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Bhatt H, Mathis KL. Small Bowel Carcinoma in the Setting of Inflammatory Bowel Disease. Clin Colon Rectal Surg 2024; 37:46-52. [PMID: 38188070 PMCID: PMC10769580 DOI: 10.1055/s-0043-1762929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Small bowel carcinomas are rare in the general population, but the incidence is increasing. Patients with inflammatory bowel diseases (IBDs) are at significantly higher risk of small bowel adenocarcinomas than their non-IBD counterparts, with Crohn's patients having at least a 12-fold increased risk and ulcerative colitis patients with a more controversial and modest 2-fold increased risk compared with the general population. IBD patients with small bowel carcinomas present with nonspecific symptoms that overlap with typical IBD symptoms, and this results in difficulty making a preoperative diagnosis. Cross-sectional imaging is rarely diagnostic, and most cancers are found incidentally at the time of surgery performed for an IBD indication. As such, most small bowel carcinomas are found at advanced stages and carry a poor prognosis. Oncologic surgical resection is the treatment of choice for patients with locoregional disease with little evidence available to guide adjuvant therapy. Patients with metastatic disease are treated with systemic chemotherapy, and surgery is reserved for palliation in this population. Prognosis is poor with few long-term survivors reported.
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Affiliation(s)
- Himani Bhatt
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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2
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Schreiber ME, Schneider MA, Murray FR, Turina M, Gubler C. Routine Endoscopy Prior to Surgical Ostomy Closure: An Obsolete Concept. Dig Dis Sci 2023; 68:4130-4139. [PMID: 37707748 PMCID: PMC10570172 DOI: 10.1007/s10620-023-08088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/20/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Closure of temporary diverting ostomies is commonly preceded by an endoscopic study of the colonic mucosa and anastomosis, despite lacking evidence of its relevance and impact on subsequent operative management. AIM We sought to determine the incidence of pathological findings and therefore evaluate the clinical benefit of routine pre-operative endoscopy in asymptomatic patients, hypothesizing sole evaluation of the anastomotic integrity to be sufficient in these cases. METHODS We retrospectively identified all adult patients with ostomy installations who were followed up for potential reversal surgery between 2002 and 2020 at the University Hospital of Zurich, Switzerland. Main outcome measures were the incidence of endoscopically identified pathological findings in the asymptomatic case cohort and their impact on the subsequent course of treatment. RESULTS Pre-procedural endoscopic data of 187 cases evaluated for ostomy closure were evaluated. Relevant mucosal findings in the asymptomatic cohort were documented in 26.3% and findings at the anastomotic site detected in 8.7%. A change in subsequent surgical management was noted in 10 patients of the entire cohort (5.3%) and in 9 (5.1%) of all asymptomatic cases. Upon multivariate analyses, the age range of 51 to 60 years old was found to be significantly linked to the presence of endoscopic findings entailing a change in patient management. CONCLUSION Our findings strongly suggest ostomy closure surgery without previous assessment of the bowel mucosa by means of endoscopy to be acceptable in asymptomatic patients. However, we found it to be indicated in all patients meeting the screening criteria for colorectal carcinoma.
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Affiliation(s)
- Maxine E. Schreiber
- Department of Gastroenterology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Marcel A. Schneider
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Fritz R. Murray
- Department of Gastroenterology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Department of Gastroenterology, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zurich, Switzerland
| | - Matthias Turina
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Christoph Gubler
- Department of Gastroenterology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Department of Gastroenterology, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zurich, Switzerland
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Aggarwal A, Lang A, Krigman HR, Dehner LP. Vascular Malformation and CAP Polyposis: A New Insight into Pathophysiology or Fortuitous Association? Fetal Pediatr Pathol 2022; 41:670-676. [PMID: 33872119 DOI: 10.1080/15513815.2021.1913537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION CAP polyposis is a benign colorectal process presenting with multiple colorectal polyps with a "CAP" of inflammatory granulation tissue whose etiology has remained largely unknown. CASE A 24-year-old male presented with a long-standing history of repeated multiple sessile colonic polyps over a period of 17 years. RESULTS The numerous polyps showed consistent histologic features of superficial erosion with a surface "CAP" of granulation tissue with minimal submucosa to evaluate over this period. A left hemicolectomy disclosed an extensive vascular malformation. CONCLUSION The underlying vascular malformation may have an etiologic correlation to the overlying CAP polyps in this patient. Future cases may benefit from an evaluation of the underlying submucosa for the presence of possible vascular malformation likely to be missed on superficial polypectomy.
