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Miller-Ocuin JL, Ashburn JH. Cancer in the Anal Transition Zone and Ileoanal Pouch following Surgery for Ulcerative Colitis. Clin Colon Rectal Surg 2024; 37:37-40. [PMID: 38188063 PMCID: PMC10769578 DOI: 10.1055/s-0043-1762562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis remains the gold standard treatment for patients with ulcerative colitis who desire restoration of intestinal continuity. Despite a significant cancer risk reduction after surgical removal of the colon and rectum, dysplasia and cancers of the ileal pouch or anal transition zone still occur and are a risk even if an anal canal mucosectomy is performed. Surgical care and maintenance after ileoanal anastomosis must include consideration of malignant potential along with other commonly monitored variables such as bowel function and quality of life. Cancers and dysplasia of the ileal pouch are rare but sometimes difficult-to-manage sequelae of pouch surgery.
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Affiliation(s)
- Jennifer L. Miller-Ocuin
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Jean H. Ashburn
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
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Le Cosquer G, Buscail E, Gilletta C, Deraison C, Duffas JP, Bournet B, Tuyeras G, Vergnolle N, Buscail L. Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis. Cancers (Basel) 2022; 14:cancers14030530. [PMID: 35158797 PMCID: PMC8833833 DOI: 10.3390/cancers14030530] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 12/29/2022] Open
Abstract
Proctocolectomy with ileal pouch-anal anastomosis is the intervention of choice for ulcerative colitis and familial adenomatous polyposis requiring surgery. One of the long-term complications is pouch cancer, having a poor prognosis. The risk of high-grade dysplasia and cancer in the anal transitional zone and ileal pouch after 20 years is estimated to be 2 to 4.5% and 3 to 10% in ulcerative colitis and familial polyposis, respectively. The risk factors for ulcerative colitis are the presence of pre-operative dysplasia or cancer, disease duration > 10 years and severe villous atrophy. For familial polyposis, the risk factors are the number of pre-operative polyps > 1000, surgery with stapled anastomosis and the duration of follow-up. In the case of ulcerative colitis, a pouchoscopy should be performed annually if one of the following is present: dysplasia and cancer at surgery, primary sclerosing cholangitis, villous atrophy and active pouchitis (every 5 years without any of these factors). In the case of familial polyposis, endoscopy is recommended every year including chromoendoscopy. Even if anal transitional zone and ileal pouch cancers seldom occur following proctectomy for ulcerative colitis and familial adenomatous polyposis, the high mortality rate associated with this complication warrants endoscopic monitoring.
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Affiliation(s)
- Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Céline Deraison
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Jean-Pierre Duffas
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Géraud Tuyeras
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
| | - Nathalie Vergnolle
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France
- Correspondence: ; Tel.: +33-5613-23055
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McKenna NP, Bews KA, Habermann EB, Dozois EJ, Lightner AL, Mathis KL. What Factors Are Associated With the Eventual Need for an Ileostomy After Total Abdominal Colectomy and Ileosigmoid or Ileorectal Anastomosis for Crohn's Colitis in the Biologic Era? Dis Colon Rectum 2020; 63:504-513. [PMID: 32015288 DOI: 10.1097/dcr.0000000000001556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Outcomes after total abdominal colectomy with ileosigmoid or ileorectal anastomosis for Crohn's colitis and risk factors for requirement of a permanent ileostomy remain poorly understood, particularly in the biologic era. OBJECTIVE This study aimed to determine long-term ostomy-free survival after ileosigmoid or ileorectal anastomosis for Crohn's colitis and potential risk factors for requirement of an ileostomy. DESIGN This is a retrospective cohort study. SETTING This study was conducted at a single-institution IBD tertiary referral center. PATIENTS Patients diagnosed with Crohn's disease and undergoing ileosigmoid or ileorectal anastomosis between 2006 and 2018 were selected. MAIN OUTCOME MEASURE Long-term ostomy-free survival and hazard ratios of potential predictors of ileostomy requirement were the primary outcomes measured. RESULTS