Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis

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.

Primary Signet Ring Cell Carcinoma of the Ileal Pouch

A 55-year-old man with a history of ulcerative colitis status post ileal pouch-anal anastomosis underwent evaluation for pouchitis. He was found to have signet ring cell cancer within the pouch. Primary cancers of the ileal pouch are rare. Signet ring cell carcinoma is a rare form of adenocarcinoma that can involve the gastrointestinal tract and other organs. We present a case of a signet ring cell carcinoma arising from an ileal pouch.

Ileal Pouchitis With Endoscopic Pictures

Ulcerative colitis (UC) is an inflammatory disorder, and almost one-third of UC patients ultimately undergo surgical interventions because of complications or refractory disease. Current restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard intervention for severe chronic UC with refractory disease. Several complications associated with this procedure can occur, including anastomotic leak, sepsis, and pouch ischemia. The most frequent long-term complication is pouchitis, an idiopathic inflammatory condition involving the ileal pouch. Presentations may vary but include stool frequency, urgency, incontinence, fatigue, malaise, and fever, less commonly bloody stools. We report a case of ileal pouchitis in a young patient, two years after proctocolectomy with IPAA responsive to antibiotic treatment. Our case supports that imaging studies like flexible sigmoidoscopy are necessary to rule out other disorders in patients with pouchitis.

Surveillance pouchoscopy for dysplasia: Cleveland Clinic Ileoanal Pouch Anastomosis Database

BACKGROUND

No formal guidelines exist for surveillance pouchoscopy following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis.

METHODS

All adults who had previously had IPAA for ulcerative colitis, and underwent a pouchoscopy between 1 January 2010 and 1 January 2020, were included.

RESULTS

A total of 9398 pouchoscopy procedures were performed in 3672 patients. The majority of the examinations were diagnostic (8082, 86·0 per cent; 3260 patients) and the remainder were for routine surveillance (1316, 14·0 per cent; 412 patients). Thirteen patients (0·14 per cent of procedures) were found to have biopsy-proven neoplasia at the time of pouchoscopy; seven had low-grade dysplasia (LGD) (0·07 per cent; all located in the anal transition zone), none had high-grade dysplasia (HGD) and six (0·06 per cent) had invasive adenocarcinoma (4 in anal transition zone and 6 in pouch). Of the six patients with adenocarcinoma, four had neoplasia at the time of proctocolectomy (2 adenocarcinoma, 1 LGD, 1 HGD); all six were symptomatic with anal bleeding or pelvic pain at the time of pouchoscopy, had a negative surveillance pouchoscopy examination within 2 years of diagnosis of adenocarcinoma, had palpable masses on digital rectal examination, and had visible lesions at the time of pouchoscopy.

CONCLUSION

Surveillance pouchoscopy is not recommended in asymptomatic patients because significant neoplasia following IPAA for ulcerative colitis is rare.

An autopsy case of primary jejunal pouch cancer which protruded from the abdominal wall 14 years after total gastrectomy for gastric cancer

Adenocarcinoma which develops in the jejunal pouch has rarely been reported, but most of such cases tend to be a recurrence of primary cancer due to the presence of residual or disseminated cancer cells. Primary jejunal pouch cancer is extremely rare. We experienced an autopsy case of primary jejunal pouch cancer which occurred 14 years after proximal gastrectomy for gastric cancer. A female in her late 60s was admitted because of hypoglycemia with liver dysfunction. She underwent total gastrectomy for fundic cancer and had been reconstructed by jejunal pouch interposition 14 years prior to this presentation. Hypoglycemia recovered by nutritional support. Computed tomography demonstrated severe fatty liver and liver biopsy proved non-alcoholic steatohepatitis, which was supposed to have been induced by malnutrition. Screening esophagogastroduodenoscopy (EGD) revealed no tumorous lesions in the jejunal pouch at this time. However, her anorexia gradually progressed and the symptom of bowel obstruction appeared. EGD performed 5 months after the previous EGD revealed adenocarcinoma which extended from the anastomosis of the interposed jejunum. Then liver metastasis developed and jejunal pouch cancer invaded the abdominal wall and protruded with ulcer formation. Finally, the patient died of malnutrition. An autopsy revealed adenocarcinoma which had developed in the interposed jejunal pouch and protruded through the abdominal wall accompanied with lung and liver metastasis. We herein describe this rare case of primary interposed jejunal pouch cancer and discuss our findings including a review of the pertinent literature.

Endoscopy in Postoperative Patients with Crohn's Disease or Ulcerative Colitis. Does It Translate to Better Outcomes?

This article discusses the use of endoscopy in patients with Crohn disease and ulcerative colitis in the postoperative setting. Endoscopy is the most sensitive and validated tool available in the diagnosis of recurrence of Crohn disease in the postoperative setting. It is also the most effective diagnostic modality available for evaluating complications of pouch anatomy in patients with ulcerative colitis. In addition to diagnosis, management postoperatively can be determined through endoscopy.

Current Practices in Ileal Pouch Surveillance for Patients With Ulcerative Colitis: A Multinational, Retrospective Cohort Study

BACKGROUND AND AIMS

There are no universally accepted guidelines regarding surveillance of ulcerative colitis [UC] patients after restorative proctocolectomy and ileal pouch-anal anastomosis [IPAA]. There also exists a lack of validated quality assurance standards for performing pouchoscopy. To better understand IPAA surveillance practices in the face of this clinical equipoise, we carried out a retrospective cohort study at five inflammatory bowel disease [IBD] referral centres.

METHODS

Records of patients who underwent IPAA for UC or IBD unclassified [IBDU] were reviewed, and patients with <1-year follow-up after restoration of intestinal continuity were excluded. Criteria for determining the risk of pouch dysplasia formation were collected as well as the use of pouchoscopy, biopsies, and completeness of reports.

RESULTS

We included 272 patients. Median duration of pouch follow-up was 10.5 [3.3-23.6] years; 95/272 [35%] had never undergone pouchoscopy for any indication; 191/272 [70%] had never undergone pouchoscopy with surveillance as the specific indication; and 3/26 [12%] high-risk patients had never undergone pouchoscopy. Two cases of adenocarcinoma were identified, occurring in the rectal cuff of low-risk patients. Patients under the care of surgeons appeared more likely to undergo surveillance, but rates of incomplete reporting were higher among surgeons [78%] than gastroenterologists [54%, p = 0.002].

