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Le Cosquer G, Buscail E, Gilletta C, Deraison C, Duffas JP, Bournet B, Tuyeras G, Vergnolle N, Buscail L. Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis. Cancers (Basel) 2022; 14:cancers14030530. [PMID: 35158797 PMCID: PMC8833833 DOI: 10.3390/cancers14030530] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Céline Deraison
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Jean-Pierre Duffas
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Géraud Tuyeras
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
| | - Nathalie Vergnolle
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France
- Correspondence: ; Tel.: +33-5613-23055
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2
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Sugita A, Koganei K, Tatsumi K, Futatsuki R, Kuroki H, Yamada K, Kimura H, Fukushima T. Postoperative functional outcomes and complications of partially intraanal canal anastomosis in stapled ileal pouch anal anastomosis for ulcerative colitis. Int J Colorectal Dis 2019; 34:1317-1323. [PMID: 31175423 DOI: 10.1007/s00384-019-03322-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 02/04/2023]
Abstract
AIM For ulcerative colitis (UC), stapled ileal pouch anal anastomosis (IPAA) reportedly results in better bowel function than does IPAA with mucosectomy. However, a potential cancer risk in the remnant mucosa has been observed. The clinical results of IPAA by double stapling technique (DS-IPAA) in which the anastomotic line was on the dentate line at posterior wall and the top of anal canal at anterior wall ("Partially intraanal canal anastomosis": PICA) to reduce the remnant mucosa were evaluated. METHODS Clinical results of PICA were retrospectively compared with those by DS-IPAA with anastomosis at above the anal canal on 1 year after open surgery. Of 211 UC cases that underwent DS-IPAA, 146 cases (69%) with PICA who were confirmed by the squamous epithelium on the posterior part of the distal donuts were included. Sixty-five cases with anastomosis above the anal canal were evaluated as the control. One stage surgery underwent in 95% of PICA and 93% of control. RESULTS One year after surgery, each group had six bowel movements daily. Nighttime evacuation was found in 16% of PICA and in 20% of control. Soiling was found in 1% of PICA and 4.8% of control. After one stage operation, anastomotic leakage that needed ileostomy was observed in 0.7% of PICA and 3% of control. CONCLUSION Partially intraanal canal anastomosis (PICA) can reduce anal canal mucosa with the same postoperative bowel function and complication rate as DS-IPAA above the anal canal. This procedure may be feasible for UC patients who can tolerate this procedure in terms of decreasing postoperative cancer risk.
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Affiliation(s)
- Akira Sugita
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 56 Okazawa cho, Hodogaya ward, Yokohama, 240-8555, Japan.
| | - Kazutaka Koganei
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 56 Okazawa cho, Hodogaya ward, Yokohama, 240-8555, Japan
| | - Kenji Tatsumi
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 56 Okazawa cho, Hodogaya ward, Yokohama, 240-8555, Japan
| | - Ryo Futatsuki
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 56 Okazawa cho, Hodogaya ward, Yokohama, 240-8555, Japan
| | - Hirosuke Kuroki
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 56 Okazawa cho, Hodogaya ward, Yokohama, 240-8555, Japan
| | - Kyoko Yamada
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 56 Okazawa cho, Hodogaya ward, Yokohama, 240-8555, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
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Liu ZX, Kiran RP, Bennett AE, Ni RZ, Shen B. Diagnosis and management of dysplasia and cancer of the ileal pouch in patients with underlying inflammatory bowel disease. Cancer 2011; 117:3081-92. [PMID: 21264836 DOI: 10.1002/cncr.25886] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 11/25/2010] [Accepted: 12/06/2010] [Indexed: 12/23/2022]
Abstract
Approximately 30% of the patients with ulcerative colitis (UC) would ultimately require colectomy for medically refractory UC or UC-associated neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for these patients. However, this procedure does not completely abolish the risk for neoplasia of the pouch. The main risk factor for pouch neoplasia is a preoperative diagnosis of UC-associated dysplasia or cancer. Although the natural history and prognosis of pouch dysplasia are not clear, mortality associated with pouch cancer, once diagnosed, appears to be high. Conversely, not all pouch neoplasia follows the chronic inflammation-dysplasia-cancer sequence, which makes pouch endoscopy with biopsy, the current gold standard for surveillance, challenging. In addition, the findings that pouch neoplasia is not common and that pouch endoscopy still misses dysplasia lead to controversy on the need and time interval of routine endoscopic surveillance. However, based on reports in the literature and their own experience, the authors recommend surveillance endoscopy to be performed in patients at risk, such as those with a precolectomy diagnosis of UC-associated neoplasia. This review appraises issues in the prevalence and incidence, risk factors, technical aspects of pouch construction, clinical and pathological features, natural history, surveillance examination, diagnosis, and management of pouch neoplasia.
