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Cotte E, Glehen O, Monneuse O, Cotton F, Vignal J. Tumeurs desmoïdes associées à la polypose adénomateuse familiale. ACTA ACUST UNITED AC 2004; 28:574-81. [PMID: 15243391 DOI: 10.1016/s0399-8320(04)95014-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Eddy Cotte
- Service de chirurgie viscérale et thoracique, Centre Hospitalier Universitaire Lyon Sud, 69495 Pierre Bénite
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Mace J, Sybil Biermann J, Sondak V, McGinn C, Hayes C, Thomas D, Baker L. Response of extraabdominal desmoid tumors to therapy with imatinib mesylate. Cancer 2002; 95:2373-9. [PMID: 12436445 DOI: 10.1002/cncr.11029] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Desmoid tumor represents a rare monoclonal neoplasm arising from deep musculoaponeurotic structures and may occur sporadically or in association with the familial adenomatous polyposis and Gardner syndromes. Desmoid tumors do not appear to demonstrate metastatic potential; however, local infiltrative growth results in significant morbidity and potential mortality. Although the delineation of optimal therapy for desmoid tumors has been confounded by several factors, surgical resection with adjuvant radiotherapy for a positive surgical margin remains the standard approach. Responses have been demonstrated to nonsteroidal antiinflammatory agents, antiestrogen compounds, and a variety of other agents in small series. Imatinib mesylate appears to demonstrate inhibitory activity against multiple class 3 receptor tyrosine kinases, including platelet-derived growth factor receptor (PDGFR)-alpha and PDGFR-beta, as well as c-kit. METHODS The authors performed immunohistochemical and qualitative real-time polymerase chain reaction analysis on nine desmoid tumor specimens that demonstrated consistent positivity for c-kit as well as PDGFR-alpha and PDGFR-beta. At the time of last follow-up, 2 patients had received therapy with imatinib mesylate at a dose of 400 mg twice daily. RESULTS Both patients demonstrated ongoing radiographic and clinical responses with a duration of 9 months and 11 months, respectively. CONCLUSIONS Imatinib mesylate has been reported to have activity against desmoid tumor, most likely because of c-kit and PDGFR receptor tyrosine kinase activity inhibition, and warrants further study. The relative novelty of this agent and the lack of long-term toxicity data should prompt its use only in the salvage setting in which established local and systemic approaches fail to control disease. In addition, the use of imatinib mesylate in the treatment of this neoplasm preferably should be in the context of a formal prospective clinical trial.
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Affiliation(s)
- Joseph Mace
- Division of Medical Oncology, Department of Internal Medicine, University of Michigan Medical Center, Comprehensive Cancer Center, Ann Arbor, Michigan 48109, USA
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Management of Hereditary Colon Cancer Syndromes. COLORECTAL CANCER 2002. [DOI: 10.1007/978-1-59259-160-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Heuschen UA, Hinz U, Allemeyer EH, Lucas M, Heuschen G, Herfarth C. One- or two-stage procedure for restorative proctocolectomy: rationale for a surgical strategy in ulcerative colitis. Ann Surg 2001; 234:788-94. [PMID: 11729385 PMCID: PMC1422138 DOI: 10.1097/00000658-200112000-00010] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To analyze the results of different strategies for restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) in ulcerative colitis. SUMMARY BACKGROUND DATA No commonly accepted criteria exist for choosing between the one-stage or the two-stage procedure (with or without temporary diverting ileostomy) for IPAA. The authors analyzed the outcome of patients principally suitable for either of the two alternative surgical strategies. METHODS A matched-pair control study was performed, comparing surgical details and the early and late outcome of the one-stage (study group, n = 57) versus the two-stage procedure (control group, n = 114), for IPAA. RESULTS No differences were found between the study group and the control group regarding the matching criteria gender, median age at IPAA, systemic corticoid medication, or activity of colitis. Comparing the patients who underwent a one-stage procedure with those who underwent a two-stage procedure, the proportion of patients without complications was significantly higher (P =.0042) and the frequency of late complications was significantly lower (P =.0022) in patients who underwent the one-stage procedure. The percentage of patients with anastomotic strictures was significantly higher in the control group than in the study group (P =.0022). No significant difference was found between the two groups regarding early complications, pouch-related septic complications, pouchitis, median duration of surgery for IPAA, median blood loss, need for transfusion, or median hospital stay. CONCLUSIONS In patients with ulcerative colitis in whom there is a choice between a one-stage procedure or a two-stage procedure with a defunctioning ileostomy, the one-stage procedure is clearly superior. This finding is of great clinical relevance both for the subjective interests of the patient and from an economic point of view.
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Affiliation(s)
- U A Heuschen
- Department of Surgery, Unit for Documentation and Statistics, University of Heidelberg, Kirschnerstrasse 1, D-69120 Heidelberg, Germany.
