Ileorectal anastomosis for inflammatory disease of the colon

Risk of Neoplasia After Colectomy in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Colorectal neoplasia can still develop after colectomy for inflammatory bowel disease. However, data on this risk are scare, and there have been few conclusive findings, so no evidence-based recommendations have been made for postoperative surveillance. We conducted a systematic review and meta-analysis to determine the prevalence and incidence of and risk factors for neoplasia in patients with inflammatory bowel disease who have undergone colectomy, including the permanent-end ileostomy and rectal stump, ileorectal anastomosis (IRA), and ileal pouch-anal anastomosis (IPAA) procedures.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library through May 2014 to identify studies that reported prevalence or incidence of colorectal neoplasia after colectomy or specifically assessed risk factors for neoplasia development. Studies were selected, quality was assessed, and data were extracted by 2 independent researchers.

RESULTS

We calculated colorectal cancer (CRC) prevalence values from 13 studies of patients who underwent rectal stump surgery, 35 studies of IRA, and 33 studies of IPAA. Significantly higher proportions of patients in the rectal stump group (2.1%; 95% confidence interval [CI], 1.3%-3.0%) and in the IRA group (2.4%; 95% CI, 1.7%-3.0%) developed CRC than in the IPAA group (0.5%; 95% CI, 0.3%-0.6%); the odds ratio (OR) for CRC in the rectal stump or IRA groups compared with the IPAA group was 6.4 (95% CI, 4.3-9.5). A history of CRC was the most important risk factor for development of CRC after colectomy (OR for patients receiving IRA, 12.8; 95% CI, 3.31-49.2 and OR for patients receiving IPAA, 15.0; 95% CI, 6.6-34.5).

CONCLUSIONS

In a meta-analysis of published studies, we found the prevalence and incidence of CRC after colectomy to be less than 3%; in patients receiving IPAA it was less than 1%. Factors that increased risk of cancer development after colectomy included the presence of a residual rectum and a history of CRC. These findings could aid in development of individualized strategies for post-surgery surveillance.

Rectal preservation in nonspecific inflammatory disease of the colon

Sixty-three patients with chronic ulcerative colitis and 80 patients with Crohn's disease underwent abdominal colectomy and primary ileorectal or ileosigmoid anastoimosis and were followed up for between five and 17 years. No patient developed carcinoma of the rectal stump. The interval proctectomy rate was similar in both groups (24 and 29%, respectively), the rate being influenced by age in the group with chronic ulcerative colitis. The young patients with ulcerative colitis required proctectomy more often than did the patients with onset later in life. The proctectomy rate was not influenced by the level of the anastomosis. In patients with normal or moderately diseased rectal mucosa, the preoperative condition of the rectum did not influence the proctectomy rate. Functional results were satisfactory in 55% of the patients with chronic ulcerative colitis who survived and in 35% of the patients with Crohn's disease who survived. Because of the non-curative nature of surgery for Crohn's disease, a conservative posture should be maintained, with preservation of normal or moderately diseased rectal segments. If sigmoidoscopie examination and biopsy are done periodically, abdominal colectomy and ileorectal or ileosigmoid anastomosis appears to be a viable option to proctocolectomy in selected patients with chronic ulcerative colitis.

Carcinoma in the retained rectum after colectomy for ulcerative colitis

A carcinoma arising in an excluded rectal stump 18 years after ileostomy and 14 years after subtotal colectomy has been described. Extent of involvement of the colon, age of the patient at onset of colitis, and duration of symptomatology are factors whcih have been shown to influence the incidence of carcinoma complicating ulcerative colitis. Fifty-eight similar cases of carcinoma developing in a retained rectum were collected from the literature. The incidence of this complication is approximately 3 per cent. Rectum-sparing operations do not appear to decrease the incidence of malignant transformation in ulcerative colitis. A decision to retain the rectum after colonic resection for ulcerative colitis must take into account both the significant incidence of malignant transformation associated with all rectum-sparing procedures and also the significant incidence of recurrent symptoms following this procedure.