Cancer of the rectum following colectomy and ileorectal anastomosis for ulcerative colitis

Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

The purpose of this study was to evaluate the incidence of dysplasia and the mucosal adaptation patterns of pelvic pouches in children and adolescents who had undergone ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

Between 1982 and 1996, 176 pediatric patients with ulcerative colitis underwent ilial pouch-anal anastomosis. Seventy-six patients were followed up after surgery at the Cleveland Clinic. Pouch biopsy specimens were reviewed for dysplasia and to determine mucosal adaptation patterns. Fifty-eight of the 76 patients had an average of three mucosal biopsies during a mean follow-up of 5 years. Demographic and surgical data were abstracted from archives of medical records. All previously obtained pouch biopsy specimens were re-evaluated by a single pathologist to ensure standardized interpretation.

RESULTS

No dysplasia was identified in screening specimens of 76 children and adolescents including 5 patients who showed dysplasia in resected colon specimens. The pattern of mucosal adaptation was categorized using previously reported criteria. Type A was defined as normal mucosa or mild villous atrophy with no or mild inflammation. Type B mucosa showed transient atrophy with temporary moderate inflammation followed by normalization of architecture. Type C mucosa was defined as a pattern of persistent atrophy with severe inflammation. In the study cohort, the patterns of mucosal adaptation, type A (56.9%; n = 33), type B (32.8%; n = 19), and type C (10.3%; n = 6), were comparable with those reported in adults. The rate of pouch failure and diagnosis of Crohn's disease were similar in each group and were not related to the specific adaptation pattern. Most of the patients with type C mucosa had clinical symptoms of pouchitis requiring periodic antibiotic therapy. No dysplasia was identified in any biopsy specimen reviewed.

CONCLUSIONS

Similar morphologic changes can be seen in ileal pouches in pediatric and adult patients. There seemed to be no increased risk of dysplasia in children and young adults who had undergone ilial pouch-anal anastomosis surgery for ulcerative colitis during a 5 year follow-up. Because the long-term risk of development of dysplasia is unknown, an initial screening should be performed 5 years after the creation of a pelvic pouch in children or when the total disease duration exceeds 7 years. Once identified, patients with Type C mucosa should have annual screening for dysplasia until further data become available.

A new look at the anal transitional zone with reference to restorative proctocolectomy and the columnar cuff

BACKGROUND

The anal transitional zone (ATZ) is of interest in relation to anorectal function and its fate during the operation of restorative proctocolectomy. There are only a few studies describing the anatomy of this structure. This study applied new techniques to quantify the ATZ in normal and inflammatory bowel disease states.

METHODS

The epithelial linings of 28 anal canals were analysed by two techniques: whole-mount Alcian blue staining and a new method of creating a computer map of the histological findings based on longitudinal sections taken every 3 mm. The Alcian blue pictures and the histology maps were measured and compared using image analysis software.

RESULTS

The ATZ usually commences just above the dentate line, which is situated a median of 1.05 cm above the lower border of the internal sphincter. The median length of the ATZ measured from computer maps of the histology was 0.45 cm. This was significantly smaller than the 0.73 cm obtained by the Alcian blue technique, which overestimates the length of the ATZ. The amount of columnar epithelium in the ATZ is very small. The median lowest point of columnar epithelium in the anal canal was 1.1 cm above the lower border of the internal sphincter.

CONCLUSION

The ATZ is only half the length described previously. After double-stapled restorative proctocolectomy there is a 1.5-2.0-cm cuff of diseased columnar epithelium remaining in the upper anal canal above the ATZ. This is suitably termed the 'columnar cuff' and is an important consideration in long-term follow-up.

Review: the surgical management of ulcerative colitis

The treatment of ulcerative colitis requires careful review of the medical and surgical options. The surgical procedure of choice is proctocolectomy with ileal pouch-anal anastomosis. This procedure removes the diseased mucosa, effectively curing the disease whilst maintaining the normal route of defecation and continence. Other surgical options that may be considered in selected patients include proctocolectomy with either a Brooke ileostomy or a Kock pouch, and abdominal colectomy with ileorectal anastomosis. The choice of operation requires consideration of the advantages and disadvantages of a particular procedure and must be tailored to an individual patient's needs and circumstances.

Restorative proctocolectomy in children and adolescents

Children and adolescents with colitis present specific problems for surgeons. There has been a fashion, particularly in North America, for restoring continuity after colectomy by a direct ileo-anal anastomosis. The authors reviewed their experience with restorative proctocolectomy with ileal reservoir (RPC) in patients under 18 years of age to evaluate the outcome and to discuss the problems and challenges associated with the procedure in this age group. Fifteen patients (6 boys, 9 girls) were operated on between 1984 and 1995. The diagnoses included 12 patients with ulcerative colitis (UC), two with familial adenomatous polyposis (FAP), and one with total colonic neuronal dysplasia. The median age of the patients at the time of ileal pouch formation was 15 years, and follow-up data were available for all patients at a median of 43 months. Ten patients with UC underwent pouch surgery 4 to 14 months after initial total abdominal colectomy (7 for acute severe disease, 3 for chronic disease). Four patients (2 with chronic UC, 2 with FAP) underwent primary RPC. There were no deaths in this series. Three (20%) patients suffered serious early morbidity (pouch hemorrhage, pelvic sepsis, severe psychological crisis). Late morbidity included three patients who had small bowel obstruction, one who required laparotomy, two who required pouch revision, and five of 12 (42%) patients with UC who presented with a documented episode of pouchitis between 2 and 72 months after ileostomy closure. All patients had acceptable bowel frequency and quality of continence. This experience suggests that RPC provides an important surgical option for children and adolescents with UC or FAP.

