Ileal pouch-anal anastomosis for chronic ulcerative colitis and familial polyposis coli complicated by adenocarcinoma

Occult and Manifest Colorectal Carcinoma in Ulcerative Colitis: How Does It Influence Surgical Decision Making?

Background

The incidence of colorectal cancer (CRC) among patients with ulcerative colitis (UC) is increased compared to the general population. The diagnosis of CRC potentially influences surgical decision making in patients with UC.

Methods

This review considers clinical studies, systematic reviews, and guidelines on the surgical therapy of CRC in UC. We searched the bibliographic databases The Cochrane Library and Medline (applying MeSH terms such as ‘Colitis, Ulcerative/surgery’, ‘Colorectal Neoplasms’, and ‘Proctocolectomy, Restorative’) with no restriction on language, date, or country. Search results as well as references of relevant publications were independently screened by both authors of this review.

Results

The surgical gold standard for proven CRC in UC is oncological proctocolectomy, if possible preferably as a restorative procedure with formation of an ileal pouch-anal anastomosis. Mucosectomy and hand-sewn anastomosis is the preferred option for fashioning the anastomosis in these patients, especially in case of dysplasia or cancer in the rectum, although the available data is not conclusive. In highly selected cases of patients with histologically confirmed sporadic CRC without dysplasia in multiple random biopsies and without relevant inflammation, a conventional limited oncological resection is adequate. If UC patients with rectal cancer require radiotherapy, it should be performed in a neoadjuvant setting because of the high risk of radiation-induced pouch failure.

Conclusion

Although restorative proctocolectomy is clearly the gold standard therapy for patients with CRC in UC, surgical decision making has to take into account the various settings and patient factors.

A think tank of the Italian Society of Colorectal Surgery (SICCR) on the surgical treatment of inflammatory bowel disease using the Delphi method: ulcerative colitis

The majority of patients suffering from ulcerative colitis (UC) are managed successfully with medical treatment, but a relevant number of them will still need surgery at some point in their life. Medical treatments and surgical techniques have changed dramatically in recent years, and available guidelines from relevant societies are rapidly evolving, providing UC experts with updated and valid practical recommendations. However, some aspects of the management of UC patients are still debated, and the application of guidelines in clinical practice may be suboptimal. The Italian Society of Colorectal Surgery (SICCR) sponsored the think tank in order to identify critical aspects of the surgical management of UC in Italy. The present paper reports the results of a think tank of Italian colorectal surgeons concerning surgery for UC and was not developed as an alternative to authoritative guidelines currently available. Members of the SICCR voted on several items proposed by the writing committee, based on evidence from the literature. The results are presented, focusing on points to be implemented. UC management relies on evaluations that need to be individualized, but points of major disagreement reported in this paper should be considered in order to develop strategies to improve the quality of the evidence and the application of guidelines in a clinical setting.

Surgical management of ulcerative colitis in the era of biologicals

PURPOSE

Proctocolectomy has been a curative option for patients with severe ulcerative colitis. In recent years, there has been a growing use of medical salvage therapy in the management of patients with moderate to severe ulcerative colitis. We aimed at reviewing the role of surgical management in a time of intensified medical management on the basis of published trial data. The aim was to determine the efficacy of aggressive medical versus surgical management in achieving multifaceted treatment goals.

METHODS

A comprehensive search of Pubmed, Medline, the Cochrane database was performed. Abstracts were evaluated for relevance. Selected articles were then reviewed in detail, including references. Recommendations were then drafted based on evidence and conclusions in the selected articles.

RESULTS

The majority of patients with UC will not need surgery. However, steroid-refractoriness and steroid-dependence signal a subset of patients with more challenging disease. Biological therapy has been shown to achieve short-term improvement and temporarily reduce the need for a colectomy. However, there is a substantial financial and medical price to pay because a high fraction of these salvaged patients will still need a curative colectomy but may be exposed to the negative impact of prolonged immunosuppression, chronic illness, and a higher probability to require 3 rather than 2 operations. Proctocolectomy with ileo-anal pouch anastomosis-performed in 1, 2, or 3 steps depending on the patient's condition-remains the surgical procedure of choice. Even though it has its share of possible complications, it has been associated with excellent long-term outcomes and high levels of satisfaction, such that in the majority of patients they become indistinguishable from unaffected normal individuals.

