Segmental resection is a safe oncological alternative to total proctocolectomy in elderly patients with ulcerative colitis and malignancy

Management of Colorectal Neoplasia in IBD Patients: Current Practice and Future Perspectives

Inflammatory bowel disease [IBD] patients are at increased risk of developing colorectal neoplasia [CRN]. In this review, we aim to provide an up-to-date overview and future perspectives on CRN management in IBD. Advances in endoscopic surveillance and resection techniques have resulted in a shift towards endoscopic management of neoplastic lesions in place of surgery. Endoscopic treatment is recommended for all CRN if complete resection is feasible. Standard [cold snare] polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection should be performed depending on lesion complexity [size, delineation, morphology, surface architecture, submucosal fibrosis/invasion] to maximise the likelihood of complete resection. If complete resection is not feasible, surgical treatment options should be discussed by a multidisciplinary team. Whereas [sub]total and proctocolectomy play an important role in management of endoscopically unresectable CRN, partial colectomy may be considered in a subgroup of patients in endoscopic remission with limited disease extent without other CRN risk factors. High synchronous and metachronous CRN rates warrant careful mucosal visualisation with shortened intervals for at least 5 years after treatment of CRN.

Segmental Colectomy in Ulcerative Colitis

BACKGROUND

Segmental colectomy in ulcerative colitis is performed in select patients who may be at increased risk for postoperative morbidity.

OBJECTIVE

To identify patients with ulcerative colitis who underwent segmental colectomy and assess their postoperative and long-term outcomes.

DESIGN

Retrospective case series.

SETTING

A tertiary care IBD center.

PATIENTS

Patients with ulcerative colitis who underwent surgery between 1995 and 2022.

INTERVENTION

Segmental colectomy.

MAIN OUTCOME MEASURES

Postoperative complications, early and late colitis, metachronous cancer development, completion proctocolectomy-free survival rates, and stoma at follow-up.

RESULTS

Fifty-five patients were included (20 [36.4%] women; age 67.8 (57.4-77.1) years at surgery; BMI 27.7 (24.2-31.1) kg/m 2 ; median follow-up 37.3 months). Thirty-two patients (58.2%) had ASA score of 3, 48 (87.3%) had at least 1 comorbidity, and 48 (87.3%) had Mayo endoscopic subscores of 0 to 1. Patients underwent right hemicolectomy (n = 28; 50.9%), sigmoidectomy (n = 17; 30.9%), left hemicolectomy (6; 10.9%), low anterior resection (n = 2; 3.6%), or a nonanatomic resection (n = 2; 3.6%) for endoscopically unresectable polyps (n = 21; 38.2%), colorectal cancer (n = 15; 27.3%), symptomatic diverticular disease (n = 13; 23.6%), and stricture (n = 6; 10.9%). Postoperative complications occurred in 16 patients (29.1%; n = 7 [12.7%] Clavien-Dindo class III-V). Early and late postoperative colitis rates were 9.1% and 14.5%, respectively. Metachronous cancer developed in 1 patient. Four patients (7.3%) underwent subsequent completion proctocolectomy with ileostomy. Six patients (10.9%) had a stoma at follow-up. Two- and 5-year completion proctocolectomy-free survival rates were 91% and 88%, respectively.

LIMITATIONS

Retrospective study and small sample size.

CONCLUSIONS

Segmental colectomy in ulcerative colitis is associated with low postoperative complication rates, symptomatic early colitis and late colitis rates, metachronous cancer development, and the need for subsequent completion proctocolectomy. Therefore, it can be safe to consider select patients, such as the elderly with quiescent colitis and other indications, for colectomy. See Video Abstract .

