgery (at least once or twice per day or once nightly), but by the end of a 3-year follow-up, none reported incontinence symptoms.36 Indeed, for many patients, soiling may be worst in the early postoperative months (within 6 months of surgery) and may improve over months to years as anal sphincter pressures normalize.34,36,37
For patients with occasional fecal incontinence, antidiarrheal medications such as loperamide, tincture of opium, or diphenoxylate atropine are often used to control stool consistency and frequency. Another potential benefit of loperamide may be increased anal pressures. In a randomized, double-blind, placebo-controlled trial evaluating the effects of loperamide, the resting anal pressure and maximal squeeze pressure increased, along with a corresponding improvement in continence, after a week of treatment.38 However, a single 16-mg dose of loperamide did not result in the same increase in resting anal pressure, suggesting a benefit only with sustained treatment with loperamide.39
When thinking about a patient’s candidacy for IPAA, special attention should be paid to 2 patient populations that are at risk for sphincter dysfunction and damage: older and elderly patients and women with a history of obstetric complications. These 2 groups are discussed in detail below.
Older and Elderly Patients
In the general population, rates of fecal incontinence are higher with advanced age.40 In the pouch literature, the definition of elderly or older varies by study. Moreover, the definition of fecal incontinence itself varies quite a bit, with evaluations ranging from daily to monthly.41 Increased rates of fecal incontinence have been noted in older IPAA patients.8 However, it is difficult to make firm conclusions given multiple age cutoffs and varied definitions of fecal incontinence.
Several studies suggest an increased rate of fecal incontinence in older or elderly patients. Dayton and Larsen evaluated 455 patients after IPAA, noting that daytime and nighttime stool frequency as well as incontinence episodes were significantly higher in patients older than 55 years.42 Of note, preoperative anal resting and squeeze pressures correlated with these postoperative findings in patients older than 55 years. Delaney and colleagues reported an increased rate of nocturnal seepage (but not full bowel movements) in pouch patients older than 65 years after 3, 5, and 10 years of follow-up when compared with younger patients.43
On the other hand, increasing age does not necessarily correlate with rates of incontinence after IPAA.34,44-46 Kim and colleagues reported stable rates of fecal leakage of approximately 25% (at least 1 leakage of stool daily) across all age groups after IPAA.47 In a retrospective cohort of 2000 IPAA patients subdivided by age at the time of surgery, a significantly higher percentage of patients older than 55 years reported incontinence at 1 and 3 years after IPAA when compared with younger patients.45 However, at 5 and 10 years of follow-up, this difference in incontinence among older and younger patients was no longer significant. This retrospective study suggests that over time, some older patients may either have improvement in sphincter function or better management of incontinence (perhaps via diet or medication), but definitive evidence to support this assumption is needed.
Thus, older and elderly patients may have increased rates of incontinence after IPAA, but the data are mixed. Elderly patients, despite some incontinence, are able to thrive after pouch surgery. Surgical technique in elderly patients should be optimized to preserve sphincter function and improve functional outcomes. For example, given the lesser risk of sphincter dysfunction, a stapled anastomosis is preferred over a hand-sewn anastomosis.48
Women With a History of Obstetric Complications
Obstetric trauma during childbirth increases the risk for both short- and long-term anal sphincter dysfunction. The reported rate of fecal incontinence was 27% in a 30-year retrospective cohort of women with anal sphincter disruption during vaginal delivery.49 Women undergoing IPAA who opted to have a vaginal delivery had a higher rate of sphincter defects and lower mean squeeze anal pressures compared to women who had a cesarean section.50 Also, in a 30-year review of IPAA in approximately 1900 patients with UC, women had significantly more episodes of occasional or frequent daytime bowel incontinence than men.8 Potentially, part of the increase in incontinence could be attributed to a history of childbirth in this cohort.
However, a history of vaginal delivery with obstetric injury is not an absolute contraindication to IPAA creation. Gearhart and colleagues reported successful IPAA in 17 women with a history of obstetric injuries such as episiotomy, prolonged labor, or forceps delivery.27 Although sphincter defects were noted on preoperative endoanal ultrasound with corresponding low anal resting pressures and shorter anal canal length on manometry, there were no significant differences in the severity of fecal incontinence or quality-of-life scores after IPAA.27
In women with a history of obstetric complications, it is important to take a careful history of soiling and seepage. If the patient has severe incontinence, creation of an IPAA is contraindicated, but continent ileostomies such as the Koch pouch could be considered. Likewise, if a continent woman with preexisting IPAA becomes pregnant, it is advisable to discuss the potential benefits of cesarean section for preserving the existing sphincter function.50
In summary, it is imperative to assess anal sphincter function prior to consideration of IPAA. A digital rectal examination should always be completed to evaluate for sphincter tone and dysfunction. Anorectal manometry evaluation of sphincter function should be considered prior to deliberation of IPAA in patients with questionable continence. Elderly patients with sphincter dysfunction and women with a history of obstetric complications should not be ruled out as candidates for IPAA without a candid discussion regarding postoperative expectations.
