Ileal pouch adenomas and carcinomas after restorative proctocolectomy for familial adenomatous polyposis

Endoscopic management of patients with familial adenomatous polyposis after prophylactic colectomy or restorative proctocolectomy - systematic review of the literature

BACKGROUND

Patients with familial adenomatous polyposis (FAP) develop early colorectal adenomas and if left untreated, progression to cancer is an inevitable event. Prophylactic surgery does not prevent further development of cancer in the rectal remnant, rectal cuff in patients with ileal pouch anal anastomosis (IPAA) and even on the ileal mucosa of the pouch body. The aim of this review is to assess long-term rates of cancer and adenoma development in patients with FAP after prophylactic surgery and to summarise current recommendations for endoscopic management and surveillance of these patients.

MATERIALS AND METHODS

A systematic literature search of studies from January 1946 through to June 2023 was conducted using the PRISMA checklist. The electronic database PubMed was searched.

RESULTS

Fifty-four papers involving 5010 patients were reviewed. Cancer rate in the rectal remnant was 8.8-16.7% in the western population and 37% in the eastern population. The cumulative risk of cancer 30 years after surgery was 24%. Mortality due to cancer in the rectal remnant is 1.1-11.1% with a 5-year survival rate of 55%. The adenoma rate after primary IPAA was 9.4-85% with a cumulative risk of 85% 20 years after surgery and a cumulative risk of 12% for advanced adenomas 10 years after surgery. Cumulative risk for adenomas after ileorectal anastomosis (IRA) was 85% after 5 and 100% after 10 years. Adenomas developed more frequently after stapled (33.9-57%) compared to hand-sewn (0-33%) anastomosis. We identified reports of 45 cancers in patients after IPAA of which 30 were in the pouch body and 15 in the rectal cuff or at the anastomosis.

CONCLUSIONS

There was a significant incidence of cancer and adenomas in the rectal remnant and ileal pouch of FAP patients during the long-term follow-up. Regular endoscopic surveillance is recommended, not only in IRA patients, but also in pouch patients after proctocolectomy.

Surveillance and Management of Pouch Neoplasia in Familial Adenomatous Polyposis: A Systematic Review

BACKGROUND

Patients with familial adenomatous polyposis often require prophylactic colectomy with IPAA to treat or reduce the risk of colorectal neoplasia. However, after surgery, patients are still at some risk of developing pouch polyps and even cancer in both handsewn and stapled anastomoses. Management relies mainly on endoscopic or surgical interventions, whereas chemopreventive agents have a limited role in the management and prevention of pouch neoplasia. Novel endoscopic techniques are evolving and may gradually overtake surgical intervention in selected cases. Because familial adenomatous polyposis is relatively rare, there is a scarcity of data regarding the natural history of pouch polyps and cancer in this population.

OBJECTIVE

This systematic literature review aims to describe the evolution, characteristics, various treatment modalities and their outcomes, and recommended surveillance strategies of pouch neoplasia.

DATA SOURCES

PubMed and Cochrane databases and the International Ileal Pouch Consortium (for expert opinion).

STUDY SELECTION

Studies published between 1990 and 2023 in English were included. Studies reporting neoplastic outcomes of only patients with IBD-related pouch neoplasia were excluded.

MAIN OUTCOME MEASURES

Incidence of pouch neoplasia and its outcomes (successful resections, surgical complications, and mortality).

RESULTS

Thirty-five studies were included.

LIMITATIONS

Most studies focused on patients with IBD-related pouch neoplasia; there were scarce data regarding polyposis patients only. Most cohorts were small and retrospective. Data on interventions were mainly descriptive, and no randomized controlled trials were available.

CONCLUSIONS

Pouch adenomas are common and well managed by endoscopic resections because advanced endoscopic techniques are becoming more available. Additional data are required for defining updated recommendations for either endoscopic or surgical intervention. Pouch cancer is a very rare event and may arise despite surveillance. Continued endoscopic surveillance is key in cancer prevention and early detection. The outcome of cancer cases is poor, and management in a referral center should be advised with tumor board discussions. See video from symposium .

The Cumulative Incidence and Progression of Ileal Pouch Adenomas in Patients With Familial Adenomatous Polyposis

BACKGROUND

Patients with familial adenomatous polyposis who have undergone restorative proctocolectomy can develop adenomas in the pouch.

OBJECTIVE

To review experience with pouch surveillance and create a classification system for polyposis severity.

DESIGN

A retrospective review of patients undergoing IPAA and follow-up at 1 institution.

SETTING

A center for hereditary colorectal cancer within a quaternary referral center.

PATIENTS

All patients undergoing IPAA and followed endoscopically after surgery by the center.

INTERVENTIONS

Yearly pouchoscopy and treatment of polyps as required.

MAIN OUTCOME MEASURES

Primary outcome measure was incidence and severity of pouch neoplasia and its changes with time.

METHODS

A retrospective study of patients who had a restorative proctocolectomy for familial adenomatous polyposis at Cleveland Clinic. Severity of polyposis was classified on the basis of size, number, and histology.

RESULTS

One hundred sixty-five patients were analyzed. The median age at IPAA was 31 years and 52% were male. The median follow-up was 10.1 years; the median number of pouchoscopies per patient was 4. The median interval between pouchoscopies was 21.9 months. Overall, the incidence of pouch adenomas was found in 47 patients (28.5%). The median time from pouch to first pouch adenoma diagnosis was 10.3 years. The estimated cumulative incidence rates of pouch adenoma at 5, 10, 15, 20, and 30 years after IPAA were 5.9%, 21.7%, 40%, 54.8%, and 69.9%, respectively. At the first diagnosis of pouch adenoma, 25 patients had stage 1, 10 had stage 2, 8 had stage 3, and 4 had stage 4. Twenty of 47 patients progressed to a higher stage. No patient developed cancer.