One hundred nine patients (56% female) underwent ileosigmoid or ileorectal anastomosis for Crohn's disease. The majority of surgical procedures were completed in 2 or 3 stages (53%). The indication for total abdominal colectomy was predominantly medically refractory disease (77%), with dysplasia the second leading indication (13%). At an overall mean follow-up of 3 years, 16 patients had undergone either proctectomy or diversion with the rectum in situ. This resulted in ostomy-free survival estimates at 5 and 10 years of 78% (95% CI, 68-90) and 58% (95% CI, 35-94). A positive distal microscopic margin was the only risk factor for later requirement of a permanent ileostomy (HR, 5.4; 95% CI, 1.7-17.2). LIMITATIONS This study is limited because it is a retrospective study at a tertiary referral center. CONCLUSIONS Long-term ostomy-free survival can be achieved in the majority of patients who undergo restoration of intestinal continuity after total abdominal colectomy for Crohn's colitis. A positive distal microscopic margin was independently associated with long-term anastomotic failure, and it should be accounted for when risk stratifying patients for postoperative prophylactic medical therapy. See Video Abstract at http://links.lww.com/DCR/B111. ¿QUÉ FACTORES ESTÁN ASOCIADOS CON LA EVENTUAL NECESIDAD DE UNA ILEOSTOMÍA DESPUÉS DE UNA COLECTOMÍA ABDOMINAL TOTAL Y UNA ANASTOMOSIS ILEOSIGMOIDEA O ILEORRECTAL PARA LA COLITIS DE CROHN EN LA ERA BIOLÓGICA?: Los resultados después de la colectomía abdominal total con anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo para el requerimiento de una ileostomía permanente siguen siendo poco conocidos, particularmente en la era biológica.Determinar la supervivencia a largo plazo sin ostomía después de una anastomosis ileosigmoidea o ileorrectal para la colitis de Crohn y los factores de riesgo potenciales para la necesidad de una ileostomía.Estudio de cohorte retrospectivo.Centro de referencia de tercel nivel para enfermedad inflamatoria intestinal de una sola institución.Pacientes diagnosticados con enfermedad de Crohn y sometidos a anastomosis ileosigmoidea o ileorrectal entre 2006 y 2018Supervivencia a largo plazo sin ostomías y cocientes de riesgo de predictores potenciales de requerimiento de ileostomía109 pacientes (56% mujeres) se sometieron a anastomosis ileosigmoidea o ileorrectal por enfermedad de Crohn. La mayoría de los procedimientos quirúrgicos se completaron en 2 o 3 etapas (53%). La indicación de colectomía abdominal total fue predominantemente enfermedad médicamente refractaria (77%), con displasia la segunda indicación principal (13%). En un seguimiento medio general de 3 años, 16 pacientes se habían sometido a una proctectomía o a una derivación con el recto in situ. Esto dio como resultado estimaciones de supervivencia sin ostomía a los 5 y 10 años de 78% (intervalo de confianza del 95%: 68-90) y 58% (intervalo de confianza del 95%: 35-94), respectivamente. Un margen microscópico distal positivo fue el único factor de riesgo para el requerimiento posterior de una ileostomía permanente (razón de riesgo: 5.4; intervalo de confianza del 95%, 1.7-17.2).Estudio retrospectivo en un centro de referencia de tercer nivel.La supervivencia a largo plazo sin ostomía se puede lograr en la mayoría de los pacientes que se someten a la restauración de la continuidad intestinal después de la colectomía abdominal total por colitis de Crohn. Un margen microscópico distal positivo se asoció de forma independiente con la insuficiencia anastomótica a largo plazo, y debe tenerse en cuenta cuando se trata de pacientes con estratificación de riesgo para el tratamiento médico profiláctico postoperatorio. Consulte Video Resumen en http://links.lww.com/DCR/B111.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Katherine A Bews
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.,The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Ishii H, Hata K, Kishikawa J, Anzai H, Otani K, Yasuda K, Nishikawa T, Tanaka T, Tanaka J, Kiyomatsu T, Kawai K, Nozawa H, Kazama S, Yamaguchi H, Ishihara S, Sunami E, Kitayama J, Watanabe T. Incidence of neoplasias and effectiveness of postoperative surveillance endoscopy for patients with ulcerative colitis: comparison of ileorectal anastomosis and ileal pouch-anal anastomosis. World J Surg Oncol 2016; 14:75. [PMID: 26960982 PMCID: PMC4784460 DOI: 10.1186/s12957-016-0833-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 03/01/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The incidence of neoplasia after surgery has not been sufficiently evaluated in patients with ulcerative colitis (UC), particularly in the Japanese population, and it is