1
|
Aelvoet AS, Buttitta F, Ricciardiello L, Dekker E. Management of familial adenomatous polyposis and MUTYH-associated polyposis; new insights. Best Pract Res Clin Gastroenterol 2022; 58-59:101793. [PMID: 35988966 DOI: 10.1016/j.bpg.2022.101793] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/21/2021] [Accepted: 03/08/2022] [Indexed: 02/07/2023]
Abstract
Familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP) are rare inherited polyposis syndromes with a high colorectal cancer (CRC) risk. Therefore, frequent endoscopic surveillance including polypectomy of relevant premalignant lesions from a young age is warranted in patients. In FAP and less often in MAP, prophylactic colectomy is indicated followed by lifelong endoscopic surveillance of the retained rectum after (sub)total colectomy and ileal pouch after proctocolectomy to prevent CRC. No consensus is reached on the right type and timing of colectomy. As patients with FAP and MAP nowadays have an almost normal life-expectancy due to adequate treatment of colorectal polyposis, challenges in the management of FAP and MAP have shifted towards the treatment of duodenal and gastric adenomas as well as desmoid treatment in FAP. Whereas up until recently upper gastrointestinal surveillance was mostly diagnostic and patients were referred for surgery once duodenal or gastric polyposis was advanced, nowadays endoscopic treatment of premalignant lesions is widely performed. Aiming to reduce polyp burden in the colorectum as well as in the upper gastrointestinal tract, several chemopreventive agents are currently being studied.
Collapse
Affiliation(s)
- Arthur S Aelvoet
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| | - Francesco Buttitta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy.
| | - Luigi Ricciardiello
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy.
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam Cancer Center Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| |
Collapse
|
2
|
MacDonald S, Au S, Thornton M, Macdonald A. Complications and functional outcomes after ileo-anal pouch excision-a systematic review of 14 retrospective observational studies. Int J Colorectal Dis 2021; 36:677-687. [PMID: 33471205 DOI: 10.1007/s00384-021-03838-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The ileo-anal pouch (IAP) has been the gold standard procedure for maintenance of bowel continuity after panproctocolectomy for ulcerative colitis, familial adenomatous polyposis or hereditary non-polyposis colorectal cancer. However, the IAP has an estimated failure rate of 13% at 10 years post-procedure (Tulchinsky et al., Ann Surg 238(2):229-34, 2003), which can result in pouch excision (P.E.). This systematic review aims to synthesise all the available studies reporting post-operative outcomes of P.E. and its impact on patient quality of life (QoL), when available, which have not previously been summarised. METHODS PubMed, Embase, Medline and the Cochrane library databases were searched with terms 'Pouch AND excision' OR 'Pouch AND removal' OR 'Pouch AND remove' OR 'IAP AND excision'. All studies reporting post-operative morbidity, mortality or functional outcomes in patients who had P.E. were included. Studies with < 5 patients, non-English studies and conference abstracts were excluded. RESULTS 14 studies comprising 1601 patients were included. Overall complications varied from 18 to 63% with the most common being persistent perineal sinus (9-40%) or surgical site infection (wound-2 to 30%; intra-abdominal collection-3 to 24%). The mortality rate was between 0.58 and 1.4%. QoL is generally lower in P.E. patients compared to the normal population across various QoL measures and P.E. patients often had urinary and sexual dysfunction post-operatively. CONCLUSIONS There is a substantial incidence of complications after P.E.; however, there is no evidence describing QoL pre- and post-P.E. Further longitudinal research comparing QoL in patients undergoing P.E. and other treatment options such as indefinite diversion is required to definitively assess QoL post-procedure.
Collapse
Affiliation(s)
- S MacDonald
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK.
| | - S Au
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK
| | - M Thornton
- Department of Surgery, Wishaw General Hospital, 50 Netherton St., Wishaw, Scotland, ML2 0DP, UK
| | - A Macdonald
- Department of Surgery, University Hospital Monklands, Airdrie, North Lanarkshire, Scotland, ML6 0JS, UK
| |
Collapse
|
3
|
Fecal continence outcomes are associated with the type, height, and stage procedure of ileal pouch-anal anastomosis. Int J Colorectal Dis 2020; 35:1749-1757. [PMID: 32474709 PMCID: PMC7415023 DOI: 10.1007/s00384-020-03626-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to analyze the quality of life in patients with an ileal pouch-anal anastomosis (IPAA) and to investigate the association between height and type of the anastomosis, the number of stage procedures and age, and the fecal continence outcomes. METHODS This is a cross-sectional retrospective study in patients who had undergone IPAA between 1992 and 2016 (N = 133). We sent questionnaires to 102 eligible patients (64% response rate). We used the Wexner score to assess fecal incontinence: 0 = no incontinence to 20 = complete incontinence. We used RAND-36 to measure quality of life. RESULTS Patients who underwent mucosectomy with hand-sewn anastomoses (n = 11, 17%) had significantly higher median Wexner scores than patients with stapled anastomoses (10 versus 3, P = 0.003). Lower anastomoses correlated significantly with increasing Wexner scores (r = - 0.468, P < 0.001). Quality of life of incontinent patients was diminished. Patients who were older at the time of IPAA surgery had higher Wexner scores (P = 0.004), while the time between surgery and questionnaire did not influence their Wexner scores (P = 0.810). Considering the stage procedures, multiple linear regression showed that the two-stage procedure without diverting ileostomy was significantly associated with higher Wexner scores (B = 0.815, P = 0.02), adjusted for sex (P = 0.008) and anastomosis type (P = 0.002). The three-stage procedure showed equally low complications and anastomotic leakage rates. CONCLUSION Mucosectomy with more distal, hand-sewn anastomosis and increasing age at IPAA surgery was associated with poorer fecal continence outcomes. The three-stage procedure appears to give the best fecal continence results without increasing complications. Furthermore, incontinence reduced patient's quality of life.
Collapse
|
4
|
A Decision Analysis for Rectal-Sparing Familial Adenomatous Polyposis: Total Colectomy With Ileorectal Anastomosis Versus Proctocolectomy With IPAA. Dis Colon Rectum 2019; 62:27-32. [PMID: 30394986 DOI: 10.1097/dcr.0000000000001186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are different approaches for the surgical management of rectal-sparing familial adenomatous polyposis with variable impacts on both quality of life and survival. OBJECTIVE The aim of this study was to quantify the trade-offs between total proctocolectomy with IPAA versus total colectomy with ileorectal anastomosis using decision analysis. DESIGN We created a disease simulation Markov model to simulate the clinical events after IPAA and ileorectal anastomosis for rectal-sparing familial adenomatous polyposis in a cohort of individuals at the age 30 years. We used available literature to obtain different transition probabilities and health-states utilities. The output parameters were quality-adjusted life-years and life-years. Deterministic and probabilistic sensitivity analyses were performed. SETTINGS A decision analysis using a Markov model was conducted at a single center. PATIENTS Patients with rectal-sparing familial adenomatous polyposis at age 30 years were included. Rectal-sparing familial adenomatous polyposis is defined as the presence of 0 to 20 polyps that can be removed endoscopically. MAIN OUTCOME MEASURES Quality-adjusted life-years were measured. RESULTS Our model showed that the mean quality-adjusted life-years for IPAA was 25.12 and for ileorectal anastomosis was 27.12 in base-case analysis. Mean life-years for IPAA were 28.81 and 28.28 for ileorectal anastomosis. A 1-way sensitivity analysis was performed for all of the parameters in the model. None of the deterministic sensitivity analyses changed the model results across the range of plausible values. Probabilistic analysis identified that, in 86.9% of scenarios, ileorectal anastomosis had improved quality-adjusted life-years compared with IPAA. LIMITATIONS The study was limited by characteristics inherent to modeling studies. CONCLUSIONS Ileorectal anastomosis was found to be preferable for patients with rectal-sparing familial adenomatous polyposis when quality of life is taken into consideration. This model was robust based on both deterministic and probabilistic sensitivity analyses. These data should be taken into consideration when counseling patients regarding a surgical approach in rectal-sparing familial adenomatous polyposis. See Video Abstract at http://links.lww.com/DCR/A715.
