Inflammation of the Rectal Cuff is Associated with Strictures and Fistulas in Patients with Ulcerative Colitis who Have an Ileal Pouch-Anal Anastomosis

Background Patients with medically refractory ulcerative colitis (UC) may undergo colectomy with ileal pouch-anal anastomosis (IPAA). Rectal cuff inflammation following surgery is common and may be associated with pouch failure, but the mechanisms underlying this association remain unclear. We assessed whether endoscopic cuff inflammation is associated with fistula and stricture development. Methods This cohort study included adults with UC who were grouped based on whether they had cuff inflammation with mucosal breaks on any endoscopy following IPAA. Endoscopic, clinical, and imaging data were reviewed for all patients to identify the development of strictures and/or fistulas. Multivariable Cox proportional hazard models were used to compare time to development of each outcome. Sub-analyses were conducted to determine whether persistent inflammation, new onset mucosal breaks, and resolution of mucosal breaks predicted the development of each outcome. Results A total of 324 patients met eligibility criteria with 96 (29.6%) patients with cuff inflammation and 228 (70.4%) of patients without inflammation. Patients with cuff inflammation had a higher risk of strictures of the pouch/pre-pouch ileum (adjusted hazard ratio [aHR] = 3.27; 95% CI, 1.70-6.33; P < .001) and fistulas of the pouch or rectal cuff (aHR = 4.24; 95% CI, 1.83-9.83; P = .001). Individuals with persistent, but not single-instance, inflammation were at higher risk of pouch strictures, fistulas, and pouch failure, and both durations were associated with a higher risk of anastomotic strictures. Conclusions Endoscopic cuff inflammation is associated with strictures and fistulas of the IPAA, and individuals with persistent inflammation appear to have the highest risk.