coloproctology

, 33:273 | Cite as

Dysplasie und Adenokarzinome im Ileum-Pouch nach restaurativer Proktokolektomie wegen Colitis ulcerosa

Standorte

Zusammenfassung

Fragestellung und Hintergrund

Die restaurative Proktokolektomie (RPC) ist der chirurgische Standard bei Colitis ulcerosa (CU). Die RPC ist bei einer CU indiziert, die in Notfällen sowie im Fall einer neoplastischen Transformation gegenüber konservativer Behandlung refraktär ist. Der Eingriff reduziert das Risiko CU-assoziierter Dysplasien/Neoplasien beträchtlich. Dennoch werden seit dem ersten Bericht 1984 mit zunehmender Häufigkeit nach einer RPC-Operation – auch mit einer Mukosektomie – Karzinome des Pouch und/oder der analen Übergangszone („anal transitional zone“, ATZ) berichtet. Diese Arbeit behandelt die pouchbezogene dysplastische und neoplastische Transformation, Prävalenz und Komplikationen, Risikofaktoren und Überwachung nach einem Eingriff wegen CU.

Patienten und Methodik

Zur Identifizierung von Patienten mit solchen Komplikationen wurden Berichte in der Literatur über Patienten ausgewertet. In die Studie wurden diejenigen Patienten aufgenommen, die sich in unterschiedlichen Kliniken bis Mai 2010 einer Pouch-Operation unterzogen hatten. Es wurde versucht, basierend auf den verfügbaren Daten eine sinnvolle Follow-up-Strategie zu entwickeln.

Ergebnisse

Bisher liegen 43 berichtete Pouch-Karzinome bzw. Karzinome in der analen Übergangszone nach einer RPC wegen einer CU vor: 16 aus retrospektiven Patientenserien, 1 aus einer prospektiven Studie und 26 aus Fallstudien. Insgesamt 30 Patienten hatten eine Mukosektomie und 13 eine Stapler-Anastomose. Bisher wurden 28 Patienten mit einer Dysplasie nach einer RPC wegen CU diagnostiziert. Bei 27 wurde eine Mukosektomie durchgeführt und bei einem Patienten wurde eine Stapler-Anastomose ohne Mukosektomie angelegt. In allen untersuchten Fällen betrug der Zeitraum zwischen dem Beginn der CU bis zur Dysplasie/Neoplasie über 10 Jahre.

Schlussfolgerung

Neoplastische Läsionen bei CU-Patienten nach RPC erwiesen sich als absolut unvermeidbar. Nicht einmal eine Mukosektomie eliminiert das Risiko vollständig. Es gibt wenige Anhaltspunkte, die eine routinemäßige Biopsie der Mukosa des Ileum oder der analen Übergangszone stützen, außer bei Patienten mit histologischen Typ-C-Veränderungen, sklerosierender Cholangitis und andauernder Pouchitis in der Mukosa des Ileum. Solche Patienten sollten einer endoskopischen Kontrolle unterzogen werden, um eine dem Pouch-Karzinom vorausgehende Dysplasie zu finden.

Schlüsselwörter

Colitis ulcerosa Restaurative Proktokolektomie Mukosektomie Stapler-Anastomose Dysplasie Adenokarzinom-Ätiologie 

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

Abstract

Purpose

Restorative proctocolectomy (RPC) is the standard surgical treatment for ulcerative colitis (UC). Restorative proctocolectomy is indicated for UC that is refractory to medical treatment, for emergency conditions, and in cases 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.

Patients and methods

Reports in the literature on patients undergoing pouch surgery at different institutions up to 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 available data.

Results

To date, there have been 43 reported cancers of the pouch or inlet after RPC for UC: 16 from retrospective series, one from a prospective study, and 26 in case reports. A total of 30 patients underwent mucosectomy and 13 had stapled anastomoses. To date, 28 patients have been diagnosed with dysplasia after RPC for UC. Mucosectomy was performed in 27 of these and in one 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.

Conclusions

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 ATZ 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.

