Development of invasive adenocarcinoma in a long-standing diverted ileal J-pouch for ulcerative colitis: report of a case

Ileal Pouch Cancer Detected More than 30 Years after Restorative Proctocolectomy for Ulcerative Colitis

INTRODUCTION

The standard surgical treatment for ulcerative colitis (UC) is proctocolectomy with hand-sewn ileoanal pouch anastomosis (hand-sewn IPAA) or stapled ileal pouch anastomosis (stapled IPAA). The occurrence of cancer in the ileal pouch after surgery for UC is rare, and a consensus on surveillance for ileal pouch cancer has not been reached. We report a case of ileal pouch cancer diagnosed by pouchoscopy 33 years after restorative proctocolectomy with IPAA for UC.

CASE PRESENTATION

A middle-aged man presented with positive fecal occult blood. The patient had undergone restorative proctocolectomy with IPAA for UC 33 years ago. Pouchoscopy had been performed every 2-3 years in the last 10 years. In April a year ago, he tested positive for fecal occult blood, and pouchoscopy revealed an ulcerative lesion and flat elevation in the ileal pouch on the proximal side of the ileoanal anastomosis. Targeted biopsies of the ulcerative lesion revealed low-grade dysplasia (LGD). After 4 months, pouchoscopy also showed an increase in the size of the flat elevation, but targeted biopsies of this lesion also showed LGD. One year later in August, endoscopic examination for hematochezia showed a full circumferential raised lesion with a white coat and mucus draining from a fistula near the anastomosis at the same site. Pathological examination identified adenocarcinoma in the ileal mucosa. The preoperative diagnosis was ileal pouch cancer after restorative proctocolectomy with IPAA for UC, cT4bN2M0 stage IIIB (UICC-TNM, 8th), and he underwent excision of the ileal pouch body and the ileoanal anastomosis. Pathological examination showed mucinous carcinoma in the ileal mucosa with chronic inflammation. The postoperative stage was pT3N0M0 stage IIA; no postoperative chemotherapy was administered, and at 6 months postoperatively, the patient remained recurrence free.

CONCLUSION

Although ileal pouch cancer is rare, it can occur after a long period following ileal pouch surgery for UC. Endoscopic surveillance for ileal pouch cancer should be performed for early diagnosis and radical resection, especially if ileal pouch cancer occurs more than 10 years after the onset of UC.

Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis

Proctocolectomy with ileal pouch-anal anastomosis is the intervention of choice for ulcerative colitis and familial adenomatous polyposis requiring surgery. One of the long-term complications is pouch cancer, having a poor prognosis. The risk of high-grade dysplasia and cancer in the anal transitional zone and ileal pouch after 20 years is estimated to be 2 to 4.5% and 3 to 10% in ulcerative colitis and familial polyposis, respectively. The risk factors for ulcerative colitis are the presence of pre-operative dysplasia or cancer, disease duration > 10 years and severe villous atrophy. For familial polyposis, the risk factors are the number of pre-operative polyps > 1000, surgery with stapled anastomosis and the duration of follow-up. In the case of ulcerative colitis, a pouchoscopy should be performed annually if one of the following is present: dysplasia and cancer at surgery, primary sclerosing cholangitis, villous atrophy and active pouchitis (every 5 years without any of these factors). In the case of familial polyposis, endoscopy is recommended every year including chromoendoscopy. Even if anal transitional zone and ileal pouch cancers seldom occur following proctectomy for ulcerative colitis and familial adenomatous polyposis, the high mortality rate associated with this complication warrants endoscopic monitoring.

Controversies in J Pouch Surgery for Ulcerative Colitis: A Focus on Handsewn Versus Stapled Anastomosis

The accepted current standard for treatment of medically refractory ulcerative colitis is total proctocolectomy with an ileal pouch-anal anastomosis for restoration of continence. There are 2 techniques by which the anastomosis can be performed, including handsewn and stapled. Handsewn anastomosis with mucosectomy was the first method described; however, it has been associated with significant incontinence. The double-stapled anastomosis was developed in response to improve postoperative function. Controversy remains as to which technique is superior as both have disadvantages. This review article addresses differences between the 2 methodologies in relation to postoperative complications, anorectal physiology, functional outcomes, and oncological safety.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Disease course and management strategy of pouch neoplasia in patients with underlying inflammatory bowel diseases

BACKGROUND

To evaluate the disease course and management strategy for pouch neoplasia.