CONCLUSIONS

The current data demonstrate that use of medical salvage therapy in the treatment of UC will likely continue to grow and evolve. Consensus is being developed to better define and predict failure of medical therapy and clarify the role of the different treatment modalities. For many patients, sacrificing the nonresponsive diseased colon is an underused or unnecessarily delayed chance to normalize their health and life. Biologicals in many instances may have to be considered the bridge to that end.

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

PURPOSE

Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients.

METHODS

Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups.

RESULTS

Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002).

CONCLUSIONS

The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

The surgical treatment of inflammatory bowel disease-associated dysplasia

Surgical management of colonic dysplasia discovered in the inflammatory bowel disease patient is controversial. Total proctocolectomy (TPC) is the most definitive treatment for the eradication of undiagnosed synchronous dysplasias and/or carcinomas and the prevention of subsequent metachronous lesions in both Crohn's disease (CD) and ulcerative colitis (UC). However, TPC is not always an attractive option owing to patient comorbidities and patient preference. Historically, dysplasia has been most studied in patients with UC, where the option of reconstruction without a stoma makes TPC more acceptable. Due to a relative lack of research on CD-related dysplasia, surveillance and treatment of CD dysplasia has followed paradigms based on UC data. However, due to pathophysiological differences in CD versus UC, options for surgical management in CD may be more varied than simple TPC, particularly in the less healthy surgical candidate and those who refuse end ileostomy.

Ileal pouch anal anastomosis with modified double-stapled mucosectomy-the experience in China

AIM: To investigate the feasibility and long-term functional outcome of ileal pouch-anal anastomosis with modified double-stapled mucosectomy.

METHODS: From January 2002 to March 2011, fourty-five patients underwent ileal pouch anal anastomosis with modified double-stapled mucosectomy technique and the clinical data obtained for these patients were reviewed.

RESULTS: Patients with ulcerative colitis (n = 29) and familial adenomatous polyposis (n = 16) underwent ileal pouch-anal anastomosis with modified double-stapled mucosectomy. Twenty-eight patients underwent one-stage restorative proctocolectomy, ileal pouch anal anastomosis, protective ileostomy and the ileostomy was closed 4-12 mo postoperatively. Two-stage procedures were performed in seventeen urgent patients, proctectomy and ileal pouch anal anastomosis were completed after previous colectomy with ileostomy. Morbidity within the first 30 d of surgery occurred in 10 (22.2%) patients, all of them could be treated conservatively. During the median follow-up of 65 mo, mild to moderate anastomotic narrowing was occurred in 4 patients, one patient developed persistent anastomotic stricture and need surgical intervention. Thirty-five percent of patients developed at least 1 episode of pouchitis. There was no incontinence in our patients, the median functional Oresland score was 6, 3 and 2 after 1 year, 2.5 years and 5 years respectively. Nearly half patients (44.4%) reported “moderate functioning”, 37.7% reported “good functioning”, whereas in 17.7% of patients “poor functioning” was observed after 1 year. Five years later, 79.2% of patients with good function, 16.7% with moderate function, only 4.2% of patients with poor function.

CONCLUSION: The results of ileal pouch anal anastomosis with modified double-stapled mucosectomy technique are promising, with a low complication rate and good long-term functional results.

Technical aspects of ileoanal pouch surgery

Ileal pouch-anal anastomosis has become the surgical procedure of choice for chronic ulcerative colitis. Since the initial description of the technique, various modifications have facilitated its evolution into a safe operation with excellent long-term outcomes. However, some aspects of the operation remain contentious. Our aim is to describe the technical aspects of ileal pouch-anal anastomosis and review the current literature in the areas of controversy.