Collapse
|
5
|
Sherman Horev H, Rabinowitz KM, Elad H, Barkan R, Ben-Shachar S, Pasmanik Chor M, Dotan I. Increase in Processing Factors Is Involved in Skewed MicroRNA Expression in Patients with Ulcerative Colitis Who Develop Small Intestine Inflammation after Pouch Surgery. Inflamm Bowel Dis 2018; 24:1045-1054. [PMID: 29688474 DOI: 10.1093/ibd/izy034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A large-scale increase in microRNA (miRNA) expression was observed in patients with ulcerative colitis who underwent pouch surgery and developed inflammation of the pouch (pouchitis). In this study, we assessed miRNA expression in these patients and investigated how regulation of its expression changes in the setting of pouchitis. METHODS Autologous samples that included mucosal biopsies, peripheral blood cells, and plasma were collected from the patients. Candidate primary and mature miRNA expressions were analyzed by quantitative polymerase chain reaction. A human intestinal epithelial cell line was used to test DICER activity, and the expression of key miRNA processing factors was analyzed by Western blot. miRNA-424 and its potential target serotonin reuptake transporter (SERT) expressions were examined by quantitative reverse transcription polymerase chain reaction and Western blot in human pouch tissues and in a human intestinal epithelial cell line stimulated with inflammatory cytokines TNF-α, IL-1β, and INF-γ. RESULTS Candidate miRNA expression and protein expression of DICER-1, EXPORTIN-5, and AGO-2 were increased in association with pouch inflammation. Similarly, inflammatory cytokines increased protein expression of DICER-1, EXPORTIN-5, and AGO-2 and DICER activity in the epithelial cell line. The miRNA-424 expression increased whereas SERT expression decreased in the patients' mucosa. Similarly, incubation of the epithelial cell line with inflammatory cytokines resulted in increased miRNA-424 and decreased SERT mRNA and protein expression. CONCLUSIONS The miRNA expression and processing are augmented in the inflamed intestinal mucosa of patients with pouchitis. These alterations are accompanied by increased expression of proteins involved in miRNA processing, suggesting that pouch inflammation contributes to miRNA processing and expression.
Collapse
Affiliation(s)
- Hadas Sherman Horev
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren M Rabinowitz
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hofit Elad
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Revital Barkan
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shay Ben-Shachar
- Genetic Institute, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Iris Dotan
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
6
|
Noh GT, Han J, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Factors affecting pouch-related outcomes after restorative proctocolectomy. PLoS One 2017; 12:e0186596. [PMID: 29049337 PMCID: PMC5648184 DOI: 10.1371/journal.pone.0186596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
Purposes Restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) is the procedure of choice for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) despite morbidities that can lead to pouch failure. We aimed to identify factors associated with pouch-related morbidities. Methods A retrospective analysis of patients who underwent RPC with IPAA was performed. To investigate the factors associated with pouch-related morbidities, patients' preoperative demographic and clinical factors, and intraoperative factors were included in the analysis. Results A total of 49 patients with UC, FAP, and colorectal cancer were included. Twenty patients (40.8%) experienced leakage-related, functional, and/or pouchitis-related morbidities. Patients with American Society of Anesthesiologists (ASA) grade 2 or 3 had a higher risk of functional morbidity than those with grade 1. Intraoperative blood loss exceeding 300.0 mL was associated with an increased risk of pouchitis-related morbidity. Conclusions Our study demonstrated associations of higher ASA grade and increased intraoperative blood loss with poor functional outcomes and pouchitis, respectively.
Collapse
Affiliation(s)
- Gyoung Tae Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeonghee Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Soo Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyuk Hur
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
- * E-mail:
| |
Collapse
|
7
|
Early and late surgical outcomes of ileal pouch-anal anastomosis within a defined population in Sweden. Eur J Gastroenterol Hepatol 2016; 28:842-9. [PMID: 26945126 DOI: 10.1097/meg.0000000000000618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Ileal pouch-anal anastomosis (IPAA), has become the procedure of choice in patients requiring reconstructive surgery for ulcerative colitis or familial adenomatous polyposis. The aim of this population-based study was to present data prospectively registered and retrospectively evaluated on the short-term and the long-term results of 124 consecutive IPAA performed chronologically by three surgeons in a single referral centre. MATERIALS AND METHODS All patients who underwent IPAA from 1993 to 2012 were included. Early and late morbidity and mortality were evaluated. RESULTS Early complications were observed in 25 patients. There was one death from cardiac failure, high output stoma occurred in six patients and wound infection occurred in four patients. Complications were associated with higher BMI (P=0.032). Four patients had to be reoperated. Peroperative bleeding was reduced when using an ultrasonically activated scalpel for the perimuscular dissection (P<0.00001). Clavien-Dindo grade III-V affected five patients. Only one patient developed anastomotic leak and septic complications.Late complications occurred in 61 patients. There was no procedure-related mortality. Pouchitis was the most common complication (n=37). Primary sclerosing cholangitis and age younger than 40 years were associated significantly with a three- and two-fold increased risk of pouchitis, respectively. Small bowel obstruction was the second most common complication (n=16), more common in women (P=0.031). The pouch failure rate was low: 2.4%. Clavien-Dindo grade III-V affected 13 patients. CONCLUSION In the hands of experienced high-volume surgeons, IPAA is a safe procedure associated with a relatively low early morbidity as well as an acceptable late morbidity.
Collapse
|
8
|
Schneider R, Schneider C, Dalchow A, Jakobeit C, Möslein G. Prophylactic surgery in familial adenomatous polyposis (FAP)--a single surgeon's short- and long-term experience with hand-assisted proctocolectomy and smaller J-pouches. Int J Colorectal Dis 2015; 30:1109-15. [PMID: 25935449 DOI: 10.1007/s00384-015-2223-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Prophylactic proctocolectomy with an ileoanal neo-reservoir is the established procedure in non-attenuated familial adenomatous polyposis (FAP). Traditionally, the ileal J-pouch is created by doubling 15 cm of the terminal ileum. Pouch inlet problems are not infrequently encountered in longer pouches. On this rationale, this series reports on the functional outcome and quality of life (QoL) following standardized construction of a shorter J-pouch with a limb of 8-9 cm length. METHODS All patients of a single-surgeon series with FAP who underwent hand-assisted laparoscopic proctocolectomy and small ileal pouch-anal anastomosis as the primary procedure between 10/2005 and 04/2010 and responded to the questionnaire were included and retrospectively analyzed. RESULTS A total of 46 patients (78 %) out of the consecutive series who underwent operation in this period were included in the study. After a mean follow-up of 38 months, 40/46 patients (87 %) did not report any incontinence and 3 patients (6.5 %) complained about occasional nocturnal incontinence (3 failed to answer this question). The mean stool frequency per 24 h was 6.25. No significant difference was encountered between the QoL outcome of our patients versus the German normative population. Comparable results were achieved in a study analyzing the long-term results in FAP patients with a 15-cm pouch. CONCLUSIONS Smaller, 8-9 cm J-pouches show excellent functional results both in short- and in long-term results. The hand-assisted procedure was safe and no conversions were required. QoL is equal to a normative population, as it is in a series of patients with larger J-pouches.
Collapse
Affiliation(s)
- Ralph Schneider
- Department of General and Visceral Surgery, Coloproctology, HELIOS St. Josefs-Hospital, Axstrasse 35, 44879, Bochum-Linden, Germany,
| | | | | | | | | |
Collapse
|
9
|
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.