LIMITATIONS

Genotype was not available for all patients.

CONCLUSIONS

There is an increasing incidence of pouch neoplasia after restorative proctocolectomy, reaching a plateau at 25 years. The polyposis is usually mild but sometimes increases in severity.

LA INCIDENCIA ACUMULADA Y LA PROGRESIN DE LOS ADENOMAS DE LA BOLSA ILEAL EN PACIENTES CON POLIPOSIS ADENOMATOSA FAMILIAR

ANTECEDENTES:Los pacientes con poliposis adenomatosa familiar que se han sometido a una proctocolectomía restauradora pueden desarrollar adenomas en la bolsa.OBJETIVO:Revisamos nuestra experiencia con la vigilancia de la bolsa y creamos un sistema de clasificación para la gravedad de la poliposis.DISEÑO:Una revisión retrospectiva de pacientes sometidos a anastomosis de bolsa ileoanal y seguimiento en una institución.ESCENARIO:Un centro para el cáncer colorrectal hereditario dentro de un centro de referencia cuaternarioPACIENTES:Todos los pacientes sometidos a anastomosis reservorio ileoanal y seguidos por vía endoscópica tras la cirugía por el centro.INTERVENCIONES:Bolsascopia anual y tratamiento de pólipos según sea necesarioPRINCIPALES MEDIDAS DE RESULTADO:Primaria: Incidencia y gravedad de la neoplasia del reservorio y sus cambios con el tiempo.MÉTODOS:Un estudio retrospectivo de pacientes que se sometieron a una proctocolectomía restauradora por poliposis adenomatosa familiar en la Clínica Cleveland. La gravedad de la poliposis se clasificó según el tamaño, el número y la histología.RESULTADOS:Se analizaron 165 pacientes. La mediana de edad del IPAA fue de 31 años y el 52% eran hombres. La mediana de seguimiento fue de 10,1 años; número medio de reservorioscopias por paciente = 4. El intervalo medio entre reservorioscopias fue de 21,9 meses. Incidencia global de adenomas de reservorio = 47/165 (28,5%). Tiempo mediano desde el reservorio hasta el primer diagnóstico de adenoma en reservorio = 10,3 años. La tasa de incidencia acumulada estimada de adenoma de bolsa a los 5, 10, 15, 20, y 30 años después de la IPAA es del 5,9%, 21,7%, 40%, 54,8%, y 69,9%, respectivamente. En el primer diagnóstico de adenoma de la bolsa, 25 pacientes tenían estadio 1, 10 estadio 2, 8 estadio 3 y 4 estadio 4. 20/47 pacientes progresaron a un estadio superior Ningún paciente desarrolló cáncer.LIMITACIONES:Genotipo no disponible para todos los pacientesCONCLUSIONES:Hay una incidencia creciente de neoplasia de la bolsa después de la proctocolectomía restauradora, alcanzando una meseta a los 25 años. La poliposis suele ser leve, pero a veces aumenta en severidad. (Traducción-Dr. Yesenia Rojas-Khalil ).

Long-term outcomes of pouch surveillance and risk of neoplasia in familial adenomatous polyposis

BACKGROUND

Long-term pouch surveillance outcomes for familial adenomatous polyposis (FAP) are unknown. We aimed to quantify surveillance outcomes and to determine which of selected possible predictive factors are associated with pouch dysplasia.

METHODS

Retrospective analysis of collected data on 249 patients was performed, analyzing potential risk factors for the development of adenomas or advanced lesions ( ≥ 10 mm/high grade dysplasia (HGD)/cancer) in the pouch body and cuff using Cox proportional hazards models. Kaplan-Meier analyses included landmark time-point analyses at 10 years after surgery to predict the future risk of advanced lesions.

RESULTS

Of 249 patients, 76 % developed at least one pouch body adenoma, with 16 % developing an advanced pouch body lesion; 18 % developed an advanced cuff lesion. Kaplan-Meier analysis showed a 10-year lag before most advanced lesions developed; cumulative incidence of 2.8 % and 6.4 % at 10 years in the pouch body and cuff, respectively. Landmark analysis suggested the presence of adenomas prior to the 10-year point was associated with subsequent development of advanced lesions in the pouch body (hazard ratio [HR] 4.8, 95 %CI 1.6-14.1; P = 0.004) and cuff (HR 6.8, 95 %CI 2.5-18.3; P < 0.001). There were two HGD and four cancer cases in the cuff and one pouch body cancer; all cases of cancer/HGD that had prior surveillance were preceded by ≥ 10-mm adenomas.

CONCLUSIONS

Pouch adenoma progression is slow and most advanced lesions occur after 10 years. HGD and cancer were rare events. Pouch phenotype in the first decade is associated with the future risk of developing advanced lesions and may guide personalized surveillance beyond 10 years.

Development of ileal adenomas after ileal pouch-anal anastomosis versus end ileostomy in patients with familial adenomatous polyposis

BACKGROUND AND AIMS

Patients with familial adenomatous polyposis (FAP) undergo (procto)colectomy to prevent colorectal cancer from developing. Interestingly, after proctocolectomy with ileal pouch-anal anastomosis (IPAA), most patients develop adenomas in the pouch. This is not well described for patients with end ileostomy. We aimed to compare ileal adenoma development in patients with IPAA with those with end ileostomy.

METHODS

This historical cohort study included FAP patients with IPAA or end ileostomy who underwent surveillance endoscopies between 2001 and 2021. Primary outcomes were the proportion of patients with ileal adenomas, location of adenomas, and proportion of patients undergoing surgical excision of pouch/end ileostomy.