CONCLUSIONS

We observed wide variation in surveillance of UC/IBDU-IPAA patients. In addition, the rate of neoplasia formation among 'low-risk' patients was higher than may have been expected. We therefore concur with previous recommendations that pouchoscopy be performed at 1 year postoperatively, to refine risk-stratification based on clinical factors alone. Reports should document findings in all regions of the pouch and biopsies should be taken.

Controversies in Pouch Surveillance for Patients with Inflammatory Bowel Disease

CASE 1

Following 2 years of rectal blood loss, a 31-year-old male was diagnosed with ulcerative pancolitis in 1978. Initial treatment consisted of both topical and systemic 5-aminosalicylic acids [5-ASAs], and remission was achieved. In both 1984 and 1986 he was hospitalised due to exacerbations necessitating treatment with intravenous corticosteroids. The following years went well, without disease activity, under treatment with 5-ASA. In 1997, at the age of 50 years, a surveillance colonoscopy showed a stenotic process with a macroscopic irregularity in the sigmoid region. Histology revealed at least high-grade dysplasia [HGD] and signs of an invasive growth pattern which could indicate colorectal cancer [CRC]. The patient underwent restorative proctocolectomy with ileal pouch-anal anastomosis [IPAA]. Histology of the resection specimen confirmed active inflammation in the colon and rectum and a carcinoma in situ was identified in the sigmoid colon without invasive growth. This patient did not have significant comorbidities-for example primary sclerosing cholangitis [PSC]-and the CRC family history was negative. What pouch surveillance strategy should be recommended?

CASE 2

A 34-year-old man presented at our inflammatory bowel disease [IBD] centre with ulcerative proctitis. Ten years later, after an initially mild disease course, his disease progressed to a pancolitis. An 11-year period with multiple exacerbations [on average every 2 year, including hospitalisation] followed and treatment consisted of topical and systemic 5-ASAs with intermittent corticosteroids. In 1998, at the age of 65 years, a two-stage restorative proctocolectomy with IPAA was performed due to disease activity refractory to systemic corticosteroids. The colectomy specimen confirmed the diagnosis of ulcerative pancolitis without evidence for colorectal dysplasia or carcinoma. Other than steroid-induced diabetes mellitus, this patient had no comorbidities. His father died from CRC at unknown age. What pouch surveillance strategy should be recommended?

Neoplasia in the colorectal specimens of patients with ulcerative colitis and ileal pouch-anal anastomosis - need for routine surveillance?

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.

Large bowel mucosal neoplasia in the original specimen may increase the risk of ileal pouch neoplasia in patients following restorative proctocolectomy for ulcerative colitis

PURPOSE

Restorative proctocolectomy is a current gold standard procedure for patients who require a colectomy for ulcerative colitis. The incidence of ileal pouch neoplasia is low. The aims of this study were to assess the prevalence of neoplasia in ileal pouch and investigate the risk factors for ileal pouch neoplasia.

METHODS

A total of 276 patients who underwent restorative proctocolectomy for ulcerative colitis between 1984 and 2009 were analyzed. Results of histological examinations of both original specimen and biopsies from the J-pouch taken during routine pouch endoscopy were evaluated. Patients' records were analyzed for ulcerative colitis duration, the time from pouch creation to pouch neoplasia, presence of pouchitis, as well as the concurrent primary sclerosing cholangitis.

RESULTS

Analyzing the original specimen of large bowel, fifty-six lesions of low-grade dysplasia, twenty-five high-grade dysplasia, and five adenocarcinoma were revealed. All patients with dysplasia (n = 8) or adenocarcinoma (n = 1) of the J-pouch were positive for dysplasia in the original specimen. Duration of ulcerative colitis before surgery and duration time following restorative proctocolectomy were found as risk factors for J-pouch neoplasia with a significant difference (p = 0.01 and p = 0.0003, respectively). Patients with pouch neoplasia developed significantly more severe pouchitis (p = 0.00001).

CONCLUSIONS

Neoplasia of the J-pouch is rare. Patients with neoplasia in the original specimen are more susceptible to develop neoplasia in the J-pouch. Precise follow-up in patients with neoplasia lesions in the original specimen should be recommended. Moreover, in patients with risk factors, the exact surveillance pouch endoscopy should be recommended.

Colorectal cancer surveillance in patients with inflammatory bowel disease and primary sclerosing cholangitis: an economic evaluation

BACKGROUND

The cost-effectiveness of annual colonoscopy for detection of colorectal neoplasia among patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is uncertain. The aim of this study was to determine whether annual colonoscopy among patients with IBD-PSC is cost-effective compared with less frequent intervals from the perspective of a publicly funded health care system.

METHODS

A cost-utility analysis using a Markov model was used to simulate a 35-year-old patient with a 10-year history of well-controlled IBD and a recent diagnosis of concomitant PSC. The following strategies were compared: no surveillance, colonoscopy every 5 years, biennial colonoscopy, and annual colonoscopy. Outcome measures included: costs, number of cases of dysplasia found, number of cancers found and missed, deaths, quality-adjusted life-years (QALYs) gained, and the incremental cost per QALY gained.

RESULTS

In the base-case analysis, no surveillance was the least expensive and least effective strategy. Compared with no surveillance, the cost per QALY of surveillance every 5 years was CAD $15,021. The cost per QALY of biennial surveillance compared with surveillance every 5 years was CAD $37,522. Annual surveillance was more effective than biennial surveillance, but at an incremental cost of CAD $174,650 per QALY gained compared with biennial surveillance.

CONCLUSIONS

More frequent colonoscopy screening intervals improve effectiveness (i.e., detects more cancers and prevents additional deaths), but at higher cost. Health systems must consider the opportunity costs associated with different surveillance colonoscopy intervals when deciding which strategy to implement among patients with IBD-PSC.