Patients of Advanced Age
As the current population ages, the prevalence of elderly patients with IBD is increasing. Approximately 15% of patients with IBD manifest their first symptoms after the age of 65 years.51 Current guidelines do not specify an age cutoff at which IPAA should not be offered for older patients.52,53 Designating a strict cutoff is difficult because, as previously mentioned, the definitions of older and elderly vary among publications, with 50, 55, 60, or 65 years being used as age cutoffs for studying outcomes.43,45,54-57 Moreover, 2 patients of the same age can differ tremendously in suitability for surgery when taking into account comorbidities and functional status.
Numerous studies report the safety and feasibility of IPAA in elderly patients.34,43-46,58-61 No increase in surgical morbidity or mortality was noted with pouch surgery in elderly patients.43,54,55,59,61,62 The rate of pouch failure in elderly patients undergoing IPAA was reported in a study to be 4.8%, which is similar to the rates of pouch failure in younger age groups.43 Considered altogether, these studies suggest that age alone is not a predictor of negative outcomes after pouch surgery in elderly patients.51
More reliable prognosticators of negative outcomes after IPAA in elderly patients include concomitant comorbidities and the need for emergent surgery.63 Elderly patients undergoing IPAA have been noted to have a longer length of inpatient stay, fewer single-stage surgeries, higher laparoscopic-to-open conversion rates, and more ileostomies.56,57 The postoperative, elderly IPAA patient is at an increased risk of dehydration, which may be related to higher rates of diverting ileostomies.54,64
The elderly IBD patient may be a complex surgical candidate. Older patients undergoing IPAA frequently have comorbidities such as chronic obstructive pulmonary disease, diabetes, hypertension, or congestive heart failure.56 Also, elderly patients have had more prior abdominal surgeries compared to younger patients.57 In addition to assessing for comorbidities that may affect surgical risk, the elderly patient’s gait and mobility should be evaluated because the frequency of stooling may increase after surgery, necessitating more frequent daytime and nocturnal ambulation to and from the restroom. In short, the patient as a whole must be taken into account when determining suitability for IPAA.
The data regarding long-term, age-related pouch function are mixed. In a prospective study of 1875 IPAA patients, pouch function, including the number of daytime and nocturnal bowel movements, remained essentially stable over 30 years of follow-up.8 The risk of pouchitis, a common complication, is independent of age at the time of pouch creation.65,66 On the other hand, age-related pouch function has been noted to change over time. Although a few longitudinal studies have reported some pouch functional deterioration over time across all age groups,60,67 other research has noted an increased risk of pouch failure only if the IPAA was performed in patients 55 years or older.43 Nocturnal stool frequency has been noted to increase from 1 to 2 bowel movements per night over 15 to 30 years of follow-up.8,68
Despite a reported decline in pouch function over time (defined as increased pad usage and incontinence), patient satisfaction and quality-of-life data remain stable in older age groups.8,60 More than 80% of patients considered to be elderly at the time of pouch creation would undergo IPAA again or would recommend the surgery to others.43 The majority of elderly patients undergoing IPAA noted improvement in quality-of-life considerations related to work and family life.54
In summary, being elderly is not a strict contraindication for IPAA. Many elderly patients are able to safely undergo IPAA with good quality of life and comparable pouch outcomes. Preoperative screening and appropriate patient selection (taking into account comorbidities, functional status, and degree of frailty) are key.
Radiation Therapy
Radiation therapy to the bowels carries a risk of acute and long-term toxicity, occasionally leading to complications such as rectal bleeding, diarrhea, and incontinence.69
Pelvic irradiation may cause tissue damage to the bowel by way of vascular injury, ischemia, and production of oxygen free radicals.70 Radiation changes can occur anywhere in the gastrointestinal tract. The small bowel is more susceptible to radiation injury than the colon.71 Because the ileal pouch is situated in the pelvis, the pouch is at risk for radiation injury in patients requiring pelvic radiation.