Keywords

Ulcerative colitis Restorative proctocolectomy Mucosectomy Stapled anastomosis Dysplasia Adenocarcinoma etiology 

Literatur

  1. 1.
    Langholz E, Munkholm P, Davidsen M, Binder V (1992) Colorectal cancer risk and mortality in patients with ulcerative colitis. Gastroenterology 103:1444–1451PubMedGoogle Scholar
  2. 2.
    Bach SP, Mortensen NJ (2007) Ileal pouch surgery for ulcerative colitis. World J Gastroenterol 13:3288–3300PubMedGoogle Scholar
  3. 3.
    M’Koma AE, Wise PE, Muldoon RL et al (2007) Evolution of the restorative proctocolectomy and its effects on gastrointestinal hormones. Int J Colorectal Dis 22:1143–1163CrossRefGoogle Scholar
  4. 4.
    Bülow S, Büow C, Vasen H et al (2008) Colectomy and ileorectal anastomosis is still an option for selected patients with familial adenomatous polyposis. Dis Colon Rectum 51:1318–1323PubMedCrossRefGoogle Scholar
  5. 5.
    Das P, Smith JJ, Tekkis PP et al (2007) Quality of life after indefinite diversion/pouch excision in ileal pouch failure patients. Colorectal Dis 9:718–724PubMedCrossRefGoogle Scholar
  6. 6.
    Parks AG, Nicholls RJ (1978) Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 2:85–88PubMedCrossRefGoogle Scholar
  7. 7.
    McLaughlin SD, Clark SK, Tekkis PP et al (2008) Review article: restorative proctocolectomy, indications, management of complications and follow-up – a guide for gastroenterologists. Aliment Pharmacol Ther 27:895–909PubMedCrossRefGoogle Scholar
  8. 8.
    Hultén L, Willén R, Nilsson O et al (2002) Mucosal assessment for dysplasia and cancer in the ileal pouch mucosa in patients operated on for ulcerative colitis – a 30-year follow-up study. Dis Colon Rectum 45:448–452PubMedCrossRefGoogle Scholar
  9. 9.
    Farouk R, Pemberton JH, Wolff BG et al (2000) Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis. Ann Surg 231:919–926PubMedCrossRefGoogle Scholar
  10. 10.
    Paterson CA, Dozois RR (1998) The ileal pouch-anal anastomosis: success and failure. Chirurg 123:545–549CrossRefGoogle Scholar
  11. 11.
    Puthu D, Rajan N, Rao R et al (1992) Carcinoma of the rectal pouch following restorative proctocolectomy. Report of a case. Dis Colon Rectum 35:257–260PubMedCrossRefGoogle Scholar
  12. 12.
    Ravitch MM (1984) The reception of new operations. Ann Surg 200:231–246PubMedCrossRefGoogle Scholar
  13. 13.
    Stern H, Walfisch S, Mullen B et al (1990) Cancer in an ileoanal reservoir: a new late complication? Gut 31:473–475PubMedCrossRefGoogle Scholar
  14. 14.
    Rodriguez-Sanjuan JC, Polavieja MG, Naranjo A, Castillo J (1995) Adenocarcinoma in an ileal pouch for ulcerative colitis. Dis Colon Rectum 38:779–780PubMedCrossRefGoogle Scholar
  15. 15.
    Sequens R (1997) Cancer in the anal canal (transitional zone) after restorative proctocolectomy with stapled ileal pouch-anal anastomosis. Int J Colorectal Dis 12:254–255PubMedCrossRefGoogle Scholar
  16. 16.
    Vieth M, Grunewald M, Niemeyer C, Stolte M (1998) Adenocarcinoma in an ileal pouch after prior proctocolectomy for carcinoma in a patient with ulcerative pancolitis. Virchows Arch 433:281–284PubMedCrossRefGoogle Scholar
  17. 17.
    Iwama T, Kamikawa J, Higuchi T et al (2000) Development of invasive adenocarcinoma in a long-standing diverted ileal J-pouch for ulcerative colitis: report of a case. Dis Colon Rectum 43:101–104PubMedCrossRefGoogle Scholar
  18. 18.
    Heuschen UA, Heuschen G, Autschbach F et al (2001) Adenocarcinoma in the ileal pouch: late risk of cancer after restorative proctocolectomy. Int J Colorectal Dis 16:126–130PubMedCrossRefGoogle Scholar
  19. 19.
    Rotholtz NA, Pikarsky AJ, Singh JJ, Wexner SD (2001) Adenocarcinoma arising from along the rectal stump after doublestapled ileorectal J-pouch in a patient with ulcerative colitis: the need to perform a distal anastomosis. Report of a case. Dis Colon Rectum 44:1214–1217PubMedCrossRefGoogle Scholar
  20. 20.