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Kulaylat MN, Karakousis CP, Keaney CM, McCorvey D, Bem J, Ambrus JL. Desmoid tumour: a pleomorphic lesion. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1999; 25:487-97. [PMID: 10527597 DOI: 10.1053/ejso.1999.0684] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Desmoid tumour (DT) is an uncommon locally invasive non-metastasizing neoplastic lesion. The aetiology of this tumour is unknown and its treatment is controversial. Twelve cases of DT are presented and the literature is reviewed. METHODS Twelve cases of DT treated at our institution during a 3.5-year period are analysed and the literature reviewed. Ten patients were referred with a primary tumour, one with local recurrence and one patient with a second primary desmoid tumour. One patient had multiple mesenteric DT (familial adenomatous polyposis coli-FAP), and in the remaining 11 patients the tumour was located in the abdominal wall in four, at an extremity in three, in the upper back in two patients, in the pelvis in one and retroperitoneally in one. RESULTS The largest mesenteric DT was marginally excised en bloc with total jejunectomy. In the remaining 11 DT, complete excision to microscopically tumour-free margins was possible in nine cases and to microscopically involved margins in two cases. At a mean follow-up of 22 months (range 7-38 months), one patient was alive with stable disease (Gardner's syndrome), 10 patients were alive and free of recurrence and one patient (9%) developed local recurrence which was re-excised-she is disease-free 10 months later. CONCLUSIONS Complete excision is the main modality of treatment for primary and recurrent DT. This is feasible in most cases except for tumours involving the base of the bowel mesentery. Surgical resection alone achieved local control of the tumour in most of the patients in this series (92%).
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Affiliation(s)
- M N Kulaylat
- State University of New York at Buffalo, Erie County Medical Center, Buffalo, New York 14215, USA
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Soravia C, Klein L, Berk T, O'Connor BI, Cohen Z, McLeod RS. Comparison of ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum 1999; 42:1028-33; discussion 1033-4. [PMID: 10458126 DOI: 10.1007/bf02236696] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.7] [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 the surgical complications and long-term outcome and assess the functional results and quality of life after ileorectal anastomosis and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis. METHODS From 1980 to 1997, 131 patients with familial adenomatous polyposis were operated on or were followed up or both at the Familial Gastrointestinal Cancer Registry at Mount Sinai Hospital. Demographic and operative data were prospectively collected in the ileal pouch-anal anastomosis group, and retrospectively in the ileorectal anastomosis group. A questionnaire or telephone interview or both were undertaken to evaluate functional outcome and quality of life. RESULTS The ileorectal anastomosis group consisted of 60 patients (mean age, 31 years; mean follow-up, 7.7 years). In the ileal pouch-anal anastomosis group there were 50 patients (mean age, 35 years; mean follow-up, 6 years). There were no statistically significant differences with respect to anastomotic leak rate in ileal pouch-anal anastomosis vs. ileorectal anastomosis (12 vs. 3 percent; P = 0.21), risk of small-bowel obstruction (24 vs. 15 percent; P = 0.58), and risk of intra-abdominal sepsis (3 vs. 2 percent; P = 0.86). Reoperation rate was similar in the two groups (14 vs. 16 percent; P = 0.94). Twenty-one patients (37 percent) with ileorectal anastomosis were converted to ileal pouch-anal anastomosis (12 patients) or proctocolectomy (9 patients), because of rectal cancer (5 patients), dysplasia (1 patient), or uncontrollable rectal polyps (15 patients). Two pelvic pouches were excised, and another one was defunctioned. Information regarding functional results and quality of life was obtained in 40 patients (66.6 percent) in the ileorectal anastomosis group and in 43 patients (86 percent) in the ileal pouch-anal anastomosis group. Patients with ileorectal anastomosis had a significantly better functional outcome with regard to nighttime continence and perineal skin irritation. But otherwise, functional results and quality of life were similar. CONCLUSIONS Although ileorectal anastomosis has a better functional outcome, ileal pouch-anal anastomosis may be preferable because of the lower long-term failure rate. Ileorectal anastomosis is still an option in patients with familial adenomatous polyposis with rectal polyp sparing and good compliance for follow-up.