METHODS

Patients undergoing ileal pouch surgery for underlying ulcerative colitis who developed low-grade dysplasia (LGD), high-grade dysplasia, or adenocarcinoma in the pouch were identified.

RESULTS

All eligible 44 patients were evaluated. Of the 22 patients with initial diagnosis of pouch LGD, 6 (27.3%) had persistence or progression after a median follow-up of 9.5 (4.1-17.6) years. Family history of colorectal cancer was shown to be a risk factor associated with persistence or progression of LGD (P = 0.03). Of the 12 patients with pouch high-grade dysplasia, 5 (41.7%) had a history of (n = 2, 16.7%) or synchronous (n = 4, 33.3%) pouch LGD. Pouch high-grade dysplasia either persisted or progressed in 3 patients (25.0%) after the initial management, during a median time interval of 5.4 (2.2-9.2) years. Of the 14 patients with pouch adenocarcinoma, 12 (85.7%) had a history of (n = 2, 14.3%) or synchronous dysplasia (n = 12, 85.7%). After a median follow-up of 2.1 (0.6-5.2) years, 6 patients with pouch cancer (42.9%) died. Comparison of patients with a final diagnosis of pouch adenocarcinoma (14, 32.6%), and those with dysplasia (29, 67.4%) showed that patients with adenocarcinoma were older (P = 0.04) and had a longer duration from IBD diagnosis or pouch construction to the detection of pouch neoplasia (P = 0.007 and P = 0.0013).

CONCLUSIONS

The risk for progression of pouch dysplasia can be stratified. The presence of family history of colorectal cancer seemed to increase the risk for persistence or progression for patients with pouch LGD. The prognosis for pouch adenocarcinoma was poor.

Systematic review of cuff and pouch cancer in patients with ileal pelvic pouch for ulcerative colitis

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for refractory or complicated ulcerative colitis (UC). Since 1990, pouch-related adenocarcinomas have been described. The aim of this study was to review the literature to evaluate the burden of this complication, seeking for risk factors, prevention, and ideal management.

METHODS

We performed a systematic review of the literature to identify all described pouch-related adenocarcinoma in patients operated on with IPAA for UC. Studies were thoroughly evaluated to select authentic de novo pouch carcinomas. Some authors were contacted for additional information. Data of patients were pooled. Meta-analyses of suitable studies were attempted to identify risk factors.

RESULTS

Thirty-four articles reported on 49 patients (2:1, male:female) who developed unequivocal pouch-related adenocarcinoma, 14 (28.6%) and 33 (67.3%) arising from the pouch and anorectal mucosa, respectively. Origin was not reported in 2 (4%). Pooled cumulative incidence of pouch-related adenocarcinoma was 0.33% (95% confidence interval [CI], 0.31-0.34) 50 years after the diagnosis and 0.35% (95% CI, 0.34-0.36) 20 years after IPAA. Primary pouch cancer incidence was below 0.02% 20 years after IPAA. Neoplasia on colectomy specimen was the strongest risk factor (odds ratio, 8.8; 95% CI, 4.61-16.80). Mucosectomy did not abolish the risk of subsequent cancer but avoiding it increased 8 times the risk of cancer arising from the residual anorectal mucosa (odds ratio, 8; 95% CI, 1.3-48.7; P = 0.02). Surveillance is currently performed yearly starting 10 years since diagnosis, but cancers escaping this pathway are reported. In patients receiving mucosectomy, a 5-year delay for surveillance could be proposed.

CONCLUSIONS

Pouch-related adenocarcinomas are rare. Diagnosis of Crohn's disease in the long term may further decrease the rates in UC. Presumed evolution from dysplasia might offer a time window for cancer prevention. Abdominoperineal excision should be recommended for pouch-related adenocarcinomas.

Adenocarcinoma of an Ileostomy in a Case of Hirschprung's Disease with Retroviral Disease

The number of ileostomies created for benign diseases such as familial adenomatous polyposis and ulcerative colitis is increasing. Long-term ileostomies are prone to develop various complications over time. Ileostomy site carcinoma is a well-established complication in ulcerative colitis and familial adenomatous polyposis that have undergone total colectomy. However, no case of ileostomy site carcinoma has been described in a patient with Hirschprung's disease. We present the first case of adenocarcinoma at an ileostomy site in a patient with Hirschprung's disease with retroviral disease.