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Affiliation(s)
- Ashna Aggarwal
- Department of Pathology and Immunology, Barnes-Jewish Hospital/St. Louis Children's Hospital, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA
| | - Adam Lang
- Department of Pathology, Blessing Health System, Quincy, IL, USA
| | - Hannah R Krigman
- Department of Pathology and Immunology, Barnes-Jewish Hospital/St. Louis Children's Hospital, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA
| | - Louis P Dehner
- Department of Pathology and Immunology, Barnes-Jewish Hospital/St. Louis Children's Hospital, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA
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Morada AO, Senapathi SH, Bashiri A, Chai S, Cagir B. A systematic review of primary ileostomy site malignancies. Surg Endosc 2022; 36:1750-1760. [PMID: 34997348 DOI: 10.1007/s00464-021-08847-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND This paper aimed to elucidate the etiologies of all primary ileostomy site malignancies published in the literature. METHODS A review of the literature was conducted following PRISMA guidelines by querying PubMed, Global Health, and Web of Science for articles published before November 2020. Search criteria contained broad terminology for ileostomy site neoplasms without language, date, or publication limitations. A full-text review of the abstracts confirmed primary malignant pathologies and was evaluated for study inclusion. RESULTS Literature search discovered 858 publications, with 76 meeting eligibility criteria. The final sample contained 91 patients, with equal males and females. The mean age of patients with ileostomy site malignancy was 62.0 ± 12.2, with an average ileostomy age of 29.4 ± 12.4. The most common indications for ileostomy creation were inflammatory bowel disease (IBD) (73.6%) and familial adenomatous polyposis (FAP) (20.9%). There was a total of eight ileostomy malignant pathologies reported, with adenocarcinoma being the most common (76.9%), followed by squamous cell carcinoma (SCC) (11.0%). Adenocarcinoma was diagnosed at a younger age than SCC (59.7 vs. 72.3) and developed over a shorter time (28.8 vs. 37.0). Patients with FAP almost exclusively developed adenocarcinoma (94.4%) at a younger stoma age (25.8 vs. 31.4) than those with IBD who developed seven diverse pathologies. With a median follow-up of 0.75 years, four patients developed disease recurrence and received oncologic resection of their cancer less often than the 55 negative patients (p = 0.04). CONCLUSION Ileostomy site malignancies are late-appearing complications that require curative surgery. Their presentation is associated with ileostomy duration and creation indication, such as FAP or IBD. We recommend screening at a stoma age ≥ 20 or patient age ≥ 50 for patients with FAP, while stoma age ≥ 25 or patient age ≥ 60 for IBD patients.
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Affiliation(s)
- Anthony Onde Morada
- Guthrie Robert Packer Hospital, Sayre, PA, USA.,Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | | | | | | | - Burt Cagir
- Guthrie Robert Packer Hospital, Sayre, PA, USA. .,Department of Surgery, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA.
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5
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Yousaf A, Beatty C, Zinn Z, Cassim R, Gayam S. Ileostomy adenocarcinoma in Crohn's disease. Int J Colorectal Dis 2020; 35:963-966. [PMID: 32144530 PMCID: PMC7957826 DOI: 10.1007/s00384-020-03554-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Adenocarcinoma of an ileostomy is rare with less than 50 reported cases in the literature. Ileostomy adenocarcinoma in Crohn's disease is even more rare, with only 4 reported cases. We present a case of ileostomy adenocarcinoma with lymph node metastasis occurring 51 years after proctocolectomy and Brooke ileostomy in a female with Crohn's disease. This case represents the longest documented interval between Brooke ileostomy and ileostomy adenocarcinoma diagnosis and summarizes clinical signs that warrant biopsy of a peristomal plaque to differentiate adenocarcinoma from clinical mimics such as pyoderma gangrenosum (PG). METHODS Clinical, histological, and surgical patient data were reviewed. A literature review of adenocarcinoma arising from ileostomy sites was performed. RESULTS We report a case of a 67-year-old woman that presented with a peristomal skin lesion developing over 10 years. After multidisciplinary discussion between gastroenterology, colorectal surgery, and dermatology, ileoscopy revealed moderately differentiated, invasive adenocarcinoma arising from the ileostomy site. Wide surgical excision and en bloc resection of the peristomal lesions were performed, and the final pathology revealed lymph node metastasis. The patient is currently undergoing adjuvant chemotherapy. CONCLUSIONS Clinicians should maintain a high level of suspicion when ileostomy patients develop a peristomal lesion.