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Affiliation(s)
- C Soravia
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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Soravia C, O'Connor BI, Berk T, McLeod RS, Cohen Z. Functional outcome of conversion of ileorectal anastomosis to ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and ulcerative colitis. Dis Colon Rectum 1999; 42:903-8. [PMID: 10411437 DOI: 10.1007/bf02237099] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of this study was to review the functional outcome in 20 patients with familial adenomatous polyposis and ulcerative colitis who were converted from ileorectal anastomosis to ileal pouch-anal anastomosis. METHODS From 1985 to 1997, 12 patients with familial adenomatous polyposis (5 males; mean age, 39.1 years) and 8 patients with ulcerative colitis (5 males; mean age, 36.7 years) underwent conversion from ileorectal anastomosis to ileal pouch-anal anastomosis. Clinical and operative data were analyzed retrospectively. Functional results were obtained by telephone interview in 16 patients (94 percent) after pouch construction. Four patients were not interviewed (2 were deceased, 1 was lost to follow-up, and 1 was not reachable). RESULTS Indications for conversion were uncontrollable rectal polyps (10 patients) and colonic cancer found in the pathology specimen after ileorectal anastomosis in patients with familial adenomatous polyposis (2 patients), intractable proctitis (5 patients), colonic cancer found in the pathology specimen of patients with ulcerative colitis after ileorectal anastomosis (2 patients), and rectal dysplasia (1 patients). Mean follow-up time was 5 (range, 1-11) years. Ileal pouch-anal anastomosis was handsewn in 14 patients, and the remaining cases were double-stapled in 4 patients with ulcerative colitis. No intraoperative difficulties were reported in 13 cases; technical problems were related to adhesions (3 cases), difficult rectal dissection (2 cases), and stapler-related difficulties (2 cases). Postoperative complications after ileal pouch-anal anastomosis included small-bowel obstruction (4 patients) and ileal pouch-anal anastomosis leak (1 patient). Patients with ileorectal anastomosis vs. those with ileal pouch-anal anastomosis had a better functional outcome with regard to nighttime continence (14 (88 percent) vs. 6 (38 percent) patients) and average bowel movements (<6/day; 12 (75 percent) vs. 4 (25 percent) patients). Complete daytime continence, 15 (94 percent) vs. 10 (62 percent) patients, was similar in the two groups. Physical and emotional well-being were similarly rated as very good to excellent. CONCLUSIONS In patients with familial adenomatous polyposis and ulcerative colitis with ileorectal anastomosis, conversion to ileal pouch-anal anastomosis may be required. In view of the risk of rectal cancer or intractable proctitis, patients seem to accept the conversion in spite of poorer bowel function.
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Affiliation(s)
- C Soravia
- Department of Surgery and the Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, University of Toronto, Canada
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Nyam DC, Brillant PT, Dozois RR, Kelly KA, Pemberton JH, Wolff BG. Ileal pouch-anal canal anastomosis for familial adenomatous polyposis: early and late results. Ann Surg 1997; 226:514-9; discussion 519-21. [PMID: 9351719 PMCID: PMC1191071 DOI: 10.1097/00000658-199710000-00012] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective was to review the early and late results of ileal pouch-anal anastomosis (IPAA) done for patients with familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA Patients with FAP will have colorectal adenomas develop and die of colorectal cancer if left untreated. Ileal pouch-anal anastomosis removes all disease-bearing mucosa while preserving transanal passage of stools. METHODS Between 1981 and 1994, 187 patients with FAP, 11 to 59 years of age with a mean follow-up of 60 months (range, 5-170 months) had proctocolectomy and IPAA at Mayo Medical Center in Rochester, Minnesota. All patients had a proximal anal canal mucosal excision and a hand-sewn anastomosis of the pouch to the anal canal at the dentate line. A temporary ileostomy was used in 85% of the patients. RESULTS No early postoperative deaths occurred, although two patients died later of metastatic colorectal carcinoma present at their initial operation. More important, no patient had a new cancer develop after IPAA. The overall morbidity after operation was 24%, with small bowel obstruction being the most common complication (13%). Patients had four bowel movements/24 hours and good fecal control, which continued during follow-up. CONCLUSIONS The IPAA eradicates the risk of colorectal cancer in patients with FAP. It can be performed with low mortality, acceptable morbidity, and good functional results over the long term.
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Affiliation(s)
- D C Nyam
- Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Schnitzler M, Cohen Z, Blackstein M, Berk T, Gallinger S, Madlensky L, McLeod R. Chemotherapy for desmoid tumors in association with familial adenomatous polyposis. Dis Colon Rectum 1997; 40:798-801. [PMID: 9221855 DOI: 10.1007/bf02055435] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess the effect of chemotherapy on complex desmoid tumors associated with familial adenomatous polyposis. METHODS Five patients (3 males, 2 females; age range, 29-45 years) had symptomatic, unresectable intra-abdominal desmoid tumors in association with familial adenomatous polyposis that were unresponsive to conventional medical therapy. Each patient was treated with a cytotoxic chemotherapeutic regimen consisting of doxorubicin and dacarbazine followed by carboplatin and dacarbazine. Response to treatment was assessed by measurement of tumor size using computerized tomography. Follow-up has been for a mean of 22 (range, 10-30) months. RESULTS One patient has had a complete response, and three patients have had a partial response, with a reduction in tumor volume of at least 50 percent. One patient had a minimum response to treatment and developed a rapid increase in tumor size on cessation of therapy. Complications of treatment included febrile neutropenia, severe epistaxis, and subclavian vein thrombosis. CONCLUSIONS The cytotoxic chemotherapeutic regimen described is effective in the treatment of selected unresectable desmoid tumors associated with familial adenomatous polyposis and should be considered in symptomatic patients who do not respond to conventional medical therapy.