Anal transitional zone and columnar cuff in restorative proctocolectomy

The popularity of double stapling the ileal pouch-anal anastomosis probably owes more to the technical ease it brings than to histological considerations or functional results. It is preservation of a 'columnar cuff' of mucosa, rather than the restricted site of the anal transitional zone, that should be the focus of research with respect to long-term risk of malignancy and inflammatory complications. If cancer is present in colon that has been removed for ulcerative colitis, there is a 25 per cent incidence of dysplasia in the columnar cuff in the short term. In other circumstances, those who are spared from carcinoma by colectomy are likely to have a similar risk of developing dysplastic change in the columnar cuff with longer follow-up. Double stapling the pouch-anal anastomosis and preserving the anal canal mucosa improves function, but long-term surveillance of the columnar cuff is then required, including biopsies.

Anal canal inflammation after ileal pouch-anal anastomosis. The need for treatment

One technique used during restorative proctocolectomy to prevent loss of continence involves preservation of the anal canal. This technique retains a small amount of colonic mucosa and transitional mucosa that may become inflamed or develop dysplastic or neoplastic changes.

PURPOSE

This study was designed to determine the presence and severity of anal canal inflammation and the need for treatment.

METHOD

Records of 217 patients with mucosal ulcerative colitis who underwent restorative proctocolectomy with a stapled ileal pouch-anal anastomosis without anal mucosectomy from 1987 through 1990 were retrospectively reviewed.

RESULTS

Anal canal inflammation was evident on both endoscopy and biopsy in 48 patients (22.11 percent); 18 patients (8.29 percent) had a normal ileal pouch (9 had symptoms; 5 required topical treatment), and 30 patients (13.82 percent) had associated ileal pouch inflammation (23 with symptoms requiring systemic treatment because of pouchitis; 10 patients had concomitant topical treatment).

CONCLUSION

Symptomatic inflammation of the retained mucosa occurred in 32 (14.7 percent) patients. Nine (4.1 percent) patients had inflammation of the anal canal alone, and 23 (10.6 percent) had pouchitis in addition. The need for treatment occurred in 28 (12.9 percent) of the total ((2.3 percent) patients with anal canal inflammation and 23 (10.6 percent) with anal canal inflammation plus pouchitis).

Assessment of dysplasia, mucosal mucins, p53 protein expression, and DNA content in ulcerative colitis patients with colectomy and ileorectal anastomosis

BACKGROUND

Patients with ileorectal anastomosis after colectomy for ulcerative colitis remain at risk of developing rectal malignancy. Detection of mucosal dysplasia has been used for regular screening but is difficult in inflammatory mucosa, prompting the search for complementary markers.

METHODS

This prospective study aimed to assess the prevalence of dysplasia, the predominance of sialomucin, DNA aneuploidy, and p53 overexpression as possible predictors of colorectal tumourigenesis, in the rectal mucosa of an unselected group of 27 patients with ileorectal anastomosis performed for ulcerative colitis. Patients had neither neoplastic nor dysplastic lesions on the colectomy specimen and the retained rectum at the time of surgery. One biopsy specimen of each lateral rectal wall was studied, using routine histology, mucin histochemistry, DNA flow cytometry, and the streptavidin-biotin complex method with D07 monoclonal antibodies directed towards the p53 protein.

RESULTS

Seventeen, seven, and three patients showed inflammatory lesions of inactive, moderate, and severe active colitis, respectively. Dysplasia, sialomucin predominance, DNA aneuploidy, and p53 overexpression were not detected.

CONCLUSIONS

The risk of malignant transformation of the rectal mucosa after ileorectal anastomosis seemed to be low in this ulcerative colitis group without high-grade dysplasia or carcinoma in the previous colectomy specimen, carefully followed up endoscopically and histologically. It remains to be evaluated which of the methods studied above will optimize the histopathologic surveillance of the rectal mucosa of ulcerative colitis patients with ileorectal anastomosis.

Update on the surgical management of ulcerative colitis and ulcerative proctitis: current controversies and problems

: The surgical management of ulcerative colitis has been revolutionized in recent years by the development of the ileal pouch-anal procedure. Although it is now the operation of choice for most patients, there remain several controversies. A variety of designs of ileal pouch are available each with advantages and disadvantages. The technique used to anastomose the pouch to the anal canal is also open to debate with some surgeons favoring distal mucosectomy with eradication of all disease and others choosing to perform a stapled anastomosis to achieve better functional results. The main concern for gastroenterologists, however, is the risk of development of pouchitis. The etiology, diagnosis, and treatment of this condition will also be discussed in this review as well as the more classical options for the surgical treatment of ulcerative colitis.