Radiation in patients who have pelvic pouches can affect pouch function. Radiation pouchitis, characterized by histologic changes such as telangiectatic vessels, focal perivascular hyalinization, and thickened vessel walls, has been described in a man who was asymptomatic after undergoing IPAA who later received external beam radiation therapy for prostate cancer.71 Also, irradiated ileal pouches have been noted to exhibit decreased capacity and compliance compared with nonirradiated pouches.72 Even though the colon is less susceptible to injury compared to the small bowel, patients with colonic pouches who underwent radiation therapy experienced significantly increased diarrhea and nocturnal defecation in a study of 28 patients being treated for rectal cancer.72
More focused radiation may also affect the pouch, although the effects may be more limited. Prostate brachytherapy limits the radiation field. Theoretically, brachytherapy has a lower risk of damage to the pouch by reducing posterior margins and extracapsular radiation exposure.69 However, short- and long-term changes in pouch function still occur. For example, a patient with IPAA developed chronic pouchitis after brachytherapy for prostate cancer.69 Also, in a small cohort of 5 IPAA patients receiving prostate brachytherapy, bowel frequency increased in all patients but returned to baseline within 4 months.73
Pelvic radiation preceding IPAA creation also affects future pouch outcomes. In a cohort of 56 patients with colon or rectal cancer undergoing IPAA, 9 patients received preoperative radiation therapy.74 Chronic pouchitis, defined as a Pouchitis Disease Activity Index score of at least 5 with symptoms lasting more than 4 weeks, occurred significantly more often in patients who had received preoperative radiation (67% vs 26%; P=.024).74 However, no differences were noted in the rates of postoperative complications such as pouch fistula, sinus, stricture, or neoplasia. In addition, the rates of pouch failure are notably increased in pouch patients who have received pelvic radiation.74,75
Thus, pelvic radiation, before or after pouch surgery, may lead to acute or delayed pouch dysfunction. Therefore, patients with an existing ileal pouch, as well as patients who may undergo IPAA in the future, should be informed of the potential risks of radiation exposure to the pouch. Limiting radiation exposure and targeting narrower fields are advisable.
Crohn’s Disease and Indeterminate Colitis
Many surgeons and gastroenterologists consider CD and even IC to be contraindications to IPAA due to fears of complications and pouch failure. For many young patients facing a lifetime with a permanent stoma, the prospect of maintaining bowel continuity, even if temporary, is highly desired. Understanding this demand, select patients with CD have undergone IPAA (CD-IPAA) at specialized pouch centers.10
Suboptimal results have been reported after IPAA in CD patients. Compared to UC and IC patients, CD patients undergoing IPAA were more likely to experience postoperative pelvic sepsis (odds ratio, 2.3) and anastomotic strictures (odds ratio, 2.1).76 Functional outcomes may also differ. In multiple case series, CD-IPAA patients have more daily bowel movements and daytime bowel incontinence than UC patients after IPAA (UC-IPAA).8,77 However, these outcomes are not consistent, as other researchers have reported fewer daily bowel movements in CD-IPAA.78,79 Finally, in an older meta-analysis by Reese and colleagues, pouch failure rates were reported to be higher in CD-IPAA patients (34.9%) compared with UC-IPAA patients (4.8%) and IC patients who have undergone IPAA (5.0%).76 However, more recent publications cite lower rates of pouch failure in CD-IPAA (Table 2).18,77,78,80,81 The rates of pouch failure in CD-IPAA increase with fistulizing disease (pouch-vaginal fistulas, pouch-perineal fistulas, pouch-enteric fistulas)77,80,82-85 and the need for immunomodulator or biologic therapy.83
More recent studies have noted better outcomes in CD-IPAA patients. Zaghiyan and colleagues reported long-term follow-up for 334 pouch patients over 10 years, finding no significant difference in the rate of pouch complications or failure when comparing UC, IC, and CD patients.86 CD-IPAA patients have similar lengths of stay postoperatively compared to UC-IPAA patients.18,79 Also, perhaps most importantly, CD-IPAA patients are happy with their pouches, scoring on par with UC-IPAA patients on quality-of-life surveys regarding dietary, social, work, or sexual restrictions.18
Selection of a specific phenotype of CD for surgery increases the likelihood of IPAA success. When selecting only CD patients with isolated colitis without perianal disease, there were no differences in the rates of postoperative complications, pelvic sepsis, or pouch failure compared with UC patients.76 Panis and colleagues studied 31 CD patients with isolated colitis without perianal or small bowel disease.79 After 5 years of follow-up, these isolated colitis CD- and UC-IPAA patients had similar outcomes with respect to stool frequency, incontinence, and pouch failure.79 The authors concluded that select CD patients without anoperineal or small bowel manifestations can be recommended for IPAA as an alternative to a more definitive end ileostomy.79
A distinction in pouch outcomes can also be made depending on the timing of CD diagnosis.78 The diagnosis of UC or IC is changed to CD in 2% to 19% of IPAA patients.77,78,80,86-89 CD can be diagnosed at numerous stages in the IPAA process: before colectomy, after histology review of the subtotal colectomy or completion proctectomy specimen, or delayed diagnosis (by months to years) post-IPAA (de novo CD of the pouch). It is difficult to predict which patients will develop de novo CD because many of the identified clinical factors such as younger age, female sex, mouth ulcerations, smoking, and family history are nonspecific.89 Multiple retrospective studies have concluded that a known diagnosis of CD prior to pouch creation portends a lower risk of pouch failure compared with a delayed or unsuspected diagnosis of CD.3,15,80,90,91 For example, Brown and colleagues noted that histologic diagnosis of CD at or before the time of pouch creation was associated with more pouch success than pouch failure (63% vs 15%; P<.05).15
Patients with IC who have pouch surgery fare better than patients with CD. Approximately 5% to 10% of patients with colitis have endoscopic, radiologic, and histologic findings from colectomy that are indeterminate, with mixed features of UC and CD.80 Patients carrying the diagnosis of IC have pouch function on par with patients with UC, with no significant difference in the number of bowel movements, incontinence rates, or nighttime seepage.92 However, patients with IC who undergo IPAA are more likely to develop CD of the pouch.8,43,80,92 Nevertheless, pouch failure rates among IC, IBD-unclassified, and UC are similar in multiple cohorts (Table 3).8,18,76,77,92
In summary, the construction of IPAA in patients with CD can be successful in carefully selected patients. Indeed, the recently published European Crohn’s and Colitis Organisation consensus on surgery in CD supports offering IPAA to CD patients without perianal disease or small bowel involvement.3 However, overall pouch failure rates are higher in CD patients compared to patients with UC or IC.8,18,78 A thorough preoperative evaluation in CD patients should include perineal examination combined with imaging of the abdomen and pelvis to rule out fistulas and small bowel disease. Potential surgical CD candidates should be counseled extensively regarding the possible need for examination under anesthesia, seton placement, use of biologic agents or immunosuppressants, and diversion. Taking all of this into account, only highly motivated patients with CD should be considered.