Is surveillance endoscopy necessary after colectomy in ulcerative colitis?

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis and management of dysplasia and cancer of the ileal pouch in patients with underlying inflammatory bowel disease

Approximately 30% of the patients with ulcerative colitis (UC) would ultimately require colectomy for medically refractory UC or UC-associated neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for these patients. However, this procedure does not completely abolish the risk for neoplasia of the pouch. The main risk factor for pouch neoplasia is a preoperative diagnosis of UC-associated dysplasia or cancer. Although the natural history and prognosis of pouch dysplasia are not clear, mortality associated with pouch cancer, once diagnosed, appears to be high. Conversely, not all pouch neoplasia follows the chronic inflammation-dysplasia-cancer sequence, which makes pouch endoscopy with biopsy, the current gold standard for surveillance, challenging. In addition, the findings that pouch neoplasia is not common and that pouch endoscopy still misses dysplasia lead to controversy on the need and time interval of routine endoscopic surveillance. However, based on reports in the literature and their own experience, the authors recommend surveillance endoscopy to be performed in patients at risk, such as those with a precolectomy diagnosis of UC-associated neoplasia. This review appraises issues in the prevalence and incidence, risk factors, technical aspects of pouch construction, clinical and pathological features, natural history, surveillance examination, diagnosis, and management of pouch neoplasia.

Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy

BACKGROUND & AIMS

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has substantially reduced the risk for ulcerative colitis (UC)-associated dysplasia or cancer (neoplasia). We characterized features, risk factors, and outcomes of pouch neoplasia in patients with inflammatory bowel disease in a historical cohort study.

METHODS

A total of 3203 patients with a preoperative diagnosis of inflammatory bowel disease underwent restorative proctocolectomy with IPAA from 1984 to 2009 at the Cleveland Clinic. Demographic, clinical, and endoscopic data were reviewed and samples were examined by histological analyses. Univariable and Cox regression analyses were performed.

RESULTS

Cumulative incidences for pouch neoplasia at 5, 10, 15, 20, and 25 years were 0.9%, 1.3%, 1.9%, 4.2%, and 5.1%, respectively. Thirty-eight patients (1.19%) had pouch neoplasia, including 11 (0.36%) with adenocarcinoma of the pouch and/or the anal-transitional zone (ATZ), 1 (0.03%) with pouch lymphoma, 3 with squamous cell cancer of the ATZ, and 23 with dysplasia (0.72%). In the Cox model, the risk factor associated with pouch neoplasia was a preoperative diagnosis of UC-associated cancer or dysplasia, with adjusted hazard ratios of 13.43 (95% confidence interval: 3.96-45.53; P < .001) and 3.62 (95% confidence interval: 1.59-8.23; P = .002), respectively. Mucosectomy did not protect against pouch neoplasia.

CONCLUSIONS

Risk for neoplasia in patients with UC and IPAA is small and not eliminated by colectomy or mucosectomy. A preoperative diagnosis of dysplasia or cancer of colon or rectum is a risk factor for pouch dysplasia or adenocarcinoma.

Surveillance for dysplasia in patients with ileal pouch-anal anastomosis for ulcerative colitis: an interim analysis

BACKGROUND

The risk of developing cancer in the ileal pouch of patients with surgery for ulcerative colitis has not been defined. Dysplasia in the pouch is quite rare. Although some suggest pouch surveillance based on previous histological assessments, there are no guidelines for surveillance of these patients. The aim of our study was to investigate that risk and identify time intervals for ileoanal pouch surveillance.

METHODS

Endoscopy and biopsies of the ileal pouch were performed at 3, 6, and/or 12 months after ileal pouch-anal anastomosis (IPAA) became functional. Biopsies were evaluated by two pathologists using Riddel's criteria. Interim data analysis using descriptive statistics is reported.

RESULTS

Thirty-eight patients have entered the study. Average patient age at 3, 6, and 12 months of surveillance was 39.1, 36.8, and 39.1 years, respectively. Average disease duration was 8.2 years. Ten of 38 cases (26%) had colonic dysplasia prior to surgery. Dysplasia within the pouch was reported in one patient 6 months after IPAA became functional. This patient demonstrated no dysplasia at 12 months or statistical divergence by age, duration of disease or history of colonic dysplasia prior to IPAA. No subgroup of patients with dysplasia was identified to calculate cumulative risk or perform comparative statistical analysis.