Managing intractable proctitis and the problematic pouch

Proctitis accounts for a significant proportion of cases of ulcerative colitis (UC), and some patients subsequently develop more extensive disease. However, most patients continue to have limited inflammation, although the changes in the distal colon and rectum can occasionally be severe, and symptoms of increased frequency, rectal bleeding and urgency can be as disabling as they are for patients with more extensive colitis. Furthermore, although symptoms are typically well controlled with standard medications, medically refractory proctitis poses particular problems. Patients generally are not systemically unwell, and there is no added fear of cancer. Therefore, the prospect of colectomy for such limited disease is resisted by patients, physicians and surgeons alike. Unusual therapies, often delivered locally by enema or suppository, have been tested in small case series without definitive outcomes. The pathogenesis of such limited, yet intractable inflammation remains unclear, and the differential diagnosis should be carefully reviewed to ensure that local disease, whether it is infectious, vascular, or a result of injury or degeneration, is not overlooked. Ileo-anal pouch formation is the surgery of choice for about 20% of patients with UC who undergo colectomy. In the majority of cases, this surgery results in an acceptable quality of life and freedom from a stoma. However, in a sizeable minority of cases, pouch dysfunction can cause intractable problems. The causes of pouch dysfunction are varied and must all be considered carefully, particularly in refractory cases. Pouchitis is a common issue and is usually transient and easily treated. However, refractory and chronic pouchitis can be challenging. Ischaemia, injury, infection and Crohn's disease can all cause refractory pouch dysfunction. In a minority of cases, there appears to be no apparent organic pathology, and the presumptive diagnosis is that of a functional pouch disorder. Although it is much rarer, neoplastic changes in the pouch must also be considered, and the risk managed appropriately. The management of both intractable proctitis and the problematic pouch is made more challenging by the wide differential diagnosis that must be considered and by the paucity of high-quality clinical trials to support any one therapy. Key strategies to overcoming these limitations include methodical and systematic investigation and review, and a willingness to tailor therapy to the individual patient. Clinical trials of new treatments should be supported, and data from the experience with small cohorts of patients should be meticulously collected, critically analysed and widely disseminated.

Chronic pouchitis is associated with pouch polyp formation in patients with underlying ulcerative colitis

BACKGROUND

Polypoid lesions can develop in ileal pouches. The risk factors associated with the development of pouch polyps have not been studied.

AIM

To characterize clinical features, risk factors, and disease course of pouch polyp in a cohort of patients with underlying inflammatory bowel disease (IBD) from a subspecialty clinic.

METHOD

A total of 1094 patients with restorative proctocolectomy and IPAA for IBD presenting to our Pouchitis Clinic from 2002 to 2010 were included. Demographic, clinical, and endoscopic variables were analyzed.

RESULTS

The median durations from UC diagnosis to colectomy and from pouch creation to the last follow-up for the whole cohort were 6 (interquartile range [IQR]: 3-13) and 9years (IQR: 5-14), respectively. A total of 2472 surveillance and/or diagnostic pouchoscopies were performed for the cohort with a median follow-up of 5 (IQR: 2-6) years in the Pouchitis Clinic. The median number of pouchoscopies per patient was 2 (IQR: 1-3). Of the 1094 patients, 96 (8.8%) were found to have pouch polyps. The median size of the polyps was 1.2 (IQR: 1.0-2.0) cm. On histology, 93 patients (96.9%) had inflammatory-type polyps and 3 (3.1%) had polyps with low-grade dysplasia or indefinite for dysplasia. Multivariate logistic regression analysis demonstrated that chronic pouch inflammatory change was a risk factor for the development of pouch polyp with an odds ratio of 2.26 (95% confidence interval: 1.35-3.79; P=0.002).

CONCLUSION

The majority of pouch polyps in patients with underlying UC were benign. Patients with concomitant chronic pouch inflammatory changes had an increased risk for developing pouch polyps.

Non-colorectal intestinal tract carcinomas in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (II)

Patients with inflammatory bowel diseases (IBD) have an excess risk of certain gastrointestinal cancers. Much work has focused on colon cancer in IBD patients, but comparatively less is known about other more rare cancers. The European Crohn's and Colitis Organization established a pathogenesis workshop to review what is known about these cancers and formulate proposals for future studies to address the most important knowledge gaps. This article reviews the current state of knowledge about small bowel adenocarcinoma, ileo-anal pouch and rectal cuff cancer, and anal/perianal fistula cancers in IBD patients.

Histopathological evaluation and risk factors related to the development of pouchitis in patients with ileal pouches for ulcerative colitis

OBJECTIVE

Many changes in mucosal morphology are observed following ileal pouch construction, including colonic metaplasia and dysplasia. Additionally, one rare but potential complication is the development of adenocarcinoma of the reservoir. The aim of this study was to evaluate the most frequently observed histopathological changes in ileal pouches and to correlate these changes with potential risk factors for complications.

METHODS

A total of 41 patients were enrolled in the study and divided into the following three groups: a non-pouchitis group (group 1) (n = 20; 8 males; mean age: 47.5 years) demonstrating optimal outcome; a pouchitis without antibiotics group (group 2) (n = 14; 4 males; mean age: 47 years), containing individuals with pouchitis who did not receive treatment with antibiotics; and a pouchitis plus antibiotics group (group 3) (n = 7; 3 males; mean age: 41 years), containing those patients with pouchitis who were administered antibiotics. Ileal pouch endoscopy was performed, and tissue biopsy samples were collected for histopathological analysis.

RESULTS

Colonic metaplasia was found in 15 (36.6%) of the 41 patients evaluated; of these, five (25%) were from group 1, eight (57.1%) were from group 2, and two (28.6%) were from group 3. However, no correlation was established between the presence of metaplasia and pouchitis (p = 0.17). and no differences in mucosal atrophy or the degree of chronic or acute inflammation were observed between groups 1, 2, and 3 (p>0.45). Moreover, no dysplasia or neoplastic changes were detected. However, the degree of mucosal atrophy correlated well with the time of postoperative follow-up (p = 0.05).