not clear whether surveillance endoscopy is effective in detecting dysplasia/cancer in the remnant rectum or pouch. The aims of this study were to assess and compare postoperative development of dysplasia/cancer in patients with UC who underwent ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) and to evaluate the effectiveness of postoperative surveillance endoscopy. METHODS One hundred twenty patients who received postoperative surveillance endoscopy were retrospectively reviewed for development of dysplasia/cancer in the remnant rectal mucosa or pouch. RESULTS Three hundred seventy-nine endoscopy sessions were conducted for 30 patients after IRA, while 548 pouch endoscopy sessions were conducted for 90 patients after IPAA. In the IRA group, 5 patients developed dysplasia/cancer during postoperative surveillance and in all cases, neoplasia was detected at an early stage. In the IRA group, no patient developed neoplasia within 10 years of diagnosis; the cumulative incidence of neoplasia after disease onset was 7.2, 12.0, and 23.9% at 15, 20, and 25 years, respectively. In one case after stapled IPAA, dysplasia was found at the ileal pouch; a subsequent 9 endoscopy sessions in 8 years did not detect any dysplasia. Neoplasia was found more frequently during postoperative surveillance in the IRA group than in the IPAA group (p = .0028). The cumulative incidence of neoplasia after IRA was 3.8, 8.7, and 21.7% at 10, 15, and 20 years, respectively, and that after IPAA was 1.6% at 20 years. CONCLUSIONS The cumulative incidence of neoplasia after IPAA was minimal. Those who underwent IRA had a greater risk of developing neoplasia than those who underwent IPAA, although postoperative surveillance endoscopy was able to detect dysplasia/cancer at an early stage. IRA can be the surgical procedure of choice only in selected cases in which it would be of benefit to the patient, with more careful surveillance.
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Affiliation(s)
- Hiroaki Ishii
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan.
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Junko Kishikawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Koji Yasuda
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Junichiro Tanaka
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Shinsuke Kazama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Hironori Yamaguchi
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Eiji Sunami
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Joji Kitayama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, 113-0033, Japan
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Block M, Börjesson L, Willén R, Bengtson J, Lindholm E, Brevinge H, Saksena P. Neoplasia in the colorectal specimens of patients with ulcerative colitis and ileal pouch-anal anastomosis - need for routine surveillance? Scand J Gastroenterol 2015; 50:528-35. [PMID: 25648657 DOI: 10.3109/00365521.2015.1004364] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patients who undergo ileal pouch-anal anastomosis (IPAA) after colectomy for ulcerative colitis (UC) occasionally have neoplasia in the IPAA. Patients with evidence of dysplasia or carcinoma in the colorectal specimen may have an increased risk of such neoplasia. A surveillance program has been suggested. The aims of this study were to evaluate the outcomes of surveillance of a large patient cohort, and to investigate the prevalences of neoplasia in the ileal pouch mucosa and in the anal transitional zone (ATZ). MATERIAL AND METHODS A total of 629 patients underwent IPAA for UC at Sahlgrenska University Hospital, Gothenburg, Sweden. Identified from a register, 73 patients with neoplasia in their specimen considered eligible for the trial were prospectively enrolled, and underwent clinical examination, endoscopy with macroscopic evaluation, and mucosal biopsies from the ileal pouch and the ATZ. The biopsies were independently evaluated by two experienced gastro-pathologists. RESULTS In all, 56 patients (39 males) with a median follow-up time of 18 (range, 1-29) years were evaluated. One patient (1.8%; 95% CI 0%-5.3%) showed low-grade dysplasia in the pouch, as recorded by one of the two pathologists. The individual pathologists recorded indefinite for dysplasia (IFD) in the pouch for 19 and 20 patients, respectively, and IFD in the ATZ for 2 and 4 patients, respectively. None of the biopsies showed evidence of high-grade dysplasia (HGD) or carcinoma. CONCLUSIONS Neoplasia in the ileal pouch or ATZ after IPAA for UC is rare in the proposed risk group. The necessity for and value of a routine surveillance program should be prospectively evaluated.
