EP820 - Colorectal Cancer Surveillance Patterns After Ileal Pouch Anal Anastomosis Surgery in a Safety-Net Health System

Purpose/Background: Patients with inflammatory bowel disease (IBD) who undergo ileal pouch-anal anastomosis (IPAA) require lifelong surveillance due to increased risk of developing colorectal cancer. The American Society of Colon and Rectal Surgeons (ASCRS) and American Gastroenterology Association (AGA) recommend pouch surveillance within one year of surgery. This study evaluates the surveillance patterns within a safety-net health system and determines overall adherence with guidelines.

Methods/Interventions: This is a retrospective cohort study of all IBD patients who underwent IPAA surgery between January 2014 and October 2024 within the safety-net hospital system. Demographic information, performing service (colorectal surgery [CRS] versus gastroenterology [GI]), and diagnostic indications were collected. The primary outcome was receipt of pouchoscopy after IPAA. Adherence to screening guidelines was defined as pouchoscopy within one year of IPAA. Secondary outcomes included dysplasia and development of colorectal cancer. Pouchoscopy performed for preoperative ileostomy takedown planning was excluded. Kaplan-Meier curves were used to estimate median time to pouchoscopy. Fisher's exact test was used to determine bivariate association.

Results/Outcomes: A total of 37 patients met inclusion criteria. Patients were predominantly diagnosed with ulcerative colitis (n=35, 94.6%). The median age was 41 years old (Interquartile Range [IQR]= 23). The majority of patients were male (n=26, 70.3%) and reported Mexican ethnicity (n=24, 64.9%).

Overall adherence to guideline recommended screening pouchoscopy within one year of IPAA was 27% (n=10). Fifteen patients (40%) underwent their first pouchoscopy after one year, and 12 patients (32%) had no documented pouchoscopy during the study period. The median time to first pouchoscopy was 524 days.

The first screening service was colorectal surgery for 12 patients (45%) and GI for 13 patients (55%). The median time to first screening (Figure 1) was shorter when performed by CRS (365 days) compared with GI (596 days). However, there was not a statistically significant difference between CRS and GI performing pouchoscopy within one year (7 vs. 3, p=0.11).

A total of 58 pouchoscopies were completed during the study period. The most common indication was for diagnostics, including blood per rectum (44%), diarrhea (36%), and pain (20%). No patients had dysplasia or new colorectal cancer identified on pouchoscopy during the study period. Three patients (8%) ultimately underwent pouch excision.

Conclusion/Discussion: Our findings reveal low rates of adherence to surveillance pouchoscopy guidelines after IPAA within our safety-net health system. While limited by a small sample size and a single health system cohort, these findings highlight a significant care gap. Future quality improvement studies should focus on identifying specific barriers to care and establishing dedicated interdisciplinary surveillance pathways to improve screening adherence for IPAA patients.

Kaplan-Meier Curve for Median Time to Pouchoscopy after IPAA
Kaplan-Meier curve depicting the median time to pouchoscopy after IPAA surgery in IBD patients. Median time to pouchoscopy when performed by CRS was 365 days; median time when performed by GI was 596 days.