Collapse
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
| | | | | | | |
Collapse
|
10
|
Zahid A, Kumar S, Koorey D, Young CJ. Pouch adenomas in Familial Adenomatous Polyposis after restorative proctocolectomy. Int J Surg 2014; 13:133-136. [PMID: 25498488 DOI: 10.1016/j.ijsu.2014.11.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 11/22/2014] [Accepted: 11/27/2014] [Indexed: 12/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- A Zahid
- Royal Prince Alfred Hospital, Australia; University of Sydney, Sydney, NSW, Australia
| | - S Kumar
- Royal Prince Alfred Hospital, Australia
| | - D Koorey
- Royal Prince Alfred Hospital, Australia; University of Sydney, Sydney, NSW, Australia
| | - C J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Royal Prince Alfred Hospital, Australia; University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital Medical Centre, 100 Carillon Ave, Newtown, NSW 2042, Australia.
| |
Collapse
|
11
|
Campos FG. Surgical treatment of familial adenomatous polyposis: Dilemmas and current recommendations. World J Gastroenterol 2014; 20:16620-16629. [PMID: 25469031 PMCID: PMC4248206 DOI: 10.3748/wjg.v20.i44.16620] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 07/14/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
12
|
Ileal pouch anal anastomosis in pediatric familial adenomatous polyposis: a 24-year review of operative technique and patient outcomes. J Pediatr Surg 2014; 49:1409-12. [PMID: 25148748 DOI: 10.1016/j.jpedsurg.2014.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 02/01/2014] [Accepted: 03/08/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is the operative procedure of choice for familial adenomatous polyposis (FAP) patients. We review 24years of operative experience and outcomes in pediatric patients with FAP. METHODS Patients with FAP, age<20years, presenting to a single institution between 1987 and 2011 were included. Operative technique and outcomes were reviewed retrospectively. Primary outcomes included postoperative complications (30days), long-term bowel function, and polyp recurrence at the anal anastomosis. RESULTS 95 patients with FAP underwent IPAA. Mean age at IPAA was 15.5years with a mean follow-up of 7.6years. 29 patients underwent 1-stage IPAA, 65 patients had a two-stage IPAA, and 1 patient underwent a 3-stage procedure. 67 patients had an open procedure, 25 underwent a laparoscopic approach, and more recently 3 patients underwent single incision laparoscopic IPAA. Patients with 1-stage IPAA demonstrate better long term bowel control vs. 2-stage IPAA patients (10.7% vs. 36.0% occasional incontinence, p=0.018). However, 1-stage IPAA patients suffered increased short-term complications, such as anastomotic leak (17.2% vs. 0%, p=0.002) and reoperation (20.7% vs. 4.6%, p=0.02) compared to 2-stage IPAA. Anal anastomosis polyp recurrence occurred in 22.7% of 1-stage patients and 10.0% of 2-stage patients. Short-term complications, polyp recurrence, or long-term continence were equivalent between open and laparoscopic cases. CONCLUSION Single-stage IPAA in children with FAP is associated with better bowel control but increased anastomotic leak, reoperative rate, and polyp recurrence. In experienced hands, laparoscopic IPAA is equivocal to open IPAA.
Collapse
|
13
|
Aygar M, Yetişir F, Salman E, Yıldırım MB, Ozdedeoğlu M, Durak D, Yalçın A. Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome. Int J Surg Case Rep 2014; 5:806-10. [PMID: 25305601 PMCID: PMC4245705 DOI: 10.1016/j.ijscr.2014.08.013] [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: 05/15/2014] [Accepted: 08/12/2014] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique. PRESENTATION OF CASE A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal. DISCUSSION There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients. CONCLUSION J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.
Collapse
Affiliation(s)
- Muhittin Aygar
- Atatürk Research and Training Hospital, General Surgery Department, Ankara, Turkey
| | - Fahri Yetişir
- Atatürk Research and Training Hospital, General Surgery Department, Ankara, Turkey.
| | - Ebru Salman
- Atatürk Research and Training Hospital, Anesthesiology and Reanimation Department, Ankara, Turkey
| | - Murat Baki Yıldırım
- Atatürk Research and Training Hospital, General Surgery Department, Ankara, Turkey
| | - Mesut Ozdedeoğlu
- Atatürk Research and Training Hospital, General Surgery Department, Ankara, Turkey
| | - Doğukan Durak
- Atatürk Research and Training Hospital, General Surgery Department, Ankara, Turkey
| | - Abdussamet Yalçın
- Atatürk Research and Training Hospital, General Surgery Department, Ankara, Turkey
| |
Collapse
|
14
|
Abstract
Patients with familial adenomatous polyposis may develop rectal cancer at their initial presentation (primary) or after colectomy and ileorectal anastomosis (secondary). Little is known about whether differences in presentation impact survival. We hypothesize that patients with secondary rectal cancer have better oncologic outcomes. Patients with rectal cancer in the context of familial adenomatous polyposis were classified into 3 groups: known rectal cancer at presentation, incidental rectal cancer unrecognized before proctocolectomy, and rectal cancer diagnosed after ileorectal anastomosis. Primary endpoint was 5-year survival. There were 58 patients, 39 with primary rectal cancer, 5 of which were incidental, and 19 with secondary rectal cancer. Median ages at diagnosis were 32 years (range 14-56) for primary cancer, 35 years (range 22-56) for incidental cancer and 49 years (range 24-66) for secondary cancer (p = 0.001). 76% of those with primary rectal cancer had symptoms, similar to those with incidental cancer (60%) but more than secondary cancer (21%) (p < 0.001). 47% of primary cancers were advanced (stages III and IV) compared to 20% of incidental cancers and 32% of secondary cancers. There was no local recurrence in any patient, but 9 patients had distant recurrences (16% overall). Overall 5-year survival of patients with primary cancer was 72.4%, incidental cancer was 100%, and secondary cancer was 69.7% (p = 0.031). More patients with primary rectal cancer have advanced disease but survival is similar to those with cancer diagnosed on surveillance. More patients with primary rectal cancer have a restorative resection when compared to other groups.
Collapse
Affiliation(s)
- Jennifer Liang
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44143, USA,
| | | |
Collapse
|
15
|
Gene expression profiles of ileal inflammatory bowel disease correlate with disease phenotype and advance understanding of its immunopathogenesis. Inflamm Bowel Dis 2013; 19:2509-21. [PMID: 24108111 DOI: 10.1097/01.mib.0000437045.26036.00] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pouchitis may develop in patients with ulcerative colitis undergoing pouch surgery. We aimed to evaluate the de novo inflammation developing in the ileal pouch, hypothesizing that it may be similar to ileitis in Crohn's disease (CD). METHODS Patients with ulcerative colitis pouch were prospectively recruited, stratified according to disease behavior into normal pouch, chronic pouchitis, and Crohn's-like disease of the pouch groups, and compared with controls. Gene expression analysis was performed using microarrays, validated by real-time polymerase chain reaction. Gene ontology and clustering were evaluated using bioinformatic tools. RESULTS Sixty-six subjects were recruited. Although in ulcerative colitis ileum there were no significant gene expression alterations, patients with normal pouch had 168 significant alterations (fold change ≥ 2, corrected P ≤ 0.05). In chronic pouchitis and Crohn's-like disease of the pouch, 490 and 1152 alterations were detected, respectively. High degree of overlap in gene expression alterations between the pouch subgroups was demonstrated. The magnitude of change correlated with pouch disease behavior. Gene expression profiles were more reflective of disease behavior compared with inflammatory indices. CD ileitis had 358 alterations, with a 90% overlap with pouchitis. Gene ontology analyses revealed multiple biological processes associated with pouch inflammation, including response to chemical stimulus, small molecule metabolic and immune system processes, and specific infection-related pathways such as Staphylococcus aureus, leishmaniasis, and tuberculosis. CONCLUSIONS Gene alterations in pouch inflammation and CD overlap, suggesting that inflammatory bowel diseases is a spectrum, rather than distinct diseases. Pouchitis may serve as a model of CD. The novel pathways associated with inflammatory bowel diseases may decipher pathophysiology and suggest targets for intervention.