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Affiliation(s)
- Zhao-Xiu Liu
- Department of Gastroenterology, The Affiliated Hospital of Nantong University, Jiangsu, China
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4
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Surveillance for dysplasia in patients with ileal pouch-anal anastomosis for ulcerative colitis: an interim analysis. Dig Dis Sci 2010; 55:2332-6. [PMID: 19842036 DOI: 10.1007/s10620-009-1006-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 09/22/2009] [Indexed: 12/09/2022]
Abstract
BACKGROUND The risk of developing cancer in the ileal pouch of patients with surgery for ulcerative colitis has not been defined. Dysplasia in the pouch is quite rare. Although some suggest pouch surveillance based on previous histological assessments, there are no guidelines for surveillance of these patients. The aim of our study was to investigate that risk and identify time intervals for ileoanal pouch surveillance. METHODS Endoscopy and biopsies of the ileal pouch were performed at 3, 6, and/or 12 months after ileal pouch-anal anastomosis (IPAA) became functional. Biopsies were evaluated by two pathologists using Riddel's criteria. Interim data analysis using descriptive statistics is reported. RESULTS Thirty-eight patients have entered the study. Average patient age at 3, 6, and 12 months of surveillance was 39.1, 36.8, and 39.1 years, respectively. Average disease duration was 8.2 years. Ten of 38 cases (26%) had colonic dysplasia prior to surgery. Dysplasia within the pouch was reported in one patient 6 months after IPAA became functional. This patient demonstrated no dysplasia at 12 months or statistical divergence by age, duration of disease or history of colonic dysplasia prior to IPAA. No subgroup of patients with dysplasia was identified to calculate cumulative risk or perform comparative statistical analysis. CONCLUSION A study with longer follow-up after IPAA should precede any attempt to recommend routine surveillance. However, the finding of dysplasia early after surgery underscores the importance of early pouch surveillance in our population, at least until definite predisposing variables are identified.
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5
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Medical management of patients with ileal pouch anal anastomosis after restorative procto-colectomy. Eur J Gastroenterol Hepatol 2009; 21:9-17. [PMID: 19011577 DOI: 10.1097/meg.0b013e328306078c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Restorative procto-colectomy with ileal pouch anal anastomosis has become the most common elective surgical procedure for patients with ulcerative colitis and is becoming popular in those with familial adenomatous polyposis coli. The procedure itself is primarily carried out in specialist surgical centres but an increasing number are being performed and followed up in district general hospitals. These patients are now filtering through general surgical and gastroenterology clinics and are frequently seen in primary care. Pouchitis, an inflammatory condition of the ileal pouch, has become the third most important form of inflammatory bowel disease. As research develops in this area, other complications are being found. The aim of this review is to provide an up-to-date, evidence-based approach to the clinical management of these patients.
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6
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Abstract
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.
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Affiliation(s)
- Simon P Bach
- Nuffield Department of Surgery, University of Oxford, United Kingdom.
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7
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Coull DB, Lee FD, Anderson JH, McKee RF, Finlay IG, Dunlop MG. Long-term cancer risk of the anorectal cuff following restorative proctocolectomy assessed by p53 expression and cuff dysplasia. Colorectal Dis 2007; 9:321-7. [PMID: 17432983 DOI: 10.1111/j.1463-1318.2006.01118.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- D B Coull
- Department of Coloproctology, Glasgow Royal Infirmary, Glasgow, UK.