CONCLUSION

A study with longer follow-up after IPAA should precede any attempt to recommend routine surveillance. However, the finding of dysplasia early after surgery underscores the importance of early pouch surveillance in our population, at least until definite predisposing variables are identified.

Intramucosal adenocarcinoma of the ileum originated 40 years after ileosigmoidostomy

Background

Small bowel adenocarcinomas (SBAs) are rare carcinomas. They are asymptomatic and usually neither endoscopy nor contrast studies are performed for screening

Case presentation

A 72-year-old Japanese male had a positive fecal occult blood test at a regular check-up in 2006. He suffered appendicitis and received an ileosigmoidostomy in 1966. A colonoscopy revealed an irregular mucosal lesion with an unclear margin at the ileum side of the anastomosis. A mucosal biopsy specimen showed adenocarcinoma histopathologically. Excision of the anastomosis was performed for this patient. The resected specimen showed a flat mucosal lesion with a slight depression at the ileum adjacent to the anastomosis. Histological examination revealed a well differentiated intramucosal adenocarcinoma (adenocarcinoma in situ). Immunohistological staining demonstrated the overexpression of p53 protein in the adenocarcinoma.

Conclusion

Adenocarcinoma of the ileum at such an early stage is a very rare event. In this case, there is a possibility that the ileosigmoidostomy resulted in a back flow of colonic stool to the ileum that caused the carcinogenesis of the small intestine.

Adenocarcinoma following ileal pouch-anal anastomosis for ulcerative colitis: review of 26 cases

The occurrence of adenocarcinoma following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is an infrequent and but potentially lethal complication. We have seen 1 such case among 520 IPAAs performed in our group practice between 1978 and February 2008. We have added this case to a review of 25 previously reported cases of adenocarcinoma of the pouch or outflow tract following IPAA for UC. Our conclusions are 1) that post-IPAA cancer can occur following either mucosectomy or stapled anastomosis; 2) that this malignancy can occur after IPAA performed for UC either with or without neoplasia; and 3) that this complication is seen whether or not the initial cancer or dysplasia had involved the rectum.

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

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

Adenocarcinoma arising from the rectal stump eleven years after excision of an ileal J-pouch in a patient with ulcerative colitis: report of a case

Adenocarcinomas in relation to the ileal J-pouch after restorative proctocolectomy for ulcerative colitis have been recently reported with increasing frequency. All previously reported cases have occurred in patients with their ileal pouch in situ. We report a case of adenocarcinoma in the anal canal 11 years after removal of a failed ileal J-pouch. Mucosectomy had been performed at the restorative proctocolectomy. The anus had been left in place at the pouch excision because of severe fibrosis in the pelvis. If it is decided to remove an ileal pouch permanently, a total abdominoperineal excision should be performed, particularly in patients with risk factors for cancer development.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Adenocarcinoma Arising Below an Ileoanal Anastomosis After Restorative Proctocolectomy for Ulcerative Colitis: Report of a Case

We report a case of adenocarcinoma developing in remnant rectal mucosa below a hand-sewn ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy for ulcerative colitis (UC). To our knowledge, this is the first such case to be reported from Japan. A 60-year-old man with a 13-year history of UC underwent proctocolectomy with a hand-sewn IPAA and mucosectomy for anal stenosis and serious tenesmic symptoms. About 7 years later, a follow-up endoscopy showed a flat elevated malignant lesion, 2 cm in diameter, below the ileoanal anastomosis. He was treated by abdominoperineal resection of the pouch and anus with total mesorectal excision. Histopathological examination of the resected specimen confirmed the presence of a well-differentiated adenocarcinoma but there were no metastatic lymph nodes. He recovered uneventfully and remains well without evidence of recurrent disease 2 years and 3 months after his last operation.

Should ileal pouch-anal anastomosis include mucosectomy?

OBJECTIVE

Debate exists as to the benefits of performing mucosectomy as part of pouch surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Whilst mucosectomy results in a more complete removal of diseased mucosa, this benefit may be at the price of poorer function. We examined these issues.

METHOD

Using Medline, Embase, Ovid and Cochrane database searches papers were identified relating to the outcome following pouch surgery with and without mucosectomy. Potential reasons for functional problems were investigated, as were rates of 'cuffitis', dysplasia, polyposis and cancer in the ileal pouch and anal canal.