Collapse
|
16
|
Tajika M, Niwa Y, Bhatia V, Tanaka T, Ishihara M, Yamao K. Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis. World J Gastroenterol 2013; 19:6774-6783. [PMID: 24187452 PMCID: PMC3812476 DOI: 10.3748/wjg.v19.i40.6774] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 07/17/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
17
|
Boostrom SY, Mathis KL, Pendlimari R, Cima RR, Larson DW, Dozois EJ. Risk of neoplastic change in ileal pouches in familial adenomatous polyposis. J Gastrointest Surg 2013; 17:1804-8. [PMID: 23949425 DOI: 10.1007/s11605-013-2319-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/06/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Neoplastic change in ileal reservoirs after proctocolectomy has been reported in patients with familial adenomatous polyposis. We aim to determine the incidence and progression of neoplastic change in the ileal pouch of familial adenomatous polyposis patients at our institution. METHODS A retrospective review of all patients who underwent proctocolectomy for familial adenomatous polyposis with construction of an ileal pouch from 1972 to 2007 was performed. Data and status at follow-up were retrieved from the Mayo Clinic Colorectal Surgery Pouch database. RESULTS One hundred seventeen patients were identified with a median age of 26, 52 were male. Ileal reservoirs included J-pouch (a = 104), Kock pouch (n = 9), S-pouch (n = 3), and W-pouch (n = 1). Median follow-up was 125 months. Polyps were biopsied in 33 patients: non-dysplastic polyps (n = 2), low-grade dysplasia (n = 30), and adenocarcinoma (n = 1). No patients had high-grade dysplasia. Median time to development of dysplasia was 149 months. Adenocarcinoma developed in one patient after 284 months. Risk of dysplasia at 10, 20, and 25 years was 17, 45, and 69%, respectively. CONCLUSION Though there is a high incidence of low-grade dysplasia in the ileal reservoir in familial adenomatous polyposis patients, high-grade dysplasia and cancer occur rarely. Patients with low-grade dysplasia may still necessitate regular follow-up.
Collapse
Affiliation(s)
- Sarah Y Boostrom
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA,
| | | | | | | | | | | |
Collapse
|
18
|
Bülow S, Højen H, Buntzen S, Larsen KL, Preisler L, Qvist N. Primary and secondary restorative proctocolectomy for familial adenomatous polyposis: complications and long-term bowel function. Colorectal Dis 2013; 15:436-41. [PMID: 22958269 DOI: 10.1111/codi.12020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of the study was to evaluate intra-operative difficulties, complications and long-term bowel function in polyposis patients undergoing conversion of an ileorectal anastomosis to an ileoanal pouch, compared with patients with a primary ileoanal pouch operation. METHOD A national register-based retrospective study was performed with clinical follow-up and a questionnaire on long-term bowel function. RESULTS There were 84 patients in the study: 59 (70%) had a primary pouch operation and in 25 (30%) a secondary pouch procedure was attempted. This was abandoned, in one case, leaving 24 patients who had a successful secondary restorative proctocolectomy. The median (range) follow-up was 123 (0-359) months. There were no intra-operative difficulties in the 59 primary operations, but intra-operative difficulties were reported in nine of 25 secondary operations (P < 0.001). Complications within 1 month of surgery occurred in six of 59 primary operations and in none of 24 secondary operations (P < 0.001); and late surgical complications occurred in eight of 55 primary operations and in eight of 24 secondary operations (P = 0.13). The only difference in bowel function was a lower frequency of nocturnal defaecation after secondary pouch formation (P = 0.02). CONCLUSION Reoperation with proctectomy after a previous ileorectal anastomosis and conversion to restorative proctocolectomy is feasible in polyposis patients, with morbidity and functional results similar to those seen after a primary pouch operation.
Collapse
Affiliation(s)
- S Bülow
- The Danish Polyposis Register and the Surgical Departments at Hvidovre University Hospital, Copenhagen, Denmark.
| | | | | | | | | | | |
Collapse
|
19
|
Smith JC, Schäffer MW, Ballard BR, Smoot DT, Herline AJ, Adunyah SE, M'Koma AE. Adenocarcinomas After Prophylactic Surgery For Familial Adenomatous Polyposis. ACTA ACUST UNITED AC 2013; 4:260-270. [PMID: 23875116 DOI: 10.4236/jct.2013.41033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Joan C Smith
- Laboratory of Inflammatory Bowel Disease Research, Division of Biomedical Sciences, Department of Biochemistry and Cancer Biology, Meharry Medical College School of Medicine, Nashville, Tennessee
| | | | | | | | | | | | | |
Collapse
|
20
|
Tannock GW, Lawley B, Munro K, Lay C, Taylor C, Daynes C, Baladjay L, Mcleod R, Thompson-Fawcett M. Comprehensive analysis of the bacterial content of stool from patients with chronic pouchitis, normal pouches, or familial adenomatous polyposis pouches. Inflamm Bowel Dis 2012; 18:925-34. [PMID: 22114001 DOI: 10.1002/ibd.21936] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 10/04/2011] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic pouchitis is an important long-term complication following ileal pouch-anal anastomosis for ulcerative colitis. Antibiotic administration reduces symptoms of pouchitis, indicating that bacteria have a role in pathogenesis. The aim of the research was to investigate the bacterial content of pouches using nucleic acid-based methods. METHODS Stool microbiota of 17 patients with normal pouches (NP), 17 patients with pouchitis (CP) utilizing samples collected from each patient when antibiotic-treated (CP-on, asymptomatic) and when untreated (CP-off, symptomatic), and 14 familial adenomatous polyposis (FAP) patients were analyzed by high-throughput sequencing, fluorescence in situ hybridization technologies, and quantitative polymerase chain reaction (qPCR). RESULTS Fluorescence in situ hybridization analysis revealed an expanded phylogenetic gap in NP and CP-off patients relative to FAP. Antibiotic treatment reduced the gap in CP stool. The phylogenetic gap of CP-off patients was due to members of the bacterial families Caulobacteriaceae, Sphingomonadaceae, Comamonadaceae, Peptostreptococcaceae, and Clostridiaceae. There was a greater diversity of phylotypes of Clostridiaceae in CP-off subjects. The phylogenetic gap of NP stool was enriched by Ruminococcaceae and Bifidobacteriaceae. CP stool microbiota had reduced diversity relative to NP and FAP stool due largely to a reduction in Lachnospiraceae/Insertae Sedis XIV/clostridial cluster IV groups. CONCLUSIONS Bacterial groups within the expanded phylogenetic gap of pouch patients may have roles in the pathogenesis of pouchitis. Further research concerning the physiology of cultured members of these groups will be necessary to explain their specific roles. Members of the Lachnospiraceae, Incertae Sedis XIV, and clostridial cluster IV could be useful biomarkers of pouch health.
Collapse
Affiliation(s)
- Gerald W Tannock
- Department of Microbiology and Immunology, University of Otago, Dunedin, New Zealand.
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Ileal pouch adenomas and carcinomas after restorative proctocolectomy for familial adenomatous polyposis. Dis Colon Rectum 2012; 55:322-9. [PMID: 22469800 DOI: 10.1097/dcr.0b013e318241e6f2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Restorative proctocolectomy and IPAA has become the treatment of choice in familial adenomatous polyposis. However, several cases of adenomas and carcinomas arising in the ileal pouch were reported. OBJECTIVE The aim of this study was to evaluate the prevalence and natural history of ileal pouch adenomas and the development of carcinomas in patients with restorative proctocolectomy for familial adenomatous polyposis. DESIGN AND SETTING We prospectively studied patients who underwent IPAA during the past 20 years at the surgical unit of the University of Florence in Italy. MAIN OUTCOME MEASURES We investigated the extent of the risk and the factors that are involved in the development of neoplastic changes of the pouch. Furthermore, because it is not entirely clear when and how polyps should be treated, we have revised our modality of treatment for this unusual pathology. PATIENTS Sixty-nine patients with familial adenomatous polyposis underwent restorative proctocolectomy. In 66 patients, handsewn ileoanal anastomosis with anal canal mucosectomy was performed. After surgery, all patients underwent endoscopic surveillance. RESULTS After 10 years of follow-up, 1 ileal pouch adenoma was found in 64.9% of restorative proctocolectomy patients, and ileal pouch carcinomas occurred in 2 patients (29 and 59 years old), 3 and 11 years after restorative proctocolectomy. The number of colonic adenomatous polyps influenced the occurrence of pouch adenomas. No patients with <200 colonic adenomas experienced pouch adenomas, but 46% of patients with >1000 colonic polyps had pouch adenomas, and 25% of patients with 200 to 1000 colonic polyps had pouch adenomas at follow-up. No relationship was found between ileal pouch adenomas and pouch shape (J, S, or straight ileoanal anastomosis with multiple myotomies) or the APC mutation. Polyps larger than 5 mm were removed by endoscopy or surgery. CONCLUSIONS Ileal pouch adenomas were common after restorative proctocolectomy. Patients >50 years of age and patients with >1000 colonic adenomas at the time of colectomy were more prone to ileal pouch adenomas. The development of malignancy in the terminal ileum can present a fast course and does not seem to follow the classic adenoma-carcinoma sequence.