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8
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Scarpa M, van Koperen PJ, Ubbink DT, Hommes DW, Ten Kate FJW, Bemelman WA. Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis. Br J Surg 2007; 94:534-45. [PMID: 17443850 DOI: 10.1002/bjs.5811] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Background
The aim of this systematic review was to assess the prevalence and site of dysplasia after restorative proctocolectomy (RPC) for ulcerative colitis (UC), and to identify risk factors that could be used in a surveillance programme.
Methods
Medical databases were searched for potentially relevant publications between 1978 and 2006. Studies that dealt with RPC for UC and postoperative surveillance were included. Two researchers independently performed study selection, quality assessment, data extraction and analysis.
Results
Twenty-three observational studies and case series were included, with a total of 2040 patients. The pooled prevalence of confirmed dysplasia in the pouch, anal transitional zone or rectal cuff was 1·13 (range 0–18·75) per cent. The prevalence of high-grade dysplasia, low-grade dysplasia and indefinite for dysplasia was 0·15 (range 0–4·49), 0·98 (range 0–15·62) and 1·23 (range 0–25·28 per cent) respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal transitional zone. Dysplasia and cancer identified before or at operation seemed to be significant predictors of the development of dysplasia. Pouchitis and duration of follow-up were not of predictive value.
Conclusion
Although based on low-level evidence from uncontrolled studies, the prevalence of dysplasia observed after RPC was remarkable. A surveillance programme that takes into account the risk factors found is therefore advocated.
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Affiliation(s)
- M Scarpa
- Department of Surgical and Gastroenterological Sciences, University of Padua, Italy
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9
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Das P, Johnson MW, Tekkis PP, Nicholls RJ. Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Colorectal Dis 2007; 9:15-27. [PMID: 17181842 DOI: 10.1111/j.1463-1318.2006.01148.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Restorative proctocolectomy (RPC) with or without mucosectomy is the treatment of choice for most patients with ulcerative colitis (UC) requiring surgery. The ileal mucosa in the reservoir and the anorectal columnar epithelium below the ileo-anal anastomosis are at risk of neoplastic transformation. METHOD The literature has been reviewed to identify patients developing this complication and an attempt has been made to develop a rational follow-up policy based on the data available. RESULTS Dysplasia in the ileal reservoir is rare. It is associated with histological type C changes, sclerosing cholangitis and unremitting pouchitis in the ileal mucosa and to the presence of sclerosing cholangitis. Nine patients who have developed adenocarcinoma in the residual anorectal mucosa and seven in the reservoir have been reported in the literature. A further hitherto unreported patient treated by the authors brings the total to 17 patients. Twelve of these had histopathological data on either dysplasia or carcinoma in the original operative specimen. The time intervals from the onset of UC and from the RPC to the development of cancer were 120-528 (median 246) and 16-216 (median 60) months respectively. Cancer appeared to be related to the duration of disease rather than to the interval from RPC. In all the reported patients the interval from the onset of UC was 10 years. CONCLUSION Based on these data a surveillance programme should begin at 10 years from the onset of disease. Patients with dysplasia or carcinoma in the original specimen, those with type C ileal mucosal changes and patients with sclerosing cholangitis should be selected for surveillance. This will involve multiple biopsies of the ileal reservoir and the anorectal mucosa below the ileo-anal anastomosis.