Conclusion
The incidence of pouch failure is decreasing,11 partly due to improved surgical technique as well as increased use of biologic medications. However, strategic patient selection also increases the likelihood of satisfactory quality of life after pouch construction.
Careful preoperative counseling regarding realistic expectations after IPAA is essential because some degree of sphincter dysfunction with potential incontinence and increased bowel frequency can be expected postoperatively. Clinicians should take into account each patient’s comorbidities, surgical history with any complications, and functional status.
Perhaps the most controversial indication for IPAA is CD. Although it is true that the diagnosis of CD is a potential contraindication to IPAA, patients with isolated Crohn’s colitis may thrive after pouch surgery. At this time, patients with isolated Crohn’s colitis (without perianal disease or small bowel involvement) have good pouch retention rates and are the optimal CD patients to consider for IPAA.79,91 In the future, studies should focus on identifying specific clinical, genetic, or serologic markers that may predict which CD patients will thrive after IPAA.
The decision to undergo IPAA should be made after an extensive discussion among multidisciplinary team members and the patient. Effort should be made to honor the patient’s wishes, taking into account his or her short- and long-term life goals. Given the potential for complications, it is recommended that IPAA be performed in high-volume referral centers with specialized expertise in surgical and medical management of pouches.53
The authors have no relevant conflicts of interest to disclose.
References
1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978;2(6130):85-88.
2. Shen B. Pouchitis: what every gastroenterologist needs to know. Clin Gastroenterol Hepatol. 2013;11(12):1538-1549.
3. Bemelman WA, Warusavitarne J, Sampietro GM, et al; European Crohn’s and Colitis Organisation (ECCO); European Society of Coloproctology (ESCP). ECCO-ESCP consensus on surgery for Crohn’s disease [published online May 11, 2017]. J Crohns Colitis. doi:10.1093/ecco-jcc/jjx061.
4. Martin ST, Vogel JD. Restorative procedures in colonic Crohn disease. Clin Colon Rectal Surg. 2013;26(2):100-105.
5. de Buck van Overstraeten A, Wolthuis AM, Vermeire S, et al. Long-term functional outcome after ileal pouch anal anastomosis in 191 patients with ulcerative colitis. J Crohns Colitis. 2014;8(10):1261-1266.
6. Karlbom U, Lindfors A, Påhlman L. Long-term functional outcome after restorative proctocolectomy in patients with ulcerative colitis. Colorectal Dis. 2012;14(8):977-984.
7. Gawad KA, Wenske S, von Schrenck T, Izbicki JR. Ileoanal-pouch reconstruction does not impair sphincter function or quality of life. Hepatogastroenterology. 2007;54(77):1477-1482.
8. Lightner AL, Mathis KL, Dozois EJ, et al. Results at up to 30 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Inflamm Bowel Dis. 2017;23(5):781-790.
9. Koerdt S, Jehle EC, Kreis ME, Kasparek MS. Quality of life after proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis. Int J Colorectal Dis. 2014;29(5):545-554.
10. Kiran RP, Remzi FH, Fazio VW, et al. Complications and functional results after ileoanal pouch formation in obese patients. J Gastrointest Surg. 2008;12(4):668-674.
11. de Zeeuw S, Ahmed Ali U, Donders RA, Hueting WE, Keus F, van Laarhoven CJ. Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies. Int J Colorectal Dis. 2012;27(7):843-853.
12. Kuruvilla K, Osler T, Hyman NH. A comparison of the quality of life of ulcerative colitis patients after IPAA vs ileostomy. Dis Colon Rectum. 2012;55(11):1131-1137.
13. Tulchinsky H, Dotan I, Halpern Z, Klausner JM, Rabau M. A longitudinal study of quality of life and functional outcome of patients with ulcerative colitis after proctocolectomy with ileal pouch-anal anastomosis. Dis Colon Rectum. 2010;53(6):866-873.
