Adenomas at resection margins do not influence the long-term development of pouch polyps after restorative proctocolectomy for familial adenomatous polyposis

Pouch adenomas in Familial Adenomatous Polyposis after restorative proctocolectomy

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.

Laparoscopic-assisted proctocolectomy with prolapsing technique for familial adenomatous polyposis

PURPOSE

The role of laparoscopic total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA) for familial adenomatous polyposis (FAP) has been controversial, given its technical difficulty of selecting the appropriate distal transection line and achieving safe anastomosis. We herein describe our initial experience with the prolapsing technique for laparoscopic-assisted TPC and IPAA (J-pouch) in the treatment of FAP.

METHODS

A consecutive series of patients with FAP undergoing laparoscopic-assisted TPC with IPAA were identified from a prospectively collected database between June 2004 and February 2012. Medical records were reviewed for patient demographics, operative outcomes, and follow-up.

RESULTS

The surgery was successfully completed in all 6 patients without any conversion to open surgery. The median operating time was 279 minutes (range, 240 to 386 min) and the median blood loss was 17.5 mL (range, 5 to 161 mL). No patient required blood transfusion. The median length of diet resumption and postoperative hospital stay were 7 days (range, 6 to 10 d) and 15 days (range, 13 to 21 d), respectively. A postoperative complication, wound infection, occurred in 1 patient. No anastomotic leakages or small bowel obstructions occurred. At a median follow-up of 59 months (range, 14.2 to 107.5 mo), no carcinoma had developed at the pouch or at the anastomotic site. Sexual function and fertility were unchanged as compared with preoperatively in 2 male patients. None of the patients experienced night-time incontinence or had to use a pad.

CONCLUSIONS

Our limited experience suggests that this prolapsing technique helps prevent problems with laparoscopic-assisted TPC and IPAA for FAP patients.

Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis

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.

Risk of neoplastic change in ileal pouches in familial adenomatous polyposis

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.

Ileal pouch adenomas and carcinomas after restorative proctocolectomy for familial adenomatous polyposis

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.

Risk of developing adenomas and carcinomas in the ileal pouch in patients with familial adenomatous polyposis

BACKGROUND & AIMS

At present, more than half of patients with familial adenomatous polyposis (FAP) are treated with a proctocolectomy and an ileal pouch-anal anastomosis (IPAA). Originally it was thought that this procedure would eliminate the risk of developing rectal cancer. However, an increasing number of studies reported development of adenoma and carcinoma in the pouch. The aim of this study was to evaluate the long-term risk of developing adenomas and carcinomas in the pouch in a large cohort of Dutch FAP patients.

METHODS

A total of 254 patients with FAP who underwent an IPAA were selected from the Dutch Polyposis Registry. The results of the surveillance examinations and the pathology reports were analyzed. Surveillance with chromoendoscopy was offered to a subgroup of patients.

RESULTS

Full information on follow-up was available in 212 (84%) patients. These patients (56% male) underwent a total of 761 endoscopies. The mean follow-up was 7.9 years (range, 0.4-20.3 years). The cumulative risk of developing an adenoma in the pouch at 10-year follow-up was 45%. Twenty-five patients (11.8%) developed an adenoma with advanced pathology, and 4 (1.9%) developed a carcinoma. The cumulative risk of developing a pouch carcinoma at 10-year follow-up was 1%. A very high prevalence (75.7%) of adenomas was found in a subgroup of patients who were examined with chromoendoscopy.

CONCLUSIONS

This study demonstrated that although the risk of developing adenomas in the pouch after an IPAA is high, the risk of malignant degeneration appears to be low. The use of chromoendoscopy improves the detection of small adenomas.

Familial adenomatous polyposis and the small bowel: a loco-regional review and current management strategies

Small-bowel tumours are an important cause of morbidity and death in patients with familial adenomatous polyposis. Intensive endoscopic surveillance is now standard in the long-term management of this condition. Thus, lesions occurring throughout the small bowel are increasingly noted by oesophagogastroduodenoscopy and flexible pouchoscopy. Some occur commonly de novo (in stomach, duodenum and ampulla), while others may occur following surgery (polyps of the ileostomy, ileoanal pouch, or small bowel above an anastomosis). These differ widely in incidence, natural history and management. This review provides a regional overview of these lesions, in terms of current research findings and management protocols.

Ileal pouch-anal anastomosis

BACKGROUND

Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application.

METHODS AND RESULTS

Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

CONCLUSION

The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.

Restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis revisited

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.

Persistence of high CD40 and CD40L expression after restorative proctocolectomy for ulcerative colitis

AIM: To focus on the role of CD40 and CD40L in their pathogenesis.

