Dysplasia associated with Crohn's colitis: segmental colectomy or more extended resection?

Surveillance and Management of Dysplasia and Malignancy in Inflammatory Bowel Disease

The paradigm for surveilling and managing inflammatory bowel disease-associated colorectal dysplasia has changed as high-definition colonoscopy and chromoendoscopy have significantly improved the visualization of dysplasia, and endoscopic mucosal resection has made more lesions endoscopically resectable. However, these patients are at high risk of recurrent dysplasia and cancer and require intensive colonoscopic surveillance. Patients with invisible high-grade dysplasia, invisible multifocal low-grade dysplasia, and colorectal cancer should be considered for surgical resection. Total proctocolectomy removes all at-risk tissue. Subtotal colectomy with ileorectal anastomosis can be considered in select patients (ie, advanced age, poor functional status, and with no rectal inflammation or dysplasia).

The Fate of the Rectum in Inflammatory Bowel Disease

For many patients with inflammatory bowel disease (IBD) proctocolitis, proctectomy offers symptom and disease control, albeit at the expense of a potentially morbid proctectomy. There are select situations, however, where definitively leaving an IBD rectum in situ, either in or out of intestinal continuity, may be a suitable alternative to proctectomy. This review explores the rare occasions where leaving the rectum in situ may be advisable and discusses the subsequent implications.

Endoscopic diagnosis and management of adult inflammatory bowel disease: a consensus document from the American Society for Gastrointestinal Endoscopy IBD Endoscopy Consensus Panel

Endoscopy plays a key role in diagnosis, monitoring of disease activity, assessment of treatment response, dysplasia surveillance, postoperative evaluation, and interventional therapy for patients with inflammatory bowel disease (IBD). Clinical practice patterns in the endoscopic management of IBD vary. A panel of experts consisting of IBD specialists, endoscopists, and GI pathologists participated in virtual conferences and developed this modified Delphi-based consensus document to address endoscopic aspects of IBD management.

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment

This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO Guidelines.

Management of Dysplasia in Inflammatory Bowel Disease

Given the chronic nature of mucosal inflammation present in patients with inflammatory bowel disease (IBD), there is a high risk of dysplastic lesions progressing to cancer, in addition to a high risk of synchronous and/or metachronous cancers developing in those diagnosed with dysplasia. Due to this, consensus guidelines recommend regular surveillance. When visible dysplasia is encountered, options include endoscopic or surgical resection depending on characteristics of the lesion. Advancements in endoscopic tools increasingly allow for endoscopic removal when appropriate. Invisible dysplasia discovered on random biopsy should prompt referral to physicians who specialize in IBD. While surgical resection with proctocolectomy significantly decreases the risk of colorectal cancer, the risk must be balanced against the morbidity of surgery and quality-of-life concerns. Management of dysplasia in IBD patients requires complex decision-making that requires balance of patient values and goals of care with cancer-related risk factors.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

High-Grade Dysplasia in Inflammatory Bowel Disease: Indication for Colectomy

BACKGROUND

Patients with inflammatory bowel disease have an increased risk of colorectal cancer and are recommended to undergo increased surveillance compared to the general population. Currently, inadequate evidence exists to guide management of colonic dysplasia discovered during screening of inflammatory bowel disease patients.

OBJECTIVE

The goal of this study was to determine the risk of colorectal cancer in patients with ulcerative colitis or Crohn's disease with dysplasia on colonoscopy.

DESIGN

This was a retrospective study.

SETTING

This study was conducted at a high-volume, quaternary referral center with an inflammatory bowel disease program.

PATIENTS

Patients with a diagnosis of inflammatory bowel disease with colonoscopy within 6 months of colectomy were included.

MAIN OUTCOME MEASURES

The primary outcome measures included finding of colorectal cancer at time of colectomy.