Collapse
|
22
|
Yan Z, Liao G, Pei H. Surgical treatment of familial adenomatous polyposis: experience from a single institution in China. Asia Pac J Clin Oncol 2012; 8:e23-8. [PMID: 22897208 DOI: 10.1111/j.1743-7563.2011.01488.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Surgical options for familiar adenomatous polyposis (FAP) have been standardized in developed countries but are still controversial in China. The aim of this study was to retrospectively evaluate the results of patients with FAP treated in a university hospital. METHODS In all 42 consecutive patients with FAP were operated on between May 1988 and June 2008. Median follow up was 7.2 years (2.2-20 years). Of these 33 patients were treated by proctocolectomy and ileal pouch anal anastomosis. A total colectomy with ileorectal anastomosis was undertaken in six and a proctocolectomy with ileostomy in three patients who had invasive rectal cancer. RESULTS Postoperative morbidity was insignificant. There were five wound infections, one intestinal obstruction, one anastomotic leakage, one anastomotic stenosis and one refractory pouchitis. One patient died from stroke. Five died from FAP-related disorders, namely, abdominal desmoids, liver metastases and advanced rectal cancer. Desmoid tumor occurred in five patients. Periampullary adenoma and carcinoma developed in four patients. In those with pouch procedure the 24-h bowel movement was 7.14 ± 1.28 (range 5-11) and their 10-year overall survival was 87.5%. CONCLUSION A proctocolectomy with ileal pouch anal anastomosis maybe the best choice for FAP patients in China. Surgical expertise, good teamwork and careful long-term follow up are mandatory.
Collapse
Affiliation(s)
- Zhongshu Yan
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China.
| | | | | |
Collapse
|
23
|
Catania G, Ruggeri L, Iuppa G, Di Stefano C, Cardì F, Iuppa A. Abdominal wall reconstruction with intraperitoneal prosthesis in desmoid tumors surgery. Updates Surg 2011; 64:43-8. [DOI: 10.1007/s13304-011-0109-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 08/27/2011] [Indexed: 01/15/2023]
|
24
|
Abstract
Colorectal cancer is one of the major causes of cancer deaths in both men and women. It is estimated that 5 to 10% of patients with colorectal cancer have an inherited germline mutation that predisposes them to cancer. Hereditary colorectal cancer syndromes can be divided into those associated with colonic polyposis - familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (aFAP), and MYH associated polyposis (MAP), and those not associated with colonic polyposis - hereditary nonpolyposis colon cancer (HNPCC). The hereditary polyposes are usually easier to diagnose than HNPCC, but their higher penetrance and variable phenotype pose some difficult problems in management and surveillance. The timing and type of surgical intervention, the management of desmoid risk, the treatment of rectal or pouch neoplasia, and the management of duodenal neoplasia are all questions that must be addressed in patients with FAP or MAP.
Collapse
Affiliation(s)
- C Neal Ellis
- Department of Surgery, University of South Alabama College of Medicine, Mobile, AL 36617, USA. nellis@ usouthal.edu
| |
Collapse
|
25
|
Kirat HT, Remzi FH. Ileal Pouch-Anal Anastomosis: Indications and Technique. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
26
|
Ault GT, Nunoo-Mensah JW, Johnson L, Vukasin P, Kaiser A, Beart RW. Adenocarcinoma arising in the middle of ileoanal pouches: report of five cases. Dis Colon Rectum 2009; 52:538-41. [PMID: 19333060 DOI: 10.1007/dcr.0b013e318199effe] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis with or without mucosectomy has become the procedure of choice in patients with long-standing ulcerative colitis complicated by malignancy or medically refractory disease and for familial polyposis syndrome. Some reports have demonstrated the development of malignancy at the ileoanal anastomosis. We present a recent series of five patients who developed adenocarcinoma in the middle of their ileal pouch including the first case of pouch carcinoma in a patient who underwent pouch formation for ulcerative colitis. We discuss their presentation and management. Development of ileal pouch cancers, while rare, has been seen with increasing frequency in our practice. Patients with long-standing ileal pouches may benefit from routine surveillance of the pouch as often as every six months, which can be performed quickly and easily in the office using flexible endoscopy.
Collapse
Affiliation(s)
- Glenn T Ault
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
| | | | | | | | | | | |
Collapse
|
27
|
Osterfeld N, Kadmon M, Brechtel A, Keller M. Preoperative and postoperative quality of life in patients with familial adenomatous polyposis. Dis Colon Rectum 2008; 51:1324-30. [PMID: 18512098 DOI: 10.1007/s10350-008-9383-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Revised: 01/24/2008] [Accepted: 03/18/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to prospectively examine functional outcome, quality of life, and patients' personal experiences and adjustment to functional changes during the first year after prophylactic surgery. METHODS Twenty-one consecutive patients with familial adenomatous polyposis were examined before proctocolectomy (T0), on ileostomy reversal (T1), and 6 (T2) and 12 months (T3) after surgery by means of standardized questionnaires and interviews. RESULTS Average physical and mental health declined profoundly after proctocolectomy, followed by a steady improvement after 6 and 12 months. The majority of patients reported the ileostomy period as particularly distressing. After one year, 75 percent of patients reported complete recovery in terms of physical, emotional, and social functioning, whereas one-quarter of patients did not regain their former level of functioning. Despite substantial improvement in pouch functions, functional impairment persists because of frequent bowel movements, resulting mainly in restricted social activities. Ten percent of patients reported impaired sex life, irrespective of gender. CONCLUSIONS The majority of patients with familial adenomatous polyposis were found to adjust favorably to functional impairment while maintaining satisfactory quality of life. Complementing standardized quality of life measures by patients' personal experiences may help to identify vulnerable patients in need of psychosocial support.
Collapse
Affiliation(s)
- Nadine Osterfeld
- Department of Psychiatry, University of Ulm, Leimgrubenweg 12-14, 89075, Ulm, Germany.
| | | | | | | |
Collapse
|
28
|
Bülow S, Bülow C, Vasen H, Järvinen H, Björk J, Christensen IJ. Colectomy and ileorectal anastomosis is still an option for selected patients with familial adenomatous polyposis. Dis Colon Rectum 2008; 51:1318-23. [PMID: 18523824 DOI: 10.1007/s10350-008-9307-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Revised: 12/03/2007] [Accepted: 12/19/2007] [Indexed: 12/15/2022]
Abstract
PURPOSE The risk of rectal cancer after colectomy and ileorectal anastomosis may be reduced in the last decades, as patients with severe polyposis now have an ileoanal pouch. We have reevaluated the risk of rectal cancer and proctectomy for all causes according to the year of operation. METHODS On the basis of the year of operation in 776 patients with ileorectal anastomosis and 471 pouch patients in Denmark, Finland, Holland, and Sweden, the "pouch period" was defined to start in 1990. Ileorectal anastomosis follow-up data was captured by May 31, 2006. The cumulative risk of rectal cancer and proctectomy was compared before and after 1990 by Kaplan-Meier analysis. RESULTS In the prepouch period 56/576 patients (10 percent) developed rectal cancer, vs. 4/200 (2 percent) in the pouch period. Neither the cumulative risk of rectal cancer (p = 0.07) nor the cumulative risk of proctectomy (p = 0.17) changed. However, in females the cumulative risk of rectal cancer (p = 0.04) and of proctectomy (p = 0.03) were lower in the pouch period. CONCLUSIONS Since the introduction of the ileoanal pouch rectal cancer has decreased after ileorectal anastomosis, but only statistically significant in females. This indicates that ileorectal anastomosis may still be justified in selected patients with mild adenomatosis, especially in young females.