METHODS: We analyzed by immunohistochemistry the CD40 and CD40L expression in the pouch mucosa of 28 patients who had undergone RPC for UC, in the terminal ileum of 6 patients with UC and 11 healthy subjects. We also examined by flow cytometry the expression of CD40 by B lymphocytes and monocytes in the peripheral blood of 20 pouch patients, 15 UC patients and 11 healthy controls.

RESULTS: Ileal pouch mucosa leukocytes presented a significantly higher expression of CD40 and CD40L as compared to controls. This alteration correlated with pouchitis, but was also present in the healthy pouch and in the terminal ileum of UC patients. CD40 expression of peripheral B lymphocytes was significantly higher in patients with UC and pouch, respect to controls. Increased CD40 levels in blood B cells of pouch patients correlated with the presence of spondyloarthropathy, but not with pouchitis, or inflammatory indices.

CONCLUSION: High CD40 expression in the ileal pouch mucosa could be implied in the pathogenesis of pouchitis following proctocolectomy for UC, whereas its increased levels on peripheral blood B lymphocytes are associated with the presence of extraintestinal manifestations.

Ileoanal pouch neoplasia in familial adenomatous polyposis: an underestimated threat

PURPOSE

Ileal pouch-anal anastomosis is one of the two main options available for the surgical treatment of patients with familial adenomatous polyposis. Its main advantage is the minimal risk of rectal cancer but a possible Achilles heel is the recurrence of epithelial neoplasia at the ileal pouch-anal anastomosis and within the ileal pouch. The significance of ileoanal anastomotic and ileal pouch adenomas is not yet fully appreciated, and there is a false sense of security about this operation. The consequences of worsening pouch polyposis are serious in that endoscopic treatment is unlikely to be an effective way of controlling it. This study has been done to alert those caring for patients with familial adenomatous polyposis to the looming danger of pouch polyposis and to suggest ways to deal with it.

METHODS

Studies reporting ileoanal pouch adenomas, ileal pouch-anal anastomotic cancers, and ileal pouch cancers in patients with familial adenomatous polyposis were reviewed. Reports of adenomas in Kock pouches and in Brooke ileostomies in the setting of familial adenomatous polyposis were included. The primary end points of the study were the time between pouch construction and the diagnosis of neoplasia, the age of the patients at the diagnosis of neoplasia, and the severity of the neoplasia.

RESULTS

There were 18 studies reporting pouch neoplasia, 15 with adenomas, and 3 with cancer. Ten were case reports, five were retrospective studies, and three were prospective studies. All three prospective studies showed that the incidence of pouch adenomas increases with time of follow-up and that the severity of the polyposis varies. The median time from pouch construction to diagnosis of pouch adenomas was 4.7 years and the range was 0.5 to 12 years. There were six studies reporting eight patients with cancer at the ileal pouch-anal anastomosis, diagnosed a median of 8 years after pouch construction (range, 3-20 years). One-half of the cancers were locally advanced (T4) and one-half were not (T1 or T2). One-half followed stapled anastomosis and one-half were after mucosectomy. There were eight case reports of cancer described in an ileostomy in patients with familial adenomatous polyposis. The median time from ileostomy construction to the ileostomy cancers was 25 (range, 9-40) years.

DISCUSSION

The combination of fecal stasis, adenomatous epithelium, and a germline APC mutation is a potent recipe for epithelial neoplasia. There is increasing evidence that this happens in an ileostomy but that the process is much faster in an ileal pouch. Endoscopic treatment of ileal adenomas is likely to be difficult, reducing the options for their control to excising the entire pouch or chemoprevention.

Adenocarcinoma after ileoanal anastomosis for familial adenomatous polyposis: review of risk factors and current surveillance apropos of a case

Restorative proctocolectomy has become the most common surgical option for familial adenomatous polyposis (FAP) patients, based on the premise that it provides good functional results and reduces colorectal cancer risk. But several adenomas may develop in the pouch mucosa over the years, and even cancer at the anastomosis or in the pouch mucosa has been reported rarely. This article aims to describe a case of pouch cancer after restorative proctocolectomy for FAP, reviewing the possible causes of this unfortunate outcome. A 40-year-old man started presenting with fecal blood loss 12 years after restorative proctocolectomy with mucosectomy and hand-sewn anastomosis for FAP. Proctologic examination revealed an elevated mass 3 cm from the anal margin, which biopsy determined to be a mucinous adenocarcinoma. The patient underwent pouch excision and terminal ileostomy. Histologic analysis showed a 2.2 cm mucinous adenocarcinoma between the ileal and anal mucosa (T2N0Mx) and multiple tubular microadenomas in the ileal pouch. The present case and the data presented here suggest that restorative proctocolectomy is not a "cancer-free" alternative to ileorectal anastomosis, because it does not remove the risk of metachronous intestinal neoplasia. Although the long-term risk of malignancy is not known, lifelong follow-up seems to be necessary after restorative proctocolectomy. Current recommendations for pouch surveillance are presented.