RESULTS

The available evidence suggests that performing a mucosectomy leads to a worse functional outcome. Meta-analysis suggested that nighttime seepage of stool and resting and squeeze pressure were worse after mucosectomy. The most likely reason for functional impairment following pouch surgery was the degree of anal manipulation. Mucosectomy does seem to confer benefit in terms of disease control but this benefit does not reach statistical significance.

CONCLUSION

Stapled anastomosis avoiding mucosectomy is the approach of choice for ileal pouch anal anastomosis because this leads to superior functional outcome. Performing mucosectomy results in some clinical benefits in terms of lower rates of inflammation and dysplasia in the retained mucosa in UC patients and lower rates of cuff polyposis in FAP patients. However, on the basis of available evidence mucosectomy is only indicated in those cases where the patient is at a high risk of disease in the retained rectal cuff.

Mucosal dysplasia in ileal pelvic pouches after restorative proctocolectomy

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis

Background

The aim of this systematic review was to assess the prevalence and site of dysplasia after restorative proctocolectomy (RPC) for ulcerative colitis (UC), and to identify risk factors that could be used in a surveillance programme.

Methods

Medical databases were searched for potentially relevant publications between 1978 and 2006. Studies that dealt with RPC for UC and postoperative surveillance were included. Two researchers independently performed study selection, quality assessment, data extraction and analysis.

Results

Twenty-three observational studies and case series were included, with a total of 2040 patients. The pooled prevalence of confirmed dysplasia in the pouch, anal transitional zone or rectal cuff was 1·13 (range 0–18·75) per cent. The prevalence of high-grade dysplasia, low-grade dysplasia and indefinite for dysplasia was 0·15 (range 0–4·49), 0·98 (range 0–15·62) and 1·23 (range 0–25·28 per cent) respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal transitional zone. Dysplasia and cancer identified before or at operation seemed to be significant predictors of the development of dysplasia. Pouchitis and duration of follow-up were not of predictive value.

Conclusion

Although based on low-level evidence from uncontrolled studies, the prevalence of dysplasia observed after RPC was remarkable. A surveillance programme that takes into account the risk factors found is therefore advocated.

Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Adenocarcinoma in an ileoanal pouch formed for ulcerative colitis in a patient with primary sclerosing cholangitis and a liver transplant: report of a case and review of the literature

This is a report of the first case of adenocarcinoma arising in an ileal pouch after proctocolectomy for ulcerative colitis in a patient who had also undergone orthotopic liver transplantation for primary sclerosing cholangitis. Previously reported cases of adenocarcinoma developing after formation of an ileoanal pouch are reviewed as is the evidence for neoplastic transformation of the ileal mucosa. The risk factors for the development of colorectal cancer in patients with ulcerative colitis and the possibility that these may be risk factors for the development of pouch malignancy are discussed. We conclude that this patient exemplifies a small group of patients who may be at increased risk of developing pouch malignancy and need endoscopic follow-up. There is also the need for longer-term follow-up data to determine the risk of this rare and potentially devastating complication of restorative proctocolectomy.

Revolution and evolution: 30 years of ileoanal pouch surgery

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

Low detoxification capacity in the ileal pouch mucosa of patients with ulcerative colitis

BACKGROUND

An ileal pouch-anal anastomosis has become the most widely accepted procedure for surgical treatment of patients with ulcerative colitis (UC). The primary function of the ileum within the pouch changes from absorption to storage. Malignancies have been described in the pouch mucosa. The detoxifying glutathione S-transferase (GST) enzymes are involved in the mucosal protection against toxins and carcinogens. Levels of GSTs are much higher in the ileum as compared with the colon. The adaptation of the ileal pouch mucosa into a more colon-like phenotype possibly influences the activity and levels of GST. This study compares the detoxification capacity of GST of the afferent ileal limb mucosa with the ileal pouch mucosa of patients with UC.

METHODS

Biopsies from normal-appearing mucosa from the ileal pouch and the ileal afferent limb were obtained from 18 patients with UC. GST isoforms were quantified by immunoblotting. GST activity was measured spectrophotometrically, and glutathione and cysteine levels were determined by high-performance liquid chromatography.

RESULTS

The GST activity and GSTA1+A2 levels were significantly lower in the pouch compared with the afferent ileal limb of patients with UC, whereas the GSTP1 levels were higher in the pouch. No differences were observed in the levels of GSTM1, GSTT1, glutathione, or cysteine.