Ileal pouch surgery for ulcerative colitis

Ulcerative colitis (UC) is a relapsing and remitting disease characterised by chronic mucosal and submucosal inflammation of the colon and rectum. Treatment may vary depending upon the extent and severity of inflammation. Broadly speaking medical treatments aim to induce and then maintain remission. Surgery is indicated for inflammatory disease that is refractory to medical treatment or in cases of neoplastic transformation. Approximately 25% of patients with UC ultimately require colectomy. Ileal pouch-anal anastomosis (IPAA) has become the standard of care for patients with ulcerative colitis who ultimately require colectomy. This review will examine indications for IPAA, patient selection, technical aspects of surgery, management of complications and long term outcome following this procedure.

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.

Practice parameters for the surgical treatment of ulcerative colitis

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Short- and long-term outcomes of ileal pouch-anal anastomosis for ulcerative colitis

Ileal pouch-anal anastomosis was an important advancement in the treatment of ulcerative colitis. The aim of this study was to determine whether early complications of ileal pouch-anal anastomosis in patients with ulcerative colitis are associated with poor late functional results.

PATIENTS AND METHODS

Eighty patients were operated on from 1986 to 2000, 62 patients with ileostomy and 18 without. The early and late complications were recorded. Specific emphasis has been placed on the incidence of pouchitis with prolonged follow-up.

RESULTS

The ileostomy was closed an average of 9.2 months after the first operation. Fourteen patients were excluded from the long-term evaluation; 6 patients were lost to regular follow-up, 4 died, and 4 patients still have the ileostomy. Of the 4 patients that died, 1 died from surgical complications. Early complications after operation (41) occurred in 34 patients (42.5%). Late complications (29) occurred in 25 patients as follows: 16 had pouchitis, 3 associated with stenosis and 1 with sexual dysfunction; 5 had stenosis; and there was 1 case each of incisional hernia, ileoanal fistula, hepatic cancer, and endometriosis. Pouchitis occurred in 6 patients (9.8%) 1 year after ileal pouch-anal anastomosis, 9 (14.8%) after 3 years, 13 (21.3%) after 5 years, and 16 (26.2%) after more than 6 years. The mean daily stool frequency was 12 before and 5.8 after operation. One pouch was removed because of fistulas that appeared 2 years later.

CONCLUSIONS

Ileal pouch-anal anastomosis is associated with a considerable number of early complications. There was no correlation between pouchitis and severe disease, operation with or without ileostomy, or early postoperative complications. The incidence of pouchitis was directly proportional to duration of time of follow-up.

Rectal cancer and ulcerative colitis: does it change the therapeutic approach?

OBJECTIVE

The aim of this study was to examine the incidence of coexisting colorectal cancer in ulcerative colitis in a population of patients undergoing ileal pouch anal anastomosis. The frequency of rectal cancer in this population, surgical intervention, general outcomes and cancer recurrence are described.

METHODS

Data on 1850 patients undergoing restorative proctocolectomy from 1983 to 2001 were reviewed. Information was gathered from data in the department's pelvic pouch database, as well as pathology and surgical reports. Follow-up questionnaires routinely sent to patients as part of the database were included in the analysis to determine current functional status. Mean follow-up period was 7.5 years after surgery.

RESULTS

Seventy patients had coexisting colorectal cancer at time of IPAA. 7 (10%) of cancers were incidental. Pre-operative duration of disease was 18.6 years. Twenty-six of the cancers were rectal cancers. The most common form of anastomosis in the rectal cancers was mucosectomy, especially in pre-operatively known rectal cancer or low lying dysplasia. Preferred surgical technique for rectal cancer in mucosal ulcerative colitis (UC) included high ligation of mesenteric vessels with radical colectomy and taped occlusion of the rectum with irrigation of the rectal stump with Turnbull solution prior to mucosectomy. Patients with Stage 3 cancers received postoperative chemotherapy. Post-operative radiation therapy was not commonly recommended. Five of 70 patients were deceased from metastatic colon cancer; 55 patients were confirmed alive with good to excellent pouch function with a follow-up range of 1-17 years.