    Hyman N (2002) Rectal cancer as a complication of stapled IPAA. Inflamm Bowel Dis 8:43–45PubMedCrossRefGoogle Scholar
  21. 21.
    Laureti S, Ugolini F, D’Errico A et al (2002) Adenocarcinoma below ileoanal anastomosis for ulcerative colitis: report of a case and review of the literature. Dis Colon Rectum 45:418–421PubMedCrossRefGoogle Scholar
  22. 22.
    Baratsis S, Hadjidimitriou F, Christodoulou M, Lariou K (2002) Adenocarcinoma in the anal canal after ileal pouch-anal anastomosis for ulcerative colitis using a double stapling technique: report of a case. Dis Colon Rectum 45:687–691PubMedCrossRefGoogle Scholar
  23. 23.
    Negi SS, Chaudhary A, Gondal R (2003) Carcinoma of pelvic pouch following restorative proctocolectomy: report of a case and review of the literature. Dig Surg 20:63–65PubMedCrossRefGoogle Scholar
  24. 24.
    Bell SW, Parry B, Neill M (2003) Adenocarcinoma in the anal transitional zone after ileal pouch for ulcerative colitis: report of a case. Dis Colon Rectum 46:1134–1137PubMedCrossRefGoogle Scholar
  25. 25.
    Lee SW, Sonoda T, Milsom JW (2005) Three cases of adenocarcinoma following restorative proctocolectomy with hand-sewn anastomosis for ulcerative colitis: a review of reported cases in the literature. Colorectal Dis 7:591–597PubMedCrossRefGoogle Scholar
  26. 26.
    Bentrem DJ, Wang KL, Stryker SJ (2003) Adenocarcinoma in an ileal pouch occurring 14 years after restorative proctocolectomy: report of a case. Dis Colon Rectum 46:544–546PubMedCrossRefGoogle Scholar
  27. 27.
    Hassan C, Zullo A, Speziale G et al (2003) Adenocarcinoma of the ileoanal pouch anastomosis: an emerging complication? Int J Colorectal Dis 18:276–278PubMedGoogle Scholar
  28. 28.
    Knupper N, Straub E, Terpe HJ, Vestweber KH (2006) Adenocarcinoma of the ileoanal pouch for ulcerative colitis – a complication of severe chronic atrophic pouchitis? Int J Colorectal Dis 21:478–482PubMedCrossRefGoogle Scholar
  29. 29.
    Ota H, Yamazaki K, Endoh W et al (2007) Adenocarcinoma arising below an ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis: report of a case. Surg Today 37:596–599PubMedCrossRefGoogle Scholar
  30. 30.
    Walker M, Radley S (2006) Adenocarcinoma in an ileoanal pouch formed for ulcerative colitis in a patient with primary sclerosing cholangitis and a liver transplant: report of a case and review of the literature. Dis Colon Rectum 49:909–912PubMedCrossRefGoogle Scholar
  31. 31.
    Sagar P (2006) Adenocarcinoma in a pouch without a preceeding history of dysplasia. Colorectal Dis 8:526–527PubMedCrossRefGoogle Scholar
  32. 32.
    Chia CS, Chew MH, Chau YP et al (2008) Adenocarcinoma of the anal transitional zone after double stapled ileal pouch-anal anastomosis for ulcerative colitis. Colorectal Dis 10:621–623PubMedCrossRefGoogle Scholar
  33. 33.
    Pedersen ME, Rahr HB, Fenger C, Qvist N (2008) Adenocarcinoma arising from the rectal stump eleven years after excision of an ileal J-pouch in a patient with ulcerative colitis: report of a case. Dis Colon Rectum 51:1146–1148PubMedCrossRefGoogle Scholar
  34. 34.
    Zmora O, Spector D, Dotan I et al (2009) Is stapled ileal pouch anal anastomosis a safe option in ulcerative colitis patients with dysplasia or cancer? Int J Colorectal Dis 24:1181–1186PubMedCrossRefGoogle Scholar
  35. 35.
    Branco BC, Sachar DB, Heimann T et al (2009) Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron ultrasonic surgical aspirator. Colorectal Dis 11:428–429PubMedCrossRefGoogle Scholar
  36. 36.
    Ziv Y, Fazio VW, Strong SA et al (1994) Ulcerative colitis and coexisting colorectal cancer: recurrence rate after restorative proctocolectomy. Ann Surg Oncol 1:512–515PubMedCrossRefGoogle Scholar
  37. 37.
    Remzi FH, Fazio VW, Delaney CP et al (2003) Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years. Dis Colon Rectum 46:6–13PubMedCrossRefGoogle Scholar
  38. 38.
