Results after restorative proctocolectomy and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and coexisting colorectal cancer

Incidental cancer in colectomy specimens from patients with familial adenomatous polyposis: single centre experience and literature review

BACKGROUND

Since cancer development is inevitable in patients with familial adenomatous polyposis (FAP), we aimed to determine the incidence of incidental malignancy in prophylactic colectomy specimens.

METHODS

The files of patients who underwent prophylactic surgery for FAP between 2010 and 2020 were retrospectively reviewed. The incidence of incidental malignancy in histopathological specimens was examined and a comprehensive literature review was made.

RESULTS

Fifty-five patients were included in the study, of whom 30 patients had a diagnosis of primary malignancy. Prophylactic colectomy was performed on 25 patients. The pathology results indicated that the specimens were benign in 12 patients (48%) and revealed carcinoma in situ in 11 patients (44%). Incidental malignancy was detected in 2 patients (8%). In the literature review, there were 243 patients who underwent prophylactic colectomy and incidental cancer was detected in 25 patients (10.3%) with the stages of 1 (7.4%), 2 (2.1%), and 3 (0.8%), respectively.

CONCLUSIONS

Incidental cancer is not rare in patients who have undergone prophylactic colectomy for FAP. Hopefully. they are usually at early stages and unexpected advanced cancers are seen rarely.

Is it really small-bowel obstruction in patients with paradox after IPAA?

BACKGROUND

Diagnosing outlet obstruction after IPAA can be challenging because the etiology is multifactorial.

OBJECTIVE

The aim of this study was to assess possible factors associated with outlet obstruction from paradoxical anal muscle contraction (paradox) after IPAA unrelated to strictures or structural abnormalities.

DESIGN

This was a retrospective study from a prospectively maintained pouch database.

SETTINGS

The study was conducted at a tertiary referral center.

PATIENTS

All of the patients with paradox after ileal J-pouch-anal anastomosis verified by anal physiology were identified from our prospectively maintained database. Patients with endoscopic or digital evidence of strictures or other anatomic abnormalities were excluded.

MAIN OUTCOME MEASURES

Demographic, clinical, and perioperative factors were obtained, including previous abdominal operations, history of pouchitis, need for anal intubation, diagnosis of small-bowel obstruction, and radiologic findings at the time of paradox diagnosis.

RESULTS

There were 40 patients (17 women) with an overall mean age of 39 years (range, 17-60 years) and a mean follow-up of 15 years (range, 1-28 years) after IPAA. Pathologic diagnoses at the time of ileal pouch creation were ulcerative colitis (n = 27), indeterminate colitis (n = 11), Crohn's disease, and familial adenomatous polyposis (1 case each). A total of 15 (37%) of 40 patients were diagnosed with small-bowel obstruction before their paradox diagnosis, 8 of whom underwent surgery, which revealed diffusely dilated small bowel and pouch without intraoperative identification of a transition point. The time from ileal pouch creation to paradox diagnosis was significantly longer in patients receiving a diagnosis of small-bowel obstruction than in the remaining paradox patients (7.2 vs 2.6 years; p < 0.001).

LIMITATIONS

This study was limited by its nonrandomized retrospective nature.

CONCLUSIONS

After an IPAA, patients with outlet obstruction from paradox can appear to have a small-bowel obstruction. A high incidence of suspicion is needed to make the correct diagnosis and avoid an unneeded laparotomy.

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

PURPOSE

Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients.

METHODS

Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups.

RESULTS

Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002).

CONCLUSIONS

The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

Familial adenomatous polyposis in three generations of a single family: a case study

Background

Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited syndrome characterized by the development of numerous polyps in the colon and rectum. If left untreated, the affected patients inevitably develop colon cancer by the age of 40 years. A resection of the colon (colectomy) or of the colon and rectum (proctocolectomy) is needed to minimize the risk of cancer.

Case Presentation

We report a case of FAP through three generations of a single family, in which the grandmother and granddaughter underwent total colectomy with ileoanal anastomosis and did not develop colon cancer, while the son underwent subtotal colectomy with ileorectal anastomosis and developed recurrent rectal cancer. Data regarding timely surgery, surveillance, and chemoprevention are discussed.

Conclusion

The FAP phenotype determines the type of treatment. In severe polyposis, proctocolectomy with ileoanal anastomosis seems to be the optimal method for minimizing the risk of cancer development. This case report advocates complete rectal removal, especially in cases of poor patient compliance with colonoscopic surveillance.

