Anal transitional zone and columnar cuff in restorative proctocolectomy

Cancer in the Anal Transition Zone and Ileoanal Pouch following Surgery for Ulcerative Colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis remains the gold standard treatment for patients with ulcerative colitis who desire restoration of intestinal continuity. Despite a significant cancer risk reduction after surgical removal of the colon and rectum, dysplasia and cancers of the ileal pouch or anal transition zone still occur and are a risk even if an anal canal mucosectomy is performed. Surgical care and maintenance after ileoanal anastomosis must include consideration of malignant potential along with other commonly monitored variables such as bowel function and quality of life. Cancers and dysplasia of the ileal pouch are rare but sometimes difficult-to-manage sequelae of pouch surgery.

Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis

Proctocolectomy with ileal pouch-anal anastomosis is the intervention of choice for ulcerative colitis and familial adenomatous polyposis requiring surgery. One of the long-term complications is pouch cancer, having a poor prognosis. The risk of high-grade dysplasia and cancer in the anal transitional zone and ileal pouch after 20 years is estimated to be 2 to 4.5% and 3 to 10% in ulcerative colitis and familial polyposis, respectively. The risk factors for ulcerative colitis are the presence of pre-operative dysplasia or cancer, disease duration > 10 years and severe villous atrophy. For familial polyposis, the risk factors are the number of pre-operative polyps > 1000, surgery with stapled anastomosis and the duration of follow-up. In the case of ulcerative colitis, a pouchoscopy should be performed annually if one of the following is present: dysplasia and cancer at surgery, primary sclerosing cholangitis, villous atrophy and active pouchitis (every 5 years without any of these factors). In the case of familial polyposis, endoscopy is recommended every year including chromoendoscopy. Even if anal transitional zone and ileal pouch cancers seldom occur following proctectomy for ulcerative colitis and familial adenomatous polyposis, the high mortality rate associated with this complication warrants endoscopic monitoring.

Common Inflammatory Disorders and Neoplasia of the Ileal Pouch: A Review of Histopathology

Ileal pouch-anal anastomosis (IPAA) is the standard restorative procedure after proctocolectomy in patients with ulcerative colitis (UC) who require colectomy. The ileal pouch is susceptible to a variety of insults including mechanical injury, ischemia, fecal stasis, and infectious agents. In addition, the development of recurrent and idiopathic inflammatory bowel disease and neoplasia may occur in the ileal pouch. Although clinical, endoscopic, and radiographic examination can diagnose many ileal pouch diseases, histologic examination plays an essential role in diagnosis and management, particularly in cases with antibiotic refractory chronic pouchitis and pouch neoplasia.

Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP)--a critical issue

INTRODUCTION

Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis.

PATIENTS AND METHODS

One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed.

RESULTS

Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) (P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02).

CONCLUSION

Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated.

Clinical course of cuffitis in ulcerative colitis patients with restorative proctocolectomy and ileal pouch-anal anastomoses

BACKGROUND

Cuffitis, considered a form of reminiscent ulcerative colitis (UC), is one of the common complications of ileal pouch-anal anastomosis (IPAA) and its disease course has not been systematically characterized. The aim was to examine the disease course of cuffitis in a large historical cohort.

METHODS

All patients with cuffitis diagnosed based on a combined evaluation of symptom and pouch endoscopy at the initial visit to our Pouchitis Clinic were included. Pouch patients with diagnoses other than cuffitis served as controls. Patients with familial adenomatous polyposis were excluded.

RESULTS

A total of 120 patients with cuffitis were included. The control group consisted of 811 patients (normal pouch, n = 85; irritable pouch syndrome, n = 155; acute pouchitis, n = 170; chronic pouchitis, n = 128; Crohn's disease [CD] of the pouch, n = 185; and surgical complications, n = 88). After a median follow-up of 6 years (interquartile range: 3-10 years) after pouch construction, there were 40 (33.3%) having 5-aminosalicylate (5-ASA)/steroid-responsive cuffitis; 22 (18.3%) having 5-ASA/steroid-dependent cuffitis, and 58 (48.4%) developing 5-ASA/steroid-refractory cuffitis. Further investigation of the 58 patients with refractory cuffitis showed that 19 (32.8%) had CD of the pouch and 14 (24.1%) had surgical complications including fistulae and anastomotic sinuses. There were 16 (13.3%) cuffitis patients who developed pouch failure during the follow-up period.