14. Ganschow P, Pfeiffer U, Hinz U, Leowardi C, Herfarth C, Kadmon M. Quality of life ten and more years after restorative proctocolectomy for patients with familial adenomatous polyposis coli. Dis Colon Rectum. 2010;53(10):1381-1387.
15. Brown CJ, Maclean AR, Cohen Z, Macrae HM, O’Connor BI, McLeod RS. Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis Colon Rectum. 2005;48(8):1542-1549.
16. Hueting WE, Buskens E, van der Tweel I, Gooszen HG, van Laarhoven CJ. Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients. Dig Surg. 2005;22(1-2):69-79.
17. Lovegrove RE, Constantinides VA, Heriot AG, et al. A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg. 2006;244(1):18-26.
18. Fazio VW, Kiran RP, Remzi FH, et al. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg. 2013;257(4):679-685.
19. Hawn MT, Bian J, Leeth RR, et al. Impact of obesity on resource utilization for general surgical procedures. Ann Surg. 2005;241(5):821-826.
20. Efron JE, Uriburu JP, Wexner SD, et al. Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients. Obes Surg. 2001;11(3):246-251.
21. Long MD, Crandall WV, Leibowitz IH, et al; ImproveCareNow Collaborative for Pediatric IBD. Prevalence and epidemiology of overweight and obesity in children with inflammatory bowel disease. Inflamm Bowel Dis. 2011;17(10):2162-2168.
22. Canedo JA, Pinto RA, McLemore EC, Rosen L, Wexner SD. Restorative proctectomy with ileal pouch-anal anastomosis in obese patients. Dis Colon Rectum. 2010;53(7):1030-1034.
23. Klos CL, Safar B, Jamal N, et al. Obesity increases risk for pouch-related complications following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). J Gastrointest Surg. 2014;18(3):573-579.
24. Scott NA, Pemberton JH, Barkel DC, Wolff BG. Anal and ileal pouch manometric measurements before ileostomy closure are related to functional outcome after ileal pouch-anal anastomosis. Br J Surg. 1989;76(6):613-616.
25. Braun J, Treutner KH, Harder M, Lerch MM, Töns C, Schumpelick V. Anal sphincter function after intersphincteric resection and stapled ileal pouch-anal anastomosis. Dis Colon Rectum. 1991;34(1):8-16.
26. Tomita R. Ano-neorectal function using manometry on patients with soiling at 10 years or more after ileal J pouch-anal anastomosis for ulcerative colitis. Hepatogastroenterology. 2009;56(94-95):1326-1330.
27. Gearhart SL, Hull TL, Schroeder T, Church J, Floruta C. Sphincter defects are not associated with long-term incontinence following ileal pouch-anal anastomosis. Dis Colon Rectum. 2005;48(7):1410-1415.
28. Cullen JJ, Kelly KA. Prospectively evaluating anal sphincter function after ileal pouch-anal canal anastomosis. Am J Surg. 1994;167(6):558-561.
29. Andersson T, Lunde OC, Johnson E, Moum T, Nesbakken A. Long-term functional outcome and quality of life after restorative proctocolectomy with ileo-anal anastomosis for colitis. Colorectal Dis. 2011;13(4):431-437.
30. Michelassi F, Lee J, Rubin M, et al. Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study. Ann Surg. 2003;238(3):433-441.
31. Stryker SJ, Kelly KA, Phillips SF, Dozois RR, Beart RW Jr. Anal and neorectal function after ileal pouch-anal anastomosis. Ann Surg. 1986;203(1):55-61.
32. Silvis R, van Eekelen JW, Delemarre JB, Gooszen HG. Endosonography of the anal sphincter after ileal pouch-anal anastomosis. Relation with anal manometry and fecal continence. Dis Colon Rectum. 1995;38(4):383-388.
33. Kobakov G, Kostov D, Temelkov T. Manometric study in ulcerative colitis patients with modified ileal pouch–anal anastomosis. Int J Colorectal Dis. 2006;21(8):767-773.
34. Reissman P, Teoh TA, Weiss EG, Nogueras JJ, Wexner SD. Functional outcome of the double stapled ileoanal reservoir in patients more than 60 years of age. Am Surg. 1996;62(3):178-183.
35. Halverson AL, Hull TL, Remzi F, Hammel JP, Schroeder T, Fazio VW. Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis. J Gastrointest Surg. 2002;6(3):316-320.
36. Tomita R, Ikeda T, Fujisaki S, et al. Ano-neorectal function using manometry on patients after restorative proctocolectomy and ileal J-pouch anal anastomosis for ulcerative colitis in children. Hepatogastroenterology. 2012;59(113):112-115.
37. Araki T, Okita Y, Fujikawa H, Uchida K, Mohri Y, Kusunoki M. Functional and manometric outcomes after redo-ileal pouch anal anastomosis in patients with ulcerative colitis. Dig Surg. 2014;31(3):190-196.