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Affiliation(s)
- Ahmed Yousaf
- Department of Dermatology, West Virginia University, Morgantown, WV, USA
| | - Colleen Beatty
- Department of Dermatology, West Virginia University, Morgantown, WV, USA
| | - Zachary Zinn
- Department of Dermatology, West Virginia University, Morgantown, WV, USA
| | - Riaz Cassim
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Swapna Gayam
- Division of Digestive Diseases, West Virginia University, Morgantown, WV, USA
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James SD, Hawkins AT, M'Koma AE. Adenocarcinoma at the Ileostomy Site After a Proctocolectomy for Ulcerative Colitis and/or Familial Adenomatous Polyposis: An Overview. OSTOMY/WOUND MANAGEMENT 2018; 64:30-40. [PMID: 30059346 PMCID: PMC10448503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Adenocarcinoma that occurs at the ileostomy site after proctocolectomy (TPC) with an end ileostomy for ulcerative colitis (UC) and/or familial adenomatous polyposis (FAP) is a late and uncommon complication. To ascertain the rate of adenocarcinoma at the empirical ileostomy site following TPC, a review of the literature was conducted. PubMed, MEDLINE, the Cumulative Index of Nursing and Allied Health Literature, EMBASE, Google search engine, and the Cochrane Database were investigated for research published between January 1975 and December 2016. Search criteria included English language and human-only publications; broad search terms related to UC, FAP, ileostomy procedures, and dysplasias were used. Abstracts were eliminated if they were foreign language and nonhuman studies; editorials also were excluded. Secondary and hand/manual searches of reference lists, other studies cross-indexed by authors, reviews, commentaries, books, and meeting abstracts also were performed. Data extracted included age at diagnosis, operation technique, interval to ileostomy cancer, age when cancer was diagnosed, histology for both UC and FAP patients, and subsequent treatment. Papers were included on the basis of available evidence for each specific point of interest. Final and conclusive agreement was assessed with the k statistics during the title review and abstract review. Studies that did not report original data also were excluded. A total of 5753 publications were identified; 5697 publications did not conform to inclusion criteria and were eliminated. Among the reviewed publications (all case studies), 57 patients were diagnosed with ileostomy adenocarcinoma after TPC; 42 had UC, and 15 had FAP. The interval between TPC operation and ileostomy cancer diagnosis ranged from 3 to 51 years for UC and from 9 to 40 years for FAP, with a mean interval of 30 and 26 years, respectively. Biopsies were performed of all polypoid lesions found at the stoma site. Patients were treated with wide excision and refashioning (diversion) of the stoma. While adenocarcinoma arising at the mucocutaneous junction at the ileostomy site with adjacent skin invasion after TPC for UC and FAP appears to be rare, patients and clinicians need to be aware of this potential complication even years after surgery and regular screening is recommended.
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Affiliation(s)
- Samuel D James
- Department of Pathology, Meharry Medical College School of Medicine, Nashville General Hospital, Nashville, TN; and Department of Pathology, Microbiology, and Immunology, Tennessee Valley Health Systems VA Medical Center, Vanderbilt University Medical Center, Nashville, TN
| | | | - Amosy E M'Koma
- Department of Biochemistry, Cancer Biology, Neuroscience and Pharmacology, Meharry Medical College School of Medicine; and Department of Surgery, Vanderbilt University School of Medicine
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7
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O'Mahoney PRA, Scherl EJ, Lee SW, Milsom JW. Adenocarcinoma of the ileal pouch mucosa: case report and literature review. Int J Colorectal Dis 2015; 30:11-8. [PMID: 25354968 DOI: 10.1007/s00384-014-2043-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2014] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Paul R A O'Mahoney
- Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, 525 East 68th Street, Box 172, New York, NY, 10065-4870, USA
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8
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Bakhshi GD, Shenoy SS, Jadhav KV, Tayade MB, Patil SR, Patel CB. Adenocarcinoma of an Ileostomy in a Case of Hirschprung's Disease with Retroviral Disease. Clin Pract 2013; 3:e27. [PMID: 24765515 PMCID: PMC3981272 DOI: 10.4081/cp.2013.e27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 06/13/2013] [Accepted: 07/03/2013] [Indexed: 02/02/2023] Open
Abstract
The number of ileostomies created for benign diseases such as familial adenomatous polyposis and ulcerative colitis is increasing. Long-term ileostomies are prone to develop various complications over time. Ileostomy site carcinoma is a well-established complication in ulcerative colitis and familial adenomatous polyposis that have undergone total colectomy. However, no case of ileostomy site carcinoma has been described in a patient with Hirschprung's disease. We present the first case of adenocarcinoma at an ileostomy site in a patient with Hirschprung's disease with retroviral disease.