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Affiliation(s)
- P Das
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK
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10
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Schluender SJ, Mei L, Yang H, Fleshner PR. Can a Meta-Analysis Answer the Question: Is Mucosectomy and Handsewn or Double-Stapled Anastomosis Better in Ileal Pouch-Anal Anastomosis? Am Surg 2006. [DOI: 10.1177/000313480607201016] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Although ileal pouch-anal anastomosis (IPAA) is the procedure of choice for polyposis and ulcerative colitis with medically refractory disease or dysplasia, controversy exists concerning whether mucosal preservation with double-stapled (DS) IPAA is superior to mucosectomy and handsewn (HS) IPAA anastomosis for postoperative function. Prospective studies have shown no statistically significant differences. The use of meta-analysis can strengthen statistical power by combining the data from related studies. A meta-analysis was performed to determine whether there was a significant difference in functional and manometric outcome between HS-IPAA and DS-IPAA. Prospective, randomized studies were identified using a literature search. Functional outcome variables included number of normal continence, minor incontinence, nocturnal evacuation, the ability to discriminate flatus from stool, and antidiarrheal medication. Manometric outcomes included postoperative resting and squeeze anal pressures. Four prospective, randomized trials were identified. Of the 184 total patients, the HS-IPAA group included 86 patients (48 men and 38 women) and the DS-IPAA group included 98 patients (49 men and 49 women). There were no significant differences in functional outcome between HS-IPAA and DS-IPAA. In addition, there was no significant difference in sphincter resting and squeeze pressures between the two patient groups. This meta-analysis demonstrates that DS-IPAA offers no advantage in functional or manometric outcome when compared with HS-IPAA.
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Affiliation(s)
| | - Ling Mei
- Medical Genetics, Departments of Surgery and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Huiying Yang
- Medical Genetics, Departments of Surgery and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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11
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Abstract
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.
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Affiliation(s)
- Simon P Bach
- Nuffield Department of Surgery, University of Oxford and the Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, United Kingdom.
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12
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Coull DB, Lee FD, Henderson AP, Anderson JH, McKee RF, Finlay IG. Risk of dysplasia in the columnar cuff after stapled restorative proctocolectomy. Br J Surg 2003; 90:72-5. [PMID: 12520578 DOI: 10.1002/bjs.4007] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- D B Coull
- Department of Coloproctology, Glasgow Royal Infirmary, Glasgow G31 2ER, UK.
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13
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Remzi FH, Fazio VW, Delaney CP, Preen M, Ormsby A, Bast J, O'Riordain MG, Strong SA, Church JM, Petras RE, Gramlich T, Lavery IC. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years. Dis Colon Rectum 2003; 46:6-13. [PMID: 12544515 DOI: 10.1007/s10350-004-6488-2] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Stapling of the ileal pouch-anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years' follow-up after ileal pouch-anal anastomosis. METHODS A total of 289 patients undergoing anal transitional zone-sparing stapled ileal pouch-anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow-up was 130 (range, 120-157) months. RESULTS Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low-grade dysplasia on two or more occasions after detection of low-grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo-ileal pouch-anal anastomosis. One patient with high-grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high-grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low-grade dysplasia on 1 or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103-133) months. CONCLUSIONS Anal transitional zone dysplasia after stapled ileal pouch-anal anastomosis is infrequent and is usually self-limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo-ileal pouch-anal anastomosis is recommended.
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Affiliation(s)
- Feza H Remzi
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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14
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O'Riordain MG, Fazio VW, Lavery IC, Remzi F, Fabbri N, Meneu J, Goldblum J, Petras RE. Incidence and natural history of dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of a five-year to ten-year follow-up. Dis Colon Rectum 2000; 43:1660-5. [PMID: 11156448 DOI: 10.1007/bf02236846] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia. METHODS Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60-124) months. RESULTS Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48-100) months. CONCLUSIONS Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.