RESULTS

Overall, 144 patients with IPAA (n = 111) and end ileostomy (n = 33) were included. Five years after surgery, 15% of patients with IPAA had ileal adenomas versus 4% after ileostomy. At 10 years, these estimates were 48% versus 9% and at 20 years were 85% versus 43% (log-rank P < .001). Adenomas developed more often in the pouch body (95%) in the IPAA group and more often at the everted site of the ileostomy (77%) in the ileostomy group. Numbers for surgical excision of the pouch (n = 9) or ileostomy (n = 3) for polyposis or cancer were comparable. Taking into account potential confounders in a multivariable Cox regression analysis, having an IPAA was significantly associated with ileal adenoma development.

CONCLUSIONS

After proctocolectomy, FAP patients with IPAA more often developed ileal adenomas than patients with end ileostomy. This could potentially affect long-term management, and patients with end ileostomy might benefit from less-frequent endoscopic surveillance.

Management of Pouch Neoplasia

BACKGROUND

Pouch neoplasia occurs following ileal pouch-anal anastomosis, with or without mucosectomy in ulcerative colitis and familiar adenomatous polyposis.

OBJECTIVES

This study aimed to review available literature and make recommendations regarding pouch neoplasia.

DATA SOURCES

Data were collected from specialty hospitals, and a literature review was conducted due to the lack of published large-scale studies. Recommendations for treatment were made based on the literature review and expert opinions.

STUDY SELECTION

Large-scale studies of pouch neoplasia were selected.

INTERVENTION

The intervention was studies with details of pouch neoplasia.

MAIN OUTCOME MEASURES

We aimed to identify the management modalities for pouch neoplasia based on the type.

RESULTS

Pouch neoplasia can occur in each component of the pouch-afferent limb, pouch body, cuff, and anal transitional zone. In patients with ulcerative colitis, pouch neoplasia is treated because colitis-associated neoplasia comprises a multifocal lesion, which most commonly involves the cuff and anal transitional zone. Close surveillance or endoscopic complete resection is optimal for low-grade dysplasia. For adenocarcinoma, high-grade dysplasia, and low-grade dysplasia with difficult complete resection, pouch excision is recommended. In familiar adenomatous polyposis patients with adenomas of the afferent limb or pouch body, endoscopic resection is optimal. Endoscopic resection is feasible for discrete adenoma in the cuff and anal transitional zone, and surgical excision is optimal for laterally spreading, extensive, large, or flat adenoma. For adenocarcinomas involving any component, pouch excision is recommended.

LIMITATIONS

Published large-scale studies were lacking because of disease rarity.

CONCLUSION

Pouch neoplasia occurs in each pouch component. In patients with ulcerative colitis, pouch excision is recommended for adenocarcinomas and high-grade dysplasia, whereas endoscopic intervention may be preferable to low-grade dysplasia. In familiar adenomatous polyposis patients, pouch excision is necessary for adenocarcinoma, and endoscopic resection or excisional surgery is optimal for adenoma.

Ileoanal pouch cancers in ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis

INTRODUCTION

Restorative proctocolectomy results in the formation of a pouch that adapts to a more colonic phenotype. The incidence of cancer of the pouch is thought to be low with most societal guidelines differing on their recommendations for surveillance.

AIMS

We conducted a systematic review with meta-analysis to report the incidence of cancer in all pouch patients.

METHODS

The Embase, Embase classic and PubMed databases were searched between June 1979- June 2021. A random effects model was performed to find the pooled incidence of pouch cancer. In addition, we also looked for risk factors for pouch cancers.

RESULTS

Forty-six studies were included. In 19,964 patients with Ulcerative Colitis (UC) the pooled incidence of pouch cancer was 0.0030 (95% CI: 0.0016 -0.0055). In 3741 patients with Familial Adenomatous Polyposis (FAP) the pooled incidence of pouch cancer was 0.01 (95% CI: 0.01 - 0.02). In UC most pouch cancers were found to occur in the pouch body (0.59 (95% CI: 0.29-0.84)).

CONCLUSIONS

The findings suggest that the pooled incidence of pouch cancer in UC is similar to that which was previously published, and this is the first meta-analysis to report a pooled incidence for pouch cancer in FAP.

Management of pouch neoplasia: consensus guidelines from the International Ileal Pouch Consortium

Surveillance pouchoscopy is recommended for patients with restorative proctocolectomy with ileal pouch-anal anastomosis in ulcerative colitis or familial adenomatous polyposis, with the surveillance interval depending on the risk of neoplasia. Neoplasia in patients with ileal pouches mainly have a glandular source and less often are of squamous cell origin. Various grades of neoplasia can occur in the prepouch ileum, pouch body, rectal cuff, anal transition zone, anus, or perianal skin. The main treatment modalities are endoscopic polypectomy, endoscopic ablation, endoscopic mucosal resection, endoscopic submucosal dissection, surgical local excision, surgical circumferential resection and re-anastomosis, and pouch excision. The choice of the treatment modality is determined by the grade, location, size, and features of neoplastic lesions, along with patients' risk of neoplasia and comorbidities, and local endoscopic and surgical expertise.

Cumulative incidence and risk factors for pouch adenomas associated with familial adenomatous polyposis following restorative proctocolectomy

BACKGROUND

The emergence of restorative total proctocolectomy has significantly reduced the lifetime colorectal cancer risk associated with familial adenomatous polyposis (FAP). However, adenomas may develop in the ileal pouch over time and may even progress to carcinoma. We evaluated the cumulative incidence, time to development, and risk factors associated with ileal pouch adenoma.

AIM

To evaluate the cumulative incidence, time to development, and risk factors associated with pouch adenoma.

METHODS

In this retrospective, observational study conducted at a tertiary center, 95 patients with FAP who underwent restorative proctocolectomy at our center between 1989 and 2018 were consecutively included. The mean follow-up period was 88 mo.