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Affiliation(s)
- Girish D Bakhshi
- Department of General Surgery, Grant Medical College and Sir J J Group of Hospitals , Mumbai, India
| | - Sachin S Shenoy
- Department of General Surgery, Grant Medical College and Sir J J Group of Hospitals , Mumbai, India
| | - Kavita V Jadhav
- Department of General Surgery, Grant Medical College and Sir J J Group of Hospitals , Mumbai, India
| | - Mukund B Tayade
- Department of General Surgery, Grant Medical College and Sir J J Group of Hospitals , Mumbai, India
| | - Sunil R Patil
- Department of General Surgery, Grant Medical College and Sir J J Group of Hospitals , Mumbai, India
| | - Chintan B Patel
- Department of General Surgery, Grant Medical College and Sir J J Group of Hospitals , Mumbai, India
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9
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Raman S, Fadipe Y, Perston Y, Karandikar S. Nicorandil-induced ulceration complicating a novel treatment of a peristomal tubovillous adenoma. ACTA ACUST UNITED AC 2012. [DOI: 10.12968/gasn.2012.10.8.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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10
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Primary adenocarcinoma of ileostomy: case report with review of the literature. Case Rep Med 2010; 2010:921328. [PMID: 20368789 PMCID: PMC2846355 DOI: 10.1155/2010/921328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 03/02/2010] [Indexed: 01/07/2023] Open
Abstract
Primary adenocarcinoma is a rare and late complication following proctocolectomy and ileostomy for ulcerative colitis, familial adenomatous polyposis, Crohn's disease and multifocal colorectal cancer. We report a case of adenocarcinoma of the ileostomy occurring 48 years after proctocolectomy for ulcerative colitis. A review of the literature suggests that there are 39 cases reported in literature and this case reports the longest interval between formation of ileostomy and diagnosis of ileostomy adenocarcinoma. This case also reports lymph node metastasis to the adjacent mesenteric lymph node. The incidence of lymphnode metastasis is 15 percent as per literature. Onces diagnosis is confirmed by biopsy enblock excision with or without stomal relocation is the main stay of treatment. Patient education and regular surveillance of patients with long-standing ileostomy is recommended for early detection of this unusual cancer.
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11
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Primary Mucinous Adenocarcinoma in an Ileostomy with Adjacent Skin Invasion: A Late Complication of Surgery for Ulcerative Colitis. J Gastrointest Cancer 2009; 39:138-40. [DOI: 10.1007/s12029-009-9066-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Accepted: 04/15/2009] [Indexed: 11/27/2022]
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12
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Matsushima K. Two different types of polypoid lesion at ileostomy site. Surgery 2007; 145:337-8. [PMID: 19231588 DOI: 10.1016/j.surg.2007.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 08/10/2007] [Indexed: 01/10/2023]
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Nilubol N, Scherl E, Bub DS, Gorfine SR, Marion J, Harris MT, Kornbluth A, Lichtiger S, Rubin P, George J, Chapman M, Harpaz N, Present D, Bauer JJ. Mucosal dysplasia in ileal pelvic pouches after restorative proctocolectomy. Dis Colon Rectum 2007; 50:825-31. [PMID: 17429711 DOI: 10.1007/s10350-007-0217-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Naris Nilubol
- Department of Surgery, The Mount Sinai Hospital, New York, New York, USA.
