EPD302 - Pyoderma Gangrenosum - a Risk Factor for IPAA Failure? A Matched Cohort Analysis

ePoster of Distinction Presenter(s)

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  Metincan Erkaya, MD

  Clinical Research Fellow
  Cleveland Clinic Digestive Diseases & Surgery Institute
  Cleveland Clinic
  Cleveland, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.

Author(s)

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  Brian Tang, MD

  Resident
  Cleveland Clinic Digestive Diseases & Surgery Institute
  CLEVELAND, Ohio, United States

  Disclosure information not submitted.
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  Arielle E. Kanters, MD, MS

  Colorectal Surgeoin
  Cleveland Clinic
  Cleveland, Ohio, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Jeremy M. Lipman, MD (he/him/his)

  Director of Graduate Medical Education
  Cleveland Clinic Foundation
  Cleveland, Ohio, United States

  Disclosure information not submitted.
• 

  Stefan D. Holubar, MD, MS, FACS, FASCRS

  Professor of Surgery; Director of Research
  Cleveland Clinic
  Case Western Reserve University
  Cleveland, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
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  Anthony de Buck van Overstraeten, MD, MSc

  Colorectal surgeon
  Cleveland Clinic
  Cleveland, Ohio, United States

  Disclosure information not submitted.
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  Scott R. Steele, MD, MBA (he/him/his)

  President, Cleveland Clinic, Main Campus Submarket and Rupert B. Turnbull M.D., Endowed Chair in Colorectal Surgery
  Cleveland Clinic
  Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
  Cleveland, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Emre Gorgun, MD, MBA. FACS, FASCRS. (he/him/his)

  Vice Chair, Department of Colorectal Surgery
  Cleveland Clinic
  Cleveland Cliinic
  Cleveland, Ohio, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.
• 

  David Liska, MD

  Associate Professor, Chair
  Department of Colorectal Surgery, Cleveland Clinic
  Cleveland Clinic, Cleveland, Ohio
  Cleveland, OH, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.

Senior Author(s)

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  Olga Lavryk, MD, PhD

  Staff, IBD Surgery Section
  Cleveland Clinic
  Cleveland, Ohio, United States

  Disclosure information not submitted.

Purpose/Background: Pyoderma gangrenosum (PG) is a rare but severe extraintestinal manifestation affecting 1-2% of patients with ulcerative colitis (UC) or Crohn's disease (CD). Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is performed in cases of medically refractory UC. While PG is associated with increased disease severity and impaired wound healing, its association with long-term outcomes after IPAA has not been described.

Methods/Interventions: We conducted a retrospective cohort study of 3,886 patients who underwent IPAA between 1983 and 2021 at a high-volume tertiary center. Thirty patients with PG (diagnosed either before or after IPAA surgery) were identified and compared to 3,856 controls without PG. To minimize confounding, propensity score matching was performed using a 1:2 nearest-neighbor approach, matching for age at surgery, gender, preoperative diagnosis, disease duration (from IBD diagnosis to IPAA surgery), IPAA stage, surgery year, anastomotic technique, pouch configuration, and length of follow-up. The primary outcome was pouch failure, defined as pouch diversion with or without pouch excision, analyzed using conditional logistic regression. Secondary outcomes included anastomotic complications, pouchitis, and fistula formation.

Results/Outcomes: Among 3,886 patients who underwent IPAA, 30 (0.8%) had PG: 13 (43%) were diagnosed a median of 8 months (IQR 6-12) prior to IPAA and 17 (57%) a median of 84 months (IQR 33-198) after IPAA creation. Female gender was more common among patients with PG compared to unmatched patients without PG (73% vs. 43%, p = 0.002). There was no significant difference in the median duration of IBD (5.4 vs. 4.0 years, p = 0.66) or follow-up time (9.2 vs. 9.0 years, p = 0.19). A three-stage approach was used more frequently in the PG group (70% vs. 47%, p = 0.03). Post-colectomy pathologic diagnosis was predominantly UC in 21 (70%) PG patients vs. 2,736 (71%) non-PG patients, while Crohn's colitis was diagnosed in 2 (7%) and 152 (4%) patients, respectively (p = 0.58).

The proportion of IPAA patients with PG increased over time: 7/1,824 (0.4%) in 1983-1999, 8/1,305 (0.6%) in 2000-2010, and 15/757 (2.0%) in 2011-2021 (p < 0.001). Propensity score matching successfully paired 29 of 30 (97%) patients with PG with 58 controls without PG, achieving excellent covariate balance. At the last follow-up, among matched PG patients, the final diagnosis was CD in 16 (55%) and UC in 13 (45%). Pouch failure was more common in PG vs. non-PG patients (21% vs. 3%, p = 0.03), and pouch-related fistula formation was significantly higher in PG patients (34.5% vs. 10.3%, p = 0.02). (Figure 1) Cumulative Kaplan-Meier analysis demonstrated significantly reduced pouch survival in patients with PG (p = 0.02; Table 1).

Conclusion/Discussion: Patients with PG have a significantly increased risk of developing Crohn's disease, fistula formation, and pouch failure following IPAA, resulting in reduced long-term pouch survival compared with patients without PG.

Clinical Outcomes in Matched Cohort
Forest plot showing association between pyoderma gangrenosum and clinical outcomes in matched cohort.