Surgical treatment of inflammatory bowel disease

Surgery continues to play an important role in the overall treatment strategy for patients with Crohn's disease and ulcerative colitis. Innovative techniques have greatly facilitated the operative approach in patients with both disorders.

Factors affecting the outcome of endoscopic surveillance for cancer in ulcerative colitis

BACKGROUND/AIMS

Cancer surveillance in patients with ulcerative colitis is of unproven benefit. This study assesses the efficacy and analyzes factors limiting the success of a surveillance program during a 21-year period in 332 patients with ulcerative colitis to the hepatic flexure and disease duration exceeding 10 years.

METHODS

Clinical assessment and sigmoidoscopy with biopsy was undertaken yearly. Colonoscopy and biopsy every 10 cm throughout the colon was performed every 2 years or more often if dysplasia was found. Only biopsy specimens reported as showing dysplasia were reviewed.

RESULTS

Surveillance contributed to detection of 11 symptomless carcinomas (8 Dukes A, 1 Dukes B, and 2 Dukes C), but 6 symptomatic tumors (4 Dukes C and 2 disseminated) presented 10-43 months after a negative colonoscopy. Dysplasia without carcinoma was confirmed in 12 symptomless patients who underwent colectomy. The 5-year predictive value of low-grade dysplasia for either cancer or high-grade dysplasia was 54% using current criteria.

CONCLUSIONS

Surveillance identified some patients at a curable stage of cancer or with dysplasia. Limiting factors were failure to include patients with presumed distal colitis, biennial colonoscopy, the number of biopsy specimens at each colonoscopy, and variation in histological identification and grading of dysplasia.

Clinicopathological characteristics of colorectal carcinoma complicating ulcerative colitis

This study examined three features associated with colorectal carcinoma complicating ulcerative colitis: (a) the distribution of 157 cancers in 120 patients with ulcerative colitis treated at St Mark's Hospital between 1947 and 1992; (b) the frequency at which dysplasia was found at a distance from the tumour in 50 total proctocolectomy specimens in which an average of 27 histology blocks were reviewed, and (c) the five year survival rate according to Dukes's stage and participation in a surveillance programme. Of 157 carcinomas, 88 (56%) occurred in the rectosigmoid, 19 (12%) in the descending colon or splenic flexure, and 50 (32%) in the proximal colon. Among the 120 patients, the rectum or sigmoid colon contained cancer in 81 (67.5%). Dysplasia was detected in 41 of 50 reviewed proctocolectomy specimens (82%). Dysplasia distant to a malignancy occurred in 37 (74%); two were classified indefinite, probably positive, 19 were low grade, and 16 were high grade; in 18 specimens there was an elevated dysplastic lesion. Survival was related to the Dukes's stage: about 90% of patients with Dukes's A or B cancer were alive at five years. The five year survival of 16 patients in whom cancer developed during surveillance was 87% compared with 55% of 104 patients who did not participate in surveillance (p = 0.024).

Transanal mucosectomy. Ileal pouch advancement for anorectal dysplasia or inflammation after restorative proctocolectomy

PURPOSE

Restorative proctocolectomy has gained increasing popularity in the surgical treatment of ulcerative colitis. However, symptomatic proctitis in an excessively long anorectal stump or high-grade dysplasia within the retained anorectal mucosa can pose challenging problems. A corrective operation for these problems is described.

METHODS

A sphincter-preserving perineal approach to mobilize the pouch was described. It allows excision of the inflamed or dysplastic-retained anorectal mucosa, followed by pouch advancement and a neoileoanal anastomosis.

RESULTS

The technique was successfully performed in two patients, one with symptomatic "proctitis" and another with high-grade dysplasia in the anorectal mucosa after a previously stapled ileoanal (distal rectal) anastomosis.

CONCLUSIONS

This report illustrates the relative ease and safety of delayed mucosectomy via a perineal approach, provided that the initially stapled anastomosis is within 3 cm to 4 cm of the dentate line. This technique also obviates the need for complex abdominopelvic surgery after previous restorative proctocolectomy.

The first 10 years' experience of restorative proctocolectomy for ulcerative colitis

Between 1976 and 1985, 110 patients had restorative proctocolectomy or proctectomy for ulcerative colitis and 103 were followed up until death or February 1992. There was one postoperative and one late death related to surgery. The cumulative probability of pouch failure was 12% at five years: half of the failures occurred within one year. The commonest reasons were perianal/pelvic sepsis and probable Crohn's disease. The cumulative probability of readmission, excluding that for ileostomy closure, was 68% at five years. There were 152 operations carried out during readmissions. These included 44 laparotomies. Function was assessed in 80 patients at a mean of 99.3 months after ileostomy closure. For 66 patients with spontaneous evacuation, average minimum diurnal frequency was 3.8, maximum 4.9, with 35 evacuating at night. One patient experienced major continence problems, 30 had minor leaks, and 49 were completely continent. Postoperatively, five patients gave birth to nine babies, four had renal stones, two myasthenia gravis, and two severe anaemia: seven had pre or postoperative thyroid dysfunction.

