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

Colorectal and extracolonic malignancy in ulcerative colitis

In a review of 1248 cases of ulcerative colitis seen at the Cleveland Clinic that were followed up to 1984 (mean, 14.4 years), 82 patients (6.5%) were subsequently found to have colorectal cancer and 48 (3.8%) had extracolonic malignancy, 6 of them with associated colorectal cancer. Most patients with colorectal cancer were men (2:1), and had extensive (90%) and long-lasting colitis (10 years or more in 93% of cases; mean 18 years). Colitis was inactive before the diagnosis of cancer in 48%. Acute onset of the first attack was rare (7%), and the disease had a remittent course in 92%. The mean age at diagnosis of cancer was 43 years. The cumulative risk of colorectal cancer was significantly higher in patients with extensive colitis than in those with left-sided disease (P less than 0.0001: 11.9% vs. 1.8% at 20 years and 25.3% vs. 3.7% at 30 years). When comparing mean duration of disease, left-sided colitis (22 years) did not differ significantly from extensive disease. The tumor was multifocal in 13.5%, proximal to the splenic flexure in 44%, and poorly differentiated in 34% of the cases. The diagnosis was suspected clinically in 64% of cases. The prognosis of colorectal cancer in patients with ulcerative colitis appears to be similar to that in the general population. The cumulative 5-year survival rate was 54%. This study supports the concept that surveillance colonoscopy should be started after 8 to 10 years of extensive colitis and after 15 years of left-sided colitis. Among those with extracolonic malignancy, the incidence of bile duct carcinoma, leukemia, bone tumors, and endometrial cancer was significantly greater than expected (P less than 0.01), whereas that of lung cancer was significantly lower than expected (P less than 0.01).

The pelvic ileal reservoir. An experimental comparison of the 3-loop and 2-loop systems

In an experimental study the function of the 3-loop (Parks) pelvic ileal reservoir was compared with that of the 2-loop (Utsunomiya) reservoir. Both types achieved satisfactory degrees of continence and evacuation when tested in the defunctioned state. Following restoration of intestinal continuity, the stools of dogs with 3-loop pouches were usually liquid (69 percent) compared to the more formed stools (72 percent) in the 2-loop group, P less than 0.001. At postmortem the reservoirs of the 3-loop group were found to have undergone much greater dilatation (P less than 0.05). These findings suggest that construction of the 3-loop (Parks) pelvic reservoir may lead to retention with overflow if catheterization is not used. It is not clear whether the superior function of the 2-loop pouch is attributable to better motor function or the absence of an efferent limb which allows it to be placed deep in the pelvis.

A prospective study of dysplasia and carcinoma in the rectal biopsies and rectal stump of eight patients following ileorectal anastomosis in ulcerative colitis

The present study concerns eight patients with ulcerative colitis treated by total colectomy and ileorectal anastomosis and subjected to follow-up rectal biopsies who later developed precancer (two cases) or carcinoma in the retained rectum. We report the results of the biopsies and the detailed mapping of lesions in the resected rectal stump to highlight certain features which may lead to increased detection rate of early malignancy. Two groups of patients emerged. Group A: in all four cases the follow-up biopsies showed increasing severity of dysplasia; altered mucin secretion with predominance of sialomucins was seen in the biopsies even in the absence of inflammation or dysplasia; the biopsy findings (morphological and secretory) mirrored those observed in the rectal stump; in three, the lesions were villous polypoid growths, of which two were invasive carcinomas. Group B: in none of the cases was dysplasia seen in the biopsies and mucus secretion was normal; similar features were seen in the rectal stump; all had invasive carcinoma of which three were flat ulcerated lesions. The different behaviour of carcinoma in the two groups almost certainly reflects the different tumour phenotype characteristics and this is a matter for further study. From the practical point of view we emphasize the risk of relying on biopsy evidence of dysplasia alone as an indicator of malignancy and the need for additional immunological or histochemical tests to assess the individual risk of cancer in colitis.