38. Hallgren T, Fasth S, Delbro DS, Nordgren S, Oresland T, Hultén L. Loperamide improves anal sphincter function and continence after restorative proctocolectomy. Dig Dis Sci. 1994;39(12):2612-2618.
39. Emblem R, Stien R, Mørkrid L. The effect of loperamide on bowel habits and anal sphincter function in patients with ileoanal anastomosis. Scand J Gastroenterol. 1989;24(8):1019-1024.
40. Rezvan A, Jakus-Waldman S, Abbas MA, Yazdany T, Nguyen J. Review of the diagnosis, management and treatment of fecal incontinence. Female Pelvic Med Reconstr Surg. 2015;21(1):8-17.
41. Sharma A, Yuan L, Marshall RJ, Merrie AE, Bissett IP. Systematic review of the prevalence of faecal incontinence. Br J Surg. 2016;103(12):1589-1597.
42. Dayton MT, Larsen KR. Should older patients undergo ileal pouch-anal anastomosis? Am J Surg. 1996;172(5):444-447.
43. Delaney CP, Fazio VW, Remzi FH, et al. Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg. 2003;238(2):221-228.
44. Tan KK, Manoharan R, Rajendran S, Ravindran P, Young CJ. Assessment of age in ulcerative colitis patients with ileal pouch creation—an evaluation of outcomes. Ann Acad Med Singapore. 2015;44(3):92-97.
45. Chapman JR, Larson DW, Wolff BG, et al. Ileal pouch-anal anastomosis: does age at the time of surgery affect outcome? Arch Surg. 2005;140(6):534-539.
46. Takao Y, Gilliland R, Nogueras JJ, Weiss EG, Wexner SD. Is age relevant to functional outcome after restorative proctocolectomy for ulcerative colitis?: prospective assessment of 122 cases. Ann Surg. 1998;227(2):187-194.
47. Kim H, Sun L, Gurland B, Hull T, Zutshi M, Church J. Does stool leakage increase in aging pouches? Dis Colon Rectum. 2015;58(12):1158-1163.
48. Stallmach A, Hagel S, Gharbi A, et al. Medical and surgical therapy of inflammatory bowel disease in the elderly—prospects and complications. J Crohns Colitis. 2011;5(3):177-188.
49. Nygaard IE, Rao SS, Dawson JD. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstet Gynecol. 1997;89(6):896-901.
50. Remzi FH, Gorgun E, Bast J, et al. Vaginal delivery after ileal pouch-anal anastomosis: a word of caution. Dis Colon Rectum. 2005;48(9):1691-1699.
51. Robertson DJ, Grimm IS. Inflammatory bowel disease in the elderly. Gastroenterol Clin North Am. 2001;30(2):409-426.
52. Cohen JL, Strong SA, Hyman NH, et al; Standards Practice Task Force American Society of Colon and Rectal Surgeons. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2005;48(11):1997-2009.
53. Magro F, Gionchetti P, Eliakim R, et al; European Crohn’s and Colitis Organisation [ECCO]. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders. J Crohns Colitis. 2017;11(6):649-670.
54. Ramage L, Qiu S, Georgiou P, Tekkis P, Tan E. Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review. Int J Colorectal Dis. 2016;31(3):481-492.
55. Almogy G, Sachar DB, Bodian CA, Greenstein AJ. Surgery for ulcerative colitis in elderly persons: changes in indications for surgery and outcome over time. Arch Surg. 2001;136(12):1396-1400.
56. Cohan JN, Bacchetti P, Varma MG, Finlayson E. Outcomes after ileoanal pouch surgery in frail and older adults. J Surg Res. 2015;198(2):327-333.
57. Colombo F, Sahami S, de Buck Van Overstraeten A, et al. Restorative proctocolectomy in elderly IBD patients: a multicentre comparative study on safety and efficacy. J Crohns Colitis. 2017;11(6):671-679.
58. Bauer JJ, Gorfine SR, Gelernt IM, Harris MT, Kreel I. Restorative proctocolectomy in patients older than fifty years. Dis Colon Rectum. 1997;40(5):562-565.
59. Delaney CP, Dadvand B, Remzi FH, Church JM, Fazio VW. Functional outcome, quality of life, and complications after ileal pouch-anal anastomosis in selected septuagenarians. Dis Colon Rectum. 2002;45(7):890-894.
60. Kiran RP, El-Gazzaz G, Remzi FH, et al. Influence of age at ileoanal pouch creation on long-term changes in functional outcomes. Colorectal Dis. 2011;13(2):184-190.
61. Pellino G, Sciaudone G, Candilio G, et al. Restorative proctocolectomy with ileal pouch-anal anastomosis is safe and effective in selected very elderly patients suffering from ulcerative colitis. Int J Surg. 2014;12(suppl 2):S56-S59.
62. Pellino G, Sciaudone G, Candilio G, et al. Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly. BMC Surg. 2013;13(suppl 2):S9.
63. Taleban S, Colombel JF, Mohler MJ, Fain MJ. Inflammatory bowel disease and the elderly: a review. J Crohns Colitis. 2015;9(6):507-515.
