Crohn's Disease after Proctocolectomy and Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

BACKGROUND Proctocolectomy with ileal pouch and anal anastomosis is considered curative for ulcerative colitis. However, signs of Crohn's disease can develop postoperatively in some cases. OBJECTIVE Our aim was to document postoperative diagnosis of Crohn's disease, to identify potential preoperative predictive factors and to review the evolution of patients under treatment. DESIGN Retrospective cohort study. SETTINGS Tertiary care center in Montreal, Canada. PATIENTS A total of 301 patients with an ileal pouch and anal anastomosis performed for ulcerative colitis between 1985 and 2014. MAIN OUTCOME MEASURES Cumulative incidence of postoperative diagnosis of Crohn's disease. RESULTS During a median follow-up of 68 months, Crohn's disease was diagnosed at a median time of 77 months (8-270) in 38 patients (12.6%). Cumulative incidence of Crohn's disease was 7.5% at 5 years postoperatively and gradually increased to 17.7 and 33.0% at 10 and 20 years. The following predictive factors for Crohn's disease were observed on univariate analysis: current tobacco smoking at surgery (Hazard ratio (HR) 3.56 (95% Confidence Interval (CI)1.54-8.22)), suspicion of indeterminate colitis (HR 3.50 (95%CI 1.69-7.24)), presence of mouth ulcers before surgery (HR 2.16 (95%CI 1.03-4.53)) and age at diagnosis of ulcerative colitis (HR 0.94 (95% CI 0.90-0.97)). Suspicion of indeterminate colitis (HR 3.18 (95% CI 1.46-6.93), p=0.004) and age at diagnosis (HR 0.95 (95%CI 0.91-0.99), p=0.018) remained statistically significant on multivariate analysis. Postoperative inflammatory disease was controlled by medical therapy in a majority of patients. Removal of the pouch was necessary in 16% of Crohn's disease patients. LIMITATIONS Retrospective single center study. CONCLUSIONS Diagnosis of Crohn's disease can occur at a distance from surgery with an increasing cumulative incidence over time. Preoperative predictive factors are few and should not determine candidacy for surgery. Therapeutic options are identical to those available for treatment of typical Crohn's disease and allow a favorable evolution in the majority of patients. See Video Abstract at http://links.lww.com/DCR/B372.

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