COLECTOMA SEGMENTARIA EN LA COLITIS ULCEROSA

ANTECEDENTES:La colectomía segmentaria en la colitis ulcerosa se realiza en pacientes seleccionados que pueden tener un mayor riesgo de morbilidad posoperatoria.OBJETIVO:Identificar pacientes con colitis ulcerosa sometidos a colectomía segmentaria y evaluar sus resultados postoperatorios y a largo plazo.DISEÑO:Serie de casos retrospectivos.AMBIENTE:Un centro de atención terciaria para enfermedades inflamatorias intestinales.PACIENTES:Pacientes con colitis ulcerosa intervenidos quirúrgicamente entre 1995 y 2022.INTERVENCIÓN(S):Colectomía segmentaria.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias, colitis temprana y tardía, desarrollo de cáncer metacrónico, tasas de supervivencia sin proctocolectomía completa y estoma en el seguimiento.RESULTADOS:Se incluyeron cincuenta y cinco pacientes [20 (36,4%) mujeres; 67,8 (57,4-77,1) años de edad al momento de la cirugía; índice de masa corporal 27,7 (24,2-31,1) kg/m2; mediana de seguimiento 37,3 meses]. La puntuación ASA fue III en 32 (58,2%) pacientes, 48 (87,3%) tenían al menos una comorbilidad y 48 (87,3%) tenían una subpuntuación endoscópica de Mayo de 0-1. Los pacientes fueron sometidos a hemicolectomía derecha (28, 50,9%), sigmoidectomía (17, 30,9%), hemicolectomía izquierda (6, 10,9%), resección anterior baja (2, 3,6%) o resección no anatómica (2, 3,6%) para; pólipos irresecables endoscópicamente (21, 38,2%), cáncer colorrectal (15, 27,3%), enfermedad diverticular sintomática (13, 23,6%) y estenosis (6, 10,9%). Se produjeron complicaciones postoperatorias en 16 (29,1%) pacientes [7 (12,7%) Clavien-Dindo Clase III-V]. Las tasas de colitis posoperatoria temprana y tardía fueron del 9,1% y el 14,5%, respectivamente. Un paciente desarrolló cáncer metacrónico. A 4 (7,3%) pacientes se les realizó posteriormente proctocolectomía completa con ileostomía. Seis (10,9%) pacientes tenían estoma en el seguimiento. Las tasas de supervivencia sin proctocolectomía completa a dos y cinco años fueron del 91% y 88%, respectivamente.LIMITACIONES:Estudio retrospectivo, tamaño de muestra pequeño.CONCLUSIONES:La colectomía segmentaria en la colitis ulcerosa se asocia con bajas tasas de complicaciones postoperatorias, tasas de colitis sintomática temprana y tasas de colitis tardía, desarrollo de cáncer metacrónico y la necesidad de una posterior proctocolectomía completa. Por lo tanto, puede ser seguro considerar pacientes seleccionados, como los ancianos con colitis inactiva y otras indicaciones de colectomía. (Traducción-Dr. Yolanda Colorado ).

Rectal Cancer and Radiation in Colitis

Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer. When IBD patients develop a rectal cancer, this should be treated with the same oncological principles and guidelines as the general population. Rectal cancer treatment includes surgery, chemotherapy, and radiation therapy (RT). Many IBD patients will require a total proctocolectomy with an ileal-pouch anal anastomosis (IPAA) and others, restoration of intestinal continuity may not be feasible or advisable. The literature is scarce regarding outcomes of IPAA after RT. In the present review, we will summarize the evidence regarding RT toxicity in IBD patients and review surgical strategies and outcomes of IPAA after RT.

Focal Cancer in Colitis

Colorectal cancer (CRC) is a known complication of inflammatory bowel disease (IBD). Widely accepted guidelines recommend that patients with ulcerative colitis diagnosed with CRC undergo total proctocolectomy with or without ileal pouch-anal anastomosis, and that patients with Crohn's disease and CRC undergo either total colectomy or proctocolectomy. These approaches are ideal for preventing synchronous and metachronous cancer, minimizing risk of refractory colitis requiring reoperation, and is the appropriate treatment for the vast majority of patients with IBD who are diagnosed with CRC and require surgical intervention. Segmental colectomy, however, may be considered in select patients with IBD and CRC, specifically in elderly patients with short disease duration, in patients with mild colitis identified preoperatively, in patients with high operative risk and prohibitive comorbidities, and in patients whose CRC appears to be sporadic as opposed to colitis-associated. Patients undergoing segmental resection must be closely surveilled postoperatively for dysplasia, recurrent cancer, and refractory colitis.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

Surgical Treatment in Ulcerative Colitis, Still Topical: A Narrative Review

In this paper, different studies were integrated to conclude the impact of ulcerative colitis (UC) on the patient's vital prognosis, specifically highlighting the association with colorectal cancer (CRC). These severe complications have led us to consider studying the role of preventive surgery in managing UC. This study reviewed total preventive colectomy in UC patients for preventing the onset of CRC, the role of surgery in UC management, and its potential as a definitive treatment for the condition. The study also emphasized the effectiveness of annual colonoscopic monitoring and preventive colectomy in reducing the incidence of colorectal cancer (CRC). It discussed the role of laparoscopic surgery in minimizing postoperative complications and highlighted that partial surgical resection of the colon can be a viable option, offering improved bowel function without increasing the risk of CRC-related mortality. Elective surgery has an important place in UC management by preventing the development of forms requiring emergency surgery. Although surgery can cure UC, it can lead to significant postoperative complications and adverse effects.