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Affiliation(s)
- M Schnitzler
- Steve Atanas Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital and University of Toronto, Ontario, Canada
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Setti-Carraro P, Nicholls RJ. Choice of prophylactic surgery for the large bowel component of familial adenomatous polyposis. Br J Surg 1996; 83:885-92. [PMID: 8813770 DOI: 10.1002/bjs.1800830704] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The surgical options for treating the large bowel component of familial adenomatous polyposis are total proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy, with or without mucosectomy. Although the first of these eradicates all mucosa at risk, it carries several disadvantages, not least of which is a permanent ileostomy. There is little to choose functionally between the other two operations. The choice should be based on the perceived risk of cancer developing in any residual rectum; the factors influencing this risk are discussed.
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Affiliation(s)
- P Setti-Carraro
- Istituto di Chirurgia d'Urgenza, Università di Milano, Ospedale Maggiore Policlinico, Italy
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Kartheuser AH, Parc R, Penna CP, Tiret E, Frileux P, Hannoun L, Nordlinger B, Loygue J. Ileal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: a ten-year experience. Surgery 1996; 119:615-23. [PMID: 8650601 DOI: 10.1016/s0039-6060(96)80185-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The choice between ileal pouch-anal anastomosis (IPAA) and ileorectal anastomosis (IRA) in the treatment of patients with familial adenomatous polyposis remains controversial. The aims of this study were to assess our 10-year experience with proctocolectomy, endoanal mucosectomy, construction of an ileal reservoir pouch, and IPAA in a series of 171 patients with familial adenomatous polyposis and to compare the functional results after IPAA with those after IRA. METHODS Data from patients treated by IPAA at one institution were prospectively accumulated from October 1983 to October 1993. Medical records of 171 consecutive patients were studied regarding morbidity and functional results. These functional results were compared with those of a series of 23 patients who underwent IRA at the same institution. RESULTS One patient (0.6%) died after operation. Sixty-two patients (36%) had concomitant colorectal carcinoma, 36 of which tumors were invasive (15 stage A, 13 stage B, and 8 stage C). Forty-six patients (27%) had at least one postoperative complication, with 14 patients requiring reoperation (8%). Twenty-six patients (15%) had obstruction. Seven patients (4%) had pelvic sepsis, and one had transient impotence (0.6%). Only two patients (1%) had a typical episode of pouchitis. The mean follow-up was 29 months (range, 3 to 100 months); 101 patients were monitored for more than 1 year. Little difference was noted between bowel function after IRA and that after IPAA. The mean daytime stool frequency after IPAA was 4.2 with 26% of patients having an average of 1 bowel movement at nighttime, compared with a stool frequency of 3.0 and 13% of patients having night evacuation after IRA. Daytime continence was normal for 98% of patients after IPAA and for all the patients after IRA. Nighttime continence was normal in 96% and 98% of patients, respectively. CONCLUSIONS Morbidity and functional results after IPAA for familial adenomatous polyposis do not differ from those reported after IRA. For this reason and because of the risk of rectal cancer after ileorectal anastomosis, IPAA with endoanal mucosectomy is our first choice in the treatment of patients with familial adenomatous polyposis.
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Affiliation(s)
- A H Kartheuser
- Department of Alimentary Tract Surgery, Hôpital Saint-Antoine, Paris, France
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Bruce JM, Bradley EL, Satchidanand SK. A desmoid tumor of the pancreas. Sporadic intra-abdominal desmoids revisited. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1996; 19:197-203. [PMID: 8807365 DOI: 10.1007/bf02787368] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
CONCLUSIONS Desmoid tumors may rarely develop at the site of an unrelated surgical procedure. This is an index description of a desmoid tumor occurring at the line of a pancreatic resection. Because sporadic intra-abdominal desmoids are markedly less prone to recurrence than genetically determined desmoids, it is reasonable to suggest re-resection for the infrequent recurrence in sporadic cases. BACKGROUND Intra-abdominal desmoid tumors are infrequently encountered in surgical practice and, when seen, are most often those genetically determined tumors associated with Gardner's Syndrome or familial polyposis. In contrast, fewer than 100 cases of sporadic intra-abdominal desmoid tumors have been reported; only 16 of these sporadic tumors have occurred at the site of a previous surgical procedure. The current report describes a case of sporadic desmoid tumor that developed at the pancreatic suture line 18 mo following distal pancreatectomy for a nonsecreting islet cell tumor. METHODS An extensive literature search was focused on desmoid tumors in general, and sporadic intra-abdominal desmoids in particular. RESULTS During the course of this collective review, it was noted that the high rate of postoperative recurrence for intra-abdominal desmoids in genetically determined cases differed markedly from the low rate of recurrence after section of sporadic tumors.