Alternatives to conventional ileostomy in chronic ulcerative colitis

As long as surgeons have performed total proctocolectomy with permanent ileostomy, efforts have been made to avoid the necessity for a permanent stoma. Preservation of sphincter function can now be achieved by more liberal application of the operation of abdominal colectomy and ileorectal anastomosis in carefully selected patients, and knowledge of the progression from dysplasia to cancer can be applied in a prospective fashion to those persons potentially at risk who have retained rectal mucosa. Individuals who are incapable of dealing with conventional permanent ileostomy and who lack the potential use of their own sphincters can be offered the alternative of a continent ileostomy. The advantages of both of these procedures can be combined by greater application of the operation of total abdominal colectomy, mucosal proctectomy, and ileoanal reservoir with ileoanal anastomosis. Although enthusiasm exists for all of these procedures, their results should be compared with the results of what must still be considered the "gold standard" operation, that is, proctocolectomy and conventional ileostomy. Nevertheless, the alternative procedures represent a considerable advance in the overall care of patients with chronic ulcerative colitis.

Sialomucins in the assessment of dysplasia and cancer-risk patients with ulcerative colitis treated with colectomy and ileo-rectal anastomosis

The clinical notes and histology of 374 patients treated by colectomy and ileo-rectal anastomosis for ulcerative colitis were reviewed. Only those with definite diagnosis of ulcerative colitis and follow-up rectal biopsies were included (171 cases). Morphology and patterns of mucin secretion were investigated to assess whether abnormal mucin with predominance of sialomucins is a useful indicator of malignancy-risk. Carcinoma has developed in six patients and 'precancer' in seven. The results show coexistence of dysplasia and sialomucin even in the absence of inflammation in all but three biopsies; in contrast the presence of both dysplasia and normal mucin profile was found in less than 1%. A significant correlation was noted between an inflamed mucosa and the development of cancer or precancer, the presence of sialomucins and the appearance of dysplasia. Sialomucins showed a greater sensitivity in detecting cancer than dysplasia (75% versus 30%). However, dysplasia was notably more specific (94% compared with 50%), hence its greater predictive value as indicator of malignancy (50% as against 15% for a positive sialomucin result). Mucin stains on routine fixed paraffin-embedded tissue provide a simple screening method to sharpen the assessment of dysplasia and cancer-risk in patients with ulcerative colitis despite the limitations referred to above. The lack of definite evidence of dysplasia in four patients who developed malignancy without premalignant changes in the rectal biopsies emphasises the need for frequent multiple biopsies in patients with an ileo-rectal anastomosis for ulcerative colitis.

Incidence of colorectal cancer in proctocolitis: a retrospective study of 959 cases over 40 years

The incidence of colorectal cancer was studied by the actuarial method in 959 patients with idiopathic proctocolitis seen from 1942 to 1981. Forty five per cent had rectal, 23% left-sided, and 32% total involvement of the colon. Six cancers were found: one in the rectal, one in the left-sided, and four in the total form of the disease. The risk of cancer per patient year in total colitis was zero per 2151 patient years in the first decade, 1/462 in the second decade, 1/315 in the third decade, and 1/75 in the fourth decade. The cumulative risk of developing cancer was zero at 10 years of duration of the disease, approximately 5% at 20 years, 15% at 30 years, and 20% at 35 years. This increase in risk of cancer is less than reported in some other series. Geographical differences in the incidence of cancer in proctocolitis could influence the risk and therefore also the long-term management of patients with proctocolitis in different geographical areas.

Complications and quality of life after ileorectal anastomosis for ulcerative colitis

Ileorectal anastomosis is a safe operation with low mortality and morbidity and offers a good prospect for success in many patients with ulcerative colitis. The functional results are good in the majority of patients, and there is a high level of patient acceptance. There is a low cancer risk with regular surveillance, but there is a relative contraindication for ileorectal anastomosis in patients with colon cancer or dysplasia present at the time of colectomy. For many patients, especially children and adolescents in their formative years and for young adults, it avoids or delays an ileostomy and avoids the risk of postoperative sexual dysfunction, while at the same time still permits the elective use of some other continence-preserving operation at a later date.