CONCLUSIONS

Cuffitis may represent a spectrum of diseases. In patients with refractory cuffitis, a diagnosis of CD or surgery-associated anal transitional zone complications should be considered.

History of and current issues affecting surgery for pediatric ulcerative colitis

Pediatric ulcerative colitis (UC) is reportedly more extensive and progressive in its clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent colectomies are needed. When physicians treat pediatric UC, they must consider the therapeutic outcome as well as the child's physical and psychological development. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This procedure was developed 100 years after the first surgical therapy, which treated UC by colon irrigation through a temporary inguinal colostomy. Predecessors in the colorectal and pediatric surgical fields have struggled against several postoperative complications and have long sought a surgical procedure that is optimal for children. We herein describe the history of the development of surgical procedures and the current issues regarding the surgical indications for pediatric UC. These issues differ from those in adults, including the definition of toxic megacolon on plain X-rays, the incidence of colon carcinoma, preoperative and postoperative steroid complications, and future growth. Surgeons treating children with UC should consider the historical experiences of pioneer surgeons to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.

Adenocarcinoma following ileal pouch-anal anastomosis for ulcerative colitis: review of 26 cases

The occurrence of adenocarcinoma following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is an infrequent and but potentially lethal complication. We have seen 1 such case among 520 IPAAs performed in our group practice between 1978 and February 2008. We have added this case to a review of 25 previously reported cases of adenocarcinoma of the pouch or outflow tract following IPAA for UC. Our conclusions are 1) that post-IPAA cancer can occur following either mucosectomy or stapled anastomosis; 2) that this malignancy can occur after IPAA performed for UC either with or without neoplasia; and 3) that this complication is seen whether or not the initial cancer or dysplasia had involved the rectum.

Use of a monoclonal antibody to sucrase-isomaltase for evaluation of the columnar cuff after stapled restorative proctocolectomy

PURPOSE

Restorative proctocolectomy with a double-stapled pouch-anal anastomosis retains a cuff of diseased columnar mucosa (columnar cuff) in the upper anal canal that may require biopsy. Biopsying this can be difficult and colonic phenotypic change in the pouch can lead to errors interpreting the histology. This study was designed to investigate the use of a monoclonal antibody to sucrase-isomaltase for differentiating ileal pouch from columnar cuff mucosa. Then, by using this antibody, the ability to accurately take and report biopsies from the anal canal was examined.

METHODS

The technique of staining for sucrase-isomaltase was developed. From 113 patients who had a double-stapled pouch-anal anastomosis, 467 formalin-fixed biopsies and 177 fresh-frozen biopsies were taken from the ileal pouch, columnar cuff, or anal transitional zone. Biopsies were stained with a monoclonal antibody to sucrase-isomaltase, and fixed biopsies were routinely reported after staining with hematoxylin and eosin.

RESULTS

A monoclonal antibody to sucrase-isomaltase reliably discriminated between ileal from rectal mucosa. A biopsy of columnar cuff mucosa as reported by routine histology was obtained during 72 percent of attempted outpatient examinations. Sucrase-isomaltase staining of reported columnar cuff biopsies showed that biopsies were of pouch rather than columnar cuff in 4.4 percent (95 percent confidence interval, 2-8) of outpatient examinations.

CONCLUSIONS

The monoclonal antibody to sucrase-isomaltase used in this study may have a clinical role when interpreting columnar cuff biopsies from patients being investigated for pouch dysfunction, or in patients having surveillance biopsies to exclude neoplasia in the columnar cuff.