RESULTS

There were 621 patients, 233 with ulcerative colitis and 388 with Crohn's disease. Of ulcerative colitis patients, 25 had low-grade dysplasia on colonoscopy with 1 (4%) found to have colorectal cancer at colectomy. High-grade dysplasia was noted preoperatively in 14 and colorectal cancer was found in 4 (29%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 1.98, p = 0.47), but high-grade dysplasia had an increased risk (OR 19.0, p < 0.001) of colorectal cancer. For the 7 patients with Crohn's disease and low-grade dysplasia, colorectal cancer was found in 1 patient (14%) at colectomy. High-grade dysplasia was noted preoperatively in 4 patients with Crohn's Disease, and colorectal cancer was found in 3 patients (75%) after colectomy. Compared to no dysplasia, low-grade dysplasia did not increase the risk of colorectal cancer (OR 12.4, p = 0.88), but high-grade dysplasia did increase the risk of colorectal cancer (OR 223.2, p < 0.001).

LIMITATIONS

This study was limited by its retrospective review.

CONCLUSION

In both ulcerative colitis and Crohn's disease, low-grade dysplasia was not associated with colorectal cancer. High-grade dysplasia was associated with an increased risk of colorectal cancer at time of colectomy. While continued surveillance may be appropriate for low-grade dysplasia, high-grade dysplasia necessitates surgical resection given the high likelihood of colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B887 .

DISPLASIA DE ALTO GRADO EN LA ENFERMEDAD INFLAMATORIA INTESTINAL INDICACIN DE COLECTOMA

ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal tienen un mayor riesgo de cáncer colorrectal y se recomienda someterse a una mayor vigilancia en comparación con la población general. Actualmente, existe evidencia inadecuada para guiar el manejo de la displasia colónica descubierta durante la valoracion de pacientes con enfermedad inflamatoria intestinal.OBJETIVO:Determinar el riesgo de cáncer colorrectal en pacientes con colitis ulcerosa o enfermedad de Crohn con displasia en la colonoscopia.DISEÑO:Este fue un estudio retrospectivo.AJUSTE:Este estudio se llevó a cabo en un centro de referencia cuaternario de alto volumen con un programa de enfermedad inflamatoria intestinal.PACIENTES:Pacientes con diagnóstico de enfermedad inflamatoria intestinal con colonoscopia dentro de los 6 meses posteriores a la colectomía.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado incluyeron el hallazgo de cáncer colorrectal en el momento de la colectomía.RESULTADOS:Hubo 621 pacientes: 233 con colitis ulcerosa y 388 con enfermedad de Crohn. De los pacientes con colitis ulcerosa, 25 tenían displasia de bajo grado en la colonoscopia y 1 (4%) tenía cáncer colorrectal en la colectomía. Se observó displasia de alto grado antes de la operación en 14 y cáncer colorrectal en 4 (29%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 1,98, p = 0,47), pero la displasia de alto grado tuvo un mayor riesgo (OR 19,0, p <0,001) de cáncer colorrectal. Para los 7 pacientes con enfermedad de Crohn y displasia de bajo grado, se encontró cáncer colorrectal en 1 (14%) en la colectomía. Se observó displasia de alto grado antes de la operación en 4 pacientes con enfermedad de Crohn y cáncer colorrectal en 3 pacientes (75%) después de la colectomía. En comparación con la ausencia de displasia, la displasia de bajo grado no aumentó el riesgo de cáncer colorrectal (Odds Ratio 12.4, p = 0.88), pero la displasia de alto grado sí aumentó el riesgo de cáncer colorrectal (Odds Ratio 223.2, p <.001).LIMITACIONES:Este estudio estuvo limitado por su revisión retrospectiva.

CONCLUSIN

Tanto en la colitis ulcerosa como en la enfermedad de Crohn, la displasia de bajo grado no se asoció con el cáncer colorrectal. La displasia de alto grado se asoció con un mayor riesgo de cáncer colorrectal en el momento de la colectomía. Si bien la vigilancia continua puede ser apropiada para la displasia de bajo grado, la displasia de alto grado requiere resección quirúrgica dada la alta probabilidad de cáncer colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B887 . (Traducción-Dr Yolanda Colorado ).