Collapse
Affiliation(s)
- Steffen Bülow
- The Danish Polyposis Register, Hvidovre University Hospital, Copenhagen, Denmark.
| | | | | | | | | | | |
Collapse
|
29
|
Sokol H, Lay C, Seksik P, Tannock GW. Analysis of bacterial bowel communities of IBD patients: what has it revealed? Inflamm Bowel Dis 2008; 14:858-67. [PMID: 18275077 DOI: 10.1002/ibd.20392] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The bacterial community, in whole or in part, resident in the bowel of humans is considered to fuel the chronic immune inflammatory conditions characteristic of Crohn's disease and ulcerative colitis. Chronic or recurrent pouchitis in ulcerative colitis patients is responsive to antibiotic therapy, indicating that bacteria are the etiological agents. Microbiological investigations of the bacterial communities in stool or of biopsy-associated bacteria have so far failed to reveal conclusively the existence of pathogens or bacterial communities of consistently altered composition in IBD patients relative to control subjects. Confounding factors need to be eliminated from future studies by using better-defined patient populations of newly diagnosed and untreated individuals and by improved sampling procedures.
Collapse
Affiliation(s)
- Harry Sokol
- Gastroenterology and Nutrition Unit, Saint-Antoine Hospital, APHP, Paris, France
| | | | | | | |
Collapse
|
30
|
Syndromic colon cancer: lynch syndrome and familial adenomatous polyposis. Gastroenterol Clin North Am 2008; 37:47-72, vi. [PMID: 18313539 DOI: 10.1016/j.gtc.2007.12.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Colon cancer, the third leading cause of mortality from cancer in the United States, afflicts about 150,000 patients annually. More than 10% of these patients exhibit familial clustering. The most common and well characterized of these familial colon cancer syndromes is hereditary nonpolyposis colon cancer syndrome (Lynch syndrome), which accounts for about 2% to 3% of all cases of colon cancer in the United States. We review the current knowledge of familial cancer syndromes, with an emphasis on Lynch syndrome and familial adenomatous polyposis.
Collapse
|
31
|
Resop DM, Harms BA, Heise CP. A multimodality approach to successful ileal pouch desmoid excision with pouch salvage: report of a case. Dis Colon Rectum 2008; 51:244-6. [PMID: 18180998 DOI: 10.1007/s10350-007-9087-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Revised: 03/12/2006] [Accepted: 03/28/2006] [Indexed: 02/08/2023]
Abstract
Desmoid tumors occur infrequently in patients who undergo proctocolectomy for familial adenomatous polyposis but may result in significant morbidity and mortality depending on the sight of desmoid location. A case of successful ileal pouch salvage using a multimodality approach for treatment of a large ileal pouch associated desmoid tumor is presented. This approach used neoadjuvant chemotherapy to induce a partial response, followed by complete surgical excision with pouch preservation. This is the first reported case of combined chemotherapy and surgical treatment of a desmoid tumor involving an ileal pouch, and the second reported successful attempt at surgical excision with pouch salvage.
Collapse
Affiliation(s)
- Dana M Resop
- Department of Surgery, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, Wisconsin 53792, USA
| | | | | |
Collapse
|
32
|
Principles of Cancer Surgery. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
Das P, Smith JJ, Tekkis PP, Heriot AG, Antropoli M, John Nicholls R. Quality of life after indefinite diversion/pouch excision in ileal pouch failure patients. Colorectal Dis 2007; 9:718-24. [PMID: 17764535 DOI: 10.1111/j.1463-1318.2007.01216.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Pouch failure occurs in up to 10% of patients over a 10-year period for a variety of reasons. One surgical option is pouch excision (PE) and form a permanent ileostomy. This is a major procedure with potential serious complications. An alternative is indefinite diversion (ID) of the pouch without excision. The aim of this study was to examine the quality of life and functional outcome in these two groups of patients. METHOD Ninety-seven patients were identified from the database to have either PE or ID. Fifty-three patients (17 men) responded; comprising 31 patients after PE and 22 patients with ID in a case-control study and completed the SF-36 general health survey and the Cleveland Clinic Foundation (CCF) functional outcomes questionnaire. RESULTS There was no significant difference in the domains of SF-36 between the two groups (P > 0.18). All patients with PE had an end ileostomy whereas most patients with ID had a loop ileostomy (18 loop vs 4 end). There was no difference in stoma related complications except for stoma retraction in ID (7%vs 47%; P = 0.003). There was no significant difference in urinary symptoms between PE and ID groups (weak stream 26%vs 14%; P = 0.49, nocturia 22%vs 4%; P = 0.12, urgency 22%vs 9%; P = 0.28, urinary incontinence 22%vs 14%; P = 0.72 respectively). There was no difference in sexually active patients (73%vs 94%; P = 0.11). Of the seven male PE patients, five (71%) could achieve an erection and four (57%) could maintain an erection, compared with all 10 male patients in the ID group (P = 0.151 and 0.05 respectively). Thirty-three per cent of patients with PE and 62% of patients with ID reported that they would have pouch surgery again if indicated (P = 0.052) and 58% of patients with PE and 81% of patients with ID reported that they would recommend pouch surgery to others (P = 0.129). No case of dysplasia was seen in 18 of 22 ID patients in whom histology was available. CONCLUSION Quality of life after PE or ID was no different and male sexual function was significantly better after ID. Retraction of the stoma was more common in this group.
Collapse
Affiliation(s)
- P Das
- Department of Surgery, St Mark's Hospital, Harrow, Middlesex, UK
| | | | | | | | | | | |
Collapse
|
34
|
Dozois EJ. Hand-sewn or stapled ileal-pouch–anal anastomosis after proctocolectomy? ACTA ACUST UNITED AC 2007; 4:74-5. [PMID: 17268541 DOI: 10.1038/ncpgasthep0712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Accepted: 11/10/2006] [Indexed: 11/09/2022]
|
35
|
Parés D, Pera M, González S, Pascual Cruz M, Blanco I. [Familial adenomatous polyposis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 29:625-35. [PMID: 17198641 DOI: 10.1157/13095198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Familial adenomatous polyposis is a rare genetic disease characterized by the development of more than a hundred adenomatous polyps in the colorectal area, as well as by extracolonic manifestations. Without treatment, this inherited disease, usually transmitted by autosomal dominant inheritance, predisposes to colorectal cancer. Treatment must be preceded by counseling about the nature of the syndrome and by recommendations for the optimal management and surveillance of the disease. Currently, prophylactic surgical therapy is imperative. However, the type of surgical technique used depends mainly on the severity of the polyposis phenotype, the age of the patient at diagnosis, and a series of special clinical circumstances. Lifetime follow-up of all patients is required. This article reviews the main studies published on familial adenomatous polyposis in order to provide an update on the most appropriate management of these patients.
Collapse
Affiliation(s)
- David Parés
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitari del Mar, Barcelona, España.
| | | | | | | | | |
Collapse
|
36
|
Kartheuser A, Stangherlin P, Brandt D, Remue C, Sempoux C. Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited. Fam Cancer 2006; 5:241-60; discussion 261-2. [PMID: 16998670 DOI: 10.1007/s10689-005-5672-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g. <5 rectal polyps) can be identified where ileorectal anastomosis (IRA) might be reasonable. We feel that the risk of rectal cancer after IRA means that IPAA should be recommended for the vast majority of FAP patients. We accept that in some very selected cases, based on clinical and genetics data (and perhaps influenced by patient choice regarding female fecundity), a stepwise surgical strategy with a primary IPA followed at a later age by a secondary proctectomy with IPAA could be proposed.
