Cancer in the excluded rectum following surgery for inflammatory bowel disease

Diversion proctocolitis and the problem of the forgotten rectum in inflammatory bowel diseases: A systematic review

Background and aims

Diversion proctocolitis (DP) is a non‐specific mucosal inflammation arising in the defunctionalized colon and/or rectum following faecal diversion (colostomy, ileostomy). Differential diagnosis of DP from the underlying disease in patients with inflammatory bowel diseases (IBD) is often unclear. As a result, it might be difficult to undertake any specific treatment. We aimed to systematically review the literature evidence on DP in IBD patients.

Methods

For this qualitative systematic review, we searched PubMed, EMBASE and Scopus to identify all studies published until July 2021 including IBD patients affected by DP.

Results

Overall, 37 papers published between 1982 and 2021 were included. A total of 1.211 IBD patients were included: 613 UC (50.6%), 524 CD (43.3%), 66 IBD‐unclassified (IBD‐U) (5.4%), 8 unspecified patients (0.7%). Most patients with DP are asymptomatic, although inflammation is detectable in almost all patients with a rectal stump. Reduced short‐chain fatty acids and an altered microbiome, may trigger mucosal inflammation and have been proposed as causing factors. An increased risk of developing cancer on DP has been reported in patients with a history of previous dysplasia/cancer.

Conclusions

The etiopathogenesis of DP is still unknown. The efficacy of mesalamine, corticosteroids or short‐chain fatty acids has not been proven by randomized trials yet. Since the incidence of cancer of the rectal stump can reach 4.5 per 1.000 diverted patients‐year, IBD patients undergoing subtotal colectomy with end‐ileostomy should undergo close endoscopic surveillance, being eventually counseled for surgery with or without the restoration of the intestinal continuity.

Challenges in Crohn's Disease Management after Gastrointestinal Cancer Diagnosis

Simple Summary

Crohn’s disease (CD) is a chronic inflammatory bowel disease affecting both young and elderly patients, involving the entire gastrointestinal tract from the mouth to anus. The chronic transmural inflammation can lead to several complications, among which gastrointestinal cancers represent one of the most life-threatening, with a higher risk of onset as compared to the general population. Moreover, diagnostic and therapeutic strategies in this subset of patients still represent a significant challenge for physicians. Thus, the aim of this review is to provide a comprehensive overview of the current evidence for an adequate diagnostic pathway and medical and surgical management of CD patients after gastrointestinal cancer onset.

Abstract

Crohn’s disease (CD) is a chronic inflammatory bowel disease with a progressive course, potentially affecting the entire gastrointestinal tract from mouth to anus. Several studies have shown an increased risk of both intestinal and extra-intestinal cancer in patients with CD, due to long-standing transmural inflammation and damage accumulation. The similarity of symptoms among CD, its related complications and the de novo onset of gastrointestinal cancer raises difficulties in the differential diagnosis. In addition, once a cancer diagnosis in CD patients is made, selecting the appropriate treatment can be particularly challenging. Indeed, both surgical and oncological treatments are not always the same as that of the general population, due to the inflammatory context of the gastrointestinal tract and the potential exacerbation of gastrointestinal symptoms of patients with CD; moreover, the overlap of the neoplastic disease could lead to adjustments in the pharmacological treatment of the underlying CD, especially with regard to immunosuppressive drugs. For these reasons, a case-by-case analysis in a multidisciplinary approach is often appropriate for the best diagnostic and therapeutic evaluation of patients with CD after gastrointestinal cancer onset.

Role of Fecal Diversion in Complex Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.

Fistula-associated anal carcinoma in Crohn's disease

Fistula-associated anal carcinoma in patients with Crohn's disease (CD) is a rare condition. More recently, this entity has been increasingly reported likely due to increased recognition, and the incidence may be greater than once appreciated. There remains a paucity of data regarding the incidence, diagnosis, treatment, and outcome of fistula-associated anal carcinoma. Area covered: This review evaluates the clinical features, pathology, treatment, and prognosis of fistula-associated anal carcinoma in patients with CD. A strategy for surveillance of this carcinoma is proposed by the authors based on the evidence obtained from this review. Expert commentary: Clinicians caring for patients with CD and perianal involvement need to be aware of the rare yet extremely important association of long-standing perianal disease and fistula-associated carcinoma. Only through awareness, a high level of suspicion will be diagnosed in a timely manner. This involves a thorough history, a proper, and complete anorectal examination, along with early imaging and examination under anesthesia. Through this approach, it is hoped that early diagnose can be achieved in at-risk patients and change the significant morbidity and mortality associated with this diagnosis.