Outcomes of Partial Versus Total Colectomy in Ulcerative Colitis: A Propensity Score-Matched Analysis

INTRODUCTION

Total abdominal colectomy (TAC) with ileostomy is the standard treatment for severe ulcerative colitis (UC). Partial colectomy (PC) with colostomy may present a less morbid treatment option.

METHODS

The 2012-19 ACS-NSQIP database was queried to assess 30-day outcomes among patients undergoing TAC versus PC for UC, utilizing propensity score matching (PSM) techniques to account for differences in disease severity, patient selection, and presentation acuity.

RESULTS

Before matching (n = 9888), patients undergoing PC were older, had more comorbidities, and experienced higher complication and 30-day mortality rates (P < 0.001). After matching (n = 1846), patients undergoing TAC experienced higher 30-day overall complications (41.9% versus 36.5%, P = 0.017) and serious complications (37.2% versus 31.5%, P = 0.011). Sensitivity analyses of older patients and those undergoing nonemergency surgery demonstrated higher overall rates of complications for patients receiving TAC. However, among patients undergoing emergency surgery only, no differences in complications were seen between the two surgical approaches.

CONCLUSIONS

PC with colostomy in the setting of ulcerative colitis has similar 30-day outcomes to TAC with ileostomy. PC may be an acceptable surgical alternative to TAC in select patients. Studies investigating longer-term outcomes are necessary to further investigate this option.

Increased Proportion of Colorectal Cancer in Patients with Ulcerative Colitis undergoing Surgery in the Netherlands

INTRODUCTION

The aim of the current study was to assess if there is an indication shift for surgery in patients with UC from refractory disease to malignant degeneration over the last 3 decades.

METHODS

All patients with histologically confirmed UC who underwent a colorectal resection between 1991 and 2020 were extracted from the nationwide Dutch Pathology Registry (PALGA). The primary outcome was the proportion of CRC in the colon specimens. Outcomes were compared between 3 periods (P1: 1991-2000, P2: 2001-2010, P3: 2011-2020).

RESULTS

Overall, 6,094 UC patients were included of which 4,854 underwent a (procto)colectomy and 1,240 a segmental resection. In 1,031 (16.9%) patients, CRC was demonstrated in the pathological resection specimen after a median disease duration of 11 years [IQR 3.0-19.0]. The proportion of CRC increased from 11.3% in P1, to 16.1% in P2, and 22.8% in P3 (p<0.001). Median disease duration at the time of resection increased from 4 years in P1, to 10 years in P2, and 17 years in P3 (p<0.001). The proportion of patients diagnosed with advanced malignancy (pT3/T4) (P1: 61.2% vs. P2: 65.2% vs. P3: 62.4%, respectively, p=0.633) and lymph node metastasis (N+) (P1: 33.0% vs. P2: 41.9% vs. P3: 38.2%, respectively, p=0.113) did not change over time.

DISCUSSION

This nationwide pathology study demonstrated an increased proportion of surgery for CRC over the last 3 decades. We hypothesize that the expanding therapeutic armamentarium for UC leads to exhausting medical options and hence postponed colectomy. This however, might be at the expense of an increased risk of CRC in the long term.

Intestinal Cancer and Dysplasia in Crohn's Disease

Crohn's disease is associated with an increased risk of adenocarcinoma of the involved portions of the small bowel and colorectum and has similar risk factors to those described in ulcerative colitis, most significantly, extent of bowel involvement, PSC, and duration of unresected disease. Prevention strategies include risk stratification and secondary prevention with colonoscopic screening and surveillance to identify dysplasia or early-stage cancers, with surgery when needed. There is emerging information to suggest that control of inflammation may provide primary prevention of neoplasia, but further studies are required to test this strategy.

Extent of Surgical Resection in Inflammatory Bowel Disease Associated Colorectal Cancer: a Population-Based Study

BACKGROUND

The extent of surgical resection in inflammatory bowel disease (IBD) patients who develop colorectal cancer (CRC) is not prescribed by guidelines. We aim to evaluate, at a population level, the association of extent of surgical resection with survival outcomes.

METHODS

Using a validated Ontario registry of Crohn's disease (CD) and ulcerative colitis (UC) patients, we identified patients who underwent colorectal cancer resection between 2007 and 2015. Patient, tumor, and treatment factors, including type of surgical resection, were collected. Resections were grouped as segmental, total colectomy, and proctocolectomy. Multivariable cox proportional hazard regression was performed to identify factors associated with survival, including extent of surgical resection.

