Ileal Pouch-anal Anastomosis Complications and Pouch Failure: A systematic review and meta-analysis

Lianne Heuthorst; Karin A T G M Wasmann; Maud A Reijntjes; Roel Hompes; Christianne J Buskens; Willem A Bemelman

doi:10.1097/AS9.0000000000000074

Ileal Pouch-anal Anastomosis Complications and Pouch Failure: A systematic review and meta-analysis

Ann Surg Open. 2021 Jun 21;2(2):e074. doi: 10.1097/AS9.0000000000000074. eCollection 2021 Jun.

Authors

Lianne Heuthorst¹, Karin A T G M Wasmann¹, Maud A Reijntjes¹, Roel Hompes¹, Christianne J Buskens¹, Willem A Bemelman¹

Affiliation

¹ From the Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.

Abstract

Objective: This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure.

Background: Previous studies demonstrated wide variation in postoperative complication rates following IPAA.

Methods: A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman's correlations.

Results: Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56-10.59) and 10.3% (95% confidence intervals: 7.24-14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1-17%), pelvic sepsis (2-18%), fistula (1-30%), stricture (1-34%), pouchitis (11-61%), and Crohn's disease of the pouch (0-18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01).

Conclusions: The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak.

Mini abstract: This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to an increased risk of pouch failure.

Keywords: ileal pouch-anal anastomosis; pouch failure; ulcerative colitis.