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Affiliation(s)
- J M Bruce
- Department of Surgery, State University of New York at Buffalo, USA
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De Pietri S, Sassatelli R, Roncucci L, Bertoni G, Landi P, Sabadini G, Tansini P, Cavallini G, Cantoni E, Mareni C. Clinical and biologic features of adenomatosis coli in Northern Italy. Scand J Gastroenterol 1995; 30:771-9. [PMID: 7481545 DOI: 10.3109/00365529509096326] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Familial adenomatous polyposis (FAP) is a hereditary disease characterized by more than 100 adenomas scattered in the large bowel and by various extracolonic manifestations. We proposed a) to establish the frequency of the disorder in Northern Italy, b) to describe the most relevant clinical findings, and c) in a subgroup of 21 patients (from 8 families), to evaluate the spectrum of mutations of the APC gene. METHODS AND RESULTS Patients with FAP diagnosed between 1961 and 1991 were referred to our Study Group from surgery and gastroenterology units of the region Emilia-Romagna. The incidence of FAP was in the order of 1 in 16,500, with about a third of patients being 'single' cases. Colorectal malignancies were present in 75.6% of symptomatic patients but absent in most (93.75%) of the asymptomatic family members ('call-up' individuals). Gastric, duodenal, and jejunal adenomas were found in 8.2%, 30.6% and 53.3% of the investigated patients, respectively. Congenital hypertrophy of the retinal pigment epithelium and occult jaw lesions were seen in 64.7% and 39.5% of FAP patients but only in 0.5% and 2.5% of a matched, by age and sex, control population. These two clinical markers had a specificity of 99% and 97%, although their sensitivity was 64% and 39%. Finally, mutations of the APC gene were detected in 6 families (16 affected individuals) of the 8 families (21 affected individuals) tested; no correlation could be found between genotype and phenotype. CONCLUSIONS This study confirms that early diagnosis is essential for an appropriate management of FAP patients, although this aim remains elusive in single cases. High-risk individuals are ideal candidates for APC gene mutation analysis, which should be offered to all first-degree relatives of affected patients.
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Affiliation(s)
- S De Pietri
- Colorectal Cancer Study Group, University of Modena, Italy
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Affiliation(s)
- M Ponz de Leon
- Università degli Studi di Modena, Istituto di Patologia Medica, Italy
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Penna C, Kartheuser A, Parc R, Tiret E, Frileux P, Hannoun L, Nordlinger B. Secondary proctectomy and ileal pouch-anal anastomosis after ileorectal anastomosis for familial adenomatous polyposis. Br J Surg 1993; 80:1621-3. [PMID: 8298945 DOI: 10.1002/bjs.1800801246] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Conversion of ileorectal anastomosis to ileal pouch-anal anastomosis (IPAA) was indicated in 29 patients with familial adenomatous polyposis but technically impossible in three because of unsuspected pelvic desmoid tumours. There was no operative mortality and overall postoperative morbidity and late complication rates were no different from those in a group of 120 patients who underwent IPAA as a first operative procedure. Unsuspected adenocarcinoma (one invasive, three in situ) was found in four patients. The functional results in patients with IPAA did not differ from those of ileorectal anastomosis before conversion or from those obtained after IPAA as a first-choice procedure. Secondary proctectomy and IPAA can be safely offered to patients with ileorectal anastomosis and a high risk of rectal cancer.
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Affiliation(s)
- C Penna
- Department of Alimentary Tract Surgery, Hôpital Saint-Antoine, Paris, France
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Balladur P, Penna C, Tiret E, Vaillant JC, Gailleton R, Parc R. Pancreatico-duodenectomy for cancer and precancer in familial adenomatous polyposis. Int J Colorectal Dis 1993; 8:151-3. [PMID: 7902405 DOI: 10.1007/bf00341189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Duodenal adenomas occur in most patients with familial adenomatous polyposis and their potential for malignant transformation appears to be high. In case of rapid polyp growth or severe dysplasia, the place of surgical resection is controversial. We report 2 patients with familial adenomatous polyposis who underwent radical pancreatico duodenectomy several years after the treatment of colonic polyposis. The first patient had a pancreaticoduodenal resection performed for a duodenal adenocarcinoma. The second patient had a pancreaticoduodenal resection with pylorus preservation and pancreatogastric anastomosis performed for recurrent duodenal adenomas with severe dysplasia. Both remained alive without recurrence and with a good functional outcome 24 and 28 months after operation. We conclude that radical prophylactic surgery may be indicated for patients with familial adenomatous polyposis who have severe duodenal polyposis.