Interventional inflammatory bowel disease: endoscopic therapy of complications of Crohn's disease

Endoscopic therapy for inflammatory bowel diseases (IBD) or IBD surgery-associated complications or namely interventional IBD has become the main treatment modality for Crohn’s disease, bridging medical and surgical treatments. Currently, the main applications of interventional IBD are (i) strictures; (ii) fistulas and abscesses; (iii) bleeding lesions, bezoars, foreign bodies, and polyps; (iv) post-operative complications such as acute and chronic anastomotic leaks; and (v) colitis-associated neoplasia. The endoscopic treatment modalities include balloon dilation, stricturotomy, strictureplasty, fistulotomy, incision and drainage (of fistula and abscess), sinusotomy, septectomy, banding ligation, clipping, polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The field of interventional IBD is evolving with a better understanding of the underlying disease process, advances in endoscopic technology, and interest and proper training of next-generation IBD interventionalists.

Long-term Oncological Outcome of Segmental Versus Extended Colectomy for Colorectal Cancer in Crohn's Disease: Results from an International Multicentre Study

BACKGROUND AND AIMS

Crohn's disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn's disease recommend pan-proctocolectomy. The aim of this study was to evaluate oncological outcomes of a less invasive surgical approach.

METHODS

This was a retrospective database analysis of Crohn's disease patients with colorectal cancer undergoing surgery at selected European and US tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy, total colectomy, and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer, and major postoperative complications.

RESULTS

Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older [p = 0.0429], had less extensive colitis [p = 0.0002] and no preoperatively identified synchronous lesions [p = 0.0109].Median follow-up was 43 [31-62] months. There was no difference in unadjusted progression-free survival [p = 0.2570] or in overall survival [p = 0.4191] between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score, and AJCC staging, confirmed no difference for progression-free survival (hazard ratio [HR] 1.00, p = 0.9993) or overall survival [HR 0.77, p = 0.6654]. Synchronous and metachronous cancers incidence was 9% and 1.5%, respectively. Perioperative mortality was nil and major complications were comparable [7.58% vs 6.06%, p = 0.9998].

CONCLUSIONS

Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.

State-of-the-art surgery for Crohn's disease: Part II-colonic Crohn's disease and associated neoplasms

Despite advances in medical therapy, surgery continues to play a vital role in the management of Crohn's disease and its complications. Continuing from Part I of this series (small intestine/ileal disease), we focus next on colonic Crohn's disease and associated neoplasms. We will first review the surgical management of medical-refractory Crohn's colitis and its complications and then examine cancer risk, surveillance, and surgical management of Crohn's-associated colorectal dysplasia and malignancy. We conclude with a discussion of restoration of gastrointestinal continuity following colonic surgery for Crohn's disease.

Systematic review with meta-analysis: incidence and factors for progression to advanced neoplasia in inflammatory bowel disease patients with indefinite and low-grade dysplasia

BACKGROUND

Due to limited research on the natural history of indefinite for dysplasia (IND) and low-grade dysplasia (LGD) in inflammatory bowel disease (IBD), the management of these patients is controversial.

AIMS

This systematic review and meta-analysis aimed to estimate the incidence and identify the risk factors for advanced neoplasia in IBD patients with IND and LGD.

METHODS

PubMed, Embase and Cochrane Central Register of Controlled Trials were searched until 24 December, 2021, to identify studies that reported pathological results of follow-up colonoscopy or surgery in IBD patients with IND and LGD. The main outcomes were the incidence and risk factors for advanced neoplasia in IBD patients with IND and LGD.

RESULTS

Based on the analysis of 38 studies, the pooled incidences of advanced neoplasia in IBD patients with IND and LGD were 9.9% (95% CI 4.4%-15.4%) and 10.7% (95% CI 7.0%-14.4%) respectively. The risk factors for advanced neoplasia in IND patients were primary sclerosing cholangitis (PSC) and aneuploidy. The risk factors for advanced neoplasia in LGD patients included male, PSC, previous IND, colonic stricture, index lesion ≥1 cm, distal location, multifocal lesions, distal and flat lesions, nonpolypoid/flat lesions and invisible lesions.

