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A Systematic Review and Meta-analysis of Randomized Clinical Trials on the Prevention and Treatment of Pouchitis after Ileoanal Pouch Anastomosis

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

This systematic review explored different medications and methods for prevention and treatment of pouchitis after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA).

Methods

PubMed, Scopus, and Web of Science were searched for randomized clinical trials that assessed prevention or treatment of pouchitis. The systematic review was reported in line with updated 2020 PRISMA guidelines. Risk of bias in the trials included was assessed using the ROB-2 tool and certainty of evidence was assessed using GRADE. The main outcomes were the incidence of new pouchitis episodes in the preventative studies and resolution or improvement of active pouchitis in the treatment studies.

Results

Fifteen randomized trials were included. A meta-analysis of 7 trials on probiotics revealed significantly lower odds of pouchitis with the use of probiotics (RR: 0.26, 95% CI: 0.16–0.42, I2 = 20%, p < 0.001) and similar odds of adverse effects to placebo (RR: 2.43, 95% CI: 0.11–55.9, I2 = 0, p = 0.579). One trial investigated the prophylactic role of allopurinol in preventing pouchitis and found a comparable incidence of pouchitis in the two groups (31% vs 28%; p = 0.73). Seven trials assessed different treatments for active pouchitis. One recorded the resolution of pouchitis in all patients treated with ciprofloxacin versus 67% treated with metronidazole. Both budesonide enema and oral metronidazole were associated with similar significant improvement in pouchitis (58.3% vs 50%, p = 0.67). Rifaximin, adalimumab, fecal microbiota transplantation, and bismuth carbomer foam enema were not effective in treating pouchitis.

Conclusions

Probiotics are effective in preventing pouchitis after IPAA. Antibiotics, including ciprofloxacin and metronidazole, are likely effective in treating active pouchitis.

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Authors and Affiliations

  1. Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA

    Sameh Hany Emile, Nir Horesh, Michael R. Freund, Zoe Garoufalia, Rachel Gefen & Steven D. Wexner

  2. General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura, Egypt

    Sameh Hany Emile

  3. Department of Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Israel

    Nir Horesh

  4. Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel

    Michael R. Freund

  5. Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel

    Rachel Gefen

  6. Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan

    Sualeh Muslim Khan

  7. Cleveland Clinic Martin Health at Tradition, Port St. Lucie, FL, USA

    Emanuela Silva-Alvarenga

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Correspondence to Steven D. Wexner.

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None of the authors has relevant financial disclosures. Dr. Wexner reports receiving consulting fees from ARC/Corvus, Astellas, Baxter, Becton Dickinson, GI Supply, ICON Language Services, Intuitive Surgical, Leading BioSciences, Livsmed, Medtronic, Olympus Surgical, Stryker, Takeda and receiving royalties from Intuitive Surgical and Karl Storz Endoscopy America Inc. Dr. Emile reports receiving consulting fees from SafeHeal.

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Table 5

Table 5 Assessment of the level of evidence of pooled outcomes using the GRADE approach
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Emile, S.H., Horesh, N., Freund, M.R. et al. A Systematic Review and Meta-analysis of Randomized Clinical Trials on the Prevention and Treatment of Pouchitis after Ileoanal Pouch Anastomosis. J Gastrointest Surg 27, 2650–2660 (2023). https://doi.org/10.1007/s11605-023-05841-3

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