Endoscopy/surveillance in inflammatory bowel disease

Patients with chronic colitis from inflammatory bowel disease (IBD) have an increased risk of colorectal cancer (CRC). Previously, to ameliorate this, prophylactic total colectomy was offered to patients who had chronic ulcerative colitis (UC); however, research has identified less invasive management options through better understanding of the pathogenesis of cancer in chronic inflammation, a more uniform histologic diagnosis by pathologists, and proper surveillance colonoscopy techniques. This article reviews the pathogenesis of neoplasia in IBD, and then reviews the risk factors for CRC in IBD, surveillance guidelines and their limitations, surveillance techniques, ileal pouch dysplasia, and chemoprevention. Although data for CRC risk in Crohn's disease (CD) are not as extensive, it has been suggested that the risks are comparable to UC.

Ileal pouch surgery for ulcerative colitis

Ulcerative colitis (UC) is a relapsing and remitting disease characterised by chronic mucosal and submucosal inflammation of the colon and rectum. Treatment may vary depending upon the extent and severity of inflammation. Broadly speaking medical treatments aim to induce and then maintain remission. Surgery is indicated for inflammatory disease that is refractory to medical treatment or in cases of neoplastic transformation. Approximately 25% of patients with UC ultimately require colectomy. Ileal pouch-anal anastomosis (IPAA) has become the standard of care for patients with ulcerative colitis who ultimately require colectomy. This review will examine indications for IPAA, patient selection, technical aspects of surgery, management of complications and long term outcome following this procedure.

Long-term cancer risk of the anorectal cuff following restorative proctocolectomy assessed by p53 expression and cuff dysplasia

OBJECTIVE

Restorative proctocolectomy (RP) for ulcerative colitis (UC) retains a 'cuff' of columnar rectal epithelium that has unknown risk of malignant change. Markers of malignant potential in UC include aberrant p53 expression and dysplasia. We undertook a prospective study comprising serial surveillance biopsy and assessed the occurrence of aberrant p53 expression, epithelial dysplasia and carcinoma in the retained anorectal cuff following stapled RP.

METHOD

A total of 110 patients who underwent stapled RP for UC between 1988 and 1998 were followed up by cuff surveillance biopsies under general anaesthesia. Histological samples were analysed by a specialist colorectal pathologist for the presence of rectal mucosa, dysplasia and carcinoma. Immunohistochemistry for p53 expression was performed for each most recent cuff biopsy. Median follow-up was 56 months (12-145) and median time since diagnosis of UC was 8.8 years (2-32).

RESULTS

Rectal mucosa was obtained from the cuff in 65% of biopsies. No overt carcinomas developed during the follow-up period and there was no dysplasia or carcinoma in any cuff biopsy. The p53 overexpression was identified in 38 specimens (50.6%), but was also identified in controls (3/3 colitis, 3/3 ileal pouch and 6/6 stapled haemorrhoidectomy donuts).

CONCLUSION

The lack of carcinoma and dysplasia in the columnar cuff epithelium specimens is reassuring. The lack of stabilized p53 and absence of a relationship between p53 stabilization and dysplasia up to 12 years after pouch formation suggests neoplastic transformation is a rare event. Furthermore, p53 expression was not useful in surveillance of cuff biopsies from patients who have undergone RP for UC and the search should continue for alternative predysplastic markers. These data suggest that in patients who do not have high-grade dysplasia or colorectal cancer at the time of RP, cuff surveillance in the first decade after pouch formation is unnecessary. However, we consider regular cuff surveillance biopsies should continue for patients with high-grade dysplasia, whether or not there was a carcinoma in the original colectomy specimen.

The fate of the rectal stump after subtotal colectomy for ulcerative colitis

OBJECTIVE

To review the outcome of patients who had undergone subtotal colectomy for ulcerative colitis with formation of a rectal stump. To specifically look at the fate of the rectal stump, whether patients underwent emergency colectomy as opposed to urgent or elective resection.

PATIENTS AND METHODS

Between January 1990 and August 2000, a total of 31 patients underwent subtotal colectomy for ulcerative colitis. Patients were identified using the computerized coding system for the years 1995 to 2000, supplemented by pathology records, discharge letters, and operation notes. Postal and telephone surveys were undertaken using a standard questionnaire assessing social, physical, sexual, and bowel activities of patients.