CONCLUSIONS

The incidence of advanced neoplasia was similar between IND and LGD in IBD patients, as high as one in ten, so more rigorous surveillance is also suggested in IND patients. Since the effects of most factors were derived from the pooled results of only two to three studies, further research was needed to confirm our results.

Clinicopathological Characteristics and Surgical Outcomes of Crohn Disease-Associated Colorectal Malignancy

PURPOSE

Carcinoma arising from Crohn disease (CD) is rare, and there is no clear guidance on how to properly screen for at-risk patients and choose appropriate care. This study aimed to evaluate the clinicopathological characteristics, treatment, and oncologic outcomes of CD patients diagnosed with colorectal cancer (CRC).

METHODS

Using medical records, we retrospectively enrolled a single-center cohort of 823 patients who underwent abdominal surgery for CD between January 2006 and December 2015. CD-associated CRC patients included those with adenocarcinoma, lymphoma, or neuroendocrine tumors of the colon and rectum.

RESULTS

Nineteen patients (2.3%) underwent abdominal surgery to treat CD-associated CRC. The mean duration of CD in the CD-associated CRC group was significantly longer than that in the benign CD group (124.7 ± 77.7 months vs. 68.9 ± 60.2 months, P = 0.006). The CD-associated CRC group included a higher proportion of patients with a history of perianal disease (73.7% vs. 50.2%, P = 0.035) and colonic location (47.4% vs. 6.5%, P = 0.001). Among 19 CD-associated CRC patients, 17 (89.5%) were diagnosed with adenocarcinoma, and of the 17 cases, 15 (88.2%) were rectal adenocarcinoma. On multivariable analyses for developing CRC, only colonic location was a risk factor (relative risk, 7.735; 95% confidence interval, 2.862-20.903; P = 0.001).

CONCLUSION

Colorectal malignancy is rare among CD patients, even among patients who undergo abdominal surgery. Rectal adenocarcinoma accounted for most of the CRC, and colonic location was a risk factor for developing CRC.

Challenges in Crohn's Disease Management after Gastrointestinal Cancer Diagnosis

Simple Summary

Crohn’s disease (CD) is a chronic inflammatory bowel disease affecting both young and elderly patients, involving the entire gastrointestinal tract from the mouth to anus. The chronic transmural inflammation can lead to several complications, among which gastrointestinal cancers represent one of the most life-threatening, with a higher risk of onset as compared to the general population. Moreover, diagnostic and therapeutic strategies in this subset of patients still represent a significant challenge for physicians. Thus, the aim of this review is to provide a comprehensive overview of the current evidence for an adequate diagnostic pathway and medical and surgical management of CD patients after gastrointestinal cancer onset.

Abstract

Crohn’s disease (CD) is a chronic inflammatory bowel disease with a progressive course, potentially affecting the entire gastrointestinal tract from mouth to anus. Several studies have shown an increased risk of both intestinal and extra-intestinal cancer in patients with CD, due to long-standing transmural inflammation and damage accumulation. The similarity of symptoms among CD, its related complications and the de novo onset of gastrointestinal cancer raises difficulties in the differential diagnosis. In addition, once a cancer diagnosis in CD patients is made, selecting the appropriate treatment can be particularly challenging. Indeed, both surgical and oncological treatments are not always the same as that of the general population, due to the inflammatory context of the gastrointestinal tract and the potential exacerbation of gastrointestinal symptoms of patients with CD; moreover, the overlap of the neoplastic disease could lead to adjustments in the pharmacological treatment of the underlying CD, especially with regard to immunosuppressive drugs. For these reasons, a case-by-case analysis in a multidisciplinary approach is often appropriate for the best diagnostic and therapeutic evaluation of patients with CD after gastrointestinal cancer onset.

Yield of Random Biopsies During Colonoscopies in Inflammatory Bowel Disease Patients Undergoing Dysplasia Surveillance

BACKGROUND

The development of chromoendoscopy (CE) and high definition endoscopy (HDE) has improved detection of subtle colonic dysplasia in patients with inflammatory bowel diseases (IBDs). The role of random biopsies for dysplasia surveillance is unclear.