RESULTS

Pouch adenomas were found in 24 (25.3%) patients, with a median time of 52 mo to their first formation. Tubular adenomas were detected in most patients (95.9%). There were no high-grade dysplasia or malignancies. Of the 24 patients with pouch adenomas, 13 had all detected adenomas removed. Among the 13 patients who underwent complete adenoma removal, four (38.5%) developed recurrence. Among 11 (45.8%) patients with numerous polyps within the pouch, seven (63.6%) exhibited progression of pouch adenoma. The cumulative risks of pouch adenoma development at 5, 10, and 15 years after pouch surgery were 15.2%, 29.6%, and 44.1%, respectively. Severe colorectal polyposis (with more than 1000 polyps) was a significant risk factor for pouch adenoma development (hazard ratio, 2.49; 95% confidence interval: 1.04-5.96; P = 0.041).

CONCLUSION

Pouch adenomas occur at a fairly high rate in association with FAP after restorative proctocolectomy, and a high colorectal polyp count is associated with pouch adenoma development.

Endoscopic Management of Adenomas in the Ileal Pouch and the Rectal Remnant after Surgical Treatment in Familial Adenomatous Polyposis

In patients with familial adenomatous polyposis (FAP), adenomas and even carcinomas may develop in the rectal remnant and the ileal pouch after surgical treatment. The aim of this study was to evaluate the outcome of endoscopic management in patients with FAP. The main outcome measurements were the appearance of secondary cancer, complications, and the need for additional surgery. Thirty-four FAP patients with Kock’s continent ileostomy (Kock) (n = 3), ileorectal anastomosis (IRA) (n = 12), and ileal pouch-anal anastomosis (IPAA) (n = 19) were identified. The median follow-up period of endoscopic surveillance was 11.5 years for pouch patients (Kock + IPAA) and 21.7 years for IRA. Metachronous adenomas appeared in 32 patients (94.1%). In pouch patients, a total of 120 treatments were given to 20 patients, and 12 sessions of delayed bleeding (10%) occurred, which was significantly higher compared to IRA patients, with 0 sessions (p < 0.001). In IRA patients, a total of 169 treatments were given to 11 patients, with one case of perforation. No adenocarcinoma has developed since the start of endoscopic surveillance. Regular endoscopic surveillance and treatment are feasible and safe. However, in pouch patients, one must be cautious about delayed bleeding in the treatment of adenomas.

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.

Prophylactic colectomy and rectal preservation in FAP: systematic endoscopic follow-up and adenoma destruction changes natural history of polyposis

Background and study aims  Prophylactic surgery of familial adenomatous polyposis (FAP) includes total colectomy with ileorectal anastomosis (IRA) to proctocolectomy with ileoanal anastomosis (IAA). Surgical guidelines rely on studies without systematic endoscopic follow-up and treatment. Our aim was to report our experience based on a different approach: therapeutic follow-up, comparing in this setting IRA and IAA in terms of oncological safety and quality of life. Patients and methods  Between January 1965 and November 2015, all patients who underwent prophylactic surgery for FAP with therapeutic endoscopic follow-up in Lyon University hospital: systematic endoscopic treatment of adenomas, were retrospectively and prospectively (since 2011) included. Results  A total of 296 patients were analyzed: 92 had proctocolectomy with IAA (31.1 %), 197 total colectomy with IRA (66.5 %), and seven abdominoperineal resections (2.4 %). Median follow-up was 17.1 years (range, 0-38.1). Incidence of secondary cancer (IR vs. IAA) was 6.1 % vs. 1.1 % ( P  = 0.06; 95 %CI 0.001-0.36). The 15-year cancer-free and overall survival (IR vs. IAA) were 99.5 % vs 100 % ( P  = 0.09) and 98.9 % vs. 98.8 % ( P  = 0.82), respectively. Postoperative morbidity occurred in 44 patients: 29 (14.7 %) in the IRA and 15 (16.3 %) in the IAA group ( P  = 0.72). The mean number of stools per day in the respective groups were 4.4 (2.5) vs. 5.5 (2.6) ( P  = 0.001). Fecal incontinence occurred in 14 patients (7.1 %) in the IRA vs. 16 (17.4 %) in the IAA group ( P  = 0.03). Conclusions  A combination of therapeutic endoscopic treatment and extended rectal preservation appears to be a safe alternative to ileoanal J-pouch anastomosis.

Gastrointestinal Polyposis in Pediatric Patients

Gastrointestinal polyps are mucosal overgrowths that, if unchecked, can undergo malignant transformation. Although relatively uncommon in the pediatric age group, they can be the harbingers of multiorgan cancer risk and require close management and follow-up. Additionally, as many polyposis syndromes are inherited, appropriate genetic testing and management of relatives is vital for the health of the entire family. In this review, we discuss both common and uncommon childhood gastrointestinal polyposis syndromes in terms of clinical presentation, management, and surveillance. We also detail any additional malignancy risk and surveillance required in the pediatric age group (<21 years old). Through this review, we provide a framework for gastroenterologists to manage the multifaceted nature of pediatric polyposis syndromes.

Long-term outcomes of metachronous neoplasms in the ileal pouch and rectum after surgical treatment in patients with familial adenomatous polyposis

Background and study aims  Restorative proctocolectomy has become the most common surgical option for patients with familial adenomatous polyposis (FAP). However, adenomas and even carcinomas may develop in the ileal pouch over time. The aim of this study was to evaluate the long-term incidence and nature of ileal pouch or distal ileal adenomas and carcinomas in patients with FAP. Patients and methods  This was a retrospective study of 47 FAP patients with Kock's continent ileostomy (Kock) (n = 8), ileorectal anastomosis (IRA) (n = 13), and ileal pouch-anal anastomosis (IPAA) (n = 26). Patients were followed with a standardized protocol including chromoendoscopy and biopsies of visible polyps in the ileal pouch, distal ileum, and rectum every 6 to 12 months. Results  Median follow-up was 21.0 years. Overall risk of adenoma development was significantly higher in IRA patients, with incidence rates of 85 % and 100 % at 5 and 10 years' follow-up, respectively, compared to pouch patients (Kock + IPAA) ( P  < 0.001). However, there was also a high frequency of adenomas in the ileal pouch mucosa, with rates of 12 %, 33 %, and 68 %, at 5, 10, and 20 years of follow-up, respectively. Maximum size of ileal pouch adenomas was significantly related to time since surgery ( P  = 0.0214). Six cases of advanced adenomas including two cases of adenocarcinomas developed in the ileal pouch mucosa. Conclusions  There is a significant incidence of adenoma(s) in the ileal pouch of FAP patients on long-term follow-up. Regular endoscopic surveillance is recommended, not only in IRA patients, but also in pouch patients after proctocolectomy.