Risk factors for rectal stump cancer in inflammatory bowel disease

BACKGROUND

Patients with long-standing colitis carry an increased risk of colorectal cancer and are therefore enrolled in colonoscopic surveillance programs. It is presently not known if endoscopic surveillance of patients with colitis with a closed rectal stump after a subtotal colectomy is justified. Neither is it clear which of these patients might be at increased risk for rectal stump cancer.

OBJECTIVE

The aim of this study is to identify the risk factors for rectal stump cancer.

DESIGN

This investigation is a retrospective descriptive case-control study.

SETTINGS

This study was conducted at tertiary referral centers in the Netherlands.

PATIENTS

Colorectal cancer cases associated with inflammatory bowel disease diagnosed between 1990 and 2006 were selected in a nationwide pathology archive. Patients with rectal stump cancer were selected from this group. The pathology archive was also used to identify inflammatory bowel disease controls matched for referral center with a closed rectal stump after subtotal colectomy, but without neoplasia. Follow-up started at the date of subtotal colectomy with the formation of a rectal stump. Demographic and disease characteristics were collected at baseline.

MAIN OUTCOME MEASUREMENTS

Hazard ratios with 95% confidence intervals were calculated for factors associated with the development of rectal stump cancer with the use of univariate Cox regression analysis. End points were rectal stump cancer, end of follow-up, or death.

RESULTS

A total of 12 patients with rectal stump cancer and 18 matching controls without neoplasia were identified. Univariate analysis showed an association between rectal stump cancer and primary sclerosing cholangitis, and disease duration until subtotal colectomy.

LIMITATIONS

This study is limited by its retrospective design, and, despite being the largest series to date, it still has a limited number of cases.

CONCLUSIONS

Risk factors for rectal stump cancer in a closed rectal stump after subtotal colectomy were primary sclerosing cholangitis and disease duration until subtotal colectomy.

Anal and rectal cancer in Crohn's disease

Several epidemiological studies have been published regarding the risk of Crohn's disease- associated colorectal cancer. The findings are, however, contradictory and it has been particularly difficult to obtain indisputable information on the incidence of cancer limited to the rectum and the anus. During 1987-2000 rectal or anal cancer was diagnosed in 335 patients in Sweden (153 males, 182 females). In other words, approximately 3 Crohn patients per million inhabitants were diagnosed with rectal or anal cancer every year during that time period which is 1% of the total number of cases. At diagnosis of cancer 36% were aged below 50 years and 58% below 60 years. Corresponding figures for all cases of anal and rectal cancer were 5% and 18%, respectively. Present knowledge from the literature implies that there is an increased risk of rectal and anal cancer only in Crohn's disease patients with severe proctitis or severe chronic perianal disease. However, the rectal remnant must also be considered a risk factor. Multimodal treatment is similar to that in sporadic cancer but proctectomy and total or partial colectomy is added depending on the extent of the Crohn's disease. The outcome is the same as in sporadic cancer at a corresponding stage but the prognosis is often poor due to the advanced stage of cancer at diagnosis. We suggest that six high-risk groups should be recommended annual surveillance after a duration of Crohn's disease of 15 years including extensive colitis, chronic severe anorectal disease, rectal remnant, strictures, bypassed segments and sclerosing cholangitis.

Anorectal Crohn's disease

Anorectal disease affects many patients with Crohn's disease. Clinical manifestations vary from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. Surgical management needs to be conservative and must focus on draining septic sites, preserving sphincter function, and palliating symptoms. Medical management has had some success in improving symptoms, but as yet, it has not been able to ameliorate most perianal complaints quickly and enduringly. Many new and exciting treatment modalities are being investigated with the hope that more effective approaches to these complex and difficult problems can be realized.

Is Hartmann's procedure safe in Crohn's disease? Report of three cases

INTRODUCTION

Crohn's disease-associated colorectal cancer may occur in an area of defunctioning bowel. Some patients with Crohn's colitis undergo subtotal colectomy, ileostomy, and low Hartmann's procedure in an effort to preserve the rectum. This procedure has also been advocated for patients with severe anorectal Crohn's disease, in whom nonhealing of the perineal wound after proctectomy occurs with alarming frequency. The authors present a review of the literature and three cases of cancer developing in the defunctioning rectal stump despite surveillance proctoscopy.