Surgery for ulcerative colitis in the era of the pouch: the St Mark's Hospital experience

The choice of operation for ulcerative colitis among 422 patients having all their surgery at one hospital between 1976 (the year of the first restorative proctocolectomy) and 1990, was reviewed. The 15 year period was divided into three quinquennia (1976-80, 1981-85, 1986-90). Elective surgery was performed in 316 patients with one operative death. The proportions of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia were 36/60, 17/60, 4/60; 29/111, 30/111, 35/111; 30/145, 17/145, 75/145. Of 106 urgent operations with three postoperative deaths, 12 had a conventional proctocolectomy and 86 a colectomy with ileostomy and preservation of the rectum. Of 85 survivors of the latter there were two late deaths and in 13 no further surgery had been done at the time of this assessment. In the remaining 70 having subsequent surgery the proportion of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia respectively were 19/27, 4/27, 14/27; 11/21, 2/21, 8/21; 5/22, 4/22, 13/22. Of the 76 patients having colectomy with ileorectal anastomosis 12 (16%) no longer had a functioning rectum at the end of 1990. Of the 153 patients having an ileoanal pouch procedure, 11 (7%) no longer had, a functioning anus. The study showed an increase in the numbers of patients having elective surgery for ulcerative colitis during the three quinquennia. It also showed a rise of restorative over conventional proctocolectomy with diminution in elective colectomy with ileorectal anastomosis in the last five year period.

Current surgical therapy for mucosal ulcerative colitis

PURPOSE

There are numerous surgical options for the treatment of mucosal ulcerative colitis.

METHODS

This article reviews the currently available options for the treatment of mucosal ulcerative colitis. Separate discussions will explore both the options in the emergency and elective settings.

RESULTS

Patients with mucosal ulcerative colitis may undergo surgery either as an emergency or in the elective setting. Emergency surgery is usually performed for one of the life-threatening complications of ulcerative colitis: fulminant colitis, toxic megacolon, or massive hemorrhage. The most commonly performed procedure under these conditions is a subtotal colectomy with end ileostomy. The rectal stump may be handled in a variety of ways. This procedure avoids proctectomy or anastomosis. Thus, patients will still have all necessary anatomic structures to allow for any of the definitive elective procedures. Elective surgery is performed for intractable disease, complications of medical therapy, dysplasia, or, occasionally, extraintestinal manifestations. In the elective setting, a definitive operation can be done to remove most or all of the disease-bearing colorectum and leave the patient with a means to control fecal elimination. Total abdominal colectomy with ileorectal anastomosis leaves the patient with diseased bowel but obviates the need for pelvic dissection. Although total proctocolectomy removes all potentially diseased mucosa, these patients have a permanent ileostomy. The stoma can either be a standard Brooke's ileostomy or a continent Kock pouch. The most common definitive procedure currently performed is the near-total proctocolectomy with ileal pouch-anal anastomosis. This option can be completed either with a rectal mucosectomy and hand-sewn anastomosis or with a double-stapled anastomosis, preserving the anal transition zone. This procedure is successful in eradicating almost all diseased mucosa while allowing the patient per anal defecation. Bowel movement frequency, degree of anal continence, and return to social and professional commitments have met with a great deal of satisfaction in most patients. A newer alternative to this procedure employs laparoscopy to facilitate a smaller incision. A one-stage procedure which omits the protective ileostomy and thus saves the patient one operation has also been used with some success in selected cases.

CONCLUSION

There are several surgical options for the treatment of mucosal ulcerative colitis. Each one has a role and should be discussed with the patient.

Results of mucosal proctectomy versus extrarectal dissection for ulcerative colitis and familial polyposis in children and young adults

Over a 5-year period, the authors examined 30 consecutively treated patients, aged 16 years or younger, who underwent total colectomy and ileal pouch-anal anastomosis, (IPAA) using two different surgical methods. In 16 patients (group I), extrarectal dissection with stapled J pouch and anastomosis was performed. In 14 patients (group II), mucosal proctectomy with hand-sewn S pouch and anastomosis was performed. The mean follow-up period this study was approximately two years (range, 1 to 5 years). With regard to postoperative complications, quality of life, and occurrence of pouchitis, there were no significant differences between the groups. Stool frequency was not significantly different between the two groups, and approached four bowel movements per day at 1 year after surgery. In both groups, daytime continence was achieved by all patients 6 months after surgery. A greater number of patients in group II demonstrated temporary nocturnal leakage than in group I, but this difference was not statistically significant (P = .09). The authors conclude that both methods of IPAA are equally effective in preserving normal sphincter function. In patients with severe rectal inflammation, extrarectal dissection with stapled anastomosis may obviate the need for extended preoperative hyperalimentation or subtotal colectomy, but may carry a small increased risk of recurrent anorectal inflammation. The long-term risk of dysplasia is unknown, but may be slightly higher after extrarectal dissection with stapled anastomosis. Further study of both methods of IPAA is recommended.

