O2194: Need for Biologic Therapy After Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis in Children with Medically Refractory Ulcerative Colitis

Background: Patients with medically refractory ulcerative colitis (UC) often undergo restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA), with pouchitis being its most common complication. Literature in pediatric patients describing pouchitis incidence, disease progression, and treatment postoperatively, including the need to resume IBD-directed therapy, is lacking.

Methods: We performed a single-center retrospective study of pediatric patients with UC and IBD-unspecified (IBD-U) who underwent RPC-IPAA from 2010-2023 at our institution. Electronic medical records were reviewed, and patients with pouchitis were identified and classified. Clinical pouchitis was defined based on symptoms often supported by endoscopic findings and labs. Patients who did not complete their IPAA before 20 years of age or did not have consistent follow-up were excluded. Analysis was conducted using Stata software with use of Fisher’s exact test and Wilcoxon rank sum test.

Results: Of 117 patients who underwent RPC-IPAA, 52 (44%) patients developed pouchitis. The median age at presentation of UC was 14.1 years (IQR 10.5, 16.3) and median age at colectomy was 15.1 years (IQR 12.5, 18). Median follow-up in patients with pouchitis was 4.9 years (IQR 3.3, 6.9). Of note, all seven IBD-U patients who underwent RPC-IPAA developed pouchitis.

Of 52 patients who developed pouchitis, 21 (40%) developed acute pouchitis, 8 (15%) chronic antibiotic-dependent pouchitis, 8 (15%) chronic antibiotic-refractory pouchitis, and 15 (29%) Crohn’s-like disease of the pouch.

Escalation to a biologic was required in 34% (n=18) of patients with pouchitis. Treatments included adalimumab (n=7), infliximab (n=5), ustekinumab (n=3), vedolizumab (n=2), and certolizumab (n=1). Of these, 12 patients required change to at least one other biologic to manage their disease. For patients with pouchitis, the Kaplan-Meier estimate for need of biologic was 35.4% by 5 years (15.3% of all patients who underwent RPC-IPAA) (Figure 1).

Conclusion: Nearly half of the pediatric UC or IBD-U patients who underwent RPC-IPAA developed pouchitis. A third of the patients who developed pouchitis required escalation to a biologic therapy within 5 years of pouch creation. These data help guide preoperative counseling regarding risk of pouchitis and need for biologic therapy after pediatric RPC-IPAA. Expanded studies are necessary to help identify risk factors for patients who are likely to require postoperative biologic therapy.