eP616 - Indications and Outcomes of Pouch Excision in Patients with Inflammatory Bowel Disease in the Modern Era of Therapy

Purpose/Background: Pouch excision after total proctocolectomy with ileoanal pouch anastomosis (IPAA) for ulcerative colitis (UC) is associated with early morbidity rates as high as 60%, with rates of urgent excision due to sepsis ranging 21-36%. Excision occurs at a median time of 5-10 years from IPAA creation, however this data is reflective of cohorts of patients dating back to the 1980s. Given the advancement in the medical and surgical therapies for inflammatory bowel disease (IBD), there is a need for analysis of indications, timing, and outcomes of pouch excisions in a cohort from the last decade.Methods/Interventions: Retrospective analysis of a prospectively maintained IBD database identified all patients who underwent pouch excision from January 2013 to June 2023 at the Mount Sinai Hospital (MSH). Demographics, details of IPAA creation and revisions, indications for and timing of pouch excision, perioperative details, and postoperative outcomes were collected.Results/Outcomes: Forty-nine patients, median age 52 (IQR 38-59), underwent pouch excision after a median time of 29.4 years (16.8-58.3) from IPAA creation. Indications for IPAA included medically refractory UC (77.6%), dysplasia (12.2%), colon or rectal cancer (2.0%), and indeterminate colitis (6.1%). Indications for excision included Crohn’s disease-like pouch inflammation (CDLPI, 51%), cancer of the pouch or rectal cuff (12.2%), refractory pouchitis (12.2%), pouch dysfunction (8.2%), rectal cuff or pouch dysplasia (6.1%), stricture limiting surveillance (4.1%), and unknown indication (6.1%). Median time from diagnosis of CDLPI to pouch excision was 142 months (43-242), compared to 14 months (4-19) from diagnosis of cancer or dysplasia of the rectal cuff or pouch. 41 patients (83.7%) underwent surgery for attempted pouch preservation including intervention for perianal disease, stricture dilation, partial excision, anastomotic revision, or temporary diverting ileostomy. 55.1% were diverted prior to excision. 70% of patients with CDLPI were treated with a biologic prior to excision. 98% of excisions were performed electively. Abdominal approach was open in 67.3% and laparoscopic in 30.6%, of which 20% required conversion to open. 53.1% of patients experienced complications within 30 days, with a highest Clavien Dindo grade of 1-2 in 32.7% and 3-4 in 20.4%. 42.9% of patients required additional surgery related to IBD >30 days after excision, the majority of which were for revision of end-ileostomies or debridement of the perineal wound.Conclusion/

Discussion: In the modern era of IBD therapy, pouch excision after IPAA for IBD is most often performed in the elective setting for patients with persistent clinical symptoms secondary to CDLPI or pouch dysfunction despite attempts at pouch revision, diversion, and/or biologic therapy. Further studies examining the impact of revision and biologic therapy for CDLPI on pouch survival would aid in the counseling and decision-making process for patients attempting pouch salvage in the setting of inflammatory conditions of the pouch.