Adenocarcinomas After Prophylactic Surgery For Familial Adenomatous Polyposis

The incidence of familial adenomatous polyposis (FAP) is one in 7,000 to 12,000 live births. Virtually, all surgically untreated patients with FAP inevitably develop colorectal-cancer in their lifetime because they carry the adenomatous polyposis coli gene. Thus prophylactic proctocolectomy is indicated. Surgical treatment of FAP is still controversial. There are however, four surgical options: ileorectal anastomosis, restorative proctocolectomy with ileal pouch-anal anastomosis, proctocolectomy with ileostomy, and proctocolectomy with continent-ileostomy. Conventional proctocolectomy options largely lie between colectomy with ileorectal anastomosis or ileal pouch-anal anastomosis. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis because of better functional results and quality of life. The functional outcome of total colectomy with ileorectal anastomosis is undoubtedly far superior to that of the ileoanal pouch; however, the risk for rectal cancer is increased by 30%. Even after mucosectomy, inadvertent small mucosal residual islands remain. These residual islands carry the potential for the development of subsequent malignancy. We reviewed the literature (1975-2012) on the incidence, nature, and possible etiology of subsequent ileal-pouch and anal transit zone adenocarcinoma after prophylactic surgery procedure for FAP. To date there are 24 studies reporting 92 pouch-related cancers; 15 case reports, 4 prospective and 5 retrospective studies. Twenty three of 92 cancers (25%) developed in the pouch mucosa and 69 (75%) in anal transit zone (ATZ). Current recommendation for pouch surveillance and treatment are presented. Data suggest lifetime surveillance of these patients.

Familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is characterized by the development of many tens to thousands of adenomas in the rectum and colon during the second decade of life. FAP has an incidence at birth of about 1/8,300, it manifests equally in both sexes, and accounts for less than 1% of colorectal cancer (CRC) cases. In the European Union, prevalence has been estimated at 1/11,300-37,600. Most patients are asymptomatic for years until the adenomas are large and numerous, and cause rectal bleeding or even anemia, or cancer develops. Generally, cancers start to develop a decade after the appearance of the polyps. Nonspecific symptoms may include constipation or diarrhea, abdominal pain, palpable abdominal masses and weight loss. FAP may present with some extraintestinal manifestations such as osteomas, dental abnormalities (unerupted teeth, congenital absence of one or more teeth, supernumerary teeth, dentigerous cysts and odontomas), congenital hypertrophy of the retinal pigment epithelium (CHRPE), desmoid tumors, and extracolonic cancers (thyroid, liver, bile ducts and central nervous system). A less aggressive variant of FAP, attenuated FAP (AFAP), is characterized by fewer colorectal adenomatous polyps (usually 10 to 100), later age of adenoma appearance and a lower cancer risk. Some lesions (skull and mandible osteomas, dental abnormalities, and fibromas on the scalp, shoulders, arms and back) are indicative of the Gardner variant of FAP. Classic FAP is inherited in an autosomal dominant manner and results from a germline mutation in the adenomatous polyposis (APC) gene. Most patients (~70%) have a family history of colorectal polyps and cancer. In a subset of individuals, a MUTYH mutation causes a recessively inherited polyposis condition, MUTYH-associated polyposis (MAP), which is characterized by a slightly increased risk of developing CRC and polyps/adenomas in both the upper and lower gastrointestinal tract. Diagnosis is based on a suggestive family history, clinical findings, and large bowel endoscopy or full colonoscopy. Whenever possible, the clinical diagnosis should be confirmed by genetic testing. When the APC mutation in the family has been identified, genetic testing of all first-degree relatives should be performed. Presymptomatic and prenatal (amniocentesis and chorionic villous sampling), and even preimplantation genetic testing is possible. Referral to a geneticist or genetic counselor is mandatory. Differential diagnoses include other disorders causing multiple polyps (such as Peutz-Jeghers syndrome, familial juvenile polyps or hyperplastic polyposis, hereditary mixed polyposis syndromes, and Lynch syndrome). Cancer prevention and maintaining a good quality of life are the main goals of management and regular and systematic follow-up and supportive care should be offered to all patients. By the late teens or early twenties, colorectal cancer prophylactic surgery is advocated. The recommended alternatives are total proctocolectomy and ileoanal pouch or ileorectal anastomosis for AFAP. Duodenal cancer and desmoids are the two main causes of mortality after total colectomy, they need to be identified early and treated. Upper endoscopy is necessary for surveillance to reduce the risk of ampullary and duodenal cancer. Patients with progressive tumors and unresectable disease may respond or stabilize with a combination of cytotoxic chemotherapy and surgery (when possible to perform). Adjunctive therapy with celecoxib has been approved by the US Food and Drug Administration and the European Medicines Agency in patients with FAP. Individuals with FAP carry a 100% risk of CRC; however, this risk is reduced significantly when patients enter a screening-treatment program.

Familial adenomatous polyposis: The practical applications of clinical and molecular screening

Familial adenomatous polyposis (FAP) is an autosomal dominant condition mostly due to a mutation of the APC gene on the chromosome 5q. Carriers have an almost 100% chance of developing colorectal cancer after having multiple (typically 100s to 1000s) of adenomatous polyps. It is usually readily identified through this phenotype of multiple adenomas. Correlations between the location of the family-specific mutation on the APC gene and clinical manifestations of the disease are of some assistance in clinical management, though there is heterogeneity in clinical course even between family members with the same mutation. FAP is important to recognize, as there are disease-specific management implications with respect to offering mutational analysis of the APC (and perhaps other) genes for predictive testing of other family members, endoscopic diagnostic procedures, surveillance planning, and surgical management. Extra-colonic manifestations, including duodenal polyposis, desmoid disease and other tumours, can dominate clinical care after colectomy. The inheritable and lethal nature of the disease, together with the availability of effective treatment strategies, makes a sensitive clinical and psychosocial approach important to maximize compliance and good outcomes for all members of affected families.