RESULTS

In 28 out of 31 patients, the follow-up was complete. Twenty-four of 28 patients (86%) underwent excision of rectal stump. Four patients (14%) preferred to undergo excision of rectum only, resulting in a permanent ileostomy; 20/28 (71%) had attempted ileal pouch-anal anastomosis, with success in 85%. In four patients (14%), the rectal stump remained in situ and was associated with a decrease in the quality of life. There were no perioperative deaths and morbidity was low for all procedures.

CONCLUSION

These data show that after subtotal colectomy, the majority of our ulcerative colitis patients undergo ileal pouch-anal anastomosis. Patients' satisfaction is high with reasonable social and excellent sexual function on quality of life assessment. During its retention, the rectal stump causes considerable symptoms. When left in situ, it is associated with a decrease in the quality of life.

Ileal pouch-anal anastomosis: the Australasian experience

OBJECTIVE

The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia.

METHOD

The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results.

RESULTS

Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P=0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16%vs 9%, P=0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P=0.0005).

CONCLUSION

A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.

Revolution and evolution: 30 years of ileoanal pouch surgery

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

Stapled restorative proctocolectomy in children with refractory ulcerative colitis

OBJECTIVE

The aim of this study was to review the results after stapled restorative proctocolectomy among children with refractory ulcerative colitis.

PATIENTS AND METHODS

Clinical records of 16 consecutive children with refractory ulcerative pancolitis undergoing colectomy and stapled straight ileoanal anastomosis at a median age of 8.3 years (range, 3.1-14.9 years) were reviewed. Periodical clinical examinations and endoscopies with biopsies above (terminal ileum) and below (columnar cuff) the anastomosis were carried out during follow-up. Median follow-up after bowel restoration lasted 5.3 years (range, 1.2-9.6 years).

RESULTS

Two major complications occurred (12.5%), 1 episode of sepsis treated conservatively and 1 bowel perforation proximal to the anastomosis treated with a temporary diverting ileostomy. All the anastomoses were functional at the end of the study. The columnar cuff averaged 2.6 cm in length and presented signs of persistent inflammation (cuffitis) in 94% of children. Inflammation responded poorly to any medical treatment but was symptomatic in 1 case only. Ileal inflammation was detected endoscopically in 31% of patients and histologically in 62.5%. No case of dysplasia or cancer was recorded. At final follow-up, children had an average of 7.1 +/- 3.1 bowel movements per day; full daytime and nighttime continence were achieved in 87.5% and 62.5% of cases, respectively. A severe inflammation of the columnar cuff was associated with an increased risk of nighttime incontinence.

CONCLUSIONS

Stapled ileoanal anastomosis in children with pancolitis is associated with low morbidity. Refractory cuffitis persists in almost all patients but is mostly asymptomatic, although it could be associated with nighttime incontinence.

Salvage surgery after restorative proctocolectomy

BACKGROUND AND METHOD

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

RESULTS

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

CONCLUSION

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

A study of the complications and pelvic visceral function after restorative proctocolectomy and W pouch construction

OBJECTIVE

Aspects of ileal pouch surgery remain controversial. The authors' single practice experience of 107 operations illustrates many of them. It was hoped that its study would contribute usefully to the debate.

PATIENTS AND METHODS

Details of all 107 restorative proctocolectomies carried out since the operation was started in Gloucester in 1984 until the study period ended have been kept prospectively. All patients had proctectomy by mesorectal dissection, and 106 had W pouch restoration. Four suffered functional failure requiring reversion to ileostomy and three patients have died. The remaining 99 were sent a questionnaire concerning pelvic visceral function and evidence of pouchitis. Records of all but one of the patients have been reviewed.

RESULTS

Surgical morbidity was low with neither chronic pelvic sepsis, pouch related fistula, pouch haemorrhage nor pouch ischaemia. Mucosectomised patients had similar bowel control to the stapled group. The policy change from routine to selective protective ileostomy proved satisfactory. W pouch function was found to be comparable to that reported from major J pouch series, although anti-diarrhoeal usage was reduced, and was not influenced by either gender, age or time since surgery.

