ILEAL POUCH-ANAL ANASTOMOSIS FOR CROHNS-DISEASE

Background Patients with Crohn's disease (CD) are not commonly conside red as candidates for ileal pouch/anal anastomosis (IPAA). This approa ch has been avoided because of the poor results observed, retrospectiv ely, in patients with an initial diagnosis of ulcerative colitis who w ere found to have CD on examination of the resected specimen. However, in 1985, we decided to investigate an alternative to coloproctectomy with definitive end-ileostomy by a prospective study of IPAA for selec ted patients with CD. Methods Between 1985 and 1992, 31 patients with CD, but with no evidence of anoperineal or small-bowel disease, were r ecruited to our study. They comprised 15 men and 16 women whose mean a ge was 36 years (SD 14; range 16-72). All CD patients underwent IPAA. The short-term and long-term functional results of this procedure were compared with those of 71 ulcerative colitis patients who also underw ent IPAA during the same period in our unit. Mean follow-up was 59 (SD 25) months. Findings No significant differences were observed between patients with CD and ulcerative colitis in the postoperative complica tion rate. Of the 31 CD patients, six (19%) experienced specific compl ications 9 months to 6 years after surgery: three had pouch-perineal f istulas, which required pouch excision in two cases; one had a pouch-v aginal fistula that was treated by gracilis muscle interposition; and one had an extrasphincteric abscess, which was treated surgically. Two patients (6%), one of whom was treated for an extrasphincteric absces s, experienced CD recurrence on the reservoir, and were treated succes sfully with azathioprine. At 5-year follow-up, there were no significa nt differences between patients with CD and ulcerative colitis in stoo l frequency (5.0 [2.0] vs 4.7 [1.4] per day; p=0.68), continence, gas/ stool discrimination, leak or need for protective pads, and sexual act ivity. Interpretation Our results show that in selected cases of CD wi thout anoperineal or small-bowel manifestations, IPAA can be recommend ed as an alternative to coloprotectomy with definitive end-ileostomy, when rectal resection is essential.