Judging the J pouch: a pictorial review

Restorative total proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with high-grade dysplasia or multi-focal low-grade dysplasia, and for patients with familial adenomatous polyposis. The natural history of the surgery is favorable, and patients generally experience improved quality of life and acceptable long-term functional outcome. However, some patients experience significant long-term morbidity from early and/or late pouch-related complications. When complications arise, radiologists must understand the advantages and disadvantages of the various imaging modalities that can be used to assess the pouch. Radiologist familiarity with the surgical technique, pouch anatomy, and imaging appearance of the various potential early and late complications will help facilitate appropriate clinical and surgical decision-making. This review provides an anatomic-based imaging review of the pouch and pouch-related complications, including numerous illustrative fluoroscopic and cross-sectional imaging examples.

Progress in surgical treatment of familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is an autosomal dominant genetic disease with a high tendency to develop colorectal cancer. The timing and choice of preventive surgical interventions should be based on the number, size and severity of adenomas, combined with a variety of considerations, in order to effectively prevent cancer and make patients easy to accept. Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) procedure, which could minimize the residual rectal mucosa and reduce the risk of adenoma recurrence, has become the first choice for patients with FAP. Besides, laparoscopic IPAA has obvious advantages such as cosmetic appearance, quick recovery, little adhesion and high pregnancy rate. Patients with FAP should be managed by experienced surgeons working in specialized medical centers in order to get the most reasonable treatment at the best time and achieve long-term effective outcomes.

A Comprehensive Approach to Pouch Disorders

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or indeterminate colitis, UC with colonic dysplasia or neoplasia, and familial adenomatous polyposis. In general, patients experience good function outcomes and quality of life with an IPAA. Although pouchitis is the most well-recognized and frequent complication after IPAA, a number of additional inflammatory, postsurgical, structural, neoplastic, and functional complications may occur, resulting in pouch dysfunction. We herein provide a comprehensive review of pouch function and an approach to diagnosis and management of pouch complications.

Risk Factors Associated With Pouch Adenomas in Patients With Familial Adenomatous Polyposis

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal reconstruction is the standard prophylactic surgical procedure for patients with familial adenomatous polyposis. However, several groups have reported the development of adenomas and even carcinomas within the ileal pouch. The predisposing factor was the time interval after pouch surgery in some studies, but it was the severity of the initial colonic disease and duodenal adenomatosis in others.

OBJECTIVE

The aim of this study was to further clarify the prevalence of pouch adenomas, clinical risk factors, and a possible phenotype-genotype relation in a large population of patients with familial adenomatous polyposis, as well as to analyze pouch adenoma-free survival.

DESIGN

This study was designed as a cohort study.

SETTINGS

This study was conducted in a specialized outpatient clinic at the University of Heidelberg.

PATIENTS

A total of 192 patients with familial adenomatous polyposis were included, and all of the available endoscopy reports after pouch surgery were screened for pouch adenomas. Additional clinical information was retrieved from the Heidelberg Polyposis Register.

MAIN OUTCOME MEASURES

This present study revealed 3 main independent risk factors for the development of pouch adenomas: age <18 years at the time of IPAA, male sex, and the presence of gastric adenomas. Secondary outcome measures were adenoma progression and overall pouch adenoma-free survival.

RESULTS

Pouch adenomas were detected in 46.9% of patients. Median follow-up was 12.8 years (interquartile range, 9.0-17.0 y) for patients with pouch adenomas and 7.3 years (interquartile range, 2.5-12.2 y) for those without them. Patients underwent pouch surgery at a median age of 27.5 years (range, 10.2-58.5 y), and pouch adenomas occurred a median of 8.5 years (range, 0.9-25.1 y) after surgery. Also detected were gastric adenomas in 37.2%, duodenal adenomas in 80.3%, and desmoid tumors in 24.5% of patients. Estimation of pouch adenoma-free survival revealed that, after 20 years, only ≈22% of patients would be free of pouch adenomas. Male sex, age ≦18 years at the time of pouch surgery, and gastric adenomas were found to be independent risk factors for the development of pouch adenomas in a multivariate Cox regression analysis (p = 0.0002, p = 0.0059, and p = 0.0020). No predisposing germline mutation for pouch adenoma development was detected.

LIMITATIONS

Detailed information on the initial preoperative findings was not fully available, and the study was only carried out as a single-center study.

CONCLUSIONS

A severe upper intestinal phenotype, male sex, and age <18 years at the time of IPAA all increase the risk for development of pouch adenomas. See Video Abstract at http://links.lww.com/DCR/A675.