CONCLUSIONS

The lower GST detoxification activity in the pouch mucosa of patients with UC may result in higher levels of toxins and carcinogens and thus partly contribute to the risk of developing malignancies in the pouch.

Three cases of adenocarcinoma following restorative proctocolectomy with hand-sewn anastomosis for ulcerative colitis: a review of reported cases in the literature

Restorative proctocolectomy (RPC) has been accepted as optimal surgical therapy for most patients with ulcerative colitis. The occurrence of adenocarcinoma adjacent to the ileoanal anastomotic site for ulcerative colitis is a serious but rare outcome. There are 16 reported cases. We report three additional cases and review previous cases in the literature.

Squamous-cell carcinoma developing after an ileoanal pouch procedure: report of a case

PURPOSE

This study was designed to report a new variant of a rare but serious complication of restorative proctocolectomy.

METHODS

We present a 47-year-old female who underwent restorative proctocolectomy after 16 years of disease. Twenty-five years after her pouch procedure, she underwent pouchoscopy for fever and poor pouch function. A suspicious mass was biopsied and pathology indicated squamous metaplasia. On referral, a mass could be palpated above the anorectal ring. Biopsy of the mass was read as invasive squamous carcinoma in the background of normal intestinal mucosa. This represents the twelfth reported case of carcinoma arising in a pouch, but the first report of a squamous carcinoma, as all previous reports had been of adenocarcinoma.

RESULTS

The patient has undergone chemoradiation. Response to therapy, functional status, and biopsy after treatment will determine whether the patient will be able to salvage the pouch.

CONCLUSIONS

Diligence and vigilance with regard to active follow-up, and a high index of suspicion, are required to prevent this from becoming a more frequently seen problem.

The risk of dysplasia and cancer in the ileal pouch mucosa after restorative proctocolectomy for ulcerative proctocolitis is low: a long-term term follow-up study

AIM

Some of the rare complications reported in patients with an ileopouch anal anastomosis (IPAA) after coloectomy for chronic ulcerative colitis are dysplasia and carcinoma. The supposed pathway is for the ileal pouch mucosa to go through adaptational changes then is to progress through the phases of chronic pouchitis, dysplasia and subsequently to adenocarcinoma. In many of these studies however, the dysplasia-cancer sequence is inconclusive since the carcinoma might have developed from the ileal mucosa itself or from residual viable rectal mucosa left behind. The purpose of this study was therefore to study the long-term ileal mucosal adaptation patterns and the incidence and grading of dysplasia in the ileal pouch mucosa in patients previously operated on for ulcerative proctocolitis.

PATIENTS AND METHODS

Forty-five patients who had been operated on with an IPAA (25 males/20 females), with a median age of 54 years (range 34-76), were invited for clinical examination and pouch endoscopy including mucosal biopsies. The duration of their colitis until surgery was median 6 years (range 1-28) and the time median interval from start of disease until time of follow up 24.8 years (range 17-46). Three independent pathologists from two different centres reviewed sequential mucosal biopsies taken from separate sites of the pouch for dysplasia and mucosal adaptation patterns.

RESULTS

The type C pattern with a severe inflammation in lamina propria together with severe atrophy of villi, sometimes with ulceration and granulation tissue, was observed by the two pathologists from one centre in 15 of 45 (33.3%) patients and in 11 (24.4%) of 45 by the third pathologist, respectively. As regards dysplasia one pathologist group evaluated 2/45 (4.4%) cases as low-grade dysplasia while the third pathologist considered one of these cases as indefinite for dysplasia and one as reactive. There was in this respect full agreement between the two centres in 43 (95.6%) of 45 cases. Neither high-grade dysplasia nor invasive carcinoma was diagnosed.

CONCLUSION

Dysplastic transformation within the ileal pouch mucosa in patients operated for ulcerative proctocolitis is rare even after a long follow-up. These results are reassuring for both patients and surgeons. There seem to be no solid grounds to support routine surveillance for dysplasia in the ileal pouch mucosa in these patients. The surveillance for neoplastic changes in the remaining muscular/epithelial cuff is a separate issue however.