CONCLUSIONS

The degree of mucosal atrophy, the presence of colonic metaplasia, and the degree of acute or chronic inflammation do not appear to constitute risk factors for the development of pouchitis. Moreover, we observed that longer postoperative follow-up times were associated with greater degrees of mucosal atrophy.

Evaluating pouch problems

IPAA is a technically demanding procedure that requires appropriate skills and expertise. Adverse sequelae of IPAA are common. Accurate diagnosis and classification of pouch disorders and associated complications are important for proper management and prognosis. Based on presenting symptoms, appropriate and combined diagnostic modalities should apply. A multidisciplinary approach involving gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and gastrointestinal radiologists is advocated for diagnosis and treatment of pouch disorders.

Comprehensive analysis of the bacterial content of stool from patients with chronic pouchitis, normal pouches, or familial adenomatous polyposis pouches

BACKGROUND

Chronic pouchitis is an important long-term complication following ileal pouch-anal anastomosis for ulcerative colitis. Antibiotic administration reduces symptoms of pouchitis, indicating that bacteria have a role in pathogenesis. The aim of the research was to investigate the bacterial content of pouches using nucleic acid-based methods.

METHODS

Stool microbiota of 17 patients with normal pouches (NP), 17 patients with pouchitis (CP) utilizing samples collected from each patient when antibiotic-treated (CP-on, asymptomatic) and when untreated (CP-off, symptomatic), and 14 familial adenomatous polyposis (FAP) patients were analyzed by high-throughput sequencing, fluorescence in situ hybridization technologies, and quantitative polymerase chain reaction (qPCR).

RESULTS

Fluorescence in situ hybridization analysis revealed an expanded phylogenetic gap in NP and CP-off patients relative to FAP. Antibiotic treatment reduced the gap in CP stool. The phylogenetic gap of CP-off patients was due to members of the bacterial families Caulobacteriaceae, Sphingomonadaceae, Comamonadaceae, Peptostreptococcaceae, and Clostridiaceae. There was a greater diversity of phylotypes of Clostridiaceae in CP-off subjects. The phylogenetic gap of NP stool was enriched by Ruminococcaceae and Bifidobacteriaceae. CP stool microbiota had reduced diversity relative to NP and FAP stool due largely to a reduction in Lachnospiraceae/Insertae Sedis XIV/clostridial cluster IV groups.

CONCLUSIONS

Bacterial groups within the expanded phylogenetic gap of pouch patients may have roles in the pathogenesis of pouchitis. Further research concerning the physiology of cultured members of these groups will be necessary to explain their specific roles. Members of the Lachnospiraceae, Incertae Sedis XIV, and clostridial cluster IV could be useful biomarkers of pouch health.

The prevalence of dysplasia in the ileoanal pouch following restorative proctocolectomy for ulcerative colitis with associated dysplasia

AIM

A recent systematic review indicated that dysplasia present before restorative proctocolectomy is a predictor of subsequent dysplasia in the pouch. This prospective study was carried out to assess the prevalence of dysplasia in the ileal pouch in patients having RPC for ulcerative colitis with co-existing dysplasia in the operation specimen.

METHOD

Eligible patients were invited for a surveillance endoscopy. The afferent and blind efferent ileal loop, ileoanal pouch and rectal cuff were examined by standard endoscopy using a dye-spray technique with methylene blue. Mucosal abnormalities were biopsied and random biopsies were taken from the afferent and blind ileal loop, pouch and rectal cuff.

RESULTS

Fourty-four patients (25 male, mean 49 years) underwent pouch endoscopy at a mean interval from RPC of 8.6 years. Dysplasia was detected in two (4.5%) patients. In one, low-grade dysplasia was found in the rectal cuff and in the other low-grade dysplasia was detected in random biopsies from the pouch and the efferent ileal loop.

CONCLUSION

This prospective pouch-endoscopy study detected dysplasia in < 5% of patients over nearly 10 years. The benefit of routine surveillance for dysplasia in the pouch is uncertain, as the significance of low-grade dysplasia in the pouch is not clear.

Pouchitis may increase the risk of dysplasia after restorative proctocolectomy in patients with ulcerative colitis

AIM

Dysplasia of the pouch mucosa after restorative proctocolectomy is rare. The aim of this study was to establish whether there is a correlation between pouchitis and dysplasia.

METHOD

A group of 276 patients treated for ulcerative colitis by restorative proctocolectomy between 1984 and 2009 was analysed. The presence or absence of pouchitis and dysplasia within the pouch was evaluated.

RESULTS

Inflammation was diagnosed in 66 (23.9%) patients, low-grade dysplasia in five (1.8%), high-grade dysplasia in three (1.1%), and cancer in one patient (0.4%). The prevalence of low-grade dysplasia was significantly higher in patients with inflammation than in those without (P < 0.04). High-grade dysplasia was significantly more frequent in pouchitis than in non-inflamed pouches (P < 0.01). Logistic regression analysis suggested that the occurrence of mucosal inflammation increased the risk of low grade dysplasia.

CONCLUSION

Patients with chronic pouchitis are at risk of dysplasia and require surveillance of the pouch.

Is surveillance endoscopy necessary after colectomy in ulcerative colitis?

The role of surveillance endoscopic followup in colectomized patients with long standing total colitis is controversial. Here, we aimed to clarify its usefulness for the early detection of dysplasia and cancer in this group of patients. Ninety-seven colectomised UC patients followedup by surveillance endoscopy were retrospectively investigated by reviewing the pathological reports. Patients had received either subtotal colectomy and ileo-rectal anastomosis (IRA) or total proctocolectomy and ileal anal anastomosis (IPAA). Definite dysplasia was diagnosed in 4 patients, who had received IRA; among them, 2 were carcinoma with submucosal invasion, and one was a high-grade dysplasia. Postoperative surveillance endoscopy is useful for the detection of early cancer in the remaining colonic mucosa of UC patients, and those receiving IRA, in which rectal mucosa is left intact, would be good candidates. However, its effectiveness for patients receiving IPAA, in which the rectal mucosa is resected, needs further investigation.