METHODS

Twenty-five patients underwent low Hartmann's procedure for severe anorectal Crohn's disease. Surveillance proctoscopy was performed as follow-up. Development of cancer in the rectal remnant or anus or recurrence of symptoms was managed by resection and adjuvant therapy.

RESULTS

One patient developed squamous-cell carcinoma of the anal canal, underwent resection and adjuvant therapy, and was disease free at the time of this study. Two patients developed adenocarcinoma of the rectum. Both underwent resection and adjuvant therapy. One patient died and the other developed a recurrence.

CONCLUSIONS

The authors recommend interval perineal proctectomy in all patients undergoing low Hartmann's procedure for severe anorectal Crohn's disease in whom rectal preservation is not possible. Regularly scheduled interim surveillance proctoscopy performed every two years, with biopsies of macroscopically normal-appearing and abnormal-appearing rectal mucosa and curetting of fistulous tracts, is also recommended to decrease the possibility of missing occult malignancies.

Colorectal adenocarcinoma in Crohn's disease: a retrospective histologic study

PURPOSE

The aim of this study was to review all histopathologic sections from surgical specimens with inflammatory bowel disease and colorectal carcinoma filed at this hospital between 1951 and 1996.

METHOD

A total of 40 surgical (n = 39) or autopsy (n = 1) colon or colorectal specimens were reviewed. Internationally accepted histologic criteria were strictly applied to differentiate Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC).

RESULTS

Of the 40 specimens with inflammatory bowel disease and carcinoma, 22 (55 percent) had CD, 16 (40 percent) had UC, and the remaining 2 (5 percent) had IC. Males accounted for 72.7 percent or 16 of the 22 patients with colorectal carcinoma in CD and for 68.7 percent or 11 of the 16 patients with carcinoma in UC. Both patients with IC and carcinoma were males. The median age of patients at diagnosis was as follows: CD, 20 (range, 7-68) years; UC, 23 (range, 5-21) years. In IC, the age was 61 and 81 years, respectively. The median disease duration (before detection of colorectal cancer) was as follows: CD, 18.5 (range, 1-45) years; UC, 19 (range, 6-38) years. For cases with IC, it was 13 and 19 years, respectively. Median age of patients at cancer diagnosis was as follows: CD, 48 (range, 21-78) years; UC, 49 (range, 21-81) years. Ages at cancer diagnosis in IC were 68 and 81 years. Colorectal carcinoma tend to develop among relatively young patients with CD and UC. Mucinous adenocarcinomas accounted for approximately one-third of the carcinomas affecting CD. Thirty percent of old specimens (before the end of 1982) had in fact carcinoma complicating CD and not UC (the latter being the diagnosis appearing in old pathologic reports). During a time lapse of 38 years (i.e., between 1951 and 1989), only 11 cases of colorectal CD with carcinoma (i.e., 0.2 cases/year) were found, but as many as 11 during the past 6.5 years (i.e., 1.7 cases/year) have been diagnosed. Only 42.3 percent (11/26) of cases with colorectal inflammatory bowel disease and carcinoma operated on between 1951 and the end of 1989 had Crohn's colitis but as many as 78.6 percent (11/14) of those operated on between 1990 and May 1996 had Crohn's colitis. Review of the literature indicated that 64.8 percent or 191 of the 295 cases of colorectal carcinomas in CD so far reported occurred in the past 6.5 years. It would seem as if the risk of colorectal carcinoma in Crohn's colitis has increased in later years.

CONCLUSIONS

1) Reports on cancer frequency in UC based on old histopathologic records should be subjected to critical histologic re-evaluation; 2) carcinoma in Crohn's colitis has increased at this hospital, particularly since 1990; 3) the surveillance program strategy used in patients with long-standing UC at this hospital should also embrace patients with Crohn's colitis.

Surgical therapy for Crohn's disease of the colon and rectum

Crohn's disease remains incurable by either medical or surgical treatment. Both physician and surgeon must work together with the common objective of restoring health by eliminating or alleviating the complications of Crohn's disease. From the surgeon's viewpoint, operation is performed for complications of the disease or for failure of medical management. Although aggressive surgical excision of affected bowel rids the patient of disease for a period of time, the beneficial effects of operation have to be considered in the context that disease recurrence is always a possibility and that reoperation for such complications may be necessary. The aim of the surgeon is to deal with the current problem as simply as possible and to maintain a long-term, strategic view of the disease process with the understanding that what is done today may affect the patient for life.