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Affiliation(s)
- Mattias Block
- Department of Surgery, Sahlgrenska University Hospital, Institution for Clinical Sciences, Sahlgrenska Academy at University of Gothenburg , Gothenburg , Sweden
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Adenocarcinoma on j-pouch after proctocolectomy for ulcerative colitis-case report and review of literature. Int J Colorectal Dis 2014; 29:1171-3. [PMID: 24743848 DOI: 10.1007/s00384-014-1864-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 02/04/2023]
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Andersson P, Norblad R, Söderholm JD, Myrelid P. Ileorectal anastomosis in comparison with ileal pouch anal anastomosis in reconstructive surgery for ulcerative colitis--a single institution experience. J Crohns Colitis 2014; 8:582-9. [PMID: 24315777 DOI: 10.1016/j.crohns.2013.11.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/12/2013] [Accepted: 11/13/2013] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Ileal pouch anal anastomosis (IPAA) is the standard procedure for reconstruction after colectomy for ulcerative colitis (UC). However, ileorectal anastomosis (IRA) as an alternative has, recently experienced a revival. This study from a single center compares the clinical outcomes of these procedures. METHODS From 1992 to 2006, 253 patients consecutively underwent either IRA (n=105) or IPAA (n=148). Selection to either procedure was determined on the basis of rectal inflammation, presence of dysplasia/cancer or patient preferences. Patient-records were retrospectively evaluated. Mean follow-up time was 5.4 and 6.3 years respectively. RESULTS Major postoperative complications occurred in 12.4% of patients after IRA and in 12.8% after IPAA (ns). Complications of any kind after IRA or IPAA, even including subsequent stoma-closure, occurred in 23.8% and 39.9% respectively (p<0.01). Estimated cumulative failure rates after 5 and 10 years were 10.1% and 24.1% for IRA and 6.1% and 18.6% for IPAA respectively (ns). The most common cause for failure was intractable proctitis (4.8%) and unspecified dysfunction (4.8%) respectively. At follow-up 76.9% of patients with IRA had proctitis and 34.1% with IPAA had pouchitis. Estimated cumulative cancer-risk after 10, 20 and 25 year duration of disease was 0.0%, 2.1% and 8.7% for IRA. Figures for IPAA were 0.7%, 1.8% and 1.8% (ns). CONCLUSION Failure-rates did not significantly differ between patients operated with IRA or IPAA. Patients operated with IPAA had a higher cumulative number of postoperative complications. The high long-term cancer-risk after IRA indicates that this procedure should be an interim solution in younger patients.
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Affiliation(s)
- Peter Andersson
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden.
| | - Rickard Norblad
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
| | - Johan D Söderholm
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
| | - Pär Myrelid
- Department of Surgery, County Council of Östergötland, Linköping, Sweden; Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
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Systematic review of cuff and pouch cancer in patients with ileal pelvic pouch for ulcerative colitis. Inflamm Bowel Dis 2014; 20:1296-308. [PMID: 24681656 DOI: 10.1097/mib.0000000000000026] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for refractory or complicated ulcerative colitis (UC). Since 1990, pouch-related adenocarcinomas have been described. The aim of this study was to review the literature to evaluate the burden of this complication, seeking for risk factors, prevention, and ideal management. METHODS We performed a systematic review of the literature to identify all described pouch-related adenocarcinoma in patients operated on with IPAA for UC. Studies were thoroughly evaluated to select authentic de novo pouch carcinomas. Some authors were contacted for additional information. Data of patients were pooled. Meta-analyses of suitable studies were attempted to identify risk factors. RESULTS Thirty-four articles reported on 49 patients (2:1, male:female) who developed unequivocal pouch-related adenocarcinoma, 14 (28.6%) and 33 (67.3%) arising from the pouch and anorectal mucosa, respectively. Origin was not reported in 2 (4%). Pooled cumulative incidence of pouch-related adenocarcinoma was 0.33% (95% confidence interval [CI], 0.31-0.34) 50 years after the diagnosis and 0.35% (95% CI, 0.34-0.36) 20 years after IPAA. Primary pouch cancer incidence was below 0.02% 20 years after IPAA. Neoplasia on colectomy specimen was the strongest risk factor (odds ratio, 8.8; 95% CI, 4.61-16.80). Mucosectomy did not abolish the risk of subsequent cancer but avoiding it increased 8 times the risk of cancer arising from the residual anorectal mucosa (odds ratio, 8; 95% CI, 1.3-48.7; P = 0.02). Surveillance is currently performed yearly starting 10 years since diagnosis, but cancers escaping this pathway are reported. In patients receiving mucosectomy, a 5-year delay for surveillance could be proposed. CONCLUSIONS Pouch-related adenocarcinomas are rare. Diagnosis of Crohn's disease in the long term may further decrease the rates in UC. Presumed evolution from dysplasia might offer a time window for cancer prevention. Abdominoperineal excision should be recommended for pouch-related adenocarcinomas.
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