Restorative proctocolectomy with a three-loop ileal reservoir for ulcerative colitis and familial adenomatous polyposis. Clinical results in 66 patients followed for up to 6 years

The results of restorative proctocolectomy with a three-loop ileal reservoir were reviewed. Of 66 patients treated between 1976 and 1982, 52 had ulcerative colitis and 14 had familial adenomatous polyposis. The temporary ileostomy was closed between 2 and 78 months previously in 63 cases. Of these, three patients had had the reservoir removed and two were lost to follow-up. One other patient was subsequently found to have Crohn's disease. Function was assessed in 55 patients who had undergone closure of the ileostomy more than 8 weeks previously. Mean frequency of defecation was 3.7 per 24 hours (range 1-9.5) and 11 patients (20%) were taking antidiarrheal medication. Spontaneous defecation occurred in 22 patients (40%) while 29 (52.7%) had to use a catheter passed per anum. Four patients defecated spontaneously but sometimes used a catheter. Continence was normal in 36 (65.4%) and minor leakage once every 2 to 3 days occurred at night in 16 (29.1%). Three patients (5.4%) had some soiling during day and night. Troublesome perianal soreness (five patients, 9.1%) necessitated a defunctioning ileostomy in one. Fifty-four of the 55 patients assessed preferred their quality of life to that with an ileostomy.

The lateral reservoir technique of ileal endorectal pull-through for ulcerative colitis and familial polyposis in children

Total abdominal colectomy and endorectal ileal pull-through have been widely used in children as a definitive continence-preserving procedure for ulcerative colitis (UC) and familial polyposis (FP). Controversy exists in regards to the results achieved with the various techniques utilized to accomplish this procedure, including straight ileal pull-through, pull-through with balloon dilatation of the lower ileal segment, and the construction of a variety of ileal reservoirs: S-shaped, J-shaped, or lateral. We have utilized the two-stage lateral reservoir approach advocated by Fonkalsrud et al, on a total of 12 patients, aged 1 to 17 years, including ten patients with UC and two with FP. Twelve patients have undergone stage 1 and seven of these stage 2. Numerous complications of stage 1 occurred early in the series, including breakdown of the ileoanal anastomosis, 3 patients; cuff abscess, 2 patients; postoperative intestinal obstruction, 2 patients; and intraabdominal abscess, 1 patient. All have fully recovered. The last six stage 1 procedures have been without complications. Five of the seven stage 2 patients are now well, continent, and having four to six controlled bowel movements a day 1 to 2 years postoperatively. Two patients are using small amounts of Immodium and Metamucil. One patient has developed marked dilatation of the pouch at 8 months postoperatively with episodic "pouchitis" requiring operative revision and diversion. One stage 2 patient suffered numerous complications including spontaneous perforation of the reservoir 2 months postoperatively, eventually leading to re-creation of a permanent ileostomy and removal of the pouch. Five patients await further treatment. The lateral reservoir technique is capable of producing a satisfied and continent patient; however, the potential technical problems and early complications are significant. The occurrence of delayed "pouchitis" is worrisome. Although the initial results with the lateral reservoir technique appear encouraging, further longterm evaluation is necessary.

Surgical options in ulcerative colitis

Five operative options are now available for treatment of ulcerative colitis: (1) proctocolectomy with ileostomy, (2) abdominal colectomy with ileostomy and retention of the rectum, (3) abdominal colectomy with ileorectal anastomosis, (4) proctocolectomy with creation of a continent stoma or conversion of a standard ileostomy after proctocolectomy to a continent stoma, and (5) restorative proctocolectomy. Each procedure has advantages and disadvantages. With careful assessment, the specific needs of each patient can best be met. In many cases a permanent stoma can be avoided. The newer procedures have not been used long enough for long-term effects to be known, and they must be offered with reservation and then only to well-informed, stable, and relatively fit and cooperative patients.

Mucosal dysplasia. A major predictor of cancer following ileorectal anastomosis

Fifty patients with ulcerative colitis managed by colectomy and ileorectal anastomosis had rectal biopsies performed in the period 1967 to 1972. Follow-up information was available on all patients. Thirty-nine patients were reviewed and rectal biopsies performed in the 1980 to 1982 period. Three patients had developed rectal cancer in the period 1975 to 1980, and two rectal cancers were detected in the 1980 to 1982 follow-up period. All cancers occurred in patients with a diagnosis of moderate or severe dysplasia in biopsy specimens from the 1969 to 1972 period. The probability of developing rectal cancer after a diagnosis of moderate or severe dysplasia in this series reached 42 per cent at nine years from diagnosis.