Inflammatory bowel disease-associated colorectal cancer: proctocolectomy and mucosectomy do not necessarily eliminate pouch-related cancer incidences

BACKGROUND

Colorectal cancer (CRC), the most lethal long-term complication of inflammatory bowel disease (IBD), is the culmination of a complex sequence of molecular and histologic derangements of the colon epithelium that are initiated and at least partially sustained by prolonged chronic inflammation. Dysplasia, the earliest histologic manifestation of this process, plays an important role in cancer prevention by providing the first clinical alert that this sequence is under way and by serving as an endpoint in colonoscopic surveillance of patients at high risk for CRC. Restorative proctocolectomy (RPC) is indicated for patients with IBD, specifically for ulcerative colitis that is refractory to medical treatment, emergency conditions, and/or in case of neoplastic transformation. Even after RPC with mucosectomy, pouch-related carcinomas have recently been reported with increasing frequency since the first report in 1984. We review IBD-associated CRC and pouch-related neoplasia prevalence, adverse events, risk factors, and surveillances.

METHODS

Literature of IBD-associated CRC patients and those undergoing RPC surgeries through 2010 were prospectively reviewed.

RESULTS

We found 12 studies from retrospective series and 15 case reports. To date, there are 43 reported cases of pouch-related cancers. Thirty-two patients had cancer in the anal transit zone (ATZ); of these, 28 patients had mucosectomy. Eleven patients had cancer found in the pouch body.

CONCLUSION

RPC with mucosectomy does not necessarily eliminate risks. There is little evidence to support routine surveillance of pouch mucosa and the ATZ except for patients associated with histological type C changes, sclerosing cholangitis, and unremitting pouchitis.

Pouch-related dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis

BACKGROUND

Restorative proctocolectomy (RPC) is the criterion standard surgical treatment for ulcerative colitis (UC). Restorative proctocolectomy is indicated for UC that is refractory to medical treatment, for emergency conditions, and in case of neoplastic transformation. The procedure substantially reduces the risk of UC-associated dysplasia/neoplasia. However, after RPC surgery, even with mucosectomy, cancers of the pouch and/or the anal-transitional zone (ATZ) have been reported with increasing frequency since the first report in 1984. This review highlights pouch-related dysplastic and neoplastic transformation, prevalence and adverse events, risk factors and surveillance following surgery for UC.

METHODS

Reports in the literature about patients undergoing pouch surgery from different institutions reported through May 2010 were reviewed to identify patients who developed these complications, and an attempt was made to develop a rational follow-up policy based on the data available.

RESULTS

To date, there are 43 reported cancers of the pouch or inlet after RPC for UC: 16 from retrospective series, 1 from a prospective study, and 26 in case reports. Thirty patients underwent mucosectomy and 13 had stapled anastomoses. To date, the number of 28 patients has been diagnosed with dysplasia after RPC for UC. Mucosectomy was performed in 27 of them and in 1 a stapled anastomosis was constructed without mucosectomy. In all cases reviewed, the time interval from the onset of UC to dysplasia/neoplasia was over 10 years.

CONCLUSION

Neoplastic lesions occurring in UC patients after RPC have been shown to be absolutely inevitable. Even mucosectomy does not completely eliminate the risk. There is little evidence to support routine biopsy of the ileal mucosa or the anal-transition zone except in patients with histological type C changes, sclerosing cholangitis, and unremitting pouchitis in the ileal mucosa. Such patients should be selected for endoscopic surveillance to detect dysplasia preceding pouch adenocarcinoma.

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.

Risk of cancer in patients with chronic pouchitis after restorative proctocolectomy for ulcerative colitis

AIM

The aim of this study was to evaluate the consequences of chronic pouchitis after restorative proctocolectomy for ulcerative colitis.

METHOD

Forty-two patients with chronic pouchitis underwent pouch endoscopy with biopsies after a median of 8.3 years of postoperative follow up. The pouchitis disease activity index (PDAI) was calculated. Morphological changes were recorded. Immunohistochemical analyses for cyclooxygenase 2 (COX-2), Ki-67 and p53 were performed, as was DNA flow cytometry. Endoscopy was also carried out in 10 patients without pouchitis and in nine healthy subjects.

RESULTS

In patients with chronic pouchitis, the PDAI was 6 (standard error of the mean ± 4). Eighteen (43%) patients used continuous medication. The PDAI correlated positively with villous atrophy (P < 0.05). None of the pouch biopsies showed dysplasia. COX-2 immunostaining was detected in 35 (83.3%) patients with chronic pouchitis, in five (50%) without pouchitis, but in none of the normal controls. COX-2 expression correlated with mucosal atrophy (P < 0.01). In 15 (35.7%) of 42 patients with chronic pouchitis, Ki-67 immunostaining was increased, but no increase was observed in either control group (P < 0.002). No p53 immunopositivity was found, and DNA flow cytometry was normal in all pouches. One of the patients developed adenocarcinoma at the anal anastomosis.

CONCLUSION

No dysplastic changes were detected during the first decade after surgery. Routine follow up of patients with chronic pouchitis with a hand-sewn anastomosis may not be necessary, although a small risk of cancer seems to remain at the anal anastomosis. The follow up should be focused on at-risk groups.

The bowel microbiota and inflammatory bowel diseases

The human bowel contains a large and biodiverse bacterial community known as the microbiota or microbiome. It seems likely that the microbiota, fractions of the microbiota, or specific species comprising the microbiota provide the antigenic fuel that drives the chronic immune inflammation of the bowel mucosa that is characteristic of Crohn's disease and ulcerative colitis. At least twenty years of microbiological research have been expended on analysis of the composition of the bowel microbiota of inflammatory bowel disease patients in comparison to that of control subjects. Despite extensive speculations about the aetiological role of dysbiosis in inflammatory bowel diseases, knowledge that can be easily translated into effective remedies for patients has not eventuated. The causes of this failure may be due to poorly defined and executed bacteriological studies, as well as the overwhelming complexity of a biome that contains hundreds of bacterial species and trillions of bacterial cells.

Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee

Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

Adenocarcinoma in ileal pouch after proctocolectomy for familial adenomatous polyposis: report of a case

Restorative proctocolectomy with ileal pouch-anal anastomosis is one of the surgical treatments of choice for patients with familial adenomatous polyposis. Although the risk of cancer developing in an ileal pouch is not yet clear, a few cases of adenocarcinoma arising in an ileal pouch have been reported. We report a case of adenocarcinoma in ileal pouch after proctocolectomy with ileal pouch-anal anastomosis. A 56-yr-old woman was diagnosed as having familial adenomatous polyposis. Total colectomy with ileorectal anastomosis was performed. Six years later, she underwent completion-proctectomy with ileal J pouch-anal anastomosis including anorectal mucosectomy for rectal cancer. After 7 yr, she presented with anal spotting. Endoscopic biopsies revealed adenocarcinoma at the ileal pouch. Resection of the ileal pouch and permanent ileostomy were performed. The risk of cancer in an ileal pouch and its prevention with regular surveillance must be emphasized.

Prevalence and outcome of anemia after restorative proctocolectomy: a clinical literature review

PURPOSE

Iron and/or vitamin B12 deficiency anemias, which have adverse effects on patients' quality of life, are commonly observed and often overlooked complications after restorative proctocolectomy. We performed a systematic review of publications on the prevalence of anemia as well as on the impact of anemia on a range of clinical, functional, quality of life, and economic outcomes in restorative proctocolectomy patients. This information is important to help healthcare providers through a comprehensive overview to increase awareness about a condition that could require therapy to improve patient healthcare and quality of life.

METHODS

We reviewed the English language publications on the incidence of anemia and its adverse effect after restorative proctocolectomy The United States National Library of Medicine database (MEDLINE), the Excerpta Medica database (EMBASE), the Cochran Library, and the Google search engine were searched for published articles on the prevalence and impact of anemia in post-restorative proctocolectomy surgical patients.

RESULTS

The long-term complication most frequently described after RPC is pouchitis. Pouchitis is significantly associated with iron deficiency anemia caused by pouch mucosal bleeding. Other causes are insufficient and/or impaired iron absorption. It has also been observed, however, that restorative proctocolectomy patients with underlying familial adenomatous polyposis rarely develop pouchitis yet show higher rates of iron deficiency anemia compared to those patients with underlying ulcerative colitis. Other causes shown as independent risk factors for iron deficiency anemia in restorative proctocolectomy patients are malignancy, desmoid tumors, and J-pouch configuration. Vitamin B12 deficiency anemia is also common after restorative proctocolectomy. About one-third of restorative proctocolectomy patients show abnormal Schilling test and 5 percent have low referenced serum cobalamin. It has been observed that the degree resection of the terminal-ileum, malabsorption, bacterial overgrowth, and dietary factors are among the known causes of cobalamin deficiency. Folate deficiency has not been reported in restorative proctocolectomy patients. Describing restorative proctocolectomy surgery and its outcomes, in patients without anemia, the quality of life is reported excellent regardless of operative technique.

CONCLUSIONS

Anemia is not uncommon following restorative proctocolectomy and has been shown to have negative effects on the patient's quality of life and the economy and may substantially increase healthcare costs. The treatment of anemia and its underlying causes is important to improving clinical and economic outcomes.

Medical management of patients with ileal pouch anal anastomosis after restorative procto-colectomy

Restorative procto-colectomy with ileal pouch anal anastomosis has become the most common elective surgical procedure for patients with ulcerative colitis and is becoming popular in those with familial adenomatous polyposis coli. The procedure itself is primarily carried out in specialist surgical centres but an increasing number are being performed and followed up in district general hospitals. These patients are now filtering through general surgical and gastroenterology clinics and are frequently seen in primary care. Pouchitis, an inflammatory condition of the ileal pouch, has become the third most important form of inflammatory bowel disease. As research develops in this area, other complications are being found. The aim of this review is to provide an up-to-date, evidence-based approach to the clinical management of these patients.

Colorectal cancer in inflammatory bowel disease

Patients with long-standing inflammatory bowel disease have an increased risk of developing colorectal cancer (CRC). CRC risk increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and severity of inflammation of the colon. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid. To reduce CRC mortality in IBD, colonoscopic surveillance remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.

Familial adenomatous polyposis and the small bowel: a loco-regional review and current management strategies

Small-bowel tumours are an important cause of morbidity and death in patients with familial adenomatous polyposis. Intensive endoscopic surveillance is now standard in the long-term management of this condition. Thus, lesions occurring throughout the small bowel are increasingly noted by oesophagogastroduodenoscopy and flexible pouchoscopy. Some occur commonly de novo (in stomach, duodenum and ampulla), while others may occur following surgery (polyps of the ileostomy, ileoanal pouch, or small bowel above an anastomosis). These differ widely in incidence, natural history and management. This review provides a regional overview of these lesions, in terms of current research findings and management protocols.

Analysis of bacterial bowel communities of IBD patients: what has it revealed?

The bacterial community, in whole or in part, resident in the bowel of humans is considered to fuel the chronic immune inflammatory conditions characteristic of Crohn's disease and ulcerative colitis. Chronic or recurrent pouchitis in ulcerative colitis patients is responsive to antibiotic therapy, indicating that bacteria are the etiological agents. Microbiological investigations of the bacterial communities in stool or of biopsy-associated bacteria have so far failed to reveal conclusively the existence of pathogens or bacterial communities of consistently altered composition in IBD patients relative to control subjects. Confounding factors need to be eliminated from future studies by using better-defined patient populations of newly diagnosed and untreated individuals and by improved sampling procedures.

Assessment of the mucosa of the indefinitely diverted ileo-anal pouch

OBJECTIVE

One surgical option to treat failure after restorative proctocolectomy (RPC) is indefinite diversion (ID) without excision of the pouch. The study aimed to assess the mucosal morphology of the pouch and ileoanal anastomosis (IAA) over time after ID with particular reference to inflammation, dysplasia and carcinoma.

METHOD

Patients with ID were identified from the hospital's Ileal Pouch Database. Individuals were invited by mail to attend for flexible pouchoscopy and biopsy from the ileal pouch and immediately distal to the IAA.