Adenomatous Polyposis Syndromes: Diagnosis and Management

Familial adenomatous polyposis (FAP) syndromes make up fewer than 1% of patients diagnosed with colorectal cancer each year. Patients with familial polyposis syndromes including FAP, attenuated FAP, and MYH-associated polyposis (MAP), are an important group often cared for by colorectal surgeons. Registry and screening programs have been shown to improve survival in patients with adenomatous polyposis, as it allows patients to undergo surgical intervention prior to the development of colorectal cancer. There are several surgical options for the treatment of colorectal polyps in patients with adenomatous polyposis, so it is important to choose the appropriate procedure for each patient after discussing the risk of cancer in the rectal remnant, as well as bowel and sexual function in a predominantly young patient group. Regardless of procedure choice, long-term follow-up is important with yearly endoscopic evaluation of the pouch or remnant rectum, as well as appropriate screening for extracolonic malignancy. Adenomatous polyposis patients require an intense care regimen, but can have a normal lifespan with good quality when cared for appropriately.

Current status of prophylactic surgical treatment for familial adenomatous polyposis in Japan

PURPOSE

We conducted this study to clarify the current clinical practice of prophylactic colectomy for patients with familial adenomatous polyposis (FAP) in Japan.

METHODS

This retrospective multi-center cohort study involved 23 specialized institutions for colorectal disease in Japan. We analyzed the records of 147 patients who underwent prophylactic surgical treatment between 2000 and 2012. Patients were divided into Group 1 (2000-2006) and Group 2 (2007-2012) based on their date of surgery.

RESULTS

Age at the time of prophylactic surgery was 27 and 31 years in Groups 1 and 2, respectively. The proportion of attenuated FAP was significantly lower in Group 2 than in Group 1 (1.0 vs. 13 %, respectively). Pathological examination revealed an increased incidence of malignant polyps in the resected specimens from Group 2 patients (10 vs. 23 %, respectively; P = 0.034). Laparoscopic surgery was more frequent in Group 2 than in Group 1 (61 vs. 40 %, respectively). There was no surgical mortality in either group.

CONCLUSION

Prophylactic surgery for FAP results in good short-term surgical outcomes in Japan. The current surgical approach is characterized by limited surgical indications for patients with attenuated FAP, delayed timing of colectomy, and the increasing standardization of laparoscopic surgery.

Pouchitis Is a Common Complication in Patients With Familial Adenomatous Polyposis Following Ileal Pouch-Anal Anastomosis

BACKGROUND & AIMS

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure most commonly selected for patients with familial adenomatous polyposis (FAP) or ulcerative colitis that is refractive to medical treatment. Pouchitis is the most common complication in patients with ulcerative colitis after IPAA, but is thought to rarely occur in patients with FAP. We investigated the frequency of pouchitis and other pouch-related complications in patients with FAP after IPAA.

METHODS

We performed a retrospective cohort study of all patients with FAP who underwent IPAA at a single tertiary institution from 1992 through 2015 (n = 113). Patients were identified using International Classification of Diseases-9 diagnostic and current procedural terminology codes. We obtained relevant demographic and clinical data from patients' electronic medical records. The frequencies of pouchitis and pouch-related complications were determined.

RESULTS

Twenty-five patients (22.1%) developed pouchitis (mean time to pouchitis, 4.1 years) and 88 did not (77.9%). Patients with pouchitis showed a trend toward developing late (>90 days after IPAA) pouch-related complications (56.0% of patients with pouchitis developed late complications, compared with 36.4% without). In patients who developed pouchitis, the disease course was acute in 72.0% and chronic in 28.0%. Of those treated, 69.6% responded to antibiotics, 13.0% became dependent on antibiotics, and 13.0% developed antibiotic resistance.

CONCLUSIONS

Pouchitis is more prevalent in patients with FAP than previously believed. Although pouchitis seems to occur later in patients with FAP than in patients with ulcerative colitis, and have a milder course, it should be considered a common complication among patients with FAP following IPAA.

Clinicopathological features of familial adenomatous polyposis in Korean patients

AIM: To identify prognostic factors and to correlate APC mutations with clinical features, including extracolic manifestations.

METHODS: One hundred thirty-five patients who underwent surgical procedures for familial adenomatous polyposis (FAP) were included. FAP was diagnosed when the number of adenomatous polyps was > 100. Data related to patient, extracoloic manifestations, cancer characteristics, operative procedure, follow up and surveillance were collected. APC mutation testing was performed in the 30 most recent patients. DNA was extracted from peripheral blood and polymerase chain reaction products using 31 primer pairs on APC gene were sequenced. A retrospective study was performed to investigate a causal relationship between prognosis and feature of patient.

RESULTS: The mean age of the 51 patients with colorectal cancer (CRC) was older than that of those without CRC (30.5 vs 36.9, P = 0.002). Older individuals were more likely to have colon cancer at the time of FAP diagnosis [odds ratio, 4.75 (95%CI: 1.71-13.89) and 5.91(1.76-22.12) for 40-49 years and age > 50 vs age < 30). The number of confirmed deaths was 13 and the median age at death was 40 years (range, 27 to 85 years). Ten of the deaths (76.9%) were from CRC. Another cause of two cases of death were desmoid tumors (15.4%). Development of cancer on remnant rectal or ileal mucosa after surgery was not observed. The APC mutation testing revealed 23 pathogenic mutations and one likely pathogenic mutation, among which were four novel mutations. The correlation between mutational status and clinical manifestations was investigated. Mutations that could prodict poor prognosis were at codon 1309 which located on mutation cluster region, codon 1465 and codon 1507.

CONCLUSION: Identification of APC mutations should aid in the diagnosis and counseling of family members in terms of early diagnosis and management of FAP.

Adenocarcinoma of the ileal pouch mucosa: case report and literature review

PURPOSE

Cancers developing near the site of the ileoanal pouch anastomosis (IPAA) have been reported, but uncommonly in the ileal pouch mucosa itself. We present a recently encountered case of ileal pouch cancer and review the literature to examine the prevalence, risk factors, and natural history of ileal pouch adenocarcinoma as well as pouch surveillance.

METHODS

A chart review of the case from our institution was conducted, and a PubMed search was undertaken for articles describing adenocarcinoma arising from the ileal pouch mucosa.