Epithelial cell proliferation in the rectal stump of patients with ileorectal anastomosis for ulcerative colitis

Epithelial cell proliferation in the rectal stump after ileorectal anastomosis for ulcerative colitis was studied in 19 patients. This was achieved through in vitro incorporation of tritiated thymidine in mucosal biopsies and radioautographic analysis of the number and position of labelled nuclei in the crypts. Rectal biopsies from nine unoperated patients with ulcerative colitis and from 10 controls, were processed simultaneously. Except for one, all patients were clinically in remission. The crypt length and number of labelled cells per crypt column were found to be similar in the rectal mucosa from the three groups of subjects. The mean labelling index, although low 8.9%, was higher (p less than 0.05) in operated patients compared with controls; but the dispersion of individual values was similar in both groups. There was an extension of the proliferative compartment towards the surface in 88% of unoperated patients and in 60% of operated patients. In addition, there was a shift of the major zone of proliferation from the lower to the middle third of the crypt in 17% of operated patients and from the lower to the upper third of the crypt in 14% of unoperated patients. No correlation was found between the labelling index and either the age of patient, the duration of disease or the period elapsed after ileorectal anastomosis. Interestingly, among operated patients with a colitis for over 10 years, 42% had a quite normal proliferative pattern with a corresponding mean postoperative period of 7.5 years.

Cancer surveillance in ulcerative colitis. Experience over 15 years

In the years 1966-80, 303 patients with radiologically extensive ulcerative colitis were followed up regularly, both by clinical assessment and by mucosal biopsies, to detect dysplastic (precancerous) change. Moderate or severe dysplasia (but no carcinoma) was found in the specimen in 8 patients treated surgically. Despite regular surveillance, carcinoma developed in 13 of the 186 patients with a history of disease for ten years or more. Of the total sixteen carcinomas in these 13 patients, eleven were Dukes stage A, three stage B, one stage C, and one was inoperable. There has been 1 death from carcinoma in this series over the fifteen year observation period. The method of follow-up has probably prevented the development of carcinoma in 8 patients and permitted diagnosis of carcinoma at a stage when cure is likely in 11. The incidence of moderate or severe dysplasia and carcinoma in these patients with mild or symptomless extensive colitis shows that either proctocolectomy or careful follow-up should be advised once the duration of symptoms reaches ten years.

Mucosal proctectomy without reservoir

Mucosal proctectomy with endorectal pull-through allows the removal of all colonic mucosa with preservation of continence. This operation was performed in 19 patients with familial polyposis coli and ulcerative colitis. A temporary loop ileostomy was used to defunctionalize the anastomosis. Intestinal continuity was restored in 17 of the 19 patients. Mean duration of follow-up was 29 months. All patients are continent, and the mean number of bowel movements per 24 hours is 6. Follow-up barium studies revealed a gradual dilatation of the terminal ileum within the rectal cuff which accounts for the decrease in the number of bowel movements. This operation eliminates the risk of carcinoma without compromising sphincter function.

The risk of rectal carcinoma following colectomy in ulcerative colitis

In a series of 1439 patients with ulcerative colitis, managed by one of the authors (E.S.R.H.), surgical resection was performed on 374 patients (26 per cent): colectomy, 273 (subtotal colectomy and mucous fistula, 172, colectomy and primary ileorectal anastomosis, 101); proctocolectomy, 61; and miscellaneous procedures, 40. Of the 172 patients undergoing subtotal colectomy and mucous fistula, 93 (54 per cent) subsequently required rectal excision, 33 (19 per cent) had ileorectal anastomosis performed as a second procedure, and in 46 (27 per cent) the rectum has remained as a mucous fistula. Two hundred seventy-three patients were at risk for the development of rectal cancer after subtotal colectomy; ten patients (3.6 per cent) subsequently developed rectal cancer. The cumulative probability of developing rectal cancer after subtotal colectomy reached 17 per cent at 27 years from disease onset. The tumors were more advanced in stage and of higher grade malignancy than those of a parallel general series of patients with rectal cancer uncomplicated by inflammatory bowel disease. Colectomy and ileorectal anastomosis has been successful for most patients. However, the experience of this series highlights the danger of carcinomatous transformation in the retained rectum, the requirement for regular long-term follow-up, the need for markers of precancerous change, and the value, where relevant, of prophylactic proctectomy.