Chronic ulcerative colitis. Traditional surgical techniques

The patient with ulcerative colitis requiring surgery has several options from which to choose. Although the pelvic pouch procedure may be preferred by many patients, in fact, all of the operations have both their advantages and disadvantages. Thus, patients should be fully informed of the various options and participate in the surgical decision making. Surgeons performing elective operations on patients with ulcerative colitis should be experienced with all of the procedures. Only then can they be unbiased in presenting the various options to the patient. Advocates of total proctocolectomy often cite the high complication rates of the Kock and pelvic pouch procedures and condemn these operations on this basis. However, the magnitude of a total proctocolectomy cannot be minimized, and the complication rate of this procedure is significant. On the other hand, total proctocolectomy is often condemned because of the permanent ileostomy and the perceived poor quality of life. This appears to be untrue. Most patients, regardless of which operation is performed, have a high quality of life. This is likely a result of the fact that physical well-being is excellent in most patients, and this may be the primary determinant of quality of life in these patients. It must be accepted, however, that some patients do have difficulties psychologically or physically with an ileostomy. Fortunately, there are several alternatives available for these people.

Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis

A study was undertaken to assess the incidence of inflammation and dysplasia in retained mucosa after double-stapled ileoanal reservoir (IAR) for mucosal ulcerative colitis (MUC). Between September 1988 and February 1992, 56 patients with MUC underwent an IAR. Forty-five patients had a double-stapled IAR (DS-IAR), seven patients had a transanal pursestring stapled IAR (PS-IAR), and four patients had a PS-IAR with mucosectomy. Distal donuts obtained from the stapled IAR were submitted for pathologic review in 55 patients. Nine patients had only small bowel, connective tissue, and/or muscle noted on review. Mucosa was qualified as squamous epithelium (SE), transitional epithelium (TE), or columnar epithelium (CE). All samples were examined for evidence of inflammation and dysplasia. Four patients had SE only, one patient had TE, and 18 had CE. In addition, three patients had SE and CE, seven patients had SE and TE, two patients had CE and TE, and nine patients had all three types. The distance from the dentate line to the anastomosis ranged from 0 to 2.5 cm (mean, 1 cm). In 19 patients (35 percent), the distal donut revealed MUC. Of these 19 patients, six had persistent MUC (43 percent) at the time of subsequent biopsy. An additional four patients had MUC evident on follow-up biopsy but not on distal donuts; two of these four patients had no mucosa in their distal donuts. Only one of the patients with evidence of MUC on donuts and/or biopsy experienced any symptoms referable to active MUC (1.8 percent). None of the specimens examined had any evidence of dysplasia. In 31 patients, no MUC was present in the initial donuts or follow-up biopsies. Although the double-stapled technique appears safe, periodic monitoring is suggested.

Carcinoma of the rectal pouch following restorative proctocolectomy. Report of a case

A case of adenocarcinoma developing in the pouch following restorative proctocolectomy is presented. This seems to be the third reported in the literature. The carcinoma developed from the remnants of precancerous rectal mucosa left in the muscular rectal cuff. The patient had been suffering from ulcerative colitis for 17 years prior to the development of the malignancy. He presented with features of subacute intestinal obstruction. Diagnosis was by sigmoidoscopic examination of the pouch and biopsy. He was treated with abdominoperineal resection of the pouch and rectum, followed by chemotherapy.

Rectal lymphoma after colectomy for ulcerative colitis

Primary colonic lymphoma is an increasingly recognised complication of ulcerative colitis. We report the first known case of rectal lymphoma occurring after colectomy and ileorectal anastomosis in ulcerative colitis.

Anal sphincter-saving operations for chronic ulcerative colitis

Three anal sphincter-saving operations--ileorectostomy, ileal pouch-anal anastomosis, and ileal pouch-distal rectal anastomosis--are currently being used in the surgical treatment of chronic ulcerative colitis. All three operations remove the disease, or most of it, and yet they maintain transanal defecation, reasonable fecal continence, and a satisfactory quality of life. All three avoid permanent abdominal ileostomy. Ileorectostomy is the easiest to perform, but it leaves residual disease in the remaining rectum and proximal anal canal that may cause symptoms and that may predispose the patient to cancer. In contrast, ileal pouch-anal anastomosis, although a more technically demanding procedure, totally eradicates the colitis. Its main drawbacks--frequent stooling, nocturnal fecal spotting, and pouchitis--are usually satisfactorily treated with loperamide hydrochloride and metronidazole. Ileal pouch-distal rectal anastomosis is somewhat easier to perform than ileal pouch-anal anastomosis and may result in less nocturnal fecal spotting. Like ileorectostomy, however, the operation leaves residual disease in the distal rectum and proximal anal canal. Considering all of these factors, the ileal pouch-anal operation is preferred today for most patients who require surgery for chronic ulcerative colitis.