RESULTS

Twenty articles containing 26 cases were reviewed in addition to our described case. More than half were reported in the last decade. Only three cases were definitively stage 1. All seven patients who underwent regular surveillance were diagnosed with stage 1 or 2 disease. Seventeen patients had neoplasia in their original proctocolectomy specimen and six did not. The mean time from pouch creation to adenocarcinoma was 8.9 years.

CONCLUSIONS

The risk of developing ileal pouch mucosa adenocarcinoma appears low. However, increasing reports of these cancers are concerning as most patients present with advanced disease after many years. Patients with a previous history of dysplasia/cancer may be at increased risk. We believe surveillance after IPAA should include the anal transition zone and the ileal pouch mucosa. The establishment of expert consensus guidelines on pouch surveillance should be considered in the near future.

Pouch adenomas in Familial Adenomatous Polyposis after restorative proctocolectomy

INTRODUCTION

Australian Clinical Practice Guidelines suggest six to twelve-monthly endoscopic pouch surveillance in patients after restorative proctocolectomy for Familial Adenomatous Polyposis (FAP). There are several reports of adenomas and carcinomas forming within the ileum, ileal pouch mucosa or residual rectal mucosa. A retrospective clinical study was performed to audit pouch endoscopic surveillance at a large Sydney tertiary referral Hospital. The aim was to evaluate adenoma development after restorative proctocolectomy for FAP and the adherence rate to published clinical guidelines.

METHODS

Thirty-nine patients who had restorative proctocolectomy for FAP from 1985 to 2011 were identified. Demographic data, details of surgery, original histopathology and details of follow-up pouch endoscopy and pathology findings were obtained.

RESULTS

Of the thirty-nine patients, twenty-seven patients were included in this study. Adenomas were found in twelve of 27 (44%) patients. Mean time to first polyp formation was 88 months and median time was 72 months (range 18-249 months). All polyps were either tubular or tubulovillous in histology. One polyp had high grade dysplasia. The remainder had mild or moderate dysplasia. Polyps were excised either endo-anally or during pouchoscopy. None of the five patients who had a hand-sewn ileal pouch-anal anastomosis (IPAA) developed polyps on follow-up, compared with 12 of the 22 (55%) with a double stapled anastomosis (fishers exact test; p=0.047 (two-tailed)). Of those who developed pouch adenomas, eight (67%) developed further pouch adenomas on follow-up.

CONCLUSIONS

This study supports guidelines recommending lifelong pouch surveillance after restorative proctocolectomy for FAP. Those who develop pouch adenomas may be at greater risk of developing further adenomas. Residual rectal mucosa at the pouch-anal anastomosis should be carefully examined.

Surgical treatment of familial adenomatous polyposis: Dilemmas and current recommendations

Familial adenomatous polyposis (FAP) is an autosomal dominant inherited syndrome characterized by multiple adenomatous polyps (predisposing to colorectal cancer development) and numerous extracolonic manifestations. The underlying genetic burden generates variable clinical features that may influence operative management. As a precancerous hereditary condition, the rationale of performing a prophylactic surgery is a mainstay of FAP management. The purpose of the present paper is to bring up many controversial aspects regarding surgical treatment for FAP, and to discuss the results and perspectives of the operative choices and approaches. Preferably, the decision-making process should not be limited to the conventional confrontation of pros and cons of ileorectal anastomosis or restorative proctocolectomy. A wide discussion with the patient may evaluate issues such as age, genotype, family history, sphincter function, the presence or risk of desmoid disease, potential complications of each procedure and chances of postoperative surveillance. Therefore, the definition of the best moment and the choice of appropriate procedure constitute an individual decision that must take into consideration patient’s preferences and full information about the complex nature of the disease. All these facts reinforce the idea that FAP patients should be managed by experienced surgeons working in specialized centers to achieve the best immediate and long-term results.

Ileal pouch-anal anastomosis surgery: anatomy, postoperative complications, and image-guided intervention

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) surgery has become the surgical procedure of choice for chronic ulcerative colitis and familial adenomatous polyposis. Since its introduction in 1978, the technique of ileal pouch-anal anastomosis has improved and is commonly performed. Although associated with low mortality, postsurgical complications are frequent with which the radiologist should be familiar. An understanding of surgical technique and postsurgical anatomy facilitates the diagnosis of these frequently encountered complications and governs their potential image-guided intervention.

Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis

Restorative proctocolectomy is the most common surgical option for patients with familial adenomatous polyposis (FAP). However, adenomas may develop in the ileal pouch mucosa over time, and even carcinoma in the pouch has been reported. We therefore reviewed the prevalence, nature, and treatment of adenomas and carcinoma that develop after proctocolectomy in the ileal pouch mucosa in patients with FAP. In 25 reports that were reviewed, the incidence of adenomas in the ileal pouch varied from 6.7% to 73.9%. Several potential factors that favor the development of pouch polyposis have been investigated, but many remain controversial. Nevertheless, it seems certain that the age of the pouch is important. The risk appears to be 7% to 16% after 5 years, 35% to 42% after 10 years, and 75% after 15 years. On the other hand, only 21 cases of ileal pouch carcinoma have been recorded in the literature to date. The diagnosis of pouch carcinoma was made between 3 to 20 years (median, 10 years) after pouch construction. Although the risk of malignant transformation in ileal pouches is probably low, it is not negligible, and the long-term risk cannot presently be well quantified. Regular endoscopic surveillance, especially using chromoendoscopy, is recommended.

Prevalence and risk factors for adenomas in the ileal pouch and the afferent loop after restorative proctocolectomy for patients with familial adenomatous polyposis

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the treatment of choice in familial adenomatous polyposis (FAP) to prevent the risk of colorectal cancer. However, it currently is recognized that adenomas may develop in the ileal pouch. The risk of adenoma occurring in the afferent ileal loop above the pouch is less clearly identified. This study aimed to evaluate the difference in prevalence of adenomas between the ileal pouch and the afferent ileum after IPAA in FAP.

