Elimination of mucosectomy during restorative proctocolectomy in patients with ulcerative colitis may provide better results in low-volume centers

Kayaalp, Cüneyt; Neşşar, Gürel; Akoğlu, Musa; Atalay, Fuat

doi:10.1016/s0002-9610(02)01376-4

Cited by 29 publications

(16 citation statements)

References 14 publications

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“…Conventional hand-sewn anastomosis after mucosectomy and double-stapled anastomosis without mucosectomy are the most common techniques used in fashioning intestinal anastomoses [3, 42]. Controversy persists over the techniques used in ileo-anal anastomosis (IAA).…”

Section: Resultsmentioning

confidence: 99%

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

M’Koma

2011

Tech Coloproctol

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Background Restorative proctocolectomy (RPC) is the criterion standard surgical treatment for ulcerative colitis (UC). Restorative proctocolectomy is indicated for UC that is refractory to medical treatment, for emergency conditions, and in case of neoplastic transformation. The procedure substantially reduces the risk of UC-associated dysplasia/neoplasia. However, after RPC surgery, even with mucosectomy, cancers of the pouch and/or the anal-transitional zone (ATZ) have been reported with increasing frequency since the first report in 1984. This review highlights pouch-related dysplastic and neoplastic transformation, prevalence and adverse events, risk factors and surveillance following surgery for UC. Methods Reports in the literature about patients undergoing pouch surgery from different institutions reported through May 2010 were reviewed to identify patients who developed these complications, and an attempt was made to develop a rational follow-up policy based on the data available. Results To date, there are 43 reported cancers of the pouch or inlet after RPC for UC: 16 from retrospective series, 1 from a prospective study, and 26 in case reports. Thirty patients underwent mucosectomy and 13 had stapled anastomoses. To date, the number of 28 patients has been diagnosed with dysplasia after RPC for UC. Mucosectomy was performed in 27 of them and in 1 a stapled anastomosis was constructed without mucosectomy. In all cases reviewed, the time interval from the onset of UC to dysplasia/neoplasia was over 10 years. Conclusion Neoplastic lesions occurring in UC patients after RPC have been shown to be absolutely inevitable. Even mucosectomy does not completely eliminate the risk. There is little evidence to support routine biopsy of the ileal mucosa or the anal-transition zone except in patients with histological type C changes, sclerosing cholangitis, and unremitting pouchitis in the ileal mucosa. Such patients should be selected for endoscopic surveillance to detect dysplasia preceding pouch adenocarcinoma.

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Section: Resultsmentioning

confidence: 99%

“…Controversy persists over the techniques used in ileo-anal anastomosis (IAA). The majority of surgeons [42] feel that with the double-stapled anastomosis, there are fewer anastomotic complications and better rectal continence is achieved. However, a cuff of rectal mucosa is retained [43] (Fig.…”

Section: Resultsmentioning

confidence: 99%

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

M’Koma

2011

Tech Coloproctol

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“…This stapling technique has permitted relatively effortless and faster pouch construction and anastomosis [23,34,[46][47][48], because of which it is preferred by the overwhelming majority of surgeons [39,49].…”

Section: Endoanal Mucosectomy Vs Double-stapled Anastomosismentioning

confidence: 99%

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

et al. 2006

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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.

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“…Conventional hand-sewn anastomosis after mucosectomy and double-stapled anastomosis without mucosectomy are the most common anastomosis techniques used [24, 155]. Controversy persists over the techniques of ileo-anal anastomosis (IAA).…”

Section: Ileal Pouch Cancer After Rpc For Uc (Vulnerability)mentioning

confidence: 99%

“…Controversy persists over the techniques of ileo-anal anastomosis (IAA). The majority of surgeons [155] feel that with the double-stapled anastomosis, less anastomotic complications, and superior rectal continence are achieved; however, a cuff of rectal mucosa is retained [35], the main concern and argument from the opponents of the double-stapling technique [15, 53]. It seems clear though, despite controversies, that mucosectomy does not rule out future development of subsequent pouch-related cancer [59, 60].…”

Section: Ileal Pouch Cancer After Rpc For Uc (Vulnerability)mentioning

confidence: 99%

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

M’Koma

Moses

Adunyah

2011

Int J Colorectal Dis

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Background Colorectal cancer (CRC), the most lethal long-term complication of inflammatory bowel disease (IBD), is the culmination of a complex sequence of molecular and histologic derangements of the colon epithelium that are initiated and at least partially sustained by prolonged chronic inflammation. Dysplasia, the earliest histologic manifestation of this process, plays an important role in cancer prevention by providing the first clinical alert that this sequence is under way and by serving as an endpoint in colonoscopic surveillance of patients at high risk for CRC. Restorative proctocolectomy (RPC) is indicated for patients with IBD, specifically for ulcerative colitis that is refractory to medical treatment, emergency conditions, and/or in case of neoplastic transformation. Even after RPC with mucosectomy, pouch-related carcinomas have recently been reported with increasing frequency since the first report in 1984. We review IBD-associated CRC and pouch-related neoplasia prevalence, adverse events, risk factors, and surveillances. Methods Literature of IBD-associated CRC patients and those undergoing RPC surgeries through 2010 were prospectively reviewed. Results We found 12 studies from retrospective series and 15 case reports. To date, there are 43 reported cases of pouch-related cancers. Thirty-two patients had cancer in the anal transit zone (ATZ); of these, 28 patients had mucosectomy. Eleven patients had cancer found in the pouch body. Conclusion RPC with mucosectomy does not necessarily eliminate risks. There is little evidence to support routine surveillance of pouch mucosa and the ATZ except for patients associated with histological type C changes, sclerosing cholangitis, and unremitting pouchitis.

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Elimination of mucosectomy during restorative proctocolectomy in patients with ulcerative colitis may provide better results in low-volume centers

Cited by 29 publications

References 14 publications

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

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

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

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

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