Collapse
Affiliation(s)
- Alex Kartheuser
- Colorectal Surgery Unit, St-Luc University Hospital, Université Catholique de Louvain (UCL), 10, Avenue Hippocrate, B-1200, Brussels, Belgium.
| | | | | | | | | |
Collapse
|
37
|
Affiliation(s)
- James Church
- Department of Colorectal Surgery, Desk A-30, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
| |
Collapse
|
38
|
Aziz O, Athanasiou T, Fazio VW, Nicholls RJ, Darzi AW, Church J, Phillips RKS, Tekkis PP. Meta-analysis of observational studies of ileorectal versus ileal pouch-anal anastomosis for familial adenomatous polyposis. Br J Surg 2006; 93:407-17. [PMID: 16511903 DOI: 10.1002/bjs.5276] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgery for familial adenomatous polyposis (FAP) aims to minimize cancer risk while providing good functional outcome. Colectomy with ileorectal anastomosis and proctocolectomy with ileal pouch-anal anastomosis both offer this, but there is no clear consensus about which is better. METHODS This is a meta-analysis of comparative studies published between 1991 and 2003 reporting early and late postoperative adverse events, functional outcomes and quality of life. RESULTS Twelve studies containing 1002 patients (53.4 per cent ileal pouch, 46.6 per cent ileorectal anastomosis) were identified. Bowel frequency (weighted mean difference 1.62 (95 per cent confidence interval (c.i.) 1.05 to 2.20)), night defaecation (odds ratio (OR) 6.64 (95 per cent c.i. 2.99 to 14.74)) and use of incontinence pads (OR 2.72 (95 per cent c.i. 1.02 to 7.23)) were significantly less in the ileorectal group, although faecal urgency was reduced with the ileal pouch (odds ratio 0.43 (95 per cent c.i. 0.23 to 0.80)). Reoperation within 30 days was more common after ileal pouch construction (23.4 versus 11.6 per cent; OR 2.11 (95 per cent c.i. 1.21 to 3.70)). There was no significant difference between the techniques in terms of sexual dysfunction, dietary restriction, or postoperative complications. Rectal cancer was a diagnosis only in the ileorectal group (5.5 per cent). CONCLUSION Ileal pouch and ileorectal anastomoses have individual merits. Further research is needed to determine which most benefits patients with FAP.
Collapse
Affiliation(s)
- O Aziz
- Department of Surgical Oncology and Technology, Imperial College London, St Mary's Hospital, London, UK
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Toiyama Y, Araki T, Yoshiyama S, Miki C, Kusunoki M. Secondary pouchitis in a post-operative patient with ulcerative colitis, successfully treated by salvage surgery. World J Gastroenterol 2006; 11:6888-90. [PMID: 16425404 PMCID: PMC4725031 DOI: 10.3748/wjg.v11.i43.6888] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We report a case of secondary pouchitis, defined as a mucosal inflammatory lesion in the ileal reservoir provoked by pouch-related complication following total colectomy and pouch anal anastomosis, which was successfully treated by salvage surgery. A 20-year-old woman with ulcerative colitis developed acute severe bloody diarrhea following proctocolectomy, ileal pouch-anal anastomosis and diverting ileostomy. She was diagnosed as having a secondary pouchitis mainly caused by a peripouch abscess and partly concerned with the abnormal pouch formation. The remnant rectum and ileal pouch were excised and ileal pouch-anal anastomosis and diverting ileostomy were constructed. The postoperative course was uneventful with no sign of pouchitis. Salvage surgery may be indicated to treat secondary pouchitis when caused by surgery-related complications.
Collapse
Affiliation(s)
- Yuji Toiyama
- The Second Department of Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | | | | | | | | |
Collapse
|
40
|
Abstract
Familial adenomatous polyposis (FAP) is an autosomal-dominant colorectal cancer syndrome, caused by a germline mutation in the adenomatous polyposis coli (APC) gene, on chromosome 5q21. It is characterized by hundreds of adenomatous colorectal polyps, with an almost inevitable progression to colorectal cancer at an average age of 35 to 40 yr. Associated features include upper gastrointestinal tract polyps, congenital hypertrophy of the retinal pigment epithelium, desmoid tumors, and other extracolonic malignancies. Gardner syndrome is more of a historical subdivision of FAP, characterized by osteomas, dental anomalies, epidermal cysts, and soft tissue tumors. Other specified variants include Turcot syndrome (associated with central nervous system malignancies) and hereditary desmoid disease. Several genotype-phenotype correlations have been observed. Attenuated FAP is a phenotypically distinct entity, presenting with fewer than 100 adenomas. Multiple colorectal adenomas can also be caused by mutations in the human MutY homologue (MYH) gene, in an autosomal recessive condition referred to as MYH associated polyposis (MAP). Endoscopic screening of FAP probands and relatives is advocated as early as the ages of 10-12 yr, with the objective of reducing the occurrence of colorectal cancer. Colectomy remains the optimal prophylactic treatment, while the choice of procedure (subtotal vs proctocolectomy) is still controversial. Along with identifying better chemopreventive agents, optimizing screening of extracolonic cancers and applying new radiological and endoscopic technology to the diagnosis and management of extracolonic features are the major challenges for the future.
Collapse
Affiliation(s)
- Polymnia Galiatsatos
- Division of Gastroenterology, Department of Medicine, The Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | |
Collapse
|
41
|
Hassan I, Chua HK, Wolff BG, Donnelly SF, Dozois RR, Larson DR, Schleck CD, Nelson H. Quality of life after ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum 2005; 48:2032-7. [PMID: 16374935 DOI: 10.1007/s10350-005-0169-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Differences in conventional outcomes such as functional results and the rate of complications have caused a controversy about whether the ileal pouch anal anastomosis or the ileorectal anastomosis is the preferred surgical treatment for patients with familial adenomatous polyposis. We therefore sought to ascertain not only the surgical results but also the perceptions of patients about their outcomes. METHODS Between 1981 and 1998, 152 patients at our institution had an ileal pouch-anal anastomosis and 32 patients had an ileorectal anastomosis for familial adenomatous polyposis. Of these 184 patients, 173 were sent a study-specific quality-of-life questionnaire and the Short Form 36 health survey to determine their health-related quality of life. RESULTS Ninety-four ileal pouch patients and 21 ileorectal patients returned the surveys. No difference was found in early postoperative complications, 5-year probability for complications, or functional results after either procedure. On the Short Form 36 health survey, the ileorectal patients had a lower mental health summary score compared with that of the ileal pouch patients but a similar physical health summary score. The study-specific questionnaire found both groups to have a comparable quality of life. CONCLUSION Because ileal pouch-anal anastomosis has the advantage of removing as much at-risk tissue as possible with similar functional results and better mental health, it may be considered the preferred operation for most patients with familial adenomatous polyposis.
Collapse
Affiliation(s)
- Imran Hassan
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
Colorectal cancer is one of the major causes of cancer deaths in both men and women. It is estimated that approximately 5% to 10% of patients with colorectal cancer have an inherited germline mutation that predisposes them to cancer. Clinically, hereditary colorectal cancer syndromes can be divided into those associated with colonic polyposis (familial adenomatous polyposis, attenuated familial adenomatous polyposis, and MYH-associated polyposis) and those not associated with colonic polyposis (hereditary nonpolyposis colon cancer). Treatment options for these patients include multiple aggressive screening regimens, chemopreventive medications, and prophylactic surgery. Selection of the appropriate management approach is best made using information obtained from the patient's clinical examination, the family medical history, and genetic evaluation. Compliance is improved when patients completely understand their disease and participate fully in the formulation of the treatment plan. Although not proved, it seems reasonable that this approach may prevent the poor outcomes so frequently associated with inherited cancer syndromes.