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14
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Affiliation(s)
- James Church
- Department of Colorectal Surgery, Desk A-30, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
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15
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Quah HM, Samad A, Maw A. Ileostomy carcinomas a review: the latent risk after colectomy for ulcerative colitis and familial adenomatous polyposis. Colorectal Dis 2005; 7:538-44. [PMID: 16232232 DOI: 10.1111/j.1463-1318.2005.00807.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ileostomy carcinoma after colectomy for ulcerative colitis and familial adenomatous polyposis is rare. METHODS Forty-three case reports from the literature and a case of ours are reviewed. RESULTS The risk of malignancy following ileostomy formation appears to be increased compared to the very low incidence of primary small bowel carcinoma. Chronic physical or chemical irritation of the stoma may predispose the ileal mucosa to colonic metaplasia with subsequent adenoma formation, dysplasia and invasive malignant change. This is particularly so where ileostomies are fashioned for familial adenomatous polyposis and ulcerative colitis. CONCLUSION Routine surveillance of patients who have had an ileostomy for 15 years or longer may lead to earlier detection of this complication.
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Affiliation(s)
- H M Quah
- Department of Colorectal and General Surgery, Glan Clwyd Hospital, Denbingshire, UK
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Achneck HE, Wong IY, Kim PJ, Fernandes MA, Walther Z, Seymour NE, Jain D. Ileostomy adenocarcinomas in the setting of ulcerative colitis. J Clin Gastroenterol 2005; 39:396-400. [PMID: 15815208 DOI: 10.1097/01.mcg.0000159216.39795.4a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Adenocarcinomas arising at ileostomy sites in patients after colon resection for various diseases, such as ulcerative colitis (UC), familial adenomatous polyposis coli, and Crohn's disease, are rare occurrences but have been reported increasingly in the last 20 years. We report a case of adenocarcinoma arising in an ileostomy site in an 85-year-old woman with longstanding UC. She had pancolitis and underwent total proctocolectomy. Thirty-nine years later, her ileostomy site developed a granulation tissue-type lesion, which on initial biopsy revealed cytologic atypia in the presence of marked inflammation. A subsequent biopsy revealed adenocarcinoma with signet-ring cells and abundant extracellular mucin. Resection of the ileostomy was undertaken and a new ileostomy was performed. The literature on adenocarcinoma arising in the 23 patients with ulcerative colitis who received a Brooke or Kock ileostomy and had no prior history of neoplasm is reviewed.
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Affiliation(s)
- Hardean E Achneck
- Department of Surgery, Yale University School of Medicine, New Haven, CT 06520-8023, USA
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17
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Ohkawara T, Kato M, Nakagawa S, Nakamura M, Takei M, Komatsu Y, Shimizu Y, Takeda H, Sugiyama T, Asaka M. Spontaneous resolution of cap polyposis: case report. Gastrointest Endosc 2003; 57:599-602. [PMID: 12665781 DOI: 10.1067/mge.2003.166] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Tatsuya Ohkawara
- Department of Gastroenterology and Hematology, Division of Endoscopy, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Abstract
Patients with ileal pouches and ostomies present with management issues that are challenging to the clinician. Endoscopy plays a significant role in diagnosing and guiding therapy in such patients. Unfortunately, there are very few prospective studies that evaluates endoscopy in these situations. Nevertheless, it is clear that endoscopy remains a powerful tool that is important for diagnosis and therapy of complications unique to these surgical procedures. It seems prudent to advocate endoscopic cancer surveillance for patients with pouches and ostomies; however, it remains to be seen whether these efforts will ultimately have an impact on long-term patient morbidity and mortality.
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Affiliation(s)
- Peter Ghali
- Division of Gastroenterology and Hepatology, McGill University Health Center, Royal Victoria Hospital Site, Division of Gastroenterology, Ross 2.28, 687 Pine Avenue, Montreal, Quebec, Canada H3A
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19
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Kotanagi H, Kon H, Iida M, Ito M, Koyama K. Adenocarcinoma at the site of ileoanal anastomosis in Crohn's disease: report of a case. Dis Colon Rectum 2001; 44:1210-3. [PMID: 11535864 DOI: 10.1007/bf02234646] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Proctocolectomy with ileoanal anastomosis has gained acceptance for the treatment of patients with ulcerative colitis. However, there are some patients with Crohn's disease who received ileoanal anastomosis, because some Crohn's colitis is difficult to differentiate from ulcerative colitis. The risk of cancer development at the site of ileoanal anastomosis has not been emphasized in Crohn's disease. METHODS A 12-year-old patient with Crohn's disease was treated by proctocolectomy with straight ileoanal anastomosis. Twenty-five years after the operation, the patient noticed the tumor that developed at the site of ileoanal anastomosis. RESULTS This article presents a patient with Crohn's disease who developed invasive adenocarcinoma at the site of ileoanal anastomosis 25 years after proctocolectomy with ileoanal anastomosis. CONCLUSIONS An ileoanal anastomosis does not eliminate the risk of cancer development, and surveillance after this operation seems advisable.