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Affiliation(s)
- P Balladur
- Department of Digestive Surgery, Hopital Saint-Antoine, Paris, France
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Penna C, Tiret E, Kartheuser A, Hannoun L, Nordlinger B, Parc R. Function of ileal J pouch-anal anastomosis in patients with familial adenomatous polyposis. Br J Surg 1993; 80:765-7. [PMID: 8392425 DOI: 10.1002/bjs.1800800638] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Pouch function after proctocolectomy and ileal J pouch-anal anastomosis was assessed at 1 and 5 years in 41 patients with familial adenomatous polyposis. The mean(s.d.) stool frequency per 24 h decreased from 4.4(1.7) to 3.9(1.8) (P < 0.05), the mean(s.d.) nocturnal stool frequency fell from 0.6(1.0) to 0.3(0.6) (P < 0.05), and the number of patients having nocturnal bowel movements decreased from 16 to seven (P < 0.05). At 5 years, only one patient still followed a strict diet (versus ten at 1 year, P < 0.05) and only two needed antidiarrhoeal medication (versus ten at 1 year, P < 0.05). There were no episodes of pouchitis or late reservoir-related complications. The function of ileal pouch-anal anastomosis improves over time in patients with familial adenomatous polyposis.
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Affiliation(s)
- C Penna
- Department of Alimentary Tract Surgery, Hôpital Saint-Antoine, Paris, France
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De Cosse JJ, Bülow S, Neale K, Järvinen H, Alm T, Hultcrantz R, Moesgaard F, Costello C. Rectal cancer risk in patients treated for familial adenomatous polyposis. The Leeds Castle Polyposis Group. Br J Surg 1992; 79:1372-5. [PMID: 1336702 DOI: 10.1002/bjs.1800791245] [Citation(s) in RCA: 86] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Total colectomy with ileorectal anastomosis (IRA) in familial adenomatous polyposis (FAP) leaves patients at risk for rectal cancer. To assess this risk, the rectal cancer incidence in 297 patients with FAP undergoing IRA since 1951 was determined in the population-based registers of Denmark, Finland and Sweden. At the same time, detailed data on 50 patients with FAP and invasive rectal cancer were obtained from 11 international polyposis registries. The cumulative incidence of rectal cancer was 13.1 per cent at 25 years. The 5-year survival rate of patients with FAP developing rectal cancer was 71 per cent. Combining both studies, the risk of dying from rectal cancer after IRA was 2.0 per cent at 15 years of follow-up. These results justify IRA as primary treatment for most patients; restorative proctocolectomy is preferred for some subgroups. The high all-cause mortality rate observed in this relatively young population necessitates lifelong surveillance of patients with FAP.
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Affiliation(s)
- J J De Cosse
- Department of Surgery, New York Hospital, Cornell Medical Center, New York 10021
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21
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Affiliation(s)
- K A Kelly
- Department of Surgery, Mayo Medical School, Rochester, Minnesota
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22
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Armitage NC. Familial Adenomatous Polyposis. Med Chir Trans 1992; 85:63-5. [PMID: 1311383 PMCID: PMC1294880 DOI: 10.1177/014107689208500201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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23
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Tsukada K, Church JM, Jagelman DG, Fazio VW, McGannon E, George CR, Schroeder T, Lavery I, Oakley J. Noncytotoxic drug therapy for intra-abdominal desmoid tumor in patients with familial adenomatous polyposis. Dis Colon Rectum 1992; 35:29-33. [PMID: 1310270 DOI: 10.1007/bf02053335] [Citation(s) in RCA: 137] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Forty of 416 patients with familial adenomatous polyposis were noted to have intra-abdominal desmoid tumors, and a subgroup of 16 were treated with noncytotoxic drug therapy. Drugs used were sulindac (14 patients), sulindac plus tamoxifen (3 patients), indomethacin (4 patients), tamoxifen (4 patients), progesterone (DEPO-PROVERA; Upjohn Co., Kalamazoo, MI) (2 patients), and testolactone (1 patient). Therapy with these drugs for continuous periods of six months or more resulted in three complete and seven partial remissions. When treated patients were compared with untreated patients (n = 12), there were significant benefits for the treated group, both in reduction of desmoid size and in improvement of symptoms, despite the inherent selection bias against this. Sulindac was the only drug used in enough patients to permit independent evaluation of its effect, with one complete and seven partial reductions of tumor size. Some patients had a delayed response to sulindac, with tumor shrinkage occurring after an initial period of tumor enlargement. When using sulindac for the treatment of desmoid tumors, this phenomenon should be considered.