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MESH Headings
- Adolescent
- Adult
- Aged
- Anal Canal/pathology
- Anastomosis, Surgical/adverse effects
- Anus Neoplasms/diagnosis
- Anus Neoplasms/epidemiology
- Anus Neoplasms/etiology
- Biopsy, Needle
- Cell Transformation, Neoplastic/pathology
- Child
- Child, Preschool
- Colitis, Ulcerative/diagnosis
- Colitis, Ulcerative/pathology
- Colitis, Ulcerative/surgery
- Female
- Follow-Up Studies
- Humans
- Incidence
- Male
- Middle Aged
- Monitoring, Physiologic
- Postoperative Complications/pathology
- Precancerous Conditions/diagnosis
- Precancerous Conditions/epidemiology
- Precancerous Conditions/etiology
- Probability
- Proctocolectomy, Restorative/adverse effects
- Proctocolectomy, Restorative/methods
- Retrospective Studies
- Risk Assessment
- Severity of Illness Index
- Treatment Outcome
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Affiliation(s)
- M G O'Riordain
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195, USA
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15
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Choi JS, Potenti F, Wexner SD, Nam YS, Hwang YH, Nogueras JJ, Weiss EG, Pikarsky AJ. 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? Dis Colon Rectum 2000; 43:1398-404. [PMID: 11052517 DOI: 10.1007/bf02236636] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- J S Choi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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16
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Thompson-Fawcett MW, Rust NA, Warren BF, Mortensen NJ. Aneuploidy and columnar cuff surveillance after stapled ileal pouch-anal anastomosis in ulcerative colitis. Dis Colon Rectum 2000; 43:408-13. [PMID: 10733125 DOI: 10.1007/bf02258310] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- M W Thompson-Fawcett
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, United Kingdom
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17
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Wexner SD, Rosen L, Lowry A, Roberts PL, Burnstein M, Hicks T, Kerner B, Oliver GC, Robertson HD, Robertson WG, Ross TM, Senatore PJ, Simmang C, Smith C, Vernava AM, Wong WD. Practice parameters for the treatment of mucosal ulcerative colitis--supporting documentation. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1997; 40:1277-85. [PMID: 9369100 DOI: 10.1007/bf02050809] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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18
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Reilly WT, Pemberton JH, Wolff BG, Nivatvongs S, Devine RM, Litchy WJ, McIntyre PB. Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa. Ann Surg 1997; 225:666-76; discussion 676-7. [PMID: 9230807 PMCID: PMC1190866 DOI: 10.1097/00000658-199706000-00004] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of the study is to compare the results of ileal pouch-anal anastomosis (IPAA) in patients in whom the anal mucosa is excised by handsewn techniques to those in whom the mucosa is preserved using stapling techniques. SUMMARY BACKGROUND DATA Ileal pouch-anal anastomosis is the operation of choice for patients with chronic ulcerative colitis requiring proctocolectomy. Controversy exists over whether preserving the transitional mucosa of the anal canal improves outcomes. METHODS Forty-one patients (23 men, 18 women) were randomized to either endorectal mucosectomy and handsewn IPAA or to double-stapled IPAA, which spared the anal transition zone. All patients were diverted for 2 to 3 months. Nine patients were excluded. Preoperative functional status was assessed by questionnaire and anal manometry. Twenty-four patients underwent more extensive physiologic evaluation, including scintigraphic anopouch angle studies and pudendel never terminal motor latency a mean of 6 months after surgery. Quality of life similarly was estimated before surgery and after surgery. Univariate analysis using Wilcoxon test was used to assess differences between groups. RESULTS The two groups were identical demographically. Overall outcomes in both groups were good. Thirty-three percent of patients who underwent the handsewn technique and 35% of patients who underwent the double-stapled technique experienced a postoperative complication. Resting anal canal pressures were higher in the patients who underwent the stapled technique, but other physiologic parameters were similar between groups. Night-time fecal incontinence occurred less frequently in the stapled group but not significantly. The number of stools per 24 hours decreased from preoperative values in both groups. After IPAA, quality of life improved promptly in both groups. CONCLUSIONS Stapled IPAA, which preserves the mucosa of the anal transition zone, confers no apparent early advantage in terms of decreased stool frequency or fewer episodes of fecal incontinence compared to handsewn IPAA, which excises the mucosa. Higher resting pressures in the stapled group coupled with a trend toward less night-time incontinence, however, may portend better function in the stapled group over time. Both operations are safe and result in rapid and profound improvement in quality of life.
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Affiliation(s)
- W T Reilly
- Eyvazzadeh Colon and Rectal Center, Bethlehem, Pennsylvania, USA
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