METHODS

We reviewed patients with IBD who underwent a CE or HDE colonoscopy and had colonic dysplasia detected. Detection of dysplasia was classified as either visible or random and graded as low grade dysplasia (LGD), high grade dysplasia (HGD), or indefinite for dysplasia. Multivariable regression adjusted for relevant confounders examined the predictors of dysplasia detectable on random biopsies alone.

RESULTS

The study included 300 patients (203 ulcerative colitis, 97 Crohn's disease with colonic involvement) contributing 442 colonoscopies; the mean disease duration was 24.5 years; 7.2% had primary sclerosing cholangitis (PSC). Three hundred sixty-two colonoscopies (82%) had only visible dysplasia, 52 (12%) had only random dysplasia, and 28 (6%) had both visible and random dysplasia. Longer disease duration (odds ratio, 1.04; 95% CI, 1.01-1.07), active inflammation (odds ratio, 2.89; 95% CI, 1.26-6.67), and concomitant PSC (odds ratio, 3.66; 95% CI, 1.21-11.08) were associated with detecting dysplasia on random biopsies compared with visible lesions. Patients with random dysplasia (21%) or both random and visible dysplasia (21%) were more likely to undergo surgical resection compared with those with only visible dysplasia (5%; P < 0.001) and have subsequent development of colorectal cancer (15%, 7%, 1%, respectively; P < 0.0001).

CONCLUSION

Nearly one fifth of dysplasia detected in patients with IBD was found on random biopsies. Patients with high risk characteristics may benefit from continuing the practice of random biopsies during surveillance examinations.

Colorectal Cancer in Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) are at an increased risk for developing colorectal cancer (CRC). However, the incidence has declined over the past 30 years, which is probably attributed to raise awareness, successful CRC surveillance programs and improved control of mucosal inflammation through chemoprevention. The risk factors for IBD-related CRC include more severe disease (as reflected by the extent of disease and the duration of poorly controlled disease), family history of CRC, pseudo polyps, primary sclerosing cholangitis, and male sex. The molecular pathogenesis of inflammatory epithelium might play a critical role in the development of CRC. IBD-related CRC is characterized by fewer rectal tumors, more synchronous and poorly differentiated tumors compared with sporadic cancers. There is no significant difference in sex distribution, stage at presentation, or survival. Surveillance is vital for the detection and subsequently management of dysplasia. Most guidelines recommend initiation of surveillance colonoscopy at 8 to 10 years after IBD diagnosis, followed by subsequent surveillance of 1 to 2 yearly intervals. Traditionally, surveillance colonoscopies with random colonic biopsies were used. However, recent data suggest that high definition and chromoendoscopy are better methods of surveillance by improving sensitivity to previously "invisible" flat dysplastic lesions. Management of dysplasia, timing of surveillance, chemoprevention, and the surgical approaches are all areas that stimulate various discussions. The aim of this review is to provide an up-to-date focus on CRC in IBD, from laboratory to bedside.

Synchronous colonic adenoma and intestinal marginal zone B-cell lymphoma associated with Crohn's disease: a case report and literature review

Background

Lymphoma and dysplasia are rare complications of long-standing Crohn’s disease. We report an exceptional case of a synchronous intestinal marginal zone B-cell lymphoma (MALT lymphoma) and colonic adenoma in a Crohn’s disease patient.

Case presentation

A 50-year-old male patient presented with right lower quadrant for the last 9 months. He also had associated weight loss and diarrhea alternating with constipation. Ileo-colonoscopy revealed a pseudopolypoid appearance of the colonic and ileal mucosa with many discontinuous ulcerations with a 3 cm sessile polypoid mass at 17 cm from the anal verge. Histological examination of the polypoid lesion revealed an adenoma with high grade dysplasia, while the biopsies of colonic mucosa showed histologic features of Crohn’s disease. Abdominal computed tomography scan (CT scan) and magnetic resonance imaging (MRI) showed circumferential wall thickening of the colon and ileum, enlarged mesenteric lymph nodes and a sessile polypoid mass of the rectosigmoid junction. The patient was scheduled for an ileocoletectomy with resection of the upper rectum and ileorectostomy.

