Crohn’s Colitis Patients Should Never Be Offered an Ileoanal Pouch

Asher Kornbluth, MD

Clinical Professor of Medicine

The Henry D. Janowitz Division of

Gastroenterology

The Icahn School of Medicine at Mount Sinai

Last Year’s Debate:22 year old, Severe UC Failing 5

Days IV SteroidsTheir Position:

Infliximab 5 mg/kg and subtotal colectomy if no improvement in 5

days

My Prior Debates:22 year old, Severe UC Failing 5 Days

IV Steroids

• Bedside Commode

• Start Kosher Diet

To Make

It Fair

For Our

Surgeon Friends

I’ll Try

To Speak

Slowly

And with only

1 or

Maybe 2

Syllables

Per

Word

Problems with Pouches in Patients with Crohn’s disease

• The problem of symptoms

• The problem of local complications

• The problem of major complications

• The problem of pouch failure and excision

Problems with Pouches in Patients with Crohn’s disease

• The problem of symptoms

• The problem of local complications

• The problem of major complications

• The problem of pouch failure and excision

Increased symptoms in Crohn’s disease pouches

Shen B, Am J Gastro 2005; 100: 93-104

Increased symptoms in patients with pre-op perineal disease

Richard et al, Dis Colon Rectum, 1997

Problems with Pouches in Patients with Crohn’s disease

• The problem of symptoms

• The problem of local complications

• The problem of major complications

• The problem of pouch failure and excision

Pouch Fistula in Crohn’s disease

Shen , et al CGH 2008

Perianal complications in patients with pre-op Crohn’s disease

Richard et al, Dis Colon Rectum, 1997

Fistula – Free Survival Analysis:IC-UC vs. IC-Crohn’s disease/Crohn’s

disease

Tekkis PP, et al. Colorectal Disease 2005; 7: 218

Problems with Pouches in Patients with Crohn’s disease

• The problem of symptoms

• The problem of local complications

• The problem of major complications

• The problem of pouch failure and excision

Meta Analysis:Major Complications of the Pouch in

Patients with Crohn’s disease

Meta Analysis of Crohn’s disease pouch outcomes: Highest quality

series

Reese GE, et al. Dis Colon Rectum 2007; 50:239

Meta Analysis of Crohn’s disease pouch outcomes: More Recent

Series

Reese GE, et al. Dis Colon Rectum 2007; 50:239

Meta Analysis of Crohn’s disease pouch outcomes: Most experienced

surgeons

Reese GE, et al. Dis Colon Rectum 2007; 50:239

Problems with Pouches in Patients with Crohn’s disease

• The problem of symptoms

• The problem of local complications

• The problem of major complications

• The problem of pouch failure and excision

Pouch Failure Rate: Crohn’s disease vs. UC

Brown CR, et al. Dis Colon Rectum 2005; 48: 1542

Pouch Survival: IC-UC vs. IC-Crohn’s disease, or CD

Tekkis PP, et al. Colorectal Disease 2005; 7: 218

Risk factors for pouch failure: The Cleveland Clinic experience

Fazio VW, et al. Ann Surgery 2003; 4:238

Planned Ileoanal Pouches for Crohn’s disease:Conclusions

• Pre-operative diagnosis of Crohn’s disease increases postoperative complications– Pouch fistula– Pelvic sepsis– Pouch failure!

• Multivariate analysis controlling for other variables likewise predict pre-op Crohn’s disease as predictor of increased pouch failure rate

• Increased incidence of poor outcomes in Crohn’s disease pouches are more common even in the most experienced centers

Thank You For Your Attention