Malignancies in inflammatory bowel disease

The risk of luminal gastrointestinal tract, hepatobiliary tract, and non-gastrointestinal tract cancers in inflammatory bowel disease remains of great interest. The purpose of this review is to report on studies published in 2002 that have addressed several important questions related to the biology, natural history, and risk factors for colonic and extracolonic cancers. Two studies reported conflicting results on the natural history of low-grade dysplasia in patients with ulcerative colitis. Other investigators focused on the safety of medications used to treat inflammatory bowel disease, one noting no increased risk of cancer with azathioprine, another suggesting that anti-tumor necrosis factor therapy may increase the risk of lymphoma. Studies of patients after total proctocolectomy and ileoanal pouch anastomosis suggest that these patients continue to have a small risk of bowel cancer. A novel observation from studies focusing on the subgroup of patients with inflammatory bowel disease and primary sclerosing cholangitis was the identification of an increased risk of pancreatic cancer. Finally, many investigators continue to pursue potential biomarkers of malignancy for use in inflammatory bowel disease cancer surveillance programs. These studies have added to our knowledge of the risk of malignancy in inflammatory bowel disease and have set the stage for future long-term studies to better delineate the risk of lymphoma with the use of anti-tumor necrosis factor therapy and the fate of low-grade dysplasia in flat mucosa. Clinical application of potential biomarkers of malignancy in inflammatory bowel disease cancer surveillance is anticipated in the near future.

Dysplasia in the ileoanal pouch

Formation of an ileo-anal pouch is an accepted technique following colectomy in the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The configuration of pouches and anastomotic techniques has varied over the last two decades. The increased use of stapling devices in formation of the pouch-anal anastomosis avoids the need for endoanal mucosal stripping and may contribute to improved functional results, but leaves a 'columnar cuff' of residual rectal mucosa in situ. Concerns regarding the long-term safety of the ileo-anal pouch have been raised by reports of the occurrence of dysplasia in the pouch mucosa and 15 cases of adenocarcinoma. In UC, persistence of underlying disease in the residual rectal mucosa, anal transition zone and columnar cuff provides the site for development of dysplasia and malignancy. Pouchitis is unlikely to be a major cause of dysplasia or malignancy, as long-term follow-up of patients with Koch pouches has demonstrated. In FAP, any persistent rectal mucosa and mucosa of the small intestine is at risk of adenomatous dysplasia due to the genetic alterations causing the disease. Long-term surveillance should focus on all FAP pouch patients, and in UC patients should be directed towards the diagnosis of residual rectal mucosa in the area distal to the pouch anastomosis. Specialist histopathological opinion is essential in the diagnosis of dysplasia in the ileo-anal pouch.

The role of endoscopy in the evaluation of pouches and ostomies

Patients with ileal pouches and ostomies present with management issues that are challenging to the clinician. Endoscopy plays a significant role in diagnosing and guiding therapy in such patients. Unfortunately, there are very few prospective studies that evaluates endoscopy in these situations. Nevertheless, it is clear that endoscopy remains a powerful tool that is important for diagnosis and therapy of complications unique to these surgical procedures. It seems prudent to advocate endoscopic cancer surveillance for patients with pouches and ostomies; however, it remains to be seen whether these efforts will ultimately have an impact on long-term patient morbidity and mortality.

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

BACKGROUND & AIMS

Recent reports have suggested the mucosa of an ileal reservoir could be at risk of neoplasia. Risk factors may include the age of the pouch, chronic pouchitis, and previous colonic neoplasia. This study examined a group of such patients to determine the risk of dysplasia.

METHODS

From a cohort of 1221 patients with ileal pouches, 171 patients with possible risk factors were selected. Successful contact was made with 138 patients who were invited for endoscopy and multiple biopsies. Biopsy specimens were stained with H&E and p53, scored for inflammatory changes including villous atrophy, and analyzed by flow cytometry.

RESULTS

One hundred six patients took part and fell into 1 or more of the following clinical categories: chronic pouchitis (n = 34), pelvic pouch for > or =12 years (n = 42); Kock pouch for > or =14 years (n = 29), and neoplasia in colectomy specimen (n = 11). Thirty-three patients had severe villous atrophy. One patient of 106 (95% confidence interval, 0.9% +/- 1.6%) with a long-standing pouch had low-grade dysplasia that was multifocal. DNA analysis by flow cytometry showed aneuploidy in this patient and 2 others.

CONCLUSIONS

These data suggest that the development of dysplasia in ileal pouches performed for ulcerative colitis is probably a rare event within 15-20 years of pouch surgery.