The histological examination of the resected segment showed histologic features of Crohn’s disease, a recto-sigmoid polyp with high grade.

dysplasia and extensive small lymphocytic infiltrate in both colonic and ileal wall which is strongly stained by CD20 and BCL2. The diagnosis of MALT lymphoma with adenoma on a background of Crohn’s disease was made.

The patient successfully completed 8 cycles of Rituximab+ chlorambucil chemotherapy.

Nowadays the patient is asymptomatic without evidence of lymphoproliferative recurrence 10 months after surgery.

Conclusion

We report the first case in the literature of Malt lymphoma with colonic adenoma associated with Crohn’s disease, and discuss his unique macroscopic and histological features in a patient.

Without immunosuppressive therapy.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Oncological outcomes of IBD-associated versus sporadic colorectal cancer in modern era: a matched case-control study

AIM

Inflammatory bowel diseases (IBD) are associated with an increased risk for colorectal cancer (CRC). However and despite significant advances in the management of IBD and CRC, the prognosis of IBD-related CRC (IBD-CRC) remains controversial. The aim of the present case-control study was to compare the prognosis of IBD-CRC to sporadic CRC.

METHODS

Consecutive patients operated for IBD-CRC from 2004 to 2014 were recruited and matched with sporadic CRC (ratio 3:1) from the same center. Matching was performed on gender, tumor stage, and location and period of surgery. Endpoints were postoperative morbidity (Dindo-Clavien III-V), quality of surgery, and long-term oncological outcomes.

RESULTS

Among 1498 CRC patients operated during the study period, 21 patients were identified with IBD-CRC and matched to 63 patients with sporadic CRC (S-CRC). Patients with IBD-CRC were significantly younger (p < 0.001), had multifocal lesions more frequently (p = 0.04), and undergone abdominoperineal excision and coloproctectomy more often (p = 0.001). Postoperative morbidity was not significantly different between the two groups (25 vs. 14%; p = 0.309), as well as the rate of R0 resection (86 vs. 95%; p = 0.162). Five-year disease-free and overall survival were 71 and 81% in patients with IBD-CRC and 69% (p = 0.801) and 78% (p = 0.845) in those with S-CRC, respectively.

CONCLUSION

In a case-control study of patients operated for CRC within the last decade, the prognosis of cancer associated with IBD is similar to sporadic cancer.

Segmental Resection versus Total Proctocolectomy for Crohn's Colitis: What is the Best Operation in the Setting of Medically Refractory Disease or Dysplasia?

Crohn's disease (CD) may affect any part of the gastrointestinal tract. When isolated to the colon, and patients become medically refractory, there are several surgical options - segmental resection, subtotal colectomy with ileorectal anastomosis, or a total proctocolectomy and end ileostomy. Unfortunately, surgery does not cure CD, and, regardless of the extent of bowel removed, recurrence may be seen in the small bowel. This may lead to need for further immunosuppression or surgery. Therefore, when appropriate, a segmental colectomy or subtotal colectomy may prevent a permanent ostomy required with a total proctocolectomy. In the setting of dysplasia identified on colonoscopy, low quality evidence guides our treatment paradigms. Even though identification of dysplasia has greatly improved with chromoendoscopy, rates of synchronous or metachronous neoplasm remain high. Thus, a total proctocolectomy and end ileostomy, whereas a larger operation, may be best for the patient to remove all at risk tissue. Further research with prospective or randomized control trials is needed to improve our practice guidelines of both scenarios.

A systematic review of segmental vs subtotal colectomy and subtotal colectomy vs total proctocolectomy for colonic Crohn's disease

AIM

Surgical management of colonic Crohn's disease (CD) is still unclear because different procedures can be adopted. The choice of operation is dependent on the involvement of colonic disease but the advantages and disadvantages of the extent of resection are still debated.