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Affiliation(s)
- K Tsukada
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195
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24
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Ambroze WL, Dozois RR, Pemberton JH, Beart RW, Ilstrup DM. Familial adenomatous polyposis: results following ileal pouch-anal anastomosis and ileorectostomy. Dis Colon Rectum 1992; 35:12-5. [PMID: 1310269 DOI: 10.1007/bf02053332] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
To compare the clinical and functional results of ileorectostomy (IR) and ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP), we reviewed the results of 94 IPAA patients and 21 IR patients who were operated upon between 1978 and 1988. The groups were similar with respect to age and sex. None of the patients died postoperatively. Postoperative complications occurred in 28 percent of the IPAA group and in 17 percent of the IR group (P greater than 0.1). Seven percent of IPAA patients described symptoms compatible with pouchitis. Sixty-one percent of IR patients required subsequent fulguration of rectal polyps at least once. IR patients had a mean (+/- SD) of 4 (+/- 2) stools per day, while IPAA patients had 5 (+/- 2) stools per day (P greater than 0.05). No significant difference in daytime soiling was present between IR (6 percent) and IPAA (4 percent). Nighttime spotting was also similar between the two groups. Nighttime soiling, however, was reported by 4 percent of IPAA patients but not by IR patients (P less than 0.05). One IPAA patient (1 percent) required pouch excision for a desmoid tumor, while two IR patients (11 percent) required proctectomy and ileostomy for recurrent dysplastic polyps (P less than 0.05). Adhesions and a shortened ileal mesentery prevented the construction of an ileoanal procedure in these latter patients. In conclusion, the postoperative complication rate and functional results are similar after IR and IPAA in patients with FAP; however, IR does not eradicate rectal polyps and may indeed preclude IPAA for those requiring subsequent proctectomy.
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Affiliation(s)
- W L Ambroze
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905
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Madden MV, Neale KF, Nicholls RJ, Landgrebe JC, Chapman PD, Bussey HJ, Thomson JP. Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis. Br J Surg 1991; 78:789-92. [PMID: 1651799 DOI: 10.1002/bjs.1800780708] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Restorative proctocolectomy with an ileal reservoir (RPC) should prevent colorectal cancer in patients with familial adenomatous polyposis. Until this is confirmed its role compared with total colectomy and ileorectal anastomosis (IRA) will depend on the relative morbidity and postoperative bowel function after the two procedures. This was analysed in 99 patients (37 RPC, 62 IRA) operated on between 1977 and 1989. Morbidity was greater after RPC with subsequent ileostomy closure (median hospital stay, 24 versus 11 days; complications, 60 versus 21 per cent; reoperation, 29 versus 3 per cent; return to normal activity; 31 versus 14 weeks). There was little difference in bowel function; after IRA median frequency was 3/24 h and urgency (unable to wait 15 min) occurred in 50 per cent, compared with 4.5/24h and 17 per cent after RPC. Night evacuation occurred in 10 and 43 per cent respectively. IRA was performed in younger patients (median 19 versus 31 years) who had fewer bowel motions before operation (2 versus 5/24 h). The greater morbidity of RPC suggests that it should be restricted to patients at higher risk of developing later rectal cancer, including those unavailable for follow-up and those with large or confluent rectal polyps or with curable colon cancer at the initial colectomy.
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Affiliation(s)
- M V Madden
- Department of Surgery, St. Mark's Hospital, London, UK
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26
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Abstract
There are 3 surgical options for patients who have familial adenomatous polyposis. None of them guarantees a 100% cure of the disease, although they all minimize or eliminate the risk of colorectal cancer. Proctocolectomy with ileostomy is rarely necessary as a procedure of choice. Its only indication would be in patients who have already developed a rectal cancer in the lower third of the rectum. It tends not to be well accepted in asymptomatic patients and acts as a deterrent to family members to even seek help through surveillance. Colectomy with ileorectal anastomosis is a comparatively safe, simple, and uncomplicated procedure with a rapid recovery and a good functional result. It does, however, leave the patient liable for a small risk of rectal cancer, although not a large risk of dying of rectal cancer. Patients who do not do well with ileorectal anastomosis or who subsequently develop large numbers of polyps or even cancer in the upper parts of the rectum at an early stage can still be converted to the third option, which is an ileoanal pouch procedure. Colectomy with rectal mucosectomy and ileoanal pouch procedure with a temporary ileostomy is not, in our view, necessary for all patients with FAP. It is reserved in our practice for patients who present late with large numbers of rectal polyps or for those who desire not to have any risk of rectal cancer and is also used for patients who have had ileorectal anastomosis who develop large numbers of polyps in follow-up surveillance and screening.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D G Jagelman
- Cleveland Clinic Foundation, Fort Lauderdale 33309
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Affiliation(s)
- H J Järvinen
- Second Dept. of Surgery, Helsinki University Central Hospital, Finland
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Macrae FA, St John DJ, Muir EP, Penfold JC, Cuthbertson AM. Impact of a hospital-based register on the management of familial adenomatous polyposis. Med J Aust 1989; 151:552-7. [PMID: 2556631 DOI: 10.5694/j.1326-5377.1989.tb101280.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Colorectal cancer in familial adenomatous polyposis is a preventable disease in at-risk relatives of patients with primary cases. Until the recent establishment of a register in Western Australia, there has been no registration of pedigrees or central organization of surveillance in Australia. In the present study, the experience of 20 such families who were associated with The Royal Melbourne Hospital was documented, with an analysis of the reasons for any failure of management. The impact of a hospital-based register on the management of the disease was studied. In each family, results were categorized according to whether "at-risk" relatives had been diagnosed at surveillance examinations, and whether the Hospital register were involved. Before involvement with the register, 24 family members presented with symptomatic polyposis after the first affected case had been diagnosed. Eighteen of these had colorectal cancer at diagnosis, and 16 subjects now are dead. Identifiable reasons for the failure of surveillance were family communication failure (two cases), family denial (two cases), failure of the hospital clinic (two cases) and a failure to cover extended branches of families who were living locally (nine cases), interstate (four cases) or overseas (three cases). In contrast, only two (6%) of 33 affected cases that were identified at a planned surveillance endoscopy had colorectal cancer at diagnosis. Without the active surveillance of at-risk family members, lethal delays in diagnosis are likely to occur. Most reasons for failure potentially are correctable by a dedicated registry that is responsible for notifying clinicians and patients about the timing of surveillance procedures.