Mucosal dysplasia and DNA content in ulcerative colitis patients with ileorectal anastomosis. Follow-up study in a defined patient group

In a follow-up study of an epidemiologically defined patient group comprising 1,274 patients with ulcerative colitis diagnosed in Stockholm County during 1955-1979, 55 patients had undergone colectomy with ileorectal anastomosis (IRA). Nine of these were found to have Crohn's disease after histopathologic review of the colectomy specimens. Of the 46 patients with ulcerative colitis remaining for evaluation, two died postoperatively. Twenty-five patients were subsequently reoperated with rectal excision owing to intractable inflammatory activity (n = 22, one postoperative death) or owing to dysplasia (n = 3). Of 19 patients with their IRA still intact at time of follow-up, 15 patients (median disease duration 23 years) had a flexible sigmoidoscopy with multiple biopsies performed. The average length of the remaining rectum and sigmoid colon was 26 cm. No patient had findings of dysplasia, carcinoma, or DNA aneuploidy. None of the four remaining patients had developed dysplasia or carcinoma at the time of the latest regular rigid sigmoidoscopy. The risk of malignant transformation in this selected group of patients with ulcerative colitis operated upon with colectomy and IRA derived from an epidemiologically defined population seems to be low.

Stapled ileoanal anastomosis for ulcerative colitis and familial polyposis without a temporary diverting ileostomy

Between March 1989 and August 1990, we performed 21 stapled J pouch ileonal procedures (20 ulcerative colitis [UC], 1 familial polyposis [FP]) without an ileostomy in 19, of whom 13 were taking prednisone and eight underwent semi-emergent surgery for uncontrollable bleeding. During the same time, an additional four patients required a standard ileonal procedure. The results of anal manometry and clinical function were compared to 25 patients who had previously undergone mucosal stripping and a sutured J pouch ileoanal anastomoses with a temporary diverting ileostomy between October 1982 and August 1990. During this same time period, an additional 19 patients underwent an anti-peristaltic reversed J pouch and 18 an S pouch, for a total of 83 ileoanal procedures. The reversed J pouch had a lower stool frequency than a standard J pouch but had an unacceptable incidence of complications and problems with pouch emptying. The S pouch had a stool frequency similar to the standard J pouch but provided greater length in patients with a short mesentery. Stapled J pouch ileoanal patients had a better (p less than 0.02) maximum and sphincter resting pressure (46 +/- 11 versus 34 +/- 12 mmHg), fewer (p less than 0.05) night-time accidents (22% versus 68%), daytime (17% versus 55%) or night-time (28 versus 61%) spotting, or use of a protective pad at night (11% versus 42%) than nonstapled J pouch ileoanal patients. Stool frequency was similar in the two groups. All but one UC patient had residual disease at the anastomosis. Anal mucosa between the dentate line and stapled anastomosis was 1.8 +/- 1.3 cm (range, 0 to 3.5 cm). Complications in the nonstapled J pouch group included 4 pouches excised (2 for complications, 2 for excessive stool frequency), 1 pelvic abscess, 2 stenosis requiring dilation under anesthesia, 1 enterocutaneous fistula after ileostomy closure, 1 ileostomy site hernia, and 2 small bowel obstructions. Of the 65 patients who underwent ileostomy closure in the entire series, 8 (12%) developed a complication requiring surgical intervention. Complications in the stapled group included 1 anastomotic leak, 1 pouch leak, and 1 pelvic abscess. Patients were managed successfully with drainage (all 3) and diverting ileostomy (1). One patient developed stenosis requiring dilation under anesthesia. The stapled J pouch ileoanal anastomosis is a simpler, safer procedure with less tension than a standard handsewn J pouch but leaves a very small cuff of residual disease. It provides significantly better stool control and may obviate the need for an ileostomy with its complications.

Mucosal cell proliferation of the rectal stump in ulcerative colitis patients after ileorectal anastomosis

The proliferative activity and polyamine levels of the rectal epithelium in unoperated ulcerative colitis patients and in ulcerative colitis patients after total colectomy and ileorectal anastomosis were determined and compared with control subjects. Cell proliferation was evaluated in rectal biopsies by in vitro 3H thymidine incorporation by measuring the labeling index and the position of labeled cells along the crypt; polyamines were determined with a chromatographic method. In ulcerative colitis patients the labeling index was significantly increased, and labeled cells were shifted toward the upper part of the crypt when compared with controls. Ileorectal anastomosis patients showed a normalization of the labeling index and a distribution of labeled cells similar to controls. Polyamine levels were also increased in ulcerative colitis patients; in ileorectal anastomosis patients, the level of polyamines was decreased in respect to unoperated patients and return to normal values except for spermine. Because the increased proliferation and higher polyamine levels are related to increased colon cancer risk, our results confirm that ulcerative colitis is a risk factor for the development of carcinoma. Ileorectal anastomosis may reduce this risk through a normalization of mucosal cell proliferative activity and of some polyamine levels.