RESULTS

Between 2007 and 2015, 84,694 patients had resections for CRC in the province of Ontario, 599 had ulcerative colitis (UC), and 366 had Crohn's disease (CD). Segmental resection was the most common operation performed and was more common in CD patients compared to UC (68% vs. 45.6%, p < 0.001). Five-year survival was 63.7% (95% CI 59.5-67.7) in UC patients and 57.5% (95% CI 51.9-62.7) in CD patients (p = 0.033). Multivariable analysis showed worse survival in patients undergoing total colectomy, compared to segmental resection [HR 1.70 (95% CI 1.31-2.21), p < 0.001]. There was no significant difference in survival between patients undergoing segmental resection and proctocolectomy [HR 0.99 (95% CI 0.78-1.27)]. This pattern was similar within the subtypes of IBD.

CONCLUSION

In the setting of IBD-associated CRC, segmental resection and proctocolectomy are associated with similar survival outcomes in both UC and CD patients. Prospective study is essential to explore these findings.

Management of Dysplasia in Ulcerative Colitis

Surveillance colonoscopies for patients with ulcerative colitis (UC) are necessary to monitor for the development of cancer and its precursor, dysplasia. The management of dysplasia in the setting of UC has been evolving over the past two decades. This is in large part due to higher resolution colonoscopes and development of advanced endoscopic techniques, such as chromoendoscopy, endoscopic mucosal resection, and endoscopic submucosal dissection. Mucosal evaluation, as well as identification and removal of dysplastic tissue, has improved markedly, such that the majority of dysplasia is now considered visible. Whereas previously random biopsies were deemed necessary for surveillance, currently their value is uncertain. Surveillance with high-definition colonoscopes is recommended and consideration of chromoendoscopy is suggested. During colonoscopy, if visible dysplasia is identified and removed completely, continued surveillance is appropriate. If dysplasia is unresectable or there are other high-risk factors such as primary sclerosing cholangitis or multifocality, patients should undergo colectomy. If random biopsies are taken and high-grade dysplasia is identified, that is, invisible dysplasia, patients should similarly consider colectomy. Surgical options include total proctocolectomy with end ileostomy versus ileal pouch-anal anastomosis. Patients undergoing pouch surgery must continue surveillance for dysplasia of the rectal cuff and the pouch. Although surgical management remains an important option for dysplasia in the setting of UC, endoscopic surveillance and resection have improved tremendously, leading to a shift in the overall management strategies for these patients.

Management of Low Rectal Cancer Complicating Ulcerative Colitis: Proposal of a Treatment Algorithm

Simple Summary

This article expresses the viewpoint of the authors’ management of low rectal cancer in ulcerative colitis (UC). This subject suffers from a paucity of literature and therefore management decision is very difficult to take. The aim of this paper is to provide a structured approach to a challenging situation. It is subdivided into two parts: a first part where the existing literature is reviewed critically, and a second part in which, on the basis of the literature review and their extensive clinical experience, a management algorithm is proposed by the authors to offer guidance to surgical and oncological practices. This text adds to the literature a useful guide for the treatment of these complex clinical scenarios.

Abstract

Low rectal Carcinoma arising at the background of Ulcerative Colitis poses significant management challenges to the clinicians. The complex decision-making requires discussion at the multidisciplinary team meeting. The published literature is scarce, and there are significant variations in the management of such patients. We reviewed treatment protocols and operative strategies; with the aim of providing a practical framework for the management of low rectal cancer complicating UC. A practical treatment algorithm is proposed.

Segmental versus extended colectomy for tumours of the transverse colon: a systematic review and meta-analysis

AIM

There is no consensus on the appropriate extent of oncological resection for tumours of the transverse colon. Concerns regarding tumour factors such as pattern of lymph node spread and technical factors such as anastomotic perfusion lead to a variety of procedures being performed.

METHODS

A comprehensive search for published studies examining outcomes following segmental versus extended colectomy for transverse colon tumours was performed adhering to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Random effects methods were used to combine data.

RESULTS

Seven comparative series examining outcomes in 3395 patients were identified. Segmental colectomy results in shorter operating times (mean difference 15.80 min, 95% CI -20.98 to -10.62, P < 0.001) and less ileus (OR 0.52, 95% CI 0.33-0.81, P = 0.004). There was no difference in length of hospital stay (mean difference 1.53 days, 95% CI -3.79 to 0.73, P = 0.18). Extended colectomy results in a lower rate of anastomotic leak (OR 0.62, 95% CI 0.40-0.97, P = 0.04). There are fewer nodes retrieved in segmental colectomy (mean difference 7.60 nodes, 95% CI -9.60 to -5.61, P < 0.001) but no difference in disease recurrence (OR 0.88, 95% CI 0.59-1.34, P = 0.56) or overall survival (OR 0.98, 95% CI 0.68-1.4, P = 0.9).