METHOD

The aim of the present study was to evaluate the differences in short-term and long-term outcomes of adult patients with colonic CD who underwent either subtotal colectomy and ileorectal anastomosis (STC) or segmental colectomy (SC) or total proctocolectomy and end ileostomy (TPC). Studies published between 1984 and 2012 including comparisons of STC vs SC and of STC vs TPC were selected. The study end-points were overall and surgical recurrence, postoperative morbidity and incidence of permanent stoma. Fixed effect models were used to evaluate the study outcomes.

RESULTS

Eleven studies, consisting of a total of 1436 patients (510 STC, 500 SC and 426 TPC), were included. Analysis of the data showed no significant difference between STC and SC in terms of overall and surgical recurrence of CD. In contrast, STC showed a higher risk of overall and surgical recurrence of CD than TPC (OR 3.53, 95% CI 2.45-5.10, P < 0.0001; OR 3.52, 95% CI 2.27-5.44, P < 0.0001, respectively). SC had a higher risk of postoperative complications compared to STC, and STC had a lower risk of complications than TPC (OR 2.84, 95% CI 1.16-6.96, P < 0.02; OR 0.19, 95% CI 0.09-0.38, P < 0.0001, respectively). SC resulted in a lower risk of permanent stoma than STC (OR 0.52, 95% CI 0.35-0.77).

CONCLUSION

All three procedures were equally effective as treatment options for colonic CD and the choice of operation remains intrinsically dependent on the extent of colonic disease. However, patients in the TPC group showed a lower recurrence risk than those in the STC group. Moreover, SC had a higher risk of postoperative complications but a lower risk of permanent stoma. These data should be taken into account when deciding surgical strategies and when informing patients about postoperative risks.

Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

Detection of Dysplasia or Cancer in 3.5% of Patients With Inflammatory Bowel Disease and Colonic Strictures

BACKGROUND & AIMS

Colonic strictures complicate inflammatory bowel disease (IBD) and often lead to surgical resection to prevent dysplasia or cancer. We assessed the frequency of dysplasia and cancer among IBD patients undergoing resection of a colorectal stricture.

METHODS

We analyzed data from the Groupe d'études et thérapeutiques des affections inflammatoires du tube digestif study. This was a nationwide retrospective study of 12,013 patients with IBD in France who underwent surgery for strictures at 16 centers from August 1992 through January 2014 (293 patients for a colonic stricture, 248 patients with Crohn's disease, 51% male, median age at stricture diagnosis of 38 years). Participants had no preoperative evidence of dysplasia or cancer. We collected clinical, endoscopic, surgical, and pathology data and information on outcomes.

RESULTS

When patients were diagnosed with strictures, they had IBD for a median time of 8 years (3-14). The strictures were a median length of 6 cm (4-10) and caused symptoms in 70% of patients. Of patients with Crohn's disease, 3 (1%) were found to have low-grade dysplasia, 1 (0.4%) was found to have high-grade dysplasia, and 2 (0.8%) were found to have cancer. Of patients with ulcerative colitis, 1 (2%) had low-grade dysplasia, 1 (2%) had high-grade dysplasia, and 2 (5%) had cancer. All patients with dysplasia or cancer received curative surgery, except 1 who died of colorectal cancer during the follow-up period. No active disease at time of surgery was the only factor associated with dysplasia or cancer at the stricture site (odds ratio, 4.86; 95% confidence interval, 1.11-21.27; P = .036).

CONCLUSIONS

In a retrospective study of patients with IBD undergoing surgery for colonic strictures, 3.5% were found to have dysplasia or cancer. These findings can be used to guide management of patients with IBD and colonic strictures.

