eP257 - Ileal Pouch Anal Anastomosis Sinus at Pouchogram Portends Pouch Failure Even If Asymptomatic

Purpose/Background: Pouchograms are routinely performed before diverting loop ileostomy (DLI) closure after ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC). However, the incidence of sinus detection, management of pouch sinuses, and long-term pouch survival remain poorly understood. Therefore, the aims of this study were to 1) determine pouch survival when compared between sinuses in symptomatic and asymptomatic patients, and 2) assess management of symptomatic versus asymptomatic IPAA sinuses.Methods/Interventions: A retrospective chart review was conducted of all patients with UC who underwent IPAA with DLI and subsequent pouchogram between January 1, 2008 and December 31, 2022 at a single institution. Pouchogram reports before DLI closure were reviewed to identify patients with an IPAA sinus. Subsequently, only patients with an IPAA sinus were included. Patients were then stratified based on whether they had a documented IPAA leak at any point before pouchogram (defined as “symptomatic”) or no prior evidence of IPAA leak (defined as “asymptomatic”). Time from first pouchogram to DLI closure, total number of pouchograms, interventions including drain placement and returns to the operating room, and pouch survival were collected. Univariate comparisons between the symptomatic and asymptomatic patients were performed. Pouch survival was calculated from time of DLI closure to the date of either IPAA excision or indefinite diversion, censoring at date of last follow-up. Kaplan-Meier survival analysis compared pouch failure between symptomatic and asymptomatic patients.Results/Outcomes: A total of 994 patients underwent a pouchogram before DLI closure with a sinus detected in 51 patients (5.1%, 95% confidence interval [CI]: 3.8-6.8%). Median age at IPAA was 42 (interquartile range [IQR], 30-54), the majority were male (57%), and most of the IPAAs were performed in three stages (n=37, 73%). Over half of the patients were asymptomatic at time of pouchogram (n=29, 57%). Eighteen of the 51 patients had undergone either pouch excision or diversion with the pouch left in situ at date of last follow-up. Pouch survival at 5 and 10 years was 53% (95% CI: 38-74) and 40% (95% CI: 21-77%) respectively and did not differ between symptomatic and asymptomatic patients (p=0.85) (FIGURE). Five patients (n=4 symptomatic, n=1 asymptomatic) never had their DLI reversed, and their pouch survival was set at 0 days.The median time between first pouchogram and DLI reversal was 67 days and was similar between symptomatic and asymptomatic patients (p=0.82). Most patients (n=31, 67%) underwent at least 2 pouchograms before DLI reversal. Number of interventions between first pouchogram and DLI reversal did not differ between symptomatic and asymptomatic patients (p=0.60), but total number of interventions between IPAA formation and sinus healing or pouch failure was higher in symptomatic patients (median of 2, IQR: 1-3 versus median of 1, IQR: 0-3, p=0.03).Conclusion/

Discussion: The presence of a sinus at pouchogram before DLI reversal is rare but is associated with poor long-term pouch survival, regardless of whether the patient had a prior anastomotic leak or not. Management of these sinuses needs to be refined to hopefully improve pouch survival.Kaplan-Meier curves demonstrating overall pouch survival (A) and pouch survival stratified by symptomatic (blue) vs. asymptomatic leaks (red) (B).The x axis correspond to a 10-year time span with hash marks every 2 years.