CONCLUSIONS

Available data are limited due to a lack of randomized controlled trials. However, based on current evidence, segmental resection for transverse colon tumours is associated with less ileus but lower lymph node yields and higher anastomotic leak rates. Length of stay is similar. Oncological outcomes are equivalent.

Segmental Colectomy for Ulcerative Colitis: Is There a Place in Selected Patients Without Active Colitis? An International Multicentric Retrospective Study in 72 Patients

BACKGROUND AND AIMS

The aim of this study was to report a multicentric experience of segmental colectomy [SC] in ulcerative colitis [UC] patients without active colitis, in order to assess if SC can or cannot represent an alternative to ileal pouch-anal anastomosis [IPAA].

METHODS

All UC patients undergoing SC were included. Postoperative complications according to ClavienDindo's classification, long term results, and risk factors for postoperative colitis and reoperation for colitis on the remnant colon, were assessed.

RESULTS: A TOTAL OF

72 UC patients underwent: sigmoidectomy [n = 28], right colectomy [n = 24], proctectomy [n = 11], or left colectomy [n = 9] for colonic cancer [n = 27], 'diverticulitis' [n = 17], colonic stenosis [n = 5], dysplasia or polyps [n = 8], and miscellaneous [n = 15]. Three patients died postoperatively and 5/69 patients [7%] developed early flare of UC within 3 months after SC. After a median followup of 40 months, 24/69 patients [35%] were reoperated after a median delay after SC of 19 months [range, 2-158 months]: 22/24 [92%] underwent total colectomy and ileorectal anastomosis [n = 9] or total coloproctectomy [TCP] [n = 13] and 2/24 [8%] an additional SC. Reasons for reoperation were: colitis [n = 14; 20%], cancer [n = 3] or dysplasia [n = 3], colonic stenosis [n = 1], and unknown reasons [n = 3]. Endoscopic score of colitis before SC was Mayo 23 in 5/5 [100%] patients with early flare vs 15/42 without early flare [36%; p = 0.0101] and in 9/12 [75%] patients with reoperation for colitis vs 11/35 without reoperation [31%; p = 0.016].

CONCLUSIONS

After segmental colectomy in UC patients, postoperative early colitis is rare [7%]. Segmental colectomy could possibly represent an alternative to IPAA in selected UC patients without active colitis.

Incidence, Risk Factors and Outcomes of Cancer of the Anal Transitional Zone in Patients with Ulcerative Colitis

BACKGROUND AND AIMS

Performing a mucosectomy with a hand-sewn ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC] theoretically reduces the risk of carcinoma arising from the anal transitional zone [ATZ]. Although current guidelines suggest a stapled anastomosis due to the low incidence of cancer after pouch surgery in UC patients, only a few small series have addressed the oncological advantage of mucosectomy. Therefore, we aimed to investigate the incidence of ATZ/pouch cancer.

METHODS

A total of 1970 UC patients who underwent surgery between April 1987 and December 2018 were included. We retrospectively analysed the incidences of primary ATZ cancer in the original operative specimen and de novo ATZ/pouch cancer after surgery. Possible risk factors for primary ATZ cancer and the pouch survival rate were assessed.

RESULTS

Fourteen [6.4%] primary ATZ cancers developed in 220 UC-colorectal cancer [CRC] cases. Multiple (odds ratio [OR] = 8.79, 95% confidence interval [CI] 2.77-27.83, p < 0.01) and rectal [OR = 6.48, 95% CI 1.41-29.7, p = 0.01] cancers were identified as independent risk factors for primary ATZ cancer. Four of 1970 [0.2%] patients developed de novo ATZ/pouch cancer and dysplasia. The 10-year estimated cumulative pouch survival rate was not significantly different between stapled IPAA and hand-sewn IPAA cases [95.9% and 97.3%, p = 0.25].

CONCLUSION

The risk of de novo ATZ/pouch cancer and dysplasia was rare. The decision to perform a hand-sewn or a stapled IAA should be made on a case-by-case basis. However, the relatively high incidence of primary ATZ cancer in UC patients with CRC suggests that mucosectomy should be recommended for this patient group.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.