RESULTS

Of 1822 patients on the database, 28 had undergone ID. Of these, 20 patients (18 ulcerative colitis, one familial adenomatous polyposis, one pseudo-obstruction) of median age 42 (18-67) years took part. There were eight males. The median (range) intervals from diagnosis of primary disease, pouch surgery and ID to the time of study were 221 (63-410), 146 (31-314) and 44 (10-159) months respectively. One patient had dysplasia in the original resection specimen. Five patients developed type C changes in the pouch. Of these three were identified between RPC and ID, one developed between ID and the present assessment and one was identified for the first time at the present assessment. No case of dysplasia or cancer was found in any of the biopsies. Rectal mucosa was found in biopsies from the IAA in four patients (three stapled; one handsewn); this was inflamed in three patients.

CONCLUSION

At a median follow-up of 12 years after RPC and 3.6 years after indefinite diversion no instance of dysplasia or carcinoma in the ileal reservoir or distal to the IAA was found in any of the 20 patients having ID. Type C changes occurred at some time in five (25%) patients, indicating the importance of continued follow up.

Cancer in inflammatory bowel disease

Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colorectal cancer (CRC). Many of the molecular alterations responsible for sporadic colorectal cancer, namely chromosomal instability, microsatellite instability, and hypermethylation, also play a role in colitis-associated colon carcinogenesis. Colon cancer risk in inflammatory bowel disease increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and degree of inflammation of the bowel. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid and statins. To reduce CRC mortality in IBD, colonoscopic surveillance with random biopsies remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Patients with small intestinal Crohn's disease are at increased risk of small bowel adenocarcinoma. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. Other extra intestinal cancers, such as hepatobiliary and hematopoietic cancer, have shown variable incidence rates. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Cancer in inflammatory bowel disease

Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colorectal cancer (CRC). Many of the molecular alterations responsible for sporadic colorectal cancer, namely chromosomal instability, microsatellite instability, and hypermethylation, also play a role in colitis-associated colon carcinogenesis. Colon cancer risk in inflammatory bowel disease increases with longer duration of colitis, greater anatomic extent of colitis, the presence of primary sclerosing cholangitis, family history of CRC and degree of inflammation of the bowel. Chemoprevention includes aminosalicylates, ursodeoxycholic acid, and possibly folic acid and statins. To reduce CRC mortality in IBD, colonoscopic surveillance with random biopsies remains the major way to detect early mucosal dysplasia. When dysplasia is confirmed, proctocolectomy is considered for these patients. Patients with small intestinal Crohn’s disease are at increased risk of small bowel adenocarcinoma. Ulcerative colitis patients with total proctocolectomy and ileal pouch anal-anastomosis have a rather low risk of dysplasia in the ileal pouch, but the anal transition zone should be monitored periodically. Other extra intestinal cancers, such as hepatobiliary and hematopoietic cancer, have shown variable incidence rates. New endoscopic and molecular screening approaches may further refine our current surveillance guidelines and our understanding of the natural history of dysplasia.

Pouchitis

While restorative proctocolectomy with ileal pouch-anal anastomosis has significantly improved the quality of life in patients with underlying ulcerative colitis who require surgery, complications can occur. Pouchitis as the most common long-term complication represents a spectrum of disease processes ranging from acute, antibiotic-responsive type to chronic antibiotic-refractory entity. Accurate diagnosis using a combined assessment of symptoms, endoscopy and histology and the stratification of clinical phenotypes is important for treatment and prognosis the disease. The majority of patients respond favorably to antibiotic therapy. However, management of chronic antibiotic-refractory pouchitis remains a challenge.

Evolution of the restorative proctocolectomy and its effects on gastrointestinal hormones

Gastrointestinal (GI) peptide hormones are chemical messengers that regulate secretory, mechanical, metabolic, and trophic functions of the gut. Restorative proctocolectomy (RPC) or resection of the colon and rectum with maintenance of intestinal continuity through the construction of an ileal pouch reservoir and preservation of the anal sphincters has become the standard of care for the surgical treatment of ulcerative colitis and familial adenomatous polyposis. The manipulation of the digestive system to create the ileal pouch involves altering gut-associated lymphoid tissue among other anatomic changes that lead to changes in GI peptides. In addition, the ileal pouch epithelium responds to a wide variety of stimuli by adjusting its cellularity and function. These adaptive mechanisms involve systemic factors, such as humoral and neural stimuli, as well as local factors, such as changes in intestinal peristalsis and intraluminal nutrients. There have been conflicting reports as to whether the alterations in GI hormones after RPC have actual clinical implications. What the studies on alterations of GI peptides' response and behavior after RPC have contributed, however, is a window into the possible etiology of complications after pouch surgery, such as pouchitis and malabsorption. Given the possibility of pharmacologically modifying GI peptides or select components of adaptation as a therapeutic strategy for patients with ileal pouch dysfunction or pouchitis, a clear understanding of human pouch mucosal adaptation is of paramount importance. In this review, we summarize the evolution of the RPC and its effects on the GI hormones as well as their possible clinical implications.

Mucosal dysplasia in ileal pelvic pouches after restorative proctocolectomy

PURPOSE

Inflammation, villous atrophy, colonic metaplasia, and dysplasia have been observed within the mucosa of ileal pelvic pouches after restorative proctocolectomy. This study was designed to determine the prevalence of mucosal dysplasia in ileal pouch and any associated risk factors.

METHODS

Prospectively registered patients having restorative proctocolectomy were recruited. A cross-sectional study was performed using a questionnaire focusing on disease history, functional results, and pouchitis after surgery. Participants underwent screening endoscopic pouch examination using sigmoidoscopy. Mucosal biopsies were taken from six specific locations in the pouch from proximal ileal-pouch (inflow) to ileoanal anastomosis. All biopsies were performed under strict surveillance protocol regardless of patients' symptoms. Biopsies were interpreted by two pathologists unaware of each other's report.

