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

Colorectal Unit/Department of Surgery, Sahlgrenska University Hospital, S-416 85 Gothenburg, Sweden.
Colorectal Disease (Impact Factor: 2.35). 12/2004; 6(6):494-8. DOI: 10.1111/j.1463-1318.2004.00716.x
Source: PubMed


Some of the rare complications reported in patients with an ileopouch anal anastomosis (IPAA) after coloectomy for chronic ulcerative colitis are dysplasia and carcinoma. The supposed pathway is for the ileal pouch mucosa to go through adaptational changes then is to progress through the phases of chronic pouchitis, dysplasia and subsequently to adenocarcinoma. In many of these studies however, the dysplasia-cancer sequence is inconclusive since the carcinoma might have developed from the ileal mucosa itself or from residual viable rectal mucosa left behind. The purpose of this study was therefore to study the long-term ileal mucosal adaptation patterns and the incidence and grading of dysplasia in the ileal pouch mucosa in patients previously operated on for ulcerative proctocolitis.
Forty-five patients who had been operated on with an IPAA (25 males/20 females), with a median age of 54 years (range 34-76), were invited for clinical examination and pouch endoscopy including mucosal biopsies. The duration of their colitis until surgery was median 6 years (range 1-28) and the time median interval from start of disease until time of follow up 24.8 years (range 17-46). Three independent pathologists from two different centres reviewed sequential mucosal biopsies taken from separate sites of the pouch for dysplasia and mucosal adaptation patterns.
The type C pattern with a severe inflammation in lamina propria together with severe atrophy of villi, sometimes with ulceration and granulation tissue, was observed by the two pathologists from one centre in 15 of 45 (33.3%) patients and in 11 (24.4%) of 45 by the third pathologist, respectively. As regards dysplasia one pathologist group evaluated 2/45 (4.4%) cases as low-grade dysplasia while the third pathologist considered one of these cases as indefinite for dysplasia and one as reactive. There was in this respect full agreement between the two centres in 43 (95.6%) of 45 cases. Neither high-grade dysplasia nor invasive carcinoma was diagnosed.
Dysplastic transformation within the ileal pouch mucosa in patients operated for ulcerative proctocolitis is rare even after a long follow-up. These results are reassuring for both patients and surgeons. There seem to be no solid grounds to support routine surveillance for dysplasia in the ileal pouch mucosa in these patients. The surveillance for neoplastic changes in the remaining muscular/epithelial cuff is a separate issue however.

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    • "Only 11 patients had severe atrophy, five of them had colon-like mucosa. This is in accordance with Börjesson et al., who described persisting severe mucosal atrophy in a minor proportion of the patients after a median followup of 16 years [18]. There was no relation between observation time and degree of atrophy. "
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    ABSTRACT: Objective. Study the functional results and mucosal changes in the ileal pouch after restorative proctocolectomy with J-reservoir for ulcerative colitis. Material and Methods. Followup study of 125 patients with J-reservoir with one disease-specific- and one general (SF-36) quality of life-questionnaire, rectoscopy with biopsies, and stool samples to evaluate inflammation, dysplasia, presence of Helicobacter pylori and calprotectin level. Results. Fourteen J-reservoirs were removed or deactivated, leaving 111 patients for followup. The followup time was 6.8 (1-15) years. 87.4% of the patients were satisfied. 93.1% had some kind of functional restriction: food- (75.5%), social- (28.9%), physical- (37%) or sexual restriction (15.3%). 18.6% had often or sometimes faecal incontinence. Low daytime faecal frequency was associated with good quality of life. 13 patients (12.6%) had a less favourable result. There was no pouch-dysplasia. Calprotectin levels were increased in patients with visible pouch inflammation or history of pouchitis. HP was diagnosed by RUT in 42.3%, but was not associated with inflammation or pouchitis. Conclusions. Most patients were satisfied with the J-reservoir in spite of a high frequency of various restrictions. 12.6% (13 patients) had a less favourable functional result, partly due to a high frequency of defecations, pain, pouchitis and inflammation.
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    ABSTRACT: Ulcerative colitis is primarily a disease of the rectal and colonic mucosa. The disease begins in 4% of patients before the age of 10, and in 18% between the ages of 10 and 20. The disease is more severe in children than in adults and is often associated with more overt symptoms. Ulcerative colitis can be cured by surgically removing the diseased colon and rectum. The aims of surgical treatment are: to remove the diseased bowel and to return the patient to health; to preserve the anus for defecation; to maintain continence; to obviate the need for a permanent ileostomy; and to lessen the risk of complications. The surgical options proposed for children affected by ulcerative colitis include endorectal mucosectomy followed by an ileo-anal anastomosis with (ileal pouch–anal anastomosis [IPAA]) or without (endorectal pull-through [ERPT]) creation of a pouch. If ERPT represents a good choice for treating severe ulcerative colitis in paediatric patients, IPAA seems to show better results. Both these procedures are illustrated, with an analysis of related advantages and complications, considering also an evaluation of the quality of life of patients who have undergone this kind of surgery.
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    Article: Pouchitis
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    ABSTRACT: Pouchitis is a major long-term complication of the continent ileostomy as well as the ileoanal pouch anastomosis. When diagnosed on the basis of clinical, endoscopic and histologic features, this syndrome has been demonstrated almost exclusively in patients with ulcerative colitis. The clinical course, the endoscopic findings and the histologic abnormalities resemble those of ulcerative colitis. The association with extra-intestinal manifestations further supports the hypothesis that pouchitis represents ulcerative colitis in the small bowel. All ileal reservoirs show bacterial overgrowth, especially of anaerobes. As a response to this altered intraluminal environment chronic inflammation and incomplete colonic metaplasia occur. The efficiency of metronidazole does suggest that bacteriological factors play an important role in the pathogenesis of pouchitis.
    Full-text · Article · Feb 1998 · Mediators of Inflammation
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