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Jonathan P Segal,1,2 Matteo Rottoli,3 Richard K Felwick,4 Guy HT Worley,1,2 Simon D McLaughlin,4 Carlo Vallicelli,3 Paul Bassett,5 Omar D Faiz,1,2 Ailsa L Hart,1,2 Susan K Clark1,2 1Inflammatory Bowel Disease Department, St Mark’s Hospital, Harrow, UK; 2Department of Surgery and Cancer, Imperial College, London, UK; 3Surgery of the Alimentary Tract, Sant’Orsola – Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy; 4Department of Gastroenterology, The Royal Bournemouth and Christchurch Hospitals, Bournemouth, UK; 5Statsconsultancy Ltd, Amersham, UK Aim: Prepouch ileitis (PPI) is inflammation of the ileum proximal to an ileoanal pouch, usually associated with pouchitis. The treatment of PPI as a specific entity has been poorly studied, but it is generally treated concurrently with pouchitis. This to our knowledge is the largest study to explore the efficacy of biologics for the specific treatment of PPI.Methods: This was a retrospective observational study reporting outcomes following biological treatment in patients with PPI across three centers. Data were collected between January 2004 and February 2018 from two centers in the UK and one center in Italy. Outcomes included the continued presence of PPI following biologic therapy, pouch failure defined by the need for an ileostomy, and remission of PPI defined by the absence of any prepouch inflammation on endoscopic assessment within a year of biologic therapy.Results: There were 29 patients in our cohort. On last endoscopic follow-up, 20/29 still had endoscopic evidence of PPI, seven had achieved endoscopic remission and avoided an ileostomy, and two had no endoscopic follow-up. In our cohort 11 patients had an ileostomy after a median time from starting a biologic of 25 months (range 14–91).Conclusion: Biologics fail to induce endoscopic remission of PPI in the majority of patients. Just under one-third patients with PPI coexistent with pouchitis can achieve endoscopic remission with biologics. In a large proportion of patients with PPI, surgery may be required despite biologic use. Keywords: pouch, biologics, prepouch ileitis, pouchitis, restorative proctocolectomy, infliximab

Introduction: Restorative proctocolectomy (RPC) and total colectomy with ileorectal anastomosis (TC-IRA) are traditional surgical options for individuals with familial adenomatous polyposis (FAP). Re-appraisal and modification to these techniques, such as near-total colectomy with ileo-distal sigmoid anastomosis (NT-IDSA) and RPC with robotic intracorporeal single-stapled anastomosis (RPC-RiSSA), have been implemented in recent years. This study aimed to evaluate the early postoperative outcomes associated with novel techniques employed in a single centre for restorative surgery in patients with FAP., Methods: A retrospective analysis was conducted using data from patients with FAP who underwent prophylactic restorative surgery between January 2008 and December 2022 at St Mark's Hospital., Results: Two hundred fifty-three individuals underwent restorative surgery over the 15-year period; 102/253 (40.3%) underwent TC-IRA, 84 (33.2%) had NT-IDSA, and 67 (26.5%) underwent RPC. Laparoscopic approach was the most common (88.2%) operative access. Seventeen patients (6.7%) underwent robotic operations. For robotic-assisted procedures, no conversions were reported. No anastomotic leaks or 30-day reoperations were reported in the NT-IDSA group compared to 8% (0/84 vs 8/102, p = 0.009) and 11% (0/84 vs 11/102, p = 0.002), respectively, in the TC-IRA group. Regarding RPC, following the introduction of robotic RPC-RiSSA in 2019, no anastomotic leakage was observed compared with 9% (0/11 vs 5/56, p = 0.3) in those undergoing conventional RPC., Conclusion: Our institution has transitioned from TC-IRA to NT-IDSA since 2014 and conventional RPC to RPC-RiSSA in 2019. To date, since refinement of the techniques there have been no anastomotic failures amongst these cohorts. The reported results may offer future horizons for patients undergoing similar procedures for alternative colorectal diseases., (© 2024. Springer Nature Switzerland AG.)