CONCLUSION

Restorative proctocolectomy with ileal pouch anal anastomosis is a successful surgical approach for patients with coexisting colorectal cancer in UC. When the appropriate surgical technique is used in patients with colon or rectal cancer, along with adjuvant chemotherapy when appropriate, prognosis and function is very good.

The Topography of Colorectal Cancer Varies by Race/Ethnicity and Affects the Utility of Flexible Sigmoidoscopy

Colorectal cancer screening beginning at age 50 is recommended for all Americans considered at “average” risk for the development of colorectal cancer either with flexible sigmoidoscopy and fecal occult blood testing (FOBT) or with colonoscopy. Patients who elect flexible sigmoidoscopy and FOBT undergo full colonoscopy only if left-sided neoplasia is detected or if the FOBT is positive. Unfortunately in blacks and whites most right-sided colorectal lesions are unaccompanied by left-sided sentinel lesions, which leads some to prefer colonoscopic screening in these patients. The topography of colorectal cancer in Asians and Latinos is unavailable. We used 1988–1995 California Cancer Registry data to determine the topography of 105,906 consecutive colorectal cancers among Asian, black, Latino, and white patients. We found that the proportion of colorectal cancer distal to the splenic flexure and therefore detectable by flexible sigmoidoscopy varied by ethnicity: Asian (71%) > Latino (63%) > white (57%) > black (55%); P < 0.001. These differences were significant after adjusting for age and sex. The risk of distal disease relative to whites was 1.61 in Asians, 1.15 in Latinos, and 0.82 in blacks ( P < 0.001). Flexible sigmoidoscopy detects a higher proportion of colorectal cancers in Asians and Latinos than in whites or blacks. Further study is needed to assess whether the topography of benign colorectal neoplasia parallels that of malignant disease. Colorectal screening recommendations may need to incorporate racial and ethnic differences in colorectal neoplasia topography.

Ileal pouch-anal anastomosis in patients with colorectal cancer: long-term functional and oncologic outcomes

When colorectal cancer complicates chronic ulcerative colitis or familial adenomatous polyposis, the role of ileal pouch-anal anastomosis is uncertain because of concerns that the procedure may compromise oncologic therapy and that oncologic therapy may compromise ileal pouch-anal anastomosis function.

AIM

This study was undertaken to investigate the impact both of ileal pouch-anal anastomosis on cancer outcomes and of cancer treatments on ileal pouch-anal anastomosis function.

PATIENTS AND METHODS

Of 1,616 patients undergoing ileal pouch-anal anastomosis for chronic ulcerative colitis or familial adenomatous polyposis (1981-1994), 77 patients were identified with adenocarcinoma of the colon (56), rectum (17), or both (4). Data were obtained from an ileal pouch-anal anastomosis registry, case notes, and postal and telephone surveys.

RESULTS

Mean age of the 77 index patients was 37 (range, 13-60) years. Stage distribution was as follows: Stage 0, 9; Stage I, 31; Stage II, 15; Stage III, 22 patients. Twelve patients died with systemic disease (6 with a local component) after a mean follow-up of 6 (range, 2-15) years. Twenty-two patients received adjuvant therapy (chemotherapy, 16; radiotherapy, 2; both, 4 patients). Chemotherapy complications requiring dose reduction or interruption occurred in three (15 percent) patients. One patient developed radiation enteritis (17 percent). Pouch failure occurred in 16 percent of cancer patients, compared with 7 percent for the overall registry. There were no differences between cancer and non-cancer groups in operative complications, median stool frequency, incontinence, pad usage, or pouchitis.

CONCLUSIONS

Although pouch failure is more common, ileal pouch-anal anastomosis can be performed in the setting of colorectal cancer without significant impact on oncologic outcome or long-term ileal pouch-anal anastomosis function.

