Is Ileoanal the Proper Operation for Indeterminate Colitis: The Case For

Indeterminate colitis is not a contraindication for one-or two-stage ileal pouch anal anastomosis. This has been my position and that of my colleagues for the past 20 years, and it continues to be our position today, even though there have been many changes and a continuing evolution in the surgery and medical treatment of chronic ulcerative colitis (CUC) and Crohn's colitis. The term indeterminate colitis has been in common usage for approximately 25 years, and the pathologic features of indeterminate colitis are seen in Table 1 (1). Indeterminate colitis occurs in approximately 5% of patients who exhibit features of both Crohn's colitis and chronic ulcerative colitis that cannot be attributed to a specific etiology. Much has been written in an attempt to categorize patients who have indeterminate colitis as having either chronic ulcerative colitis or Crohn's colitis. Is indeterminate colitis “colitis in evolution” or is it a distinct category of inflammatory bowel disease? The medical treatments of the two major types of colitis are different, and so the distinction, if one can be made, is relevant in this respect. Pathologic features of patients with indeterminate colitis Pathologic features of patients with indeterminate colitis Serologic markers have been used as a method for differentiating Crohn's disease and ulcerative colitis. Anti-saccharomyces cerevisiae antibody (ASCA) and perinuclear antineutrophil cytoplasmic antibody (p-ANCA) have been investigated thoroughly in the hope of developing a noninvasive method to differentiate the two. This is particularly important in severe colitis because ulcerative colitis and Crohn's colitis can exhibit a similar appearance, including full thickness inflammation. ASCA (2) has a specificity of approximately 90% with Crohn's disease and a positive predictive value of 88%. p-ANCA is aligned with ulcerative colitis with a specificity approaching 90%. The sensitivity of each test is only 40% to 60%, making their usefulness somewhat disappointing in cases of severe indeterminate colitis. Also, medical therapy has been known to alter the histology of the colitis, which heightens the importance of the features of the colitis found at original presentation before treatment was instituted. A recent article about the use of 1H magnetic resonance spectroscopy (1HMRS) shows promise in classification of indeterminate colitis. Colonic mucosal biopsy samples (45 ulcerative colitis and 31 Crohn's disease) were examined by 1HMRS and an accuracy of 98.6% was found in classification of either ulcerative colitis or Crohn's disease, with only one case of Crohn's disease misclassified and no missed cases of ulcerative colitis (3). Whereas the most accurate distinction in classification is ultimately an issue for the surgical pathologist, it remains the experienced clinician/endoscopist, familiar with the patterns of disease and the appearance of colitis over time, who has an intuitive feel for what is the best management program. There is some help in that it has been reported that patients presenting with fever and segmental involvement and who are smokers are more likely to have Crohn's colitis than CUC (4). However, for reasons that are not clear, ulcerative colitis patients have rarely undergone previous appendectomy. In any case, ultimate disposition is based on the patient's symptoms and severity of disease rather than microscopic features of the colon. Therefore, painstaking classification of indeterminate colitis into either “likely chronic ulcerative colitis” or “likely Crohn's colitis” frequently becomes moot. So, let us assume that a patient cannot be classified as having Crohn's colitis or chronic ulcerative colitis but is given a provisional diagnosis of “indeterminate colitis.” The time has come to address surgical options, and one frequent question comes to the mind of the sentient surgeon: does the patient have, or has the patient had in the past, perianal disease such as a fistula, anal fissure, or perianal abscess? In a patient with indeterminate colitis, the presence of perianal disease may indeed be a warning sign that this patient in fact has Crohn's colitis. Nevertheless, we have all seen cryptogenic abscesses and fistulas, as well as ordinary fissures, in patients with well-established chronic ulcerative colitis; however, this is uncommon. In such patients, the risk for ileoanal anastomotic leak or postoperative perianal complications is