Ileostomy options. Asking the right questions

The patient requiring ileostomy may have the opportunity to choose from four options. The Brooke ileostomy has afforded thousands of patients a secure, comfortable life. Appliances adhere well, and complications are few. The continent ileostomy or Kock pouch permits a patient to forego the wearing of an appliance. It is about 90 per cent successful but has a significant complication rate. Crohn's disease and physical frailties preclude its use. In "endorectal pull-through," the colon and rectal mucous membrane are removed to cure polyposis or ulcerative colitis. The ileum is led through the rectal muscular cylinder and anastomosed to the anus. The operation is tedious and not uniformly successful. A period of training must follow. It is unfit for people with Crohn's disease. Ileal anastomosis to a rectal segment is simpler but leaves disease behind. It may be used in Crohn's disease but may expose the patient to the hazard of recurrent disease or cancer. We must understand and ask the right questions if we are to give our patients the right answers.

Colorectal carcinoma in patients with ulcerative colitis

Analysis of a 30 year (1950 to 1979) series of colorectal carcinoma disclosed 29 patients with ulcerative colitis, who were compared in this retrospective study with 1,032 noncolitic patients. Colitic tumors were often multiple and had a predilection for the transverse colon. Nineteen patients were resected with the intention of cure, for a curability rate of 66 percent, which is comparable to the 69 percent rate in noncolitic patients. The 5 year survival rate was 31 percent overall and 47 percent in curable cases, rates similar to those in noncolitic patients (34 and 47 percent). All patients with Dukes' A lesions survived 5 years. A high incidence of Dukes' C lesions was observed; one third of these patients survived 5 years . Apart from the advanced stage, no signs of "aggressiveness" or particular virulence were demonstrated in colitic cancer. Results of procedures less than proctocolectomy in 13 patients were dismal: 4 died from cancer within 3 years, and 6 developed late carcinoma in the retained part of the bowel, with a fatal outcome in all.

The occurrence of severe epithelial dysplasia and its bearing on treatment of longstanding ulcerative colitis

One hundred twenty-four patients with extensive ulcerative proctocolitis were operated upon with proctocolectomy. The mean observation time was 10.3 years. Before surgery rectal biopsies were taken in all patients. The relationship between precancerous lesion in rectal biopsies and the presence of precancer and/or cancer in the rectum or colon in the removed specimen was evaluated. Thirteen out of 14 patients showed evidence of severe rectal dysplasia as well as severe dysplasia in the large bowel specimen, and five of these patients had a carcinoma as well. The 14th patient showed severe dysplasia only in the rectum as well as a rectal carcinoma. Of 110 patients without severe rectal dysplasia, 36 showed evidence of severe colon dysplasia, and three of these patients had a large bowel carcinoma as well. Only one patient had a large bowel carcinoma without evidence of severe dysplasia in the rectum or colon. Thus, nine patients out of ten with large bowel carcinoma showed severe dysplasia in rectum and/or colon. Four of these carcinomas were unknown before surgery. Although severe dysplasia in the rectal biopsy is a strong indication of a large bowel carcinoma (6/14), a negative rectal biopsy does not exclude a large bowel carcinoma (4/110). Proctocolectomy cannot be looked upon only as a prophylactic procedure in patients with severe dysplasia in the rectal biopsy, but also as an attempt to curative surgery, as large bowel carcinoma may have already developed in a considerable number of patients where precancer is diagnosed in biopsies.

Total colectomy with ileo-endomuscular pull-through in the treatment of ulcerative colitis in children

Since ulcerative colitis is primarily a mucosal disease, total colectomy with rectal mucosectomy and ileo-endomuscular pull-through (Soave) offers many theoretical advantages. The diseased colon is removed, the anal sphincteric mechanism is preserved, and permanent ileostomy is avoided, bladder and sexual function are preserved, and problems with perineal wound healing are avoided. Of critical importance is the state of rectal mucosal disease in the selection of patients for this operation. Our experience with four children in whom the operation has been performed is presented. Postoperative diarrhea has not proved to be a significant problem and continence has been maintained.