Cancer surveillance in ulcerative colitis

During a 13-year period, 213 patients with ulcerative colitis who had no clinical or endoscopic evidence of colonic carcinoma were enrolled in a biopsy surveillance program for dysplasia and carcinoma. The aims of the study were to determine whether such a program could decrease the cancer risk in this group of patients, to determine whether patients with a low risk of carcinoma could be identified, thus enabling them to retain their colon, and to accomplish these goals with a reasonable expenditure of resources. Eighteen patients had dysplasia detected in the initial biopsy specimens; 15 of these patients underwent colectomy, and 7 had unsuspected carcinoma (1 Dukes' stage A, 2 stage B, and 4 stage C). Eleven patients had dysplasia detected during follow-up; 7 of these patients had colectomy, and only 1 patient had carcinoma (Dukes' B). Dysplasia developed in 5 of 20 patients with indefinite changes on initial biopsy samples; 3 of these patients underwent colectomy, and 1 patient had carcinoma (Dukes' B). There was no difference in the prevalence of dysplasia between patients with left-sided disease and patients with extensive disease. With the exception of 2 patients with inadequate surveillance, there has been no clinical evidence of carcinoma in any of the 148 patients whose biopsy results remained negative throughout the study; carcinoma has not developed in any of 175 patients without dysplasia on initial biopsy sample. All 4 patients who died of carcinoma had high-grade dysplasia in their initial colonoscopic biopsy samples. It is concluded that a biopsy surveillance program can be an effective aid in helping control the risk of carcinoma in patients with long-standing ulcerative colitis, that the short-term risk of carcinoma for patients with negative biopsy results is low and colectomy for risk of carcinoma can be deferred in this group, and that patients with extensive and left-sided disease share the same risk of the development of dysplasia.

Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm County

The long-term results of ileorectal anastomosis in patients with ulcerative colitis in Stockholm County over a 30-year period, 1955 to 1984, were investigated. During this time, 486 patients underwent colectomy and ileorectal anastomosis was performed in 60 of those patients (12 percent). A retrospective histologic examination of the slides of the operative specimens in the latter group revealed that nine patients had Crohn's disease. Of the 51 remaining patients with ulcerative colitis, the colectomy and ileorectal anastomosis was performed as an elective procedure in 44 cases (86 percent) and as a one-stage procedure in 48 patients (94 percent). Complications occurred in 7 of 43 patients (16 percent) undergoing an elective, one-stage procedure. There were two postoperative deaths (4 percent). There were 22 patients (43 percent) who had their ileorectal anastomosis in function at the time of follow-up, with a mean time of observation of 13 years. The cumulative probability of having the ileorectal anastomosis in function at 10 years was 51 percent. The causes of total excision were recurrent inflammation in the retained rectum (N = 23), dysplasia (N = 3), and postoperative complications (N = 3). No rectal carcinoma occurred. Patients with preoperative mild rectal disease had a better outcome (ileorectal anastomosis in function at time of follow-up) compared with patients with moderate rectal disease (P less than 0.001). The functional outcome of ileorectal anastomosis was, if anything, better than what is stated in the literature following pelvic pouch procedure.

Restorative proctocolectomy: a procedure for the district general hospital?

Restorative proctocolectomy is widely regarded as the surgical procedure of choice for patients with ulcerative colitis or familial adenomatous polyposis, the majority being carried out within specialised regional centres. The use of this procedure outside such centres has been investigated by reviewing the results from a District General Hospital (DGH) over the 8 year period 1981-1989. Seventeen patients (11 male and 6 female with a median age of 36 years) underwent total colectomy and ileoanal anastomosis with formation of a pelvic reservoir (TC-IA). Fourteen had ulcerative colitis (UC), 2 familial adenomatous polyposis (FAP) and one a colonic and rectal cancer. Three pouch designs were used ("S" in 7, "J" in 8 and "W" in 2) with no operative or perioperative deaths. Further laparotomy was required in two patients for adhesions and pelvic sepsis. Functional results were assessed in 16 patients at a mean of 5 years after surgery. The median daily stool frequency was 5 (range 2-6). Twelve of the 16 patients defaecate spontaneously, 2 regularly self-catheterized and 2 do so occasionally. None of the patients is incontinent of formed or liquid stool but one has occasional soiling. These results suggest that TC-IA may be satisfactorily performed outside a specialised unit.

Surgical alternatives for ulcerative colitis

There is no medical cure of ulcerative colitis except for the removal of the entire large intestine, or at least its mucosa. It is unknown as to what percentage of patients with ulcerative colitis present for surgical correction, and the potential for surgery in turn usually is related to the extent of large intestine involved. This article explores new alternatives that are available so that proctocolectomy and ileostomy are no longer the sole option for patients with ulcerative colitis.

Anal canal mucosa in restorative proctocolectomy for ulcerative colitis

In an attempt to improve continence after restorative proctocolectomy, ileal reservoir-anal anastomosis at the level of the anorectal junction has been advocated. This procedure preserves the entire mucosa of the anal canal. The histological appearances of the anal mucosa have been examined in 16 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis. In 14 patients there was chronic inflammation characteristic of ulcerative colitis. Four patients had moderate dysplasia and in one of these patients an unsuspected adenocarcinoma of the anal canal extending down to the level of the dentate line was present. We believe that the anal mucosa should always be removed down to the level of the dentate line in restorative proctocolectomy for ulcerative colitis.

Current status of ileorectal anastomosis for inflammatory bowel disease

Between September 1959 and December 1986, a total of 210 patients in a consecutive series were operated on for inflammatory bowel disease. One hundred ten (66 percent) had ileorectal anastomosis performed. There were no postoperative deaths. There were six failures in 53 ileorectal anastomoses for ulcerative colitis (11 percent), and five failures (8 percent) in 61 for Crohn's disease. The overall failure rate was 11 in 110 (10 percent). Ileorectal anastomosis, in suitable patients, is still a viable operation in the late 1980s.