METHODS

The study analyzed 442 endoscopies performed between 2003 and 2008 for 139 FAP patients. The patients had undergone an IPAA in 118 cases, an ileorectal anastomosis in 13 cases, or an ileostomy in 8 cases.

RESULTS

Among the 118 IPAA patients, 57 (48.3 %) had pouch adenomas a median of 15 years after surgery. The risk factors for pouch adenomas were delay since pouch construction [odds ratio (OR), 1.11; p = 0.016] and presence of advanced duodenal adenomas (OR, 4.35; p = 0.011). Seven patients had pouch adenomas with high-grade dysplasia. Only nine patients had afferent ileal loop adenomas (6.5 %). The only significant risk factor for ileal adenomas was the presence of pouch adenomas (OR, 2.16; p = 0.007).

CONCLUSION

After restorative proctocolectomy in FAP, adenoma recurrence is frequent in the pouch, with a higher risk for patients with advanced duodenal adenomas and an increasing risk over time, whereas adenomas are rarely found in the afferent ileal loop. This finding may help to propose redo ileal pouch anal anastomosis if required.

Adenoma formation and malignancy after restorative proctocolectomy with or without mucosectomy in patients with familial adenomatous polyposis

BACKGROUND

There is controversy concerning whether or not to perform mucosectomy after IPAA in patients with familial adenomatous polyposis. Although more frequent adenoma formation at the anastomotic site in patients without a mucosectomy is documented, the interpretation of the theoretical reflections and empirical findings are ambiguous.

OBJECTIVE

The aim of this study was to assess the differences in adenoma formation at the anastomotic site and in the ileal pouch among patients with familial adenomatous polyposis after IPAA with or without mucosectomy.

DESIGN

Data were gathered from The Norwegian Polyposis Registry and The Cancer Registry of Norway.

PATIENTS

Sixty-one patients with familial adenomatous polyposis who had IPAA were included in the Norwegian Polyposis Registry.

MAIN OUTCOME MEASURES

The frequency of adenoma development in the pouch or at the anastomotic site was measured.

RESULTS

Thirty-nine patients had a pelvic pouch performed with mucosectomy and 22 patients without. The observational time was 15.5 and 13.7 years. Adenoma formation at the anastomotic site was 4 in 39 and 14 in 22, and the estimated rate was 17% vs 75% (p = 0.0001). One patient without mucosectomy had a cancer (Dukes A) at the anastomotic site. There was no estimated long-term difference in adenoma formation in the ileal pouches between the 2 surgical procedures (38%) (p = 0.10).

LIMITATIONS

The study is retrospective, in part, and relies on data from registries. There is a limited number of cases, and selection bias because of surgeon preference may exist.

CONCLUSION

In patients with familial adenomatous polyposis who undergo IPAA, adenoma formation at the anastomotic site is significantly reduced after mucosectomy. Mucosectomy may be the preferable procedure to prevent adenomas at the anastomotic site.

Adenocarcinomas After Prophylactic Surgery For Familial Adenomatous Polyposis

The incidence of familial adenomatous polyposis (FAP) is one in 7,000 to 12,000 live births. Virtually, all surgically untreated patients with FAP inevitably develop colorectal-cancer in their lifetime because they carry the adenomatous polyposis coli gene. Thus prophylactic proctocolectomy is indicated. Surgical treatment of FAP is still controversial. There are however, four surgical options: ileorectal anastomosis, restorative proctocolectomy with ileal pouch-anal anastomosis, proctocolectomy with ileostomy, and proctocolectomy with continent-ileostomy. Conventional proctocolectomy options largely lie between colectomy with ileorectal anastomosis or ileal pouch-anal anastomosis. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis because of better functional results and quality of life. The functional outcome of total colectomy with ileorectal anastomosis is undoubtedly far superior to that of the ileoanal pouch; however, the risk for rectal cancer is increased by 30%. Even after mucosectomy, inadvertent small mucosal residual islands remain. These residual islands carry the potential for the development of subsequent malignancy. We reviewed the literature (1975-2012) on the incidence, nature, and possible etiology of subsequent ileal-pouch and anal transit zone adenocarcinoma after prophylactic surgery procedure for FAP. To date there are 24 studies reporting 92 pouch-related cancers; 15 case reports, 4 prospective and 5 retrospective studies. Twenty three of 92 cancers (25%) developed in the pouch mucosa and 69 (75%) in anal transit zone (ATZ). Current recommendation for pouch surveillance and treatment are presented. Data suggest lifetime surveillance of these patients.

What we know now: pouch surgery 40 years on

For many patients, ileal pouch-anal anastomosis (also called ileo-anal pouch surgery) not only eradicates disease but also preserves the anal sphincter, enabling the patient to defecate in the normal way. Pouch surgery is approaching 40 years and within this time has become the 'gold standard' in surgical management for ulcerative colitis and familial adeomatous polyposis. Much of the research over the years has explored surgical techniques and pouch function, failure and satisfaction, as well as long-term follow-up; however, some pouch problems continue to be a mystery. This short article aims to bring us up to date with what we know now that might have been beneficial to know then.

Should we recycle more than our plastic?

For many patients, ileal pouch-anal anastomosis (also called ileoanal pouch surgery) not only eradicates disease but also preserves the anal sphincter, enabling the patient to defecate in the normal way. Pouch surgery is approaching 40 years and within this time has become the ‘gold standard’ in surgical management for ulcerative colitis and familial adeomatous polyposis. Much of the research over the years has explored surgical techniques and pouch function, failure and satisfaction, as well as long-term follow-up; however, some pouch problems continue to be a mystery. This short article aims to bring us up to date with what we know now that might have been beneficial to know then.