Introduction
Pouchoscopy is indicated for pouch assessment and surveillance following ileal pouch-anal anastomosis (IPAA) surgery. Annual surveillance is suggested in cases who are at high risk of neoplasia (i.e. Primary Sclerosing Cholangitis (PSC)/ colonic dysplasia/ neoplasia), and 5 yearly in low risk patients1,2. Biopsies are recommended. With the pressures on endoscopy services continuing we reviewed endoscopy utilisation in our cohort of pouch patients.
Aims & Methods
We searched via health informatics for all patients who underwent IPAA surgery at our centre the Queen Elizabeth Hospital, Birmingham, United Kingdom, from 2012 to 2022. Via case note review, we reviewed indication, timing, presence of high-risk features and pouchoscopy report
Results
56 patients underwent surgery for formation of new IPAA during this study period. The majority were performed were performed from 2012- 2015 (36 cases, 62%). 6 (10%) were undertaken as a single stage procedure, the remainder were 2 stage and 1 (1.8%) was a conversion from an ileo-rectal anastamosis. Indication for IPAA was medically refractory inflammatory bowel disease (IBD) in 48 (86%) cases, colonic dyslpasia in the context of IBD in 5 (9%), and 3 (5%) had an underlying genetic disorder for malignancy e.g. FAP or HNPCC. 16 patients had high risk features (PSC colitis=5, Dysplasia/neoplasia =11), although 2 were referred elsewhere for surveillance.
148 pouchoscopies were performed on this cohort of patients, with an average of 1 pouchoscopy every 3 years from IPAA date (range: 1 pouchoscopy per 0.4 – 10 years). The majority (113, 76%) of procedures were for pouch symptoms e.g. frequency, pain. Biopsies were taken in 98 (66%). Dye spray surveillance was not performed. No biopsy showed pouch or rectal neoplasia, but 73 (74%) showed pouchitis/cuffitis/inflammation.
Despite high resource utilisation, adherence to surveillance protocols remained poor.
| Appropriate number of pouchoscopies as per guidelines | Appropriate number of pouchoscopies with biopsies | Number of patients who did not undergo pouchoscopy despite pouch duration >1 years (high risk) or >5 years (low risk) |
| High risk (n=14) | 2 (14%) | 1 (7%) | 3 (21%) |
| Low risk (n=40) | 30 (75%) | 29 (73%) | 10 (25%) |
2 patients went on to have their IPAA excised, and 5 have since died; 2 due to PSC associated liver failure, 2 due to non-pouch malignancy and 1-details unavailable.
Conclusion
This study shows poor implementation of pouch surveillance guidelines yet high use of endoscopy for pouch assessment often without biopsy. Our findings suggest that surveillance for neoplasia is an overlooked component of the care of patients who have under IPAA surgery. Furthermore, there is uncertainty within guidelines about frequency of surveillance particularly in low risk groups, although these patients do have a recognised risk of neoplasia2,3.
We recommend that endoscopists take biopsies routinely when assessing pouch such as Type C mucosa in the pouch (mucosa exhibiting permanent persistent atrophy and severe inflammation) has a greater propensity for neoplastic changes. In addition, more data is needed to determine the risk of neoplasia in different subgroups of patients who have undergone IPAA surgery, as well as develop robust guidelines on use of endoscopy in pouch management.
References
1 = Derikx LA, Nissen LH, Oldenburg B, Hoentjen F. Controversies in Pouch Surveillance for Patients with Inflammatory Bowel Disease. J Crohns Colitis. 2016 Jun;10(6):747-51. doi: 10.1093/ecco-jcc/jjw035. Epub 2016 Jan 28. PMID: 26822612.
2 = Lamb CA, Kennedy NA, Raine T, et al British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults Gut 2019;68:s1-s106.
3=Samaan MA, Forsyth K, Segal JP, De Jong D, Vleugels JLA, Elkady S, Kabir M, Campbell S, Kok K, Armstrong DG, Penez L, Arenaza AP, Seward E, Vega R, Mehta S, Rahman F, McCartney S, Bloom S, Patel K, Pollok R, Westcott E, Darakhshan A, Williams A, Koumoutsos I, Ray S, Mawdsley J, Anderson S, Sanderson JD, Dekker E, D'Haens GR, Hart A, Irving PM. Current Practices in Ileal Pouch Surveillance for Patients With Ulcerative Colitis: A Multinational, Retrospective Cohort Study. J Crohns Colitis. 2019 May 27;13(6):735-743. doi: 10.1093/ecco-jcc/jjy225. PMID: 30590513.