Malignancy in ulcerative colitis

All patients with ulcerative colitis referred to Rigshospitalet, Copenhagen, from 1 April 1964 to 1 January 1983 (18 years and 9 months) were studied from time of referral until death, proctocolectomy, or end of the study (1983). There were 759 patients, 423 females (56%) and 336 males (44%). None was lost to follow-up study. Median time from onset of disease until death, proctocolectomy, or end of the study was 11 years (range, 0-54 years). Median age at onset was 28 years (range, 0-83) among the males and 28 years (range, 4-83) among the females. Pancolitis was present in 312 patients (41%), left-sided colitis in 212 (28%), and haemorrhagic proctitis in 235 (31%). Surgical treatment was performed in 299 patients (39%): proctocolectomy in 197 (26%), colectomy with occluded rectal stump in 72 (9%), and colectomy with ileorectal anastomosis in 30 (4%). Altogether, 49 patients developed cancer, 20 being intestinal and 29 extraintestinal cancer. Compared with the general population matched for age, sex, and calendar time, there was an excessive number with intestinal cancer in both sexes (p less than 0.05). In females the number with extraintestinal cancer was higher than in the general population (p less than 0.01), a finding that has not been reported elsewhere. We found a similar, significantly increased incidence of extraintestinal cancer in females with Crohn's disease in a previous report. We found no increased risk of colorectal cancer in patients with early onset of ulcerative colitis. For all age classes we found that the age of appearance of colorectal cancer followed the equation: age at colorectal cancer = 14 + age at onset of ulcerative colitis. We found no higher potential for development of colorectal cancer in patients with pancolitis. In our series the incidence of colorectal cancer in pancolitis and left-sided colitis was equal. The incidence in patients with haemorrhagic proctitis was zero.

Dysplasia and carcinoma in the rectal stump of total colitics who have undergone colectomy and ileo-rectal anastomosis

From a group of 374 patients with ulcerative colitis who underwent colectomy and ileo-rectal anastomosis between 1952 and 1976, 104 presented for follow-up rectal biopsies over a 5 year period to 1986. These patients have been followed for an average of 28 years since the onset of the disease (range 11-56) and provide a unique model for the study of the development of carcinoma in colitis. A total of 443 biopsies was examined and epithelial morphology assessed according to the classification of Riddell et al. (1983). Five patients developed carcinoma of whom two showed dysplasia in biopsies taken a year or more before the diagnosis; one showed dysplasia 2 months before the appearance of cancer, another synchronous with it, and in the fifth patient dysplasia was not detected. Of 20 biopsies classified as 'indefinite for dysplasia, probably negative', 80% were associated with subsequent resolution, while of nine 'indefinite for dysplasia, probably positive' biopsies, eight (89%) were subsequently associated with either carcinoma (six) or dysplasia (two). The results emphasize the danger of absolute reliance upon dysplasia in assessing individual cancer risk in colitics, appear to demonstrate the usefulness of Riddell's classification and provide additional information on the natural history of dysplasia.

Straight ileoanal anastomosis with preserved anal mucosa for ulcerative colitis and familial polyposis

Thirty-two patients were treated with colectomy, mucosal proctectomy, and straight ileoanal anastomosis. Mucosal dissection was performed from the abdominal side, and an anal mucosal brim of 1-2 cm was preserved. Diverting ileostomy was not used, and four patients developed anastomotic leak with pelvic sepsis. Three patients had take-down of the anastomosis for reasons related to the operative method. The remaining patients are all completely continent day and night and have a median stool frequency of 6/24 h 1 year after the operation. The frequency was significantly higher in patients with ulcerative colitis (UC) than in patients with familial polyposis (FP). No dysplasia, ulceration, or stricture formation was found in the preserved mucosa in the UC patients. Regrowth of polyps in the mucosal brim occurred in 10 of 13 FP patients, with atypia in 1. The FP patients had more late complications attributed to extracolonic manifestations of the FP disease.

Ileostomy or ileal pouch for the surgical treatment of ulcerative colitis?

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Operative treatment of ulcerative colitis: conventional proctectomy with Brooke ileostomy versus mucosal proctectomy with ileoanal anastomosis

Fifty-four patients with ulcerative colitis were operated on during a 3-year period; 35 had conventional proctectomy and Brooke ileostomy, and 19 had mucosal proctectomy, performed from the abdominal side, leaving 1-2 cm of the distal anal mucosa, and a straight ileoanal anastomosis (IAA) without diverting ileostomy. There were no operative deaths. In the ileostomy group 19 (54%) of the patients had a total of 38 reoperations: 10 laparotomies and 28 revisions of a perineal sinus. Three (16%) of the IAA patients had a total of five reoperations: four laparotomies and one closure of a loop ileostomy. All IAA patients had perfect continence day and night and a median stool frequency of 7.5/24 h 1 year after the operation. Ileostomy patients had significantly longer time out of work, and more urinary, sexual, and social dysfunctions than the IAA patients. After 2-3 years' follow-up study, all differences in results are greatly in favour of the ileoanal procedure.