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Affiliation(s)
- F A Macrae
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC
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Dozois RR, Kelly KA, Welling DR, Gordon H, Beart RW, Wolff BG, Pemberton JH, Ilstrup DM. Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis. Ann Surg 1989; 210:268-71; discussion 272-3. [PMID: 2549890 PMCID: PMC1357983 DOI: 10.1097/00000658-198909000-00002] [Citation(s) in RCA: 127] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The aim of this study was to compare the immediate postoperative results and the long-term outcome of ileal pouch-anal anastomosis in 94 patients with familial adenomatous polyposis to those in 758 patients with ulcerative colitis. Two colitis patients died after operation (0.3%), but no polyposis patients died. Overall operative complications appeared in 26% and 29% of polyposis and colitis patients, respectively (NS). Reoperation for intestinal obstruction did not differ between the two groups, but sepsis requiring reoperation was more common in colitis patients (6%) than in polyposis patients (0%, p less than 0.04). At follow-up (mean, 3 years), polyposis patients had fewer daytime stools (4.5 stools per day), less nighttime fecal spotting (26%), and less pouchitis (7%) than colitis patients (5.8 stools per day; spotting, 40%; pouchitis, 22%; p less than 0.002). The conclusion was that polyposis patients tolerated the operation better and had less long-term disability than did colitis patients. The data suggest that postoperative sepsis, daytime stooling frequency, nocturnal incontinence, and pouchitis may be, at least in part, disease related and not surgeon or operation related.
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Affiliation(s)
- R R Dozois
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905
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30
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Abstract
Familial adenomatous polyposis is an autosomal dominant disease that includes early development of up to thousands of colorectal adenomas and several extracolonic manifestations. All untreated patients will develop colorectal adenocarcinoma. The treatment of choice is colectomy and ileorectal anastomosis, but restorative proctocolectomy may be considered in selected cases. Polyposis patients treated with ileorectal anastomosis should be followed for life, with regular proctosigmoidoscopy and destruction of new adenomas. Furthermore, regular gastroduodenoscopy should be carried out because of frequent occurrence of premalignant duodenal adenomas. The prognosis is good after prophylactic colectomy in patients without carcinoma. All first degree relatives of affected family members should be examined regularly with proctosigmoidoscopy from the age of ten, and prophylaxis should be organised using a national or regional polyposis register. The recent detection of a specific gene for familial adenomatous polyposis is a long step forward, and several problems may be solved by increasing international cooperation.
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Affiliation(s)
- S Bülow
- Department of Surgical Gastroenterology, Hvidovre Hospital, University of Copenhagen, Denmark
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31
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Myrhøj T, Bülow S, Mogensen AM. Multiple adenomas in terminal ileum 25 years after restorative proctocolectomy for familial adenomatous polyposis. Report of a case. Dis Colon Rectum 1989; 32:618-20. [PMID: 2544383 DOI: 10.1007/bf02554184] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A patient with familial adenomatous polyposis was treated with colectomy, mucosal proctectomy, and a straight ileoanal anastomosis in 1962. Thirteen to 21 years later recurrent adenomas developed at the ileoanal anastomosis, and 25 years after the operation multiple adenomas were found in the terminal ileum up to 12 cm from the ileoanal anastomosis. It is concluded that colectomy and mucosal proctectomy, with or without an ileoanal reservoir, does not eliminate the future risk of adenoma formation. Thus, this method should be used only in selected polyposis patients.
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Affiliation(s)
- T Myrhøj
- Department of Surgical Gastroenterology Rigshospitalet, University of Copenhagen, Denmark
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