CONCLUSION

None of the following reasonably intuitive assumptions seem supported by our findings: that mesorectal excision necessarily poses a greater danger to pelvic visceral function than close rectal dissection, that the greater capacity of W pouches will be reflected in markedly less frequency, that mucosectomy would impair anal control, or that a defunctioning ileostomy is a mandatory precaution. Pouch frequency is less if wind can be passed separately; otherwise functional outcome seems determined by other, non-technical, factors.

Risk of dysplasia in the columnar cuff after stapled restorative proctocolectomy

BACKGROUND

Stapled restorative proctocolectomy (SRP) for ulcerative colitis retains a 'cuff' of columnar epithelium, which carries a risk of undergoing malignant change. The risk of neoplastic transformation was studied in a series of patients who underwent SRP for ulcerative colitis.

METHODS

One hundred and thirty-five patients who underwent SRP for ulcerative colitis between 1988 and 1998 were followed up by cuff surveillance biopsy. The median follow-up was 56 (range 12-145) months and the median time since diagnosis of ulcerative colitis was 8.8 (range 2-32) years.

RESULTS

The cuff biopsies showed no dysplasia or carcinoma. The accuracy of obtaining cuff mucosa in the biopsy was 65 per cent. Chronic inflammation was present in 94 per cent of cuff biopsies.

CONCLUSION

This study shows no evidence of either dysplasia or carcinoma in the columnar cuff mucosa, up to 12 years after pouch formation. This suggests that cuff surveillance in the first decade after SRP, in the absence of dysplasia or carcinoma in the original colectomy specimen, may be unnecessary. Regular cuff surveillance biopsies after SRP should continue for patients with high-grade dysplasia or carcinoma in the original resection specimen.

Functional outcome of stapled ileal pouch-anal canal anastomosis versus handsewn pouch-anal anastomosis

This study was conducted to determine whether stapled ileal pouch-anal canal anastomosis (IACA) preserving the anal transitional zone (ATZ) or hand-sewn ileal pouch-anal anastomosis with mucosectomy (IPAA) is more beneficial in achieving disease eradication and better postoperative function. IACA was performed in 10 patients with ulcerative colitis (UC) and 10 patients with familial adenomatous polyposis (FAP), 15 of whom were examined proctoscopically. IPAA was performed in 4 patients with UC and 8 patients with FAP. The mean maximum resting pressure (MRP) was 55 mmHg in the IACA group and 34 mmHg in the IPAA group (P < 0.01). The anorectal inhibitory reflex was positive in 18 patients (90%) from the IACA group and 5 (42%) from the IPAA group (P < 0.05). The pre- and postoperative MRPs were 61 mmHg and 55 mmHg, respectively, in the IACA group vs 63 mmHg and 34 mmHg, respectively, in the IPAA group (P < 0.01). Whereas 16 (80%) of the 20 IACA patients could discriminate feces from gas, only 4 (33%) of the 12 IPAA patients could (P < 0.05). The mean observation period was 2.3 years, the mean length of the columnar cuff was 2.8 cm, and no case of dysplasia or adenoma was seen. Postoperative function is more favorable following IACA than following IPAA, both physiologically and symptomatically. However, long-term surveillance of the residual mucosa is necessary before making a final recommendation.

Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique: is there a relation to tissue type?

PURPOSE

The aim of this study was to evaluate any differences in functional outcome in patients with mucosal ulcerative colitis after restorative proctocolectomy and ileal pouch-anal anastomosis with use of the double stapling technique relative to the type of tissue in the stapled doughnut.

METHODS

Between September 1988 and June 1997, the pathology of all patients with mucosal ulcerative colitis who underwent ileal pouch-anal anastomosis with use of the double stapling technique were reviewed. Information was obtained regarding the tissue types in the distal tissue rings (doughnuts) obtained from the stapled ileal pouchanal anastomosis. The level of anastomosis was classified according to the type of tissue in the distal doughnut: Group I- patients in whom the anal transitional zone was removed and the distal doughnut included squamous epithelium or transitional epithelium and Group II- patients in whom the anal transitional zone was preserved because the distal doughnut revealed only columnar epithelium. Functional outcomes were assessed and compared by detailed questionnaires mailed to all patients at least one year after ileal pouch-anal anastomosis surgery.