The risk of cancer following colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis

A retrospective study was performed on 89 patients who underwent total colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis between the years 1957 and 1977 in order to determine the risk of developing cancer of the rectum. The 30-day operative mortality rate was 0%. Of the 84 patients available for follow-up study, four patients, (4.8%) developed a carcinoma of the rectum. The risk of cancer per patient-year was zero in the first decade, 1/206 in the second decade, and 1/116 in the third decade. The cumulative risk of developing cancer was 0% at 10 years, 2.1% +/- 2.1% at 15 years, 5.0% +/- 3.5% at 20 years, and 12.9% +/- 8.3% after 25 years of disease. Patients with cancer or precancer in the colon at the time of colectomy appear to be at high risk for the later development of rectal cancer.

Surgical management of inflammatory bowel disease

Indications for operation in patients with inflammatory bowel disease are now standardized as a result of the vast surgicaL experience that has been accumulated during the past 40 years. The surgical indications in Crohn's disease and chronic ulcerative colitis vary minimally with the anatomic distribution of either disease, and can be recognized easily in a particular patient. Consequently, decision or judgment regarding the need for operation is rarely difficult. Delaying operation on the basis of fear of recurrence of Crohn's disease is unrealistic because (1) indications for operation are complications of the disease that have not responded or cannot be expected to respond to medical treatment, (2) conservative resection primarily removes diseased bowel that will never return to normal, (3) many patients, perhaps 50%, will never have recurrence of disease, and (4) those who have recurrence will have experienced varying periods when they were free of disease and relieved of the serious complications for which their operations were performed. The value of surgery in the treatment of patients with chronic ulcerative colitis can be stated even more positively, because recurrence of disease is never a concern after proctocolectomy.

Colonoscopy and the detection of dysplasia in patients with longstanding ulcerative colitis

The role of colonoscopy in the surveillance of patients with ulcerative colitis for dysplasia was investigated in 43 patients with longstanding disease extending proximally beyond the splenic flexure. The examination was well tolerated and no complications were recorded. Dysplasia was found in 9 patients in one or more biopsies and was severe in 2, moderate in 1, and mild in 6. Both the patients with severe dysplasia had a carcinoma at subsequent operation. Colonoscopy may allow complete examination of the colon and biopsy of suspicious lesions and, since dysplasia may spare the rectum, colonoscopy with biopsy is a desirable component of any surveillance programme of the at-risk colitic.

Proctocolectomy with ileal reservoir and anal anastomosis

A technique of proctocolectomy avoiding an ileostomy has been developed for patients with ulcerative colitis or polyposis coli. After excision of all diseased tissue a reservoir of terminal ileum is constructed which is brought through the rectal stump denuded of mucosa; an ileo-anal anastomosis is then carried out. Twenty-one patients (17 ulcerative colitis, 4 polyposis) have been treated and 20 followed for from 2 to 34 months (mean 13.5 months). There was no mortality but early complications occurred in 9 patients. All are currently well, with no disturbance of urinary or sexual function. Continence of faeces is complete in all during the day, but 1 patient evacuates unconsciously at night. The average frequency of evacuation is 3.8 times in 24 h. Ten patients void spontaneously. All patients tolerate a full diet and only 2 use medicaments to reduce frequency. This operation appears to be a satisfactory alternative to proctocolectomy with a permanent ileostomy.

Ileorectal anastomosis for inflammatory bowel disease: 15-year follow-up

A personal series (E.S.R.H.) of 37 patients with inflammatory bowel disease, treated by colectomy and ileorectal anastomosis 15 years or more ago, is reviewed. Twenty-one patients (57 per cent) continue to be in satisfactory condition. Patients subjected to the two-stage operation have a notably lower rate of conversion to ileostomy than those treated by one-stage colectomy. One patient developed a carcinoma of the rectal stump. This 15-year review leads support to the opinion that ileorectal anastomosis has an important place in the treatment of inflammatory bowel disease.