RESULTS

A total of 138 patients completed the protocol. Colectomy specimens from restorative proctocolectomy showed chronic ulcerative colitis in 118 (85.6 percent), familial adenomatous polyposis in 10 (7.2 percent), Crohn's colitis in 2 (1.4 percent), and indeterminate colitis in 8 (5.8 percent) patients. Twenty-two patients (18.3 percent) had dysplasia and eight (6.7 percent) had invasive cancer found in colectomy specimens after restorative proctocolectomy. Median interval between proctocolectomy and pouch biopsy was 5.4 years. Inflammatory changes were present in a majority of specimens, but these did not correlate with clinical history of pouchitis. No villous atrophy was identified. Pouch biopsies from only one patient were indefinite for dysplasia. Subsequent biopsies were negative.

CONCLUSIONS

Clinical and microscopic evidence of ileal-pouch inflammation is common. Ileal-pouch mucosal dysplasia is uncommon, occurring in only 1 of 138 patients. Villous atrophy and colonic metaplasia were not observed in this series. Routine pouch surveillance with biopsies may not be warranted.

Clinical features of ileal pouch polyps in patients with underlying ulcerative colitis

PURPOSE

Polypoid lesions rarely occur in the ileal pouch in ulcerative colitis patients after restorative proctocolectomy. Clinical features, malignant potential, and management of pouch polyps have not been characterized.

METHODS

We identified 23 ulcerative colitis patients with large polyps (size> or =1 cm) of the ileal pouch from our 2,512-case ulcerative colitis pouch database. Demographic, clinical, endoscopic, and histologic data were reviewed. The Pouchitis Disease Activity Index symptom score (range, 0-6) was used to quantify patients' symptoms before and after polypectomy.

RESULTS

Of the 23 patients, 95.7 percent (22 patients) had pouch endoscopy indicated for the evaluation of symptoms when polyps were detected, and 60.9 percent of patients had the polyps in the pouch, 26.1 percent in the anal transitional zone, and 21.7 percent in the afferent limb. The mean size of pouch polyps was 1.9 cm +/- 1 cm. Twenty-one patients (91.3 percent) had concomitant pouchitis, cuffitis, or Crohn's disease. On histology, 21 patients (91.3 percent) had inflammatory-type polyps, and 2 (8.7 percent) had dysplastic or malignant polyps. In 18 patients who had endoscopic polypectomy with concurrent medical therapy, the prepolypectomy and postpolypectomy mean symptom scores were 3.4 +/- 1.7 and 1.1 +/- 1.2 points, respectively (P = 0.015). Two patients (8.7 percent) had pouch excision for malignancy or for concomitant chronic refractory pouchitis.

CONCLUSIONS

The majority of patients with large ileal pouch polyps were symptomatic. These polyps were typically detected on the background of pouchitis, cuffitis, or Crohn's disease. Although the majority of polyps were inflammatory type, polyps in two patients were dysplastic or malignant. Endoscopic polypectomy with concomitant medical therapy seemed to improve patients' symptom scores.

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.

Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis

OBJECTIVE

Restorative proctocolectomy (RPC) with or without mucosectomy is the treatment of choice for most patients with ulcerative colitis (UC) requiring surgery. The ileal mucosa in the reservoir and the anorectal columnar epithelium below the ileo-anal anastomosis are at risk of neoplastic transformation.

METHOD

The literature has been reviewed to identify patients developing this complication and an attempt has been made to develop a rational follow-up policy based on the data available.

RESULTS

Dysplasia in the ileal reservoir is rare. It is associated with histological type C changes, sclerosing cholangitis and unremitting pouchitis in the ileal mucosa and to the presence of sclerosing cholangitis. Nine patients who have developed adenocarcinoma in the residual anorectal mucosa and seven in the reservoir have been reported in the literature. A further hitherto unreported patient treated by the authors brings the total to 17 patients. Twelve of these had histopathological data on either dysplasia or carcinoma in the original operative specimen. The time intervals from the onset of UC and from the RPC to the development of cancer were 120-528 (median 246) and 16-216 (median 60) months respectively. Cancer appeared to be related to the duration of disease rather than to the interval from RPC. In all the reported patients the interval from the onset of UC was 10 years.

CONCLUSION

Based on these data a surveillance programme should begin at 10 years from the onset of disease. Patients with dysplasia or carcinoma in the original specimen, those with type C ileal mucosal changes and patients with sclerosing cholangitis should be selected for surveillance. This will involve multiple biopsies of the ileal reservoir and the anorectal mucosa below the ileo-anal anastomosis.

Adenocarcinoma of the ileoanal pouch for ulcerative colitis--a complication of severe chronic atrophic pouchitis?

BACKGROUND

The appearance of a carcinoma in the ileal pouch after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative proctocolitis is rare. Most of these adenocarcinomas previously described in literature develop from residual viable rectal mucosa. We report a case of an adenocarcinoma arising in all probability from the ileal pouch after malignant transformation of the ileal pouch mucosa based on a chronic atrophic pouchitis.

PATIENT AND METHODS

A 34-year-old man developed an adenocarcinoma after a double-stapled ileorectal J-pouch for ulcerative colitis (UC) proceeded from malignant ileal transformation. Before surgery, he had a 20-year history of UC refractory to medical therapy, but no occurrence of backwash ileitis, dysplasia or colitis-associated illness. He experienced severe pouchitis after IPAA since the ileostomy closure. Carcinoma was ensured by endoscopy, and the patient underwent an abdominoperineal pouch extirpation combined with excision of perirectal tissues and anal canal. Histology after surgery showed a pT4,pN2(4/16)pM0,G3 adenocarcinoma with global severe chronic atrophic pouchitis (CAP), villous atrophy and malignant ileal transformation. No metaplasia of the rectal mucosa was found, not even malignant epithelial transformation of the anal canal.

CONCLUSION

This case suggests that a malignant transformation of the ileal pouch mucosa may occur as a pure complication of severe CAP, even in the absence of backwash ileitis or a previous history of cancer. The absence of metaplasia of the rectal mucosa revealed the passage from CAP to dysplastic epithelium and to cancer. A multifactorial development of carcinogenesis is supposed, but we emphasize the importance of severe CAP, and that careful surveillance is needed in patients after IPAA. We must submit that this is just a case report and cannot stand for general cancer development in ulcerative colitis, but it may point out the risk factor of chronic inflammation and leads the surgeon to skillful working when building the pouch.