RESULTS

Distal doughnuts were obtained from the stapled ileal pouch-anal anastomosis in 222 patients with mucosal ulcerative colitis. Follow-up data at a mean of 38 (range, 12-132) months were obtained in 138 (62.2 percent) patients, including 72 males, with a mean age of 46.9 (range, 13-79) years. Group I consisted of 40 patients (29 percent; 35 (25.4 percent) who had squamous epithelium and 5 (3.6 percent) who had transitional epithelium in the distal tissue rings). Group II consisted of 98 patients (71 percent) with columnar epithelium in the distal tissue rings. Age at diagnosis and operation, duration of disease, length of follow-up, and stage of pouch surgery were similar in the two groups. Incontinence scores, frequency of bowel movement, use of a protective pad, discrimination between gas and stool, use of antidiarrheals, life-style alteration, and patient satisfaction showed similar functional results between the two groups.

CONCLUSIONS

The tissue type in the stapler distal doughnut did not greatly influence functional outcome. Failure to identify a relationship may attest to the variable height and composition of the anal transitional zone.

Aneuploidy and columnar cuff surveillance after stapled ileal pouch-anal anastomosis in ulcerative colitis

PURPOSE

A stapled pouch-anal anastomosis without mucosectomy is widely used in restorative proctocolectomy. Uncertainty exists about the longer-term outcome of retaining a columnar cuff of epithelium in the anal canal and about the need for surveillance of the columnar cuff. The aim of this article was to assess the ability to obtain biopsies of the columnar cuff, to assess the risk of dysplasia, and to search for the presence of aneuploidy as an early of marker of dysplasia in nondysplastic epithelium.

METHOD

A total of 457 biopsy specimens were taken during 203 examinations of 113 patients. All biopsy specimens were stained with hematoxylin and eosin and examined by microscopy. One hundred thirty-two of these biopsy specimens from 67 patients were frozen and analyzed by flow cytometry for aneuploidy.

RESULTS

Mean follow-up after pouch formation was 2.5 years, and the time after diagnosis of ulcerative colitis was 10.1 years. Successful columnar cuff biopsies were done on 93 percent of patients. There was no dysplasia. Two biopsy specimens from one patient had aneuploidy.

CONCLUSION

To date, neoplastic change in the columnar cuff is rare. A selective policy of surveillance biopsies is recommended that includes patients greater than ten years after the diagnosis of ulcerative colitis and patients with dysplasia or cancer in their proctocolectomy specimen, but long-term follow-up data are needed.

Retocolectomia total e anastomose íleo-anal com reservatório ileal: experiência de 16 anos

O reservatório ileal pélvico tem sido a melhor opção cirúrgica para a retocolite ulcerativa (RCU) e polipose adenomatosa familiar (PAF). Desde 1983 esta técnica vem sendo empregada, e o objetivo deste trabalho é apresentar revisão desta casuística, analisando seus resultados e seus pontos controversos. Setenta e três pacientes, com média de idade de 34,6 (13-63) anos e com predomínio do sexo feminino (42 pacientes, 56,7%) se submeteram ao procedimento para tratamento de RCU (46 pacientes - 63,0%) e PAF(27 - 37,0%). Foram utilizadas as seguintes variantes técnicas: em S, de grande tamanho e ramo eferente longo (oito); em S pequeno e ramo eferente reduzido (22); em "dupla câmara" (20); em J (23). Todos os procedimentos foram seguidos da construção de ileostomia de proteção. De 1993 em diante, todos os pacientes tiveram a arcada do colo direito preservada. Setenta pacientes têm pelo menos um ano de pós-operatório e 61 têm dois anos ou mais com média de 7,01 (1-16) anos. Foram consideradas complicações precoces aquelas que ocorreram até o 30º dia de pós- operatório e tardias, após esse tempo. Resultados funcionais foram analisados após um ano do fechamento da ileostomia. Ocorreram 35 complicações precoces em 22 pacientes e 39 complicações tardias em 35 pacientes. Vinte e cinco pacientes não apresentaram complicações. As principais complicações foram: obstrução intestinal (19,1 %), fistulizações cutâneas, com vagina ou trato urinário (10,9%), isquemia de reservatório (parcial ou total), (9,5%), e ileíte do reservatório (pouchitis) (6,8%). Nove pacientes (12,3%) têm ileostomia funcionante, sendo que sete pacientes têm ainda o reservatório mantido no lugar e dois tiveram-no ressecado. A mortalidade diretamente relacionada ao procedimento foi em dois pacientes, mas outros quatro pacientes evoluíram tardiamente ao óbito, por causas como desnutrição crônica e tumor de cerebelo. Em conclusão, apesar da morbidade e da existência ainda de questões controversas, as perspectivas tardias têm sido animadoras e têm estimulado a indicação deste tipo de procedimento.