Review: the surgical management of ulcerative colitis

The treatment of ulcerative colitis requires careful review of the medical and surgical options. The surgical procedure of choice is proctocolectomy with ileal pouch-anal anastomosis. This procedure removes the diseased mucosa, effectively curing the disease whilst maintaining the normal route of defecation and continence. Other surgical options that may be considered in selected patients include proctocolectomy with either a Brooke ileostomy or a Kock pouch, and abdominal colectomy with ileorectal anastomosis. The choice of operation requires consideration of the advantages and disadvantages of a particular procedure and must be tailored to an individual patient's needs and circumstances.

Results after restorative proctocolectomy and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and coexisting colorectal cancer

Although the operation of choice for patients with familial adenomatous polyposis (FAP) is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA), its place in the management of patients with FAP and cancer has not been defined. The authors have reviewed their experience with these patients to determine the safety of IPAA and its efficacy as a cancer operation. The records of 55 patients with FAP who had undergone IPAA were examined. Follow-up studies included an annual questionnaire and physical examination. Eight patients had FAP with coexisting colorectal cancer. Median age at diagnosis was 25 (range 13-46) years, and at operation 33 (range 22-36) years. Of the eight patients (four men), four had colonic cancer and four had rectal cancer. Synchronous colorectal carcinoma was found in two patients. Staging according to the tumor node metastasis classification showed that five patients had stage 1 tumour, two had stage 2 and one had stage 3. Tumours were well, moderately or poorly differentiated in one, five and two patients respectively. During a median follow-up of 56 (range 14-98) months, metastasis developed in the liver of one patient 66 months after surgery. Two patients suffered complications: one had small bowel obstruction and the other mucosal prolapse. Tubular adenomas were found in the pouch of two patients and in the anal transitional zone of one. Pouch function is good to excellent in all surviving patients. Restorative proctocolectomy for patients with FAP and coexisting colorectal cancer can be undertaken with a favourable prognosis and function. It is compatible with curative intent.

Long-term causes of death following ileal pouch-anal anastomosis

PURPOSE

The aim of this study was to identify the overall long-term causes of death in a large series of patients who were undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA).

METHODS

Records of patients who underwent proctocolectomy with IPAA at the Mayo Clinic affiliated hospitals between January 1981 and October 1994 were reviewed to determine overall mortality, cause, and timing of death.

RESULTS

A total of 1,603 patients underwent proctocolectomy with IPAA reconstruction (1,407 for chronic ulcerative colitis (CUC), 187 for familial polyposis (FAP), and 9 for other diagnoses). Thirty-two patients have died, with an overall mortality rate of 2 percent. Mean age at time of death was 40 (23-60) years. There was no significant difference in overall mortality between patients with CUC and patients with FAP. Three deaths occurred postoperatively (0.2 percent) because of pulmonary embolism, perforated gastric ulcer, and subarachnoid hemorrhage. Late deaths occurred in 29 patients (1.8 percent), 10 months to 10.4 years after the operation. The most common cause of late death was cancer, including colon and rectal carcinoma (10 patients), hematologic malignancies (4 patients), cholangiocarcinoma (3 patients), and germ-cell carcinoma (1 patient). Four patients died from unrelated sepsis, two died following myocardial infarction, two patients died from complications of subsequent orthopedic surgery, and one patient died of cirrhosis. Two additional patients committed suicide. No late deaths were directly attributable to the IPAA procedure.

CONCLUSIONS

Proctocolectomy with IPAA is a safe procedure. Operative mortality is low, and late deaths are related to carcinogenic and extracolonic manifestations of underlying or unrelated coexisting diseases and events.

