Disease Complications
Ece Unal, MD (she/her/hers)
Resident Physician
Cleveland Clinic Foundation
Cleveland, Ohio, United States
Background: Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard operative treatment for patients with medically refractory inflammatory bowel disease or familial adenomatous polyposis requiring colectomy. In patients who develop malignancy after IPAA, chemoradiation has been shown to increase the risk of pouch failure in small studies. We aimed to review our institutional experience with pouch survival after gynecologic surgery for malignancy, expecting that the presence of malignancy would be associated with higher rates of pouch failure.
Methods: We retrospectively reviewed adults who underwent IPAA and developed gynecologic cancer afterwards between 1986 and 2023. Patients with IPAA and gynecologic malignancy were matched using 1:5 nearest neighbor propensity score matching to control patients with history of IPAA only, on age, year of IPAA, colorectal diagnosis, and procedure. Demographics, operative data, complications, and pouch survival were collected.
Results: Fifteen patients were diagnosed with gynecologic malignancy after IPAA in our review. A summary of their demographic, operative and pathologic information is provided in the tables below. Median overall survival was 51 months (IQR 21-106 months); median disease-free survival was 41.3 months (IQR 8-106 months). Pouch failure was seen in 4 (26.7%) patients, of these, 2 patients (40%) underwent pouch revision, and 2 patients (40%) underwent pouch excision with permanent end ileostomy. Etiology of pouch failure included pouch inlet obstruction (n=2, 40%), radiation enteritis of the pouch (n=2, 40%), and recurrent anastomotic leak secondary to invasive ovarian cancer recurrence (n=1, 20%). After matching, 61 control patients were included for a total of 76 unique patients. Kaplan-Meier survival analysis was conducted to assess and compare pouch failure in case versus control patients; the hazard ratio for pouch failure in IPAA patients with gynecologic malignancy was 2.489 (p=0.4, 95% CI 0.735-8.425), which was clinically but not statistically significant.
Conclusions:
In experienced hands, surgery for gynecologic malignancy in pouch patients was safe. However, the patients who suffered recurrence or underwent chemoradiation were at increased risk of pouch failure compared to the average pouch patient in a clinically significant manner, especially after diagnosis of malignancy. Patients who develop gynecologic malignancy after IPAA should be monitored closely for pouch dysfunction due to postoperative treatment protocols and have a multidisciplinary approach to optimize pouch survival after pelvic surgery.