increased, but the pouch procedure is still an acceptable alternative for these patients with previous perianal disease because the overall pouch failure rate is not significantly increased (5). Obviously, patients with multiple perianal fistulae or shaggy deep fissures typical for Crohn's disease should not undergo an ileal pouch anal anastomosis. Crohn's colitis has traditionally been a contraindication for the ileal pouch anal procedure for most surgeons. Nevertheless, one report describes 41 patients, of whom 26 had a preoperative diagnosis of Crohn's disease that was colonic-only disease, who have undergone ileal pouch anal anastomosis in France (6). The authors report Crohn's disease-related complications of 35% at 10 years, and a remarkably low pouch excision rate of 10% at 10 years. The advent of newer medical agents, such as infliximab, has also led to some reconsideration of pouch procedures in patients with “minimal Crohn's colitis.” Pouch salvage has occurred at the Mayo Clinic in six of seven patients in whom Crohn's disease developed after ileal pouch anal anastomosis. Indeed, in our experience, 45% of such patients will retain a functioning pouch (7). Therefore, why should we be so concerned about the outcome of pouch procedures in patients with indeterminate colitis, in whom 80% or more will have a functional result similar to that of those who have CUC? Our policy has been to remove the abdominal portion of the colon in patients who undergo colectomy. We then send this specimen to experienced surgical pathologists to perform frozen section on the specimen. If their diagnosis is chronic ulcerative colitis or indeterminate colitis, we proceed with a pouch procedure if that is what the patient desires. If the pathologist reports that this is unequivocal Crohn's colitis, we will complete the proctocolectomy and perform a Brooke ileostomy (or perform ileorectostomy in highly selected cases). At Mayo, we have performed three assessments of indeterminate colitis over the past 20 years (1,8,9). In each of these articles, the success rate in indeterminate colitis patients who undergo IPAA is 73% to 85%. This compares with a success rate in definitive CUC patients of 89%. In the most recent study, 1,437 patients with ulcerative colitis and 82 patients with indeterminate colitis (IC) who underwent ileal pouch anal anastomosis between 1981 and 1985 were assessed after 10 years. Patients with indeterminate colitis had significantly more episodes of pelvic sepsis (17% IC vs. 7% CUC), pouch fistula (31% vs. 9%), and pouch failure (27% vs. 11%) (9). Two percent of CUC patients ultimately had a diagnosis changed to Crohn's disease, and 15% of the 82 indeterminate colitis patients had a similar change in diagnosis. The remaining 70 indeterminate colitis patients continued to receive a diagnosis of indeterminate colitis, which led us to wonder whether they do in fact have CUC (Fig. 1). When the outcomes of the patients with Crohn's disease are considered separately, the complication rates are equivalent—the complication rate of the remaining patients with indeterminate colitis is identical to that of CUC patients. Functional outcomes are comparable in all three groups, lending further support to the thought that Crohn's disease in a pouch patient is not always an unmitigated disaster. Similar results have been reported by the Cleveland Clinic (10). There are many colorectal procedures that we perform (e.g., colorectal carcinoma) that have much higher morbidity and mortality rates and lower success rates. Why should we deny patients a chance for enhanced quality of life and good health if a procedure can be performed safely with a minimal number of operations? The principal potential negative alternative is a Brooke ileostomy, which was the only real alternative in the first place. Kaplan-Meier curves depicting the probabilities of (A) remaining free of any complications;(B) no pelvic sepsis;(C) no pouch fistula; and (D) overall success in patients with indeterminate colitis (IC) and chronic ulcerative colitis (CUC) by year after ileal pouch anal anastomosis (IPAA) was performed. In a comment in the middle article in the Mayo series, my friend Dr. Schoetz once said, “Time will tell.” He was right to be skeptical, because the Lahey Clinic experience with indeterminate colitis has been somewhat different from ours. With the latest assessment by Yu, Pemberton, and Larson with a 10-year follow-up, we feel that time has told.

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