Stapled ileal pouch-anal anastomosis with resection of the anal transition zone

We assessed the outcome of stapled ileal J-pouch-anal anastomosis with intersphincteric resection of the anal transition zone in 83 consecutive patients with ulcerative colitis (n = 71) or familial adenomatous polyposis (n = 12). There was no postoperative mortality. Two patients (2.4%) required permanent ileostomy for manifestation of unsuspected Crohn's disease. Major postoperative complications consisted of pelvic sepsis, anastomotic leakage, and pancreatitis with 3.6% each. Both, frequency of bowel movements and degree of continence improved with time. Two years after takedown of the diverting ileostomy 45 patients with ulcerative colitis and 12 with familial adenomatous polyposis were assessed with a frequency of bowel movements of 5.6 +/- 2 and 3.2 +/- 1 per 24 h, respectively (P < 0.05). At this time none of them had major daytime or nighttime incontinence. Minor incontinence was reported by 9% and 14% of the patients with ulcerative colitis during day-time and night-time, respectively. The patients with familial adenomatous polyposis demonstrated better results, without day-time seepage and intermittent nocturnal seepage in only 9%. It is concluded that direct ileal J-pouch-anal anastomosis is a safe procedure with excellent functional results for patients with ulcerative colitis and familial adenomatous polyposis.

Ulcerative colitis and coexisting colorectal cancer: recurrence rate after restorative proctocolectomy

BACKGROUND

The association between mucosal ulcerative colitis (MUC) and adenocarcinoma is well established.

METHODS

Records of patients who had undergone restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1983 through 1992 were examined. Of these, 604 had MUC and 27 (4.3%) had MUC with coexisting cancer. Patients were surveyed annually for recurrent disease. Pouch function and quality of life were evaluated with a questionnaire and physical examination.

RESULTS

The duration of disease was longer (p = 0.001) in patients with cancer (16.1 +/- 8.0 years) than in those without cancer (9.1 +/- 7.1 years), although the mean age at diagnosis of MUC was the same. Of the 27 patients, 20 had colon cancer and seven had rectal cancer. Multicentricity was found in seven (25.9%) patients. Using the TNM staging classification, 14 patients (51.8%) had stage 1 cancer, eight (29.6%) had stage 2, four (14.8%) had stage 3, and one (3.8%) had stage 4. The patient with stage 4 cancer died 5 months after surgery and was excluded from the follow-up analysis. During a mean follow-up time of 4.3 +/- 2.6 years, cancer recurred in two of the remaining 26 patients (7.7%). In one patient, a local recurrence was found 8 months after surgery, and distant metastases were found in the other patient 35 months after surgery. Both recurrences were in patients with colon cancer. Two of the 26 patients died; one death was related to cancer recurrence (3.8%). Pouch function is good to excellent in all surviving patients.

CONCLUSIONS

Restorative proctocolectomy for patients with MUC and coexisting colorectal cancer can be performed with a favorable prognosis and function. It is appropriate for curative intent, given that an adequate margin without tumor is obtained.

Functional outcome in handsewn versus stapled ileal pouch-anal anastomosis

Eighty-eight of 119 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis were evaluated. Forty patients had a handsewn anastomosis (Hs) with mucosectomy, and 48 had a stapled anastomosis (St). In each patient, we evaluated operative, morphologic, functional, and manometric features. The results in the Hs and St groups were similar when the anastomosis was within 1 cm of the dentate line. In particular, there was no correlation between the type of anastomosis and the number of bowel movements in a 24-hour period, the presence of the urge to defecate, and the use of antidiarrheal drugs. Leakage was significantly higher in the Hs group, even when the anastomosis was less than 1 cm from the dentate line. Pouchitis was more frequent in the Hs group, and, within this group, among those with a short distance between the anastomosis and the dentate line. No correlations were found between the presence of columnar epithelium or active colitis in the mucosa below the anastomosis, the functional outcomes, and the incidence of pouchitis.

Results of ileal J-pouch-anal anastomosis in familial adenomatous polyposis complicated by rectal carcinoma

PURPOSE

Rectal cancer frequently occurs in patients with familial adenomatous polyposis (FAP) and, in some cases, proctocolectomy and ileal pouch-anal anastomosis (IPAA) can be proposed as an alternative to end ileostomy. This study aimed to assess the results of IPAA for familial adenomatous polyposis complicated by rectal carcinoma.