Collapse
Affiliation(s)
- C Neal Ellis
- Department of Surgery, University of South Alabama, Mobile, AL 36617-2293, USA.
| |
Collapse
|
43
|
Strijbos SAM, Hueting WE, Schipper MEI, Oostvogel HJM, van Vroonhoven TJMV, Gooszen HG, van Laarhoven CJHM. The ileo neo rectal anastomosis (INRA) in patients with familial adenomatous polyposis: clinical results at two years. Colorectal Dis 2005; 7:354-9. [PMID: 15932558 DOI: 10.1111/j.1463-1318.2005.00802.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Ileo neo rectal anastomosis (INRA) is a promising alternative for patients with familial adenomatous polyposis (FAP) to restorative proctocolectomy with its morbidity and unpredictable functional outcome to colectomy with ileo rectal anastomosis (IRA) with the continuing risk of rectal cancer. The aims of the present study were to evaluate the function of the neorectum, to assess the morbidity and complications of the operation and to determine the incidence of neorectal polyps. METHODS Data of all patients having INRA, including bowel function and complications, were prospectively recorded. The reservoir capacity was determined repeatedly by physiologic tests. The anal sphincter complex was assessed by manometry and ultrasound examination. Evaluation of the neorectal mucosa was performed by endoscopy. RESULTS Six patients underwent the INRA procedure for FAP. Median defaecation frequency two years postoperatively was 5.5/24 h (range 4-7) including 1/night (range 0-2). Endoscopic examination showed normal mucosa and no evidence of polyp formation in all patients. CONCLUSION INRA affords a good functional reservoir and is accompanied by few reservoir-related complications. At a minimum follow up period of two years, no growth of polyps in the neorectum occurred.
Collapse
Affiliation(s)
- S A M Strijbos
- Department of Surgery, University Medical Centre, Utrecht, the Netherlands
| | | | | | | | | | | | | |
Collapse
|
44
|
Muldoon RL, Lowney JK. Familial Adenomatous Polyposis. SEMINARS IN COLON AND RECTAL SURGERY 2004. [DOI: 10.1053/j.scrs.2005.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
45
|
Parc Y, Piquard A, Dozois RR, Parc R, Tiret E. Long-term outcome of familial adenomatous polyposis patients after restorative coloproctectomy. Ann Surg 2004; 239:378-82. [PMID: 15075655 PMCID: PMC1356236 DOI: 10.1097/01.sla.0000114216.90947.f6] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Restorative proctocolectomy (RPC) eliminates the risk of colorectal adenocarcinoma in familial adenomatous polyposis (FAP) patients, but desmoid tumors, duodenal, and ileal adenomas can still develop. Our aim was to assess the long-term outcome of FAP patients after RPC. PATIENTS AND METHODS FAP patients who had RPC between 1983 and 1990 were contacted for interview and upper gastrointestinal (GI) and ileal pouch endoscopy. RESULTS Sixty-two males and 48 females had undergone hand-sewn RPC during this period. One patient died postoperatively (0.9%). Among 96 patients available for a minimal follow-up of 11 years, 7 patients died: 3 from causes unrelated to FAP, 2 from metastatic colorectal cancer, and 2 from mesenteric desmoid tumor (MDT). Thirteen patients had a symptomatic MDT (13.5%). Of 73 patients who had an upper GI endoscopy, 52 developed duodenal and/or ampullary adenomas. Four patients required surgical treatment of their duodenal lesions. Among 54 patients who underwent ileal pouch endoscopy, pouch adenomas were noted in 29. No invasive duodenal or ileal pouch carcinoma were detected. Functional results of RPC were significantly worse in MDT patients. CONCLUSIONS RPC eliminates the risk of colorectal cancer, and close upper GI surveillance may help prevent duodenal malignancy. MDTs are the principal cause of death, once colorectal cancer has been prevented, and the main reason for worsening functional results.
Collapse
Affiliation(s)
- Yann Parc
- Department of Digestive Surgery, Hôpital Saint-Antoine AP-HP, University Pierre et Marie Curie, Paris, France.
| | | | | | | | | |
Collapse
|
46
|
Günther K, Braunrieder G, Bittorf BR, Hohenberger W, Matzel KE. Patients with familial adenomatous polyposis experience better bowel function and quality of life after ileorectal anastomosis than after ileoanal pouch. Colorectal Dis 2003; 5:38-44. [PMID: 12780925 DOI: 10.1046/j.1463-1318.2003.00413.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the quality of life with emphasis on bowel function in patients undergoing either total colectomy with ileorectal anastomosis (IRA) or restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for familial adenomatous polyposis (FAP). PATIENTS AND METHODS All 151 patients operated on in our department between 1971 and 2000 were analysed retrospectively. Since 42 patients had to undergo reoperations, a total of 194 bowel procedures were performed. The final operative breakdown was: 48 IRA, 62 IPAA, 33 total proctocolectomies and 8 other procedures. By the end of the period under consideration, 40 patients had died, 28 had been lost to follow-up, 83 patients were still alive and of these 76 were analysed. Continence function and quality of life with emphasis on overall bowel function (Wexner (WS)-, Jostarndt (JS)-, Oresland (OS)- and Pemberton (PS)-scores) were recorded in 59 patients (22 IRA and 37 IAP). RESULTS Continence and bowel function were significantly better after IRA than after IPAA (mean scores: WS, 1.1 vs 5.4, P=0.001; JS, 32.5 vs 24.7, P=0.0001; OS, 2.9 vs 7.9, P=0.0001), as was quality of life (PS, 25.6 vs 19.6, P=0.001). The mean values for each single item of all 4 scores were consistently better after IRA. Neither gender, age nor type of pouch-anal anastomosis (stapled vs hand-sewn) had a significant influence on outcome. IPAA patients with uneventful follow-up (n = 27) had better mean values for all 4 scores (WS, 4.2 vs 7.3; JS, 26.1 vs 23.1; PS, 20.4 vs 17.7; OS, 6.6 vs 9.9) than those with postoperative complications (n = 10; 27%), but statistical significance was reached only in the OS (P = 0.026). No such difference was seen after IRA (14% complication rate). CONCLUSION The significantly better continence after IRA resulting in superior patient comfort and quality of life must be balanced against the oncological disadvantage of this procedure. On the basis of large patient population studies, genotype-phenotype correlations with respect to the risk for rectal cancer may need to be taken into account. Postoperative complications may have a lasting negative effect on outcome after IPAA.
Collapse
Affiliation(s)
- K Günther
- Department of Surgery, University of Erlangen, Krankenhausstrasse 12, D-91054 Erlangen, Germany.
| | | | | | | | | |
Collapse
|
47
|
Prevention and Chemoprevention of Colorectal Neoplasms. COLORECTAL CANCER 2002. [DOI: 10.1007/978-3-642-56008-8_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
48
|
Abstract
Main purpose of the review is to analyse the impact of the current approaches for colorectal cancer prevention, including chemoprevention. Available evidence does not support the contention that a more appropriate diet can be of great help in the prevention of these neoplasms, either because the scientific evidence is poor and highly controversial, or because changes in diet are difficult to implement, at least in many Western countries. Similarly, a preventive approach based on the modification of lifestyle remains improbable, either in the short --or in the long period of time. Secondary prevention--i.e., the systematic removal of adenomatous polyps--can hardly be applied in the general population, with the exception of individuals at risk because members of families with Adenomatosis coli or Lynch syndrome, or affected by inflammatory bowel diseases. Finally, chemoprevention (i.e., the attempt to prevent tumour development through the administration of drugs or natural compounds that interfere with various phases of carcinogenesis) is still in its infancy Though attractive, this approach requires well-designed studies which should be carried out for years before being evaluated and interpreted; so far most of these investigations gave inconsistent or controversial results. In conclusion, both primary and secondary prevention of colorectal malignancies appear difficult to apply in the general population, and chemoprevention is still at the beginning of a (presumably] long story. The final impression is that notwithstanding the remarkable advancements made in the last two decades in colorectal cancer research, the practical application of these new concepts remains difficult.
Collapse
Affiliation(s)
- DeLeonM Ponz
- Department of Medical, Oncological and Radiological Science, University of Modena and Reggio Emilia, Italy.
| |
Collapse
|
49
|
Management of Hereditary Colon Cancer Syndromes. COLORECTAL CANCER 2002. [DOI: 10.1007/978-1-59259-160-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
50
|
Ponz de Leon M. Familial Adenomatous Polyposis. COLORECTAL CANCER 2002. [DOI: 10.1007/978-3-642-56008-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|