64. Paquette IM, Solan P, Rafferty JF, Ferguson MA, Davis BR. Readmission for dehydration or renal failure after ileostomy creation. Dis Colon Rectum. 2013;56(8):974-979.
65. Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg. 1998;85(6):800-803.
66. Lohmuller JL, Pemberton JH, Dozois RR, Ilstrup D, van Heerden J. Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis. Ann Surg. 1990;211(5):622-627.
67. Bengtsson J, Börjesson L, Lundstam U, Oresland T. Long-term function and manovolumetric characteristics after ileal pouch-anal anastomosis for ulcerative colitis. Br J Surg. 2007;94(3):327-332.
68. Hahnloser D, Pemberton JH, Wolff BG, Larson DR, Crownhart BS, Dozois RR. The effect of ageing on function and quality of life in ileal pouch patients: a single cohort experience of 409 patients with chronic ulcerative colitis. Ann Surg. 2004;240(4):615-621.
69. Cherian S, Kittel JA, Reddy CA, et al. Safety and efficacy of iodine-125 permanent prostate brachytherapy in patients with J-pouch anastomosis after total colectomy for ulcerative colitis. Pract Radiat Oncol. 2015;5(5):e437-e442.
70. Kani HT, Shen B. Male issues of the ileal pouch. Inflamm Bowel Dis. 2015;21(3):716-722.
71. Kulkarni G, Liu X, Shen B. Pouchitis associated with pelvic radiation for prostate cancer. ACG Case Rep J. 2016;3(4):e129.
72. Dehni N, McNamara DA, Schlegel RD, Guiguet M, Tiret E, Parc R. Clinical effects of preoperative radiation therapy on anorectal function after proctectomy and colonic J-pouch-anal anastomosis. Dis Colon Rectum. 2002;45(12):1635-1640.
73. Williamson R, Smaldone MC, Gibbons EP, Smith RP, Beriwal S, Benoit RM. Prostate brachytherapy after ileal pouch-anal anastomosis reconstruction. Urology. 2009;73(2):369-373.
74. Wu XR, Kiran RP, Remzi FH, Katz S, Mukewar S, Shen B. Preoperative pelvic radiation increases the risk for ileal pouch failure in patients with colitis-associated colorectal cancer. J Crohns Colitis. 2013;7(10):e419-e426.
75. Radice E, Nelson H, Devine RM, et al. Ileal pouch-anal anastomosis in patients with colorectal cancer: long-term functional and oncologic outcomes. Dis Colon Rectum. 1998;41(1):11-17.
76. Reese GE, Lovegrove RE, Tilney HS, et al. The effect of Crohn’s disease on outcomes after restorative proctocolectomy. Dis Colon Rectum. 2007;50(2):239-250.
77. Gu J, Stocchi L, Kiran RP, Shen B, Remzi FH. Do clinical characteristics of de novo pouch Crohn’s disease after restorative proctocolectomy affect ileal pouch retention? Dis Colon Rectum. 2014;57(1):76-82.
78. Grucela AL, Bauer JJ, Gorfine SR, Chessin DB. Outcome and long-term function of restorative proctocolectomy for Crohn’s disease: comparison to patients with ulcerative colitis. Colorectal Dis. 2011;13(4):426-430.
79. Panis Y, Poupard B, Nemeth J, Lavergne A, Hautefeuille P, Valleur P. Ileal pouch/anal anastomosis for Crohn’s disease. Lancet. 1996;347(9005):854-857.
80. Melton GB, Kiran RP, Fazio VW, et al. Do preoperative factors predict subsequent diagnosis of Crohn’s disease after ileal pouch-anal anastomosis for ulcerative or indeterminate colitis? Colorectal Dis. 2010;12(10):1026-1032.
81. Le Q, Melmed G, Dubinsky M, et al. Surgical outcome of ileal pouch-anal anastomosis when used intentionally for well-defined Crohn’s disease. Inflamm Bowel Dis. 2013;19(1):30-36.
82. Gu J, Remzi FH, Shen B, Vogel JD, Kiran RP. Operative strategy modifies risk of pouch-related outcomes in patients with ulcerative colitis on preoperative anti-tumor necrosis factor-α therapy. Dis Colon Rectum. 2013;56(11):1243-1252.
83. Shen B, Remzi FH, Brzezinski A, et al. Risk factors for pouch failure in patients with different phenotypes of Crohn’s disease of the pouch. Inflamm Bowel Dis. 2008;14(7):942-948.
84. Haveran LA, Sehgal R, Poritz LS, McKenna KJ, Stewart DB, Koltun WA. Infliximab and/or azathioprine in the treatment of Crohn’s disease-like complications after IPAA. Dis Colon Rectum. 2011;54(1):15-20.
85. Braveman JM, Schoetz DJ Jr, Marcello PW, et al. The fate of the ileal pouch in patients developing Crohn’s disease. Dis Colon Rectum. 2004;47(10):1613-1619.
