IPAA has come to represent the procedure of choice for patients requiring surgery for mucosal UC . In contrast, a proven diagnosis of Crohn's disease is generally held to preclude IPAA. However, patients with IPAA for apparent mucosal UC who are subsequently found to have Crohn's disease have a variable course.
In fact, up to 15% of cases of UC are mistakenly diagnosedin patients with Crohn's disease because of overlap in the clinical, endoscopic and histologic findings [52-54]. Even the classic histologic abnormality of Crohn's disease, noncaseating granuloma, is found in only 50-60% of resected specimens .
As a result, as many as 3.5-9% of patients who undergo total proctocolectomy and IPAA are found to develop recurrent Crohn's disease in the ileal pouch [55, 56] so that, in retrospect, these individuals presumably had surgery for Crohn's disease involving the colon rather than for UC.
In general, patients with Crohn's disease are not usually offered IPAA because recurrence, refractory fistulase, abscesses and strictures, extraintestinal manifestation and the high morbidity in these patients [57, 58,] may lead to a higher incidence of pouch failure. Neoplastic transformation of the pelvic pouch has also been reported, particularly in patients with chronic pouchitis.
Moreover, when total proctocolectomy is required for patients with intractableCrohn's colitis (i.e. granulomatous colitis), some surgeons advocate an IPAA in select cases to avoid the need for a permanent end ileostomy [59,60].
However, surgery for Crohn's disease is only a temporary intervention in most cases because of the high rate of recurrencet: the reported prevalence of radiographic or endoscopic recurrence of Crohn's disease in the small bowel at or near surgical anastomoses is as high as 18-55% at 5 years and40-76% at 10 years .
Most colorectal surgeons therefore do not recommend an IPAA for Crohn's colitis because of the high risk of developing recurrent Crohn's disease in the ileal pouch and the high morbidity in these patients [62-66].
Nevertheless the secondary diagnosis of Crohn's disease after IPAA is associated with protracted freedom from clinically evident Crohn's disease, low pouch-loss rate and good functional outcome. Such results can only be improved by the continued development of medical strategies for long-term suppression of Crohn's disease. These data support a prospective evaluation of IPAA in selected patients with Crohn's disease. [62-64].
Despite the fact that a diagnosis of Crohn's disease is currently considered a contraindication for an IPAA, some patients with secondary diagnosis of Crohn's disease have good functional outcome and quality of life after restorative proctocolectomy. [65, 66].
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