Development of invasive adenocarcinoma in a long-standing diverted ileal J-pouch for ulcerative colitis: report of a case

We report a case of a 50-year-old male with ulcerative colitis who developed well-differentiated adenocarcinoma in the ileal J-pouch, which had been defunctioning for 18 years. The extension of the carcinoma in the pouch suggested that it had recently appeared in the pouch. Monitoring by endoscopic examination and biopsy or pouch excision seems to be an appropriate action if a pouch is out of the fecal stream.

Guidelines for the surveillance and management of familial adenomatous polyposis (FAP): a world wide survey among 41 registries

OBJECTIVES

 FAP is an autosomal dominant disease characterized by numerous adenomas in the colorectum. The majority of patients also develop adenomas in the duodenum. The purpose of the study was to evaluate the management and screening protocols implemented in FAP families at various polyposis registries in the world.

METHODS

 A questionnaire was mailed to the members of The Leeds Castle Polyposis Group requesting information on: diagnostic evaluation of polyposis, recommendations for screening and surgical management of the colon, surveillance of the upper gastrointestinal tract and the management of duodenal polyposis.

RESULTS

 Almost all members agreed that a newly diagnosed patient should be referred to a polyposis registry and to a clinical genetics centre for genetic counselling and DNA testing. If the mutation has been detected in the family, DNA testing should be offered to first-degree relatives of patients from age 10-12 years onwards. The surveillance protocol generally advised includes sigmoidoscopy from age 10-12 years at 2-year intervals until age 40 years. There was no agreement on the preferred surgical treatment of colonic polyposis. Almost all members advised follow up after colonic surgery. Surveillance of the duodenum was recommended by most members; this would start from age 30 years. There was no agreement on the preferred surgical treatment of duodenal polyposis, or on the indication for operation.

CONCLUSION

 This survey provides insight into the guidelines used at various polyposis registries for the surveillance and management of FAP patients, and this insight may contribute to the appropriate management of these patients.

Evolution of the pelvic pouch procedure at one institution: the first 100 cases

BACKGROUND

Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series.

METHODS

Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation.

RESULTS

After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis.

CONCLUSIONS

Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.

"Cuffitis" and inflammatory changes in the columnar cuff, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis

PURPOSE

During the past eight to ten years most surgeons have adopted the double-stapled technique to accomplish the pouch-anal anastomosis in restorative proctocolectomy for ulcerative colitis. Little attention has been focused on the functional implications of retaining a segment of diseased columnar mucosa in the upper anal canal. The aim of this study was to investigate clinically significant inflammation in the columnar cuff.

METHOD

In all, 113 patients were studied and 715 biopsies were performed during a 2.5-year period. Biopsy specimens were taken from two or three sites, including the columnar cuff, ileal pouch, and anal transitional zone. Acute and chronic inflammation was scored for biopsy specimens from all three sites and compared with endoscopic assessment and pouch function.

RESULTS

In the columnar cuff acute histologic inflammation was found in 13 percent of patients, and in 9 percent this was symptomatic during follow-up and was accompanied by evidence of endoscopic inflammation. Most patients had mild inflammation in the cuff that persisted over time. Inflammation in the pouch, pouch frequency, and anastomotic height were not related to columnar cuff inflammation.

CONCLUSIONS

Cuffitis is a cause of pouch dysfunction after a double-stapled restorative proctocolectomy. We propose a triad of diagnostic criteria, including symptoms and endoscopic and histologic inflammation.

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.