P1620 - Preoperative Small Bowel Evaluation to Predict Crohn’s Disease Diagnosis After Total Proctocolectomy/Ileopouch Anal Anastomosis for Ulcerative Colitis

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Joseph Soucy, MD

Thomas Jefferson University Hospital
Philadelphia, PA, United States

Melissa Vitolo, MD¹, Joseph Soucy, MD¹, Nicholas Noverati, MD¹, John Ebeid, ², Patricia Kozuch, MD¹
¹Thomas Jefferson University Hospital, Philadelphia, PA; ²Drexel University College of Medicine, Philadelphia, PA

Introduction: Total proctocolectomy with ileopouch anal anastomosis (TPC/IPAA) is indicated for refractory ulcerative colitis (UC). As Crohn’s disease (CD) may mimic UC, evaluation of the small bowel (SB) prior to TPC/IPAA is favored. However, there is no consensus regarding modality of screening for SB disease. The aim of this study was to compare the types of preoperative SB assessment in UC patients who underwent TPC/IPAA in predicting postoperative CD (pCD).

Methods: Retrospective chart review was done on patients who underwent TPC/IPAA from 2003-2018. Inclusion criteria were age >18 years, preoperative diagnosis of UC or indeterminate colitis, and follow-up for ≥1 year postoperatively. SB screening was endoscopic (capsule or terminal ileum intubation +/- biopsies) or radiographic (MR or CT enterography or small bowel series). Diagnosis of pCD was defined by noncaseating granulomas on histology, CD complication (fistula/abscess/stricture), SB inflammation proximal to pouch, or initiation of a biologic or immunomodulator postoperatively.

Results: Ninety patients were included (69% male, mean age 40 years), most with extensive (78%) and refractory (79%) disease. Sixty-four patients (71%) had SB screening preoperatively. Eighteen patients (20%) were diagnosed with pCD. Mean follow-up after surgery was 6.9 vs 4.4 years for those with and without pCD respectively. The most common SB evaluation was endoscopic (38.9%), followed by radiographic (25.6%). Univariate analysis showed that endoscopic evaluation was associated with significantly reduced incidence of pCD compared to other screening modalities (p=0.03). Comparison of endoscopic evaluation vs no screening had a reduced incidence rate ratio (IRR) of 0.69. Combined radiographic/endoscopic assessment in both univariate and multivariate analyses compared to no screening showed increased IRR of 2.78 and 1.80 respectively. In multivariate analysis comparing any screening vs no screening, there was a trend toward decreased IRR of 0.71.

Discussion: Endoscopic preoperative SB screening is associated with reduced incidence of pCD compared to other screening modalities, but did not reach significance compared to no screening. Combined radiographic and endoscopic evaluation is associated with increased incidence risk compared to either modality alone, which may reflect greater clinical suspicion of CD preoperatively. There was a trend toward benefit of any small bowel screening vs no screening, however this did not reach statistical significance.

Univariate analysis of associations with postoperative Crohn's Disease
Variable	Level	Incidence Rate (per 100 person-years)	95% CI	IRR	95% CI	p-value
Sex	Female	5.6	3.0 to 10.3	1.61	0.73 to 3.56	0.24
	Male	3.5	2.1 to 5.8	Ref

Extent of Disease	Extensive	4.0	2.5 to 6.4	1.16	0.20 to 6.66	0.99
	Left-sided	4.0	1.6 to 10.0	1.16	0.17 to 7.89
	Proctitis	3.4	0.6 to 18.6	Ref

Small bowel screening	Endoscopic	2.8	1.3 to 6.0	0.69	0.25 to 1.91	0.030
Small bowel screening	Radiographic	5.4	2.5 to 11.6	1.34	0.49 to 3.70
	Radiographic and Endoscopic	11.1	6.0 to 20.6	2.78	1.13 to 6.83
	None	4.0	2.1 to 7.7	Ref

Number of small bowel screenings	2	7.9	4.3 to 14.5	1.97	0.81 to 4.83	0.15
Number of small bowel screenings	1	3.6	2.0 to 6.4	0.89	0.37 to 2.14
	0	4.0	2.1 to 7.7	Ref

Any screening	Yes	4.1	2.5 to 7.7	1.03	0.45 to 2.33	0.94
	No	4.0	2.1 to 7.7	Ref

Multivariate analysis of associations with postoperative Crohn's Disease
Sex	Female	N/A	N/A	2.06	0.90 to 4.74	0.087
	Male	N/A	N/A	Ref

Small bowel screening	Endoscopic	N/A	N/A	0.45	0.17 to 1.15	0.023
	Radiographic	N/A	N/A	0.99	0.39 to 2.54
	Radiographic and Endoscopic	N/A	N/A	1.80	0.83 to 3.90
	None	N/A	N/A	Ref

Any screening	Yes	N/A	N/A	0.71	0.34 to 1.50	0.37
	No	N/A	N/A	Ref

Table: Key: Incidence Rate Ratio - IRR; Direct endoscopic - terminal ileum intubation +/- biopsies or capsule endoscopy; Radiographic - small bowel series, CT enterography, or MR enterography

Disclosures:

Melissa Vitolo indicated no relevant financial relationships.

Joseph Soucy indicated no relevant financial relationships.

Nicholas Noverati indicated no relevant financial relationships.

John Ebeid indicated no relevant financial relationships.

Patricia Kozuch indicated no relevant financial relationships.

Melissa Vitolo, MD¹, Joseph Soucy, MD¹, Nicholas Noverati, MD¹, John Ebeid, ², Patricia Kozuch, MD¹. P1620 - Preoperative Small Bowel Evaluation to Predict Crohn’s Disease Diagnosis After Total Proctocolectomy/Ileopouch Anal Anastomosis for Ulcerative Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.