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Affiliation(s)
- H Kotanagi
- Department of Surgery, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan
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Thompson-Fawcett MW, Marcus V, Redston M, Cohen Z, McLeod RS. Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis. Gastroenterology 2001; 121:275-81. [PMID: 11487537 DOI: 10.1053/gast.2001.26442] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Recent reports have suggested the mucosa of an ileal reservoir could be at risk of neoplasia. Risk factors may include the age of the pouch, chronic pouchitis, and previous colonic neoplasia. This study examined a group of such patients to determine the risk of dysplasia. METHODS From a cohort of 1221 patients with ileal pouches, 171 patients with possible risk factors were selected. Successful contact was made with 138 patients who were invited for endoscopy and multiple biopsies. Biopsy specimens were stained with H&E and p53, scored for inflammatory changes including villous atrophy, and analyzed by flow cytometry. RESULTS One hundred six patients took part and fell into 1 or more of the following clinical categories: chronic pouchitis (n = 34), pelvic pouch for > or =12 years (n = 42); Kock pouch for > or =14 years (n = 29), and neoplasia in colectomy specimen (n = 11). Thirty-three patients had severe villous atrophy. One patient of 106 (95% confidence interval, 0.9% +/- 1.6%) with a long-standing pouch had low-grade dysplasia that was multifocal. DNA analysis by flow cytometry showed aneuploidy in this patient and 2 others. CONCLUSIONS These data suggest that the development of dysplasia in ileal pouches performed for ulcerative colitis is probably a rare event within 15-20 years of pouch surgery.
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Affiliation(s)
- M W Thompson-Fawcett
- Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto M5G 1X5 Canada
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Kajihara H, Uno Y, Ying H, Tanaka M, Munakata A. Features of cap polyposis by magnifying colonoscopy. Gastrointest Endosc 2000; 52:775-8. [PMID: 11115917 DOI: 10.1067/mge.2000.109874] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- H Kajihara
- First Departments of Internal Medicine and the Second Department of Pathology, Hirosaki University, Aomori, Japan
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Affiliation(s)
- Wilson
- Department of Colorectal Surgery, Hope Hospital, Salford, UK
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Iwama T, Kamikawa J, Higuchi T, Yagi K, Matsuzaki T, Kanno J, Maekawa A. Development of invasive adenocarcinoma in a long-standing diverted ileal J-pouch for ulcerative colitis: report of a case. Dis Colon Rectum 2000; 43:101-4. [PMID: 10813131 DOI: 10.1007/bf02237251] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We report a case of a 50-year-old male with ulcerative colitis who developed well-differentiated adenocarcinoma in the ileal J-pouch, which had been defunctioning for 18 years. The extension of the carcinoma in the pouch suggested that it had recently appeared in the pouch. Monitoring by endoscopic examination and biopsy or pouch excision seems to be an appropriate action if a pouch is out of the fecal stream.
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Affiliation(s)
- T Iwama
- Department of Surgery, Kyoundo Hospital, Sasaki Institute, Tokyo, Japan
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Vaizey CJ, van den Bogaerde JB, Emmanuel AV, Talbot IC, Nicholls RJ, Kamm MA. Solitary rectal ulcer syndrome. Br J Surg 1998; 85:1617-23. [PMID: 9876062 DOI: 10.1046/j.1365-2168.1998.00935.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Solitary rectal ulcer syndrome is a rare disorder characterized by erythema or ulceration of the rectal wall, associated with typical histological features, and disturbed defaecatory behaviour with the passage of blood and mucus. METHODS This is a review based on a literature search using a computer database (Medline) and manual cross-referencing. RESULTS The pathogenesis is likely to vary in different patients; it includes trauma from straining, direct digital trauma and possibly primary neuromuscular pathology. The histological findings of extension of the muscularis mucosa between crypts and muscularis propria disorganization on full-thickness specimens are characteristic. Biofeedback defaecation retraining, including habit training, can lead to symptom improvement and return to work in a majority of patients. Abdominal rectopexy offers long-term symptom improvement in approximately 50 per cent of patients. Rectal ulceration may persist after any treatment, even if symptoms improve. CONCLUSION Behavioural therapy and carefully considered operations offer the best treatment results. Further work on psychological factors and neuromuscular and vascular pathology is required.
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