PATIENTS AND METHODS

Postoperative morbidity and bowel function following IPAA were assessed in six patients who had a mesorectal excision for rectal cancer. The functional results were compared with those obtained after IPAA in 134 FAP patients without bowel cancer.

RESULTS

Carcinomas were located at a mean of 11 cm from the dentate line. There were no postoperative complications. One patient with synchronous hepatic metastases died 6 months after operation and the 5 others were alive without recurrence after a mean follow-up of 29 months. Mean frequency of defecation was 6.5/day (vs. 4.2/day in patients without carcinoma), 86 percent of patients had nocturnal defecation (vs. 50 percent), day and night continence were normal in 66 percent and 33 percent of patients, respectively, compared with 90 percent and 85 percent for IPAA without cancer. Pouch excision was required in one patient for unsatisfactory functional result.

CONCLUSION

IPAA can be safely performed for cancer of the upper rectum complicating FAP, but a poor functional outcome related to mesorectal excision has to be expected.

The ileal pouch operation for ulcerative colitis

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma

Between 1977 and 1987, 519 patients underwent operation for rectal carcinoma. Sixty-three patients underwent intersphincteric resection with direct coloanal anastomosis (CAA), and 77 had an abdominoperineal resection (APR). Curative surgery was achieved in 57 and 65 patients, respectively. Both groups were comparable regarding age, stage of tumors, and localization of tumors. During the mean period of 6.7 years (range: 3 to 13.6 years), all patients were examined according to a predefined follow-up plan. From those patients with curative surgery, 11% presented with pelvic recurrence and 33% with distant metastases after coloanal anastomosis; the rates of recurrence and distant metastases after APR were 17% and 35%, respectively. The corrected 5-year survival rates were 62% following CAA and 53% following APR. Eighty-five percent of the patients with CAA reported good functional results regarding anal continence. Our study demonstrates that the intersphincteric resection with CAA is a valuable surgical technique for rectal carcinoma with the benefit of preservation of continence. It is suitable for neoplasms with high- and medium-grade differentiation (G1 to G2) and a localization that allows a minimum distal clearence of 3 cm.

Ileal pouch-anal anastomosis: state of the art

IPAA surgery has evolved to assume a major role in the operative management of CUC and FAP. In experienced centres, the safety of performing this somewhat complex procedure, often in gravely ill patients, has been confirmed. A significant decrease in morbidity has accompanied increased experience and simplification of the operative techniques. Two major issues await resolution. The first has to do with the less than totally predictable functional results of IPAA surgery. While many patients do well, others, for no apparent reason, do poorly with excess frequency, urgency and incontinence. Whether operative modifications or preoperative testing can alter this outcome is at this time unclear. The second issue has to do with the potential long-term sequelae of IPAA surgery. Pouchitis and nutritional and metabolic consequences, including the potential for malignant transformation of ileal mucosa or of retained rectal mucosa, cannot be ignored. At present, these risks seem remote but only long-term follow-up will determine whether IPAA surgery deserves its current enthusiasm.

Overview of screening and management of familial adenomatous polyposis

The rarity of familial adenomatous polyposis (FAP) means that many clinicians may be unaware of the major advances that have taken place in screening for the condition over the past five years. This review is not only to document the current scene but also to give details of those involved in establishing registries throughout the country. FAP is a hereditary disorder which carries with it almost a 100% risk of colorectal cancer. The aim of screening is to detect gene carriers before they present with symptoms attributable to colonic polyps. In this way the incidence of colorectal cancer can be greatly reduced. The use of gene probes to identify patients with FAP is in its infancy but in selected pedigrees gene carriers can be identified using a venous blood sample. The recognition that congenital hypertrophy of the retinal pigment epithelium is an extracolonic manifestation of FAP in most pedigrees allows non-invasive ophthalmological screening of relatives at risk. The combination of these new screening methods with an effective regional registry for FAP can increase the number of patients detected by screening rather than by symptoms. This facilitates appropriate prophylactic surgery and reduces mortality related to colorectal cancer.