Diagnosis and management of gastrointestinal polyps: pediatric considerations

Painless, bright red, rectal bleeding with normal stool frequency and consistency is the hallmark presentation of colorectal polyps at any age. Most polyps in children are sporadic, usually isolated, colorectal juvenile polyps that do not require any further surveillance after they are removed. There is, however, increasing recognition of syndromes, including familial adenomatous polyposis, juvenile polyposis coli, Peutz-Jeghers syndrome, and infrequent conditions, such as PTEN hamartoma and hereditary mixed polyposis syndromes. The aim of this review is to allow the reader to correctly identify the patients who do not require follow-up and the smaller group of patients who do require follow-up because of syndromic polyp conditions.

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.

Ileorectal anastomosis is appropriate for a subset of patients with familial adenomatous polyposis

BACKGROUND & AIMS

This study reevaluates the risk of rectal cancer and the frequency of subsequent proctectomy for nonmalignant causes in patients with familial adenomatous polyposis (FAP) who have undergone colectomy with ileorectal anastomosis (IRA). Potential risk factors for rectal cancer in this setting are also examined, and recommendations for the choice of surgical procedure are made.

METHODS

The national polyposis registries in Denmark, Finland, The Netherlands, and Sweden included 659 patients undergoing surgery with IRA in 1940-1997. Kaplan-Meier analysis and Cox regression analysis were performed to evaluate cumulative risk, survival, and predictive risk factors.

RESULTS

Rectal carcinoma was diagnosed in 47 patients, with a cumulative 40-year risk of 0.32. The cumulative risk according to chronologic age was 0.30 at age 60, and higher in patients undergoing surgery above age 25 (P = 0.0016). Chronologic age was the only independent risk factor (P = 0.0016). The cumulative 5-year survival rate after rectal carcinoma was 0.60. The apc mutation was known in 167 patients, of whom 7 had rectal cancer. The cumulative 40-year risk of secondary proctectomy was 0.70, and higher in patients with a mutation in codon 1250-1500 than outside this region (P = 0.005). However, all 7 rectal cancers were found in the latter group. None of the 18 patients with attenuated FAP (mutation in codon 0-200 or >1500) had a secondary proctectomy.

CONCLUSIONS

IRA is recommended in (1) young patients with few rectal adenomas and a family history of a mild phenotype and (2) patients with attenuated FAP (a mutation in codon 0-200 or >1500), provided there is acceptance of life-long rectal surveillance. Patients with many rectal polyps and/or a family history of severe polyposis should be offered a restorative proctocolectomy with an ileal pouch-anal anastomosis.

Tumores colorretais hereditários

Cerca de 4% a 15% dos tumores colorretais são hereditários e divididos em dois grupos: polipose adenomatosa familiar (FAP) e câncer colorretal hereditário sem polipose (HNPCC). Ambas são doenças autossômicas dominantes, com transmissão vertical, geração após geração, sem preferência por sexo. A FAP tem penetrância praticamente completa, caracterizada por mais de cem pólipos adenomatosos no intestino grosso, que aparecem em geral após a puberdade e se transformam em câncer em todos os casos não tratados, levando o paciente ao óbito em tomo dos 45 anos de idade. Manifestações extracolônicas são comuns, tais como: pólipos em estômago e duodeno, sarcomas abdominais, pigmentação de retina, osteomas, entre outras. A FAP é causada por mutação no gene APC, que está localizado no cromossomo 5q. Seu tratamento é basicamente cirúrgico, com retirada do intestino grosso, podendo-se preservar o reto, se este não apresentar muitos pólipos. O HNPCC tem penetrância em torno de 80% e não apresenta os pólipos benignos como na FAP, que permitem identificar pacientes com o fenótipo da doença. Geralmente, o diagnóstico da lesão colônica é realizado já na fase maligna, em torno dos 45 anos de idade, com preferência para o lado direito do cólon. Pode haver associação com tumores de endométrio na mulher, estômago, pâncreas, entre outros. É causada por mutação em genes de reparo do DNA (hMSH2, hMLH1, hPMS1, hPMS2, hMSH6/GTBP). A colectomia total deve ser realizada em pacientes com câncer de cólon e HNPCC. Se o tumor estiver localizado no reto, a proctocolectomia total pode ser uma opção. Em indivíduos portadores do defeito genético predisponente ao HNPCC, porém, assintomáticos, a indicação de cirurgias profiláticas é controversa. Atualmente, podem-se identificar indivíduos portadores de defeito genético herdado tanto na FAP como no HNPCC. Esses testes baseiam-se no estudo direto dos genes responsáveis pela respectiva doença ou pela proteína produto dos mesmos. É de suma importância uma abordagem multidisciplinar de pacientes portadores de FAP ou HNPCC, pois existe uma preocupação ética muito grande na realização dos testes genéticos de predisposição, considerando suas conseqüências psicológicas e sociais.