Double stapled ileal pouch anal anastomosis (DS-IPAA) for mucosal ulcerative colitis (MUC): is there a correlation between the tissue type in the circular stapler donuts and in follow-up biopsy?

Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques

BACKGROUND

Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques.

OBJECTIVE

To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy.

DATA SOURCE

Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

STUDY SELECTION

Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis.

INTERVENTION

IPAA technique.

MAIN OUTCOME MEASURES

Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function).

RESULTS

Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques.

LIMITATIONS

A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy.

CONCLUSIONS

Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.

Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis

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.

Diagnosis and management of dysplasia and cancer of the ileal pouch in patients with underlying inflammatory bowel disease

Approximately 30% of the patients with ulcerative colitis (UC) would ultimately require colectomy for medically refractory UC or UC-associated neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for these patients. However, this procedure does not completely abolish the risk for neoplasia of the pouch. The main risk factor for pouch neoplasia is a preoperative diagnosis of UC-associated dysplasia or cancer. Although the natural history and prognosis of pouch dysplasia are not clear, mortality associated with pouch cancer, once diagnosed, appears to be high. Conversely, not all pouch neoplasia follows the chronic inflammation-dysplasia-cancer sequence, which makes pouch endoscopy with biopsy, the current gold standard for surveillance, challenging. In addition, the findings that pouch neoplasia is not common and that pouch endoscopy still misses dysplasia lead to controversy on the need and time interval of routine endoscopic surveillance. However, based on reports in the literature and their own experience, the authors recommend surveillance endoscopy to be performed in patients at risk, such as those with a precolectomy diagnosis of UC-associated neoplasia. This review appraises issues in the prevalence and incidence, risk factors, technical aspects of pouch construction, clinical and pathological features, natural history, surveillance examination, diagnosis, and management of pouch neoplasia.

Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis

Background

The aim of this systematic review was to assess the prevalence and site of dysplasia after restorative proctocolectomy (RPC) for ulcerative colitis (UC), and to identify risk factors that could be used in a surveillance programme.

Methods

Medical databases were searched for potentially relevant publications between 1978 and 2006. Studies that dealt with RPC for UC and postoperative surveillance were included. Two researchers independently performed study selection, quality assessment, data extraction and analysis.

Results

Twenty-three observational studies and case series were included, with a total of 2040 patients. The pooled prevalence of confirmed dysplasia in the pouch, anal transitional zone or rectal cuff was 1·13 (range 0–18·75) per cent. The prevalence of high-grade dysplasia, low-grade dysplasia and indefinite for dysplasia was 0·15 (range 0–4·49), 0·98 (range 0–15·62) and 1·23 (range 0–25·28 per cent) respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal transitional zone. Dysplasia and cancer identified before or at operation seemed to be significant predictors of the development of dysplasia. Pouchitis and duration of follow-up were not of predictive value.

Conclusion

Although based on low-level evidence from uncontrolled studies, the prevalence of dysplasia observed after RPC was remarkable. A surveillance programme that takes into account the risk factors found is therefore advocated.