Does Wireless Capsule Endoscopy Affect Outcomes After Ileal Pouch-Anal Anastomosis in IBD Patients Treated With Anti-TNF Agents?

Abstract

BACKGROUND: The extent of known preoperative small-bowel mucosal inflammation may be impacted by the use of anti-TNF drugs in medically refractory ulcerative colitis (UC) patients evaluated while on therapy just prior to surgery. This “masking effect” may hide small bowel disease during wireless capsule endoscopy (WCE) that might only be revealed when patients are taken off therapy after surgery. We have previously published that WCE does not predict outcomes in a cohort of patients with UC or inflammatory bowel disease-unspecified (IBDU) undergoing ileal pouch-anal anastomosis (IPAA). This is an expanded study examining whether preoperative wireless capsule endoscopy (WCE) could help predict outcome of IPAA in UC and IBDU patients treated with anti-TNF agents. METHODS: UC or IBDU patients undergoing WCE before IPAA were identified in a prospectively maintained surgical database. Patients were grouped into three categories: medically-refractory disease on anti-TNF agents at time of WCE, medically- refractory disease not on anti-TNF agents at time of WCE, and patients having dysplasia/cancer. Patients with a normal WCE study were classified as WCEnegative (WCE-). Patients were classified as being positive (WCE+) if either more than 3 mucosal ulcerations or mucosal erosions were found. Only patients having a complete WCE examination were included in the study cohort. Outcome was assessed prospectively and included no pouchitis (NP), acute pouchitis (AP), chronic pouchitis (CP), or de novo Crohn's disease (CD). Analysis was performed on SPSS v19 using the chi-squared test. RESULTS: The 137 study patients (81 UC, 56 IBDU) had a median age of 39 years and included 68 (50%) males. WCE was positive (WCE+) in 28 patients (20%) and negative (WCE-) in 109 patients (80%). The incidence of WCE+ in UC was 16% compared to 44% in IBDU (P = 0.02). There was no significant difference in WCE+ between the 109 patients treated with anti-TNF (18%) vs the 28 patients without anti-TNF treatment (29%). Median follow-up time after ileostomy closure was 30 months (3-113 months). Pouch inflammation developed in 49 patients (35%), and included 19 (14%) patients with AP, 7 (5%) patients with CP, and 23 (17%) patients with de novo CD. The overall incidence of AP, CP, CD in the WCE-positive patient group was 4%, 11%, 25% compared with 17%, 4%, 15% in the WCE-negative patient group (P = 0.10). Associations between anti-TNF therapy, WCE findings and outcome are shown in Table 1. There was no significant difference in outcome between patients with medically-refractory disease on anti-TNF agents at time of WCE, medically-refractory disease not on anti-TNF agents at time of WCE, and patients having dysplasia/cancer. CONCLUSION(S): WCE findings are not influenced by the preoperative use of anti- TNF agents. WCE findings do not affect outcome after IPAA regardless of surgical (Table Presented) indication or preoperative anti-TNF use. The value of WCE in the preoperative evaluation of these patients is questionable.