Carcinoma and the ileal pouch-anal anastomosis

Of 362 patients undergoing ileal pouch-anal anastomosis, 12 (five with chronic ulcerative colitis and seven with familial adenomatous polyposis) had 16 associated carcinomas. Incidental carcinoma was found in four patients who had undergone ileal pouch-anal anastomosis, six patients had known carcinoma, and carcinoma was suspected in two patients with high-grade dysplasia. No tumor was Stage C or D. After a median observation period of 24 months, no evidence of recurrence was documented. Data suggest that patients with carcinoma complicating chronic ulcerative colitis and familial adenomatous polyposis can safely undergo ileal pouch-anal anastomosis; however, it may be prudent to perform resection and later ileal pouch-anal anastomosis after a period of observation and appropriate adjuvant therapy because of the difficulty in intraoperative staging.

Ileoanal anastomosis with interposition of the ileal 'Kock pouch'. Preliminary results

For patients needing proctocolectomy, there are several alternatives available today for the previously dominating conventional ileostomy. Currently, the ileal pouch-anal anastomosis attracts major interest. Various reservoir procedures have been proposed, but the ideal reservoir design is still debated. The double-folded ileal reservoir (Kock pouch) has a large capacity, low pressure, and is expandable. It is successfully used for the construction of continent ileostomies, continent urostomies, and for replacing the urinary bladder by connecting the reservoir to the urethra. In view of these facts, it was decided to interpose the Kock pouch between the ileum and the anus after colectomy and mucosal proctectomy in a small number of patients, and to study and evaluate its merits in this position. Six consecutive patients formed the study group. Three months after ileostomy closure the stool frequency was 4 every 24-hours, range 3 to 5, and remained so during the follow-up period. All patients could sleep through the night without bowel movements or soiling. None of the patients used pads. The capacity of the reservoir increased from a mean of 100 ml preoperatively to 550 ml one year after ileostomy closure. The large reservoir capacity and the low pressure can explain the good functional results.

Familial adenomatous polyposis

Familial adenomatous polyposis is an autosomal dominant disease that includes early development of up to thousands of colorectal adenomas and several extracolonic manifestations. All untreated patients will develop colorectal adenocarcinoma. The treatment of choice is colectomy and ileorectal anastomosis, but restorative proctocolectomy may be considered in selected cases. Polyposis patients treated with ileorectal anastomosis should be followed for life, with regular proctosigmoidoscopy and destruction of new adenomas. Furthermore, regular gastroduodenoscopy should be carried out because of frequent occurrence of premalignant duodenal adenomas. The prognosis is good after prophylactic colectomy in patients without carcinoma. All first degree relatives of affected family members should be examined regularly with proctosigmoidoscopy from the age of ten, and prophylaxis should be organised using a national or regional polyposis register. The recent detection of a specific gene for familial adenomatous polyposis is a long step forward, and several problems may be solved by increasing international cooperation.

Conservative proctocolectomy: a dubious option in ulcerative colitis

Conservative proctocolectomy was performed for ulcerative colitis in 19 patients, Crohn's disease in three and familial adenomatous polyposis in one. Healing was uncomplicated in only three patients (13 per cent). Eleven developed an anal discharge and nine an infected pelvic haematoma despite peranal drainage. Fourteen patients developed pelvic sepsis and, despite surgical curettage in 11, none healed. Six of these patients have had the anal sphincter divided, with healing in only one, and the anal canal has been excised in two. Eleven patients have ultimately healed at a median time of 28 months and eight have persistent sepsis after a median period of 45 months. Two patients with sepsis have had a successful ileoanal anastomosis. Conservative proctocolectomy cannot be recommended as a definitive operation for ulcerative colitis even though it may permit a subsequent restorative procedure.