Complications of Ileal Pouch-Anal Anastomosis (IPAA) in Pediatric Patients with Ulcerative Colitis: A Systematic Review

Abstract

Background: Ulcerative colitis (UC) is an increasingly prevalent chronic inflammatory bowel disease in the pediatric population. For those who fail medical therapy, total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the definitive surgical treatment. However, complication rates in children differ substantially from those reported in adults, and a comprehensive, pediatric-specific synthesis of these data is lacking.

Objective: To systematically review published evidence on early and late complications of IPAA in pediatric patients (age ≤21 years) with ulcerative colitis, encompassing anastomotic, septic, inflammatory, and functional complications, pouch failure, and associated risk factors.

Methods: A systematic literature search of PubMed/MEDLINE, EMBASE, and the Cochrane Library was conducted following PRISMA 2020 guidelines for studies published from January 1998 through December 2023. Eligible studies reported IPAA outcomes in pediatric UC patients. Early complications (anastomotic leak, pelvic sepsis, intra-abdominal abscess, small bowel obstruction [SBO], surgical site infection) and late complications (pouchitis, chronic pouchitis, anastomotic stricture, pouch fistula, pouch failure, and Crohn's disease reclassification) were extracted and narratively synthesized.

Results: Eleven studies encompassing over 1,900 pediatric patients (UC and UC/indeterminate colitis) were included. The pooled anastomotic leak rate ranged from 3.3% to 7.3% (pooled mean 4.8%), while SBO occurred in 8.4–20.0% of patients (pooled mean 12.4%). Pouchitis affected 17.9–45.0% of patients, and chronic pouchitis was reported in 10.9–25.0%. Pouch failure ranged from 0% (short follow-up) to 14.0% (long-term), with pooled estimates of approximately 7.7%. De novo Crohn's disease reclassification was the most clinically impactful late complication, reported in 16.3–35.7% of patients. Anti-TNF therapy prior to colectomy and development of pouch fistula were significant risk factors for pouch failure. Five-year pouch survival was 28% lower among children operated in the modern biologic era compared to historical cohorts.

Conclusion: IPAA in pediatric UC patients carries substantial early and late morbidity. Pouchitis and Crohn's disease reclassification dominate the long-term complication profile. Pouch failure rates, while overall acceptable (~7.7%), are worsening in the modern anti-TNF era. Prospective multicenter studies with standardized, long-term outcome reporting are urgently needed.