Microscopic features of colorectal neoplasia in inflammatory bowel diseases

The risk of developing dysplasia leading to colorectal cancer (CRC) is increased in both ulcerative colitis and Crohn’s disease. The prognosis of CRC may be poorer in patients with inflammatory bowel disease (IBD) than in those without IBD. Most CRCs, in general, develop from a dysplastic precursor lesion. The interpretation by the pathologist of the biopsy will guide decision making in clinical practice: colonoscopic surveillance or surgical management. This review summarizes features of dysplasia (or intraepithelial neoplasia) with macroscopic and microscopic characteristics. From an endoscopic (gross) point of view, dysplasia may be classified as flat or elevated (raised); from a histological point of view, dysplasia is separated into 3 distinct categories: negative for dysplasia, indefinite for dysplasia, and positive for dysplasia with low- or high-grade dysplasia. The morphologic criteria for dysplasia are based on a combination of cytologic (nuclear and cytoplasmic) and architectural aberrations of the crypt epithelium. Immunohistochemical and molecular markers for dysplasia are reviewed and may help with dysplasia diagnosis, although diagnosis is essentially based on morphological criteria. The clinical, epidemiologic, and pathologic characteristics of IBD-related cancers are, in many aspects, different from those that occur sporadically in the general population. Herein, we summarize macroscopic and microscopic features of IBD-related colorectal carcinoma.

Metachronous, colitis-associated rectal cancer that developed after sporadic adenocarcinoma in an adenoma in a patient with longstanding Crohn's disease: a case report

BACKGROUND

Colorectal cancer associated with Crohn's disease (CD) is increasing in proportion to the number of patients with CD in Japan. There are two subtypes of colorectal cancer with CD: sporadic cancer and colitis-associated cancer. Early diagnosis of colitis-associated cancer is sometimes difficult; when colorectal cancer is found in patients with CD, both colitis-associated cancer and sporadic cancer should be kept in mind. Here, we describe a case of metachronous, colitis-associated rectal cancer that developed after the complete resection of an adenoma that became a sporadic adenocarcinoma in a patient with longstanding CD. To the best of our knowledge, this is the first report of colitis-associated cancer in a patient with CD after removal of a sporadic cancer.

CASE PRESENTATION

We describe a 51-year old man with CD who had difficulty in defecation. A rectal polyp was detected and a transanal resection of the polyp was performed. A histopathological examination showed an adenoma with sporadic adenocarcinoma. After three years, a follow-up colonoscopy revealed a reddish, elevated lesion in the patient's rectum. A colonoscopic biopsy showed a signet ring cell carcinoma. We performed an abdominoperineal resection of the rectum and a bilateral pelvic lymph node dissection. A histopathological examination revealed a mucinous adenocarcinoma with signet ring cell carcinoma and lymph node metastasis. The patient received adjuvant chemotherapy with oral uracil 224 mg combined with tegafur 100 mg plus leucovorin. No signs of recurrence were noted at a follow-up 18 months after the third surgery and 60 months after the second surgery.

Chronic ulcerative colitis and colorectal cancer

One of the most important consequences of chronically active ulcerative colitis (UC) or Crohn's disease (CD) - the two major forms of inflammatory bowel disease (IBD) - is the development of colorectal cancer (CRC). An increased risk for the occurrence of CRC in up to 30% of affected patients after 35years of UC has been reported. Recent evidence from population based studies indicates a lower risk. Nevertheless the incidence is still significantly increased as compared to individuals without chronic colitis. Colitis-associated CRC (CAC) does not display the adenoma-carcinoma sequence which is typical for sporadic CRC and the pathophysiology appears to be different. Chronic inflammation and the increased turnover of epithelial cells contribute to the development of low- and high-grade dysplasia which may further transform into CAC. Reactive oxygen species (ROS) generated by the inflammatory infiltrate are thought to contribute to the generation of dysplastic lesions. In sporadic CRC the sequence of mutations that finally lead to malignancy involves early activation of Wnt/β-catenin pathway (in 90% of cases) including mutations in adenomatous polyposis coli (APC) tumor suppressor gene, its regulating kinase GSK3β and β-catenin itself. β-catenin mutations are rarer in CAC and mutations in APC occur rather late during the disease progression, whereas there are earlier mutations in p53 and K-ras. Recent data indicate that the intestinal microbiome and its interaction with a functionally impaired mucosal barrier may also play a role in CAC development. CACs frequently show aggressive growth and early metastases. The treatment of CAC in patients with colitis always includes proctocolectomy with ileoanal anastomosis as meta- or synchronic lesions are frequent.

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.