Crohn's disease of the colon, rectum, and anus

The varied presentations and complexities of Crohn's disease involving the colon, rectum, and anus mandate decisions that can challenge even the most experienced surgeon. Symptomatic large-bowel disease, with its number of operative indications, is often amenable to resection that maintains intestinal continuity with acceptable rates of recurrence. Disease of the anus, occurring with or without proximal disease, typically is treated in a conservative manner, although occasional definitive treatment may yield improved results. As Crohn's disease is recognized as incurable, the treatment options discussed focus on the amelioration of symptoms while optimizing function without risking excessive morbidity.

Factors predictive of persistent or recurrent Crohn's disease in excluded rectal segments

The fate of the excluded rectal segment after surgery for Crohn's colitis remains poorly defined. To determine prognostic factors relating to the fate of the rectal segment, records of 47 patients who underwent creation of an excluded rectal segment were studied. Disease developed in 33 patients (70 percent) in the excluded rectal segment by five years; 24 patients (51 percent) had completion proctectomy by 2.4 years; and 9 patients (19 percent) retained a rectum with disease at a median follow-up period of five years (range, 2-13 years). At a median follow-up time of six years (range, 2-21 years), 14 patients were without clinical disease. The three groups were equivalent with respect to sex, duration of preoperative disease, indication for operation, distribution of disease, and histologic involvement of the proximal rectal margin. The median age of patients in the proctectomy group at diagnosis tended to be younger than that of patients with a retained excluded rectal segment (22, 30, and 31 years for patients having proctectomy, patients with a diseased excluded rectal segment, and patients with a normal excluded rectal segment, respectively). Neither initial involvement of the terminal ileum nor endoscopic inflammatory changes seen in the rectum predicted eventual disease of the excluded rectal segment. However, initial perianal disease complicating Crohn's colitis was predictive of persistent excluded rectal segment disease and often required proctectomy. Therefore, because the presence of perianal disease and Crohn's colitis predicts persistent or recurrent excluded rectal segment disease, primary total proctocolectomy or early completion proctectomy may be indicated in this subgroup of patients.

Bowel cancer characteristics in patients with regional enteritis

We report 10 carcinomas in 8 patients with regional enteritis. Five of the cancers were in the ileum, 4 in the right colon, and 1 in the rectum. The visualized small bowel cancers appeared as benign strictures in small bowel involved by regional enteritis. Most were poorly differentiated. The colon cancers had a more typical radiographic appearance of malignancy. In some patients with small bowel cancer the malignancy was discovered only on histologic evaluation; the malignant nature of the lesion was not appreciated by radiography or gross examination at surgery.

Colorectal carcinoma in patients with Crohn's disease

Epidemiologic studies have shown a fourfold to 20-fold increased risk of colorectal carcinoma in patients with Crohn's disease as compared with the general population, but management for this risk is controversial. This paper presents a series of 10 patients with Crohn's disease and colorectal carcinoma from one institution and a review of the literature. Compared with 118 consecutive patients having colorectal carcinoma of the usual type at the same institution, the 10 patients were younger (mean age 55 vs. 65 yr, p less than 0.05) and had a higher prevalence of mucinous carcinoma (50% vs. 9%, p less than 0.01), providing evidence in addition to the previous epidemiologic results that Crohn's disease is a predisposing (premalignant) condition for colorectal carcinoma. Eight of the 10 patients had an antecedent history of Crohn's disease, ranging from 4 to 51 yr (mean 24 yr); 2 patients presented with colorectal carcinoma and were found to have Crohn's disease. Of particular note, 9 of the 10 patients had colitis or ileocolitis, and carcinoma occurred in bypassed rectum in 2 patients. One patient had two carcinomas. Three of the 11 carcinomas were not recognized preoperatively. The anatomic sites of the cancers were not significantly different from usual colorectal carcinoma, with 7 of the 11 tumors (64%) in the sigmoid colon and rectum. Dysplasia was identified in all 10 patients, and all of the 10 resected carcinomas were found to be contiguous with high-grade dysplasia. The findings in this study support the proposals based upon epidemiologic data that surveillance should be considered for patients with clinically evident colorectal involvement by Crohn's disease or a bypassed segment of colorectum.