86. Zaghiyan K, Kamiński JP, Barmparas G, Fleshner P. De novo Crohn’s disease after ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified: long-term follow-up of a prospective inflammatory bowel disease registry. Am Surg. 2016;82(10):977-981.
87. Mortellaro VE, Green J, Islam S, Bass JA, Fike FB, St Peter SD. Occurrence of Crohn’s disease in children after total colectomy for ulcerative colitis. J Surg Res. 2011;170(1):38-40.
88. Lightner AL, Pemberton JH, Loftus EJ Jr. Crohn’s disease of the ileoanal pouch. Inflamm Bowel Dis. 2016;22(6):1502-1508.
89. Ahmed S, Melmed G, McGovern D, et al. Nonbloody diarrhea but not significant weight loss at diagnosis is associated with the development of de novo Crohn’s disease after ileal pouch-anal anastomosis for ulcerative colitis. Inflamm Bowel Dis. 2016;22(3):654-661.
90. Mylonakis E, Allan RN, Keighley MR. How does pouch construction for a final diagnosis of Crohn’s disease compare with ileoproctostomy for established Crohn’s proctocolitis? Dis Colon Rectum. 2001;44(8):1137-1142.
91. Regimbeau JM, Panis Y, Pocard M, et al. Long-term results of ileal pouch-anal anastomosis for colorectal Crohn’s disease. Dis Colon Rectum. 2001;44(6):769-778.
92. Jackson KL, Stocchi L, Duraes L, Rencuzogullari A, Bennett AE, Remzi FH. Long-term outcomes in indeterminate colitis patients undergoing ileal pouch-anal anastomosis: function, quality of life, and complications. J Gastrointest Surg. 2017;21(1):56-61.
93. Shen B, Patel S, Lian L. Natural history of Crohn’s disease in patients who underwent intentional restorative proctocolectomy with ileal pouch-anal anastomosis. Aliment Pharmacol Ther. 2010;31(7):745-753.
94. Hyman NH, Fazio VW, Tuckson WB, Lavery IC. Consequences of ileal pouch-anal anastomosis for Crohn’s colitis. Dis Colon Rectum. 1991;34(8):653-657.
95. Fazio VW, Ziv Y, Church JM, et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg. 1995;222(2):120-127.
96. Grobler SP, Hosie KB, Affie E, Thompson H, Keighley MR. Outcome of restorative proctocolectomy when the diagnosis is suggestive of Crohn’s disease. Gut. 1993;34(10):1384-1388.
97. Tekkis PP, Heriot AG, Smith O, Smith JJ, Windsor AC, Nicholls RJ. Long-term outcomes of restorative proctocolectomy for Crohn’s disease and indeterminate colitis. Colorectal Dis. 2005;7(3):218-223.
98. Hartley JE, Fazio VW, Remzi FH, et al. Analysis of the outcome of ileal pouch-anal anastomosis in patients with Crohn’s disease. Dis Colon Rectum. 2004;47(11):1808-1815.
99. de Oca J, Sánchez-Santos R, Ragué JM, et al. Long-term results of ileal pouch-anal anastomosis in Crohn’s disease. Inflamm Bowel Dis. 2003;9(3):171-175.
100. Rudolph WG, Uthoff SM, McAuliffe TL, Goode ET, Petras RE, Galandiuk S. Indeterminate colitis: the real story. Dis Colon Rectum. 2002;45(11):1528-1534.
101. Truta B, Li DX, Mahadevan U, et al. Serologic markers associated with development of Crohn’s disease after ileal pouch anal anastomosis for ulcerative colitis. Dig Dis Sci. 2014;59(1):135-145.
102. Gramlich T, Delaney CP, Lynch AC, Remzi FH, Fazio VW. Pathological subgroups may predict complications but not late failure after ileal pouch-anal anastomosis for indeterminate colitis. Colorectal Dis. 2003;5(4):315-319.
103. Pezim ME, Pemberton JH, Beart RW Jr, et al. Outcome of “indeterminant” colitis following ileal pouch-anal anastomosis. Dis Colon Rectum. 1989;32(8):653-658.
104. Pishori T, Dinnewitzer A, Zmora O, et al. Outcome of patients with indeterminate colitis undergoing a double-stapled ileal pouch-anal anastomosis. Dis Colon Rectum. 2004;47(5):717-721.
105. Delaney CP, Remzi FH, Gramlich T, Dadvand B, Fazio VW. Equivalent function, quality of life and pouch survival rates after ileal pouch-anal anastomosis for indeterminate and ulcerative colitis. Ann Surg. 2002;236(1):43-48.
106. Yu CS, Pemberton JH, Larson D. Ileal pouch-anal anastomosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum. 2000;43(11):1487-1496.
107. Marcello PW, Schoetz DJ Jr, Roberts PL, et al. Evolutionary changes in the pathologic diagnosis after the ileoanal pouch procedure. Dis Colon Rectum. 1997;40(3):263-269.