    Kariv R, Remzi FH, Lian L et al (2010) Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology 139:806–812PubMedCrossRefGoogle Scholar
  39. 39.
    Gullberg K, Stählberg D, Liljeqvist L et al (1997) Neoplastic transformation of the pelvic pouch mucosa in patients with ulcerative colitis. Gastroenterology 112:1487–1492PubMedCrossRefGoogle Scholar
  40. 40.
    Veress B, Reinholt FP, Lindquist K et al (1995) Long-term histomorphological surveillance of the pelvic ileal pouch: dysplasia develops in a subgroup of patients. Gastroenterology 109:1090–1097PubMedCrossRefGoogle Scholar
  41. 41.
    Das P, Johnson MW, Tekkis PP, Nicholls RJ (2007) Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Colorectal Dis 9:15–27PubMedCrossRefGoogle Scholar
  42. 42.
    Kayaalp C, Nessar G, Akoglu M, Atalay F (2003) Elimination of mucosectomy during restorative proctocolectomy in patients with ulcerative colitis may provide better results in low-volume centers. Am J Surg 185:268–272PubMedCrossRefGoogle Scholar
  43. 43.
    Heppell J, Weiland LH, Perrault J et al (1983) Fate of the rectal mucosa after rectal mucosectomy and ileoanal anastomosis. Dis Colon Rectum 26:768–771PubMedCrossRefGoogle Scholar
  44. 44.
    O’Connell PR, Pemberton JH, Weiland LH et al (1987) Does rectal mucosa regenerate after ileoanal anastomosis? Dis Colon Rectum 30:1–5CrossRefGoogle Scholar
  45. 45.
    Heald RJ, Allen DR (1986) Stapled ileo-anal anastomosis: a technique to avoid mucosal proctectomy in the ileal pouch operation. Br J Surg 73:571–572PubMedCrossRefGoogle Scholar
  46. 46.
    Koh PK, Doumit J, Downs-Kelly E et al (2008) Ileo-anal j-pouch cancer: an unusual case in an unusual location. Tech Coloproctol 12:341–345PubMedCrossRefGoogle Scholar
  47. 47.
    Schaus BJ, Fazio VW, Remzi FH et al (2007) Clinical features of ileal pouch polyps in patients with underlying ulcerative colitis. Dis Colon Rectum 50:832–838PubMedCrossRefGoogle Scholar
  48. 48.
    Gullberg K, Liljeqvist L (2001) Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients. Int J Colorectal Dis 16:221–227PubMedCrossRefGoogle Scholar
  49. 49.
    Thompson-Fawcett MW, Marcus V, Redston M et al (2001) Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis. Gastroenterology 121:275–281PubMedCrossRefGoogle Scholar
  50. 50.
    Löfberg R, Liljeqvist L, Lindquist K et al (1991) Dysplasia and DNA aneuploidy in a pelvic pouch. Report of a case. Dis Colon Rectum 34:280–283 (discussion 283–284)PubMedCrossRefGoogle Scholar
  51. 51.
    Barrett M, Schoetz D, Semple J et al (1998) Long-term risk of neoplastic changes in ileoanal pouches in patients with ulcerative colitis. Dis Colon Rectum 41:A26CrossRefGoogle Scholar
  52. 52.
    Setti Carraro P, Talbot IC, Nicholls RJ (1994) Longterm appraisal of the histological appearances of the ileal reservoir mucosa after restorative proctocolectomy for ulcerative colitis. Gut 35:1721–1727CrossRefGoogle Scholar
  53. 53.
    Herline AJ, Meisinger LL, Rusin LC et al (2003) Is routine pouch surveillance for dysplasia indicated for ileoanal pouches? Dis Colon Rectum 46:156–159PubMedCrossRefGoogle Scholar
  54. 54.
    Branco BC, Sachar DB, Heimann T et al (2009) Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultrasonic Surgical Aspirator(R). Colorectal Dis 11:428–429PubMedCrossRefGoogle Scholar
  55. 55.
    Tarroni D, Wilkinson KH, Saunders B et al (2002) Long-term histological assessment of the ileal reservoir following restorative proctocolectomy for ulcerative colitis and dysplasia. Dis Colon Rectum 45:A7Google Scholar
  56. 56.
    Börjesson L, Willén R, Haboubi N et al (2004) The risk of dysplasia and cancer in the ileal pouch mucosa after restorative proctocolectomy for ulcerative proctocolitis is low: a long-term term follow-up study. Colorectal Dis 6:494–498PubMedCrossRefGoogle Scholar
  57. 57.
    Geiger JD, Teitelbaum DH, Hirschl RB, Coran AG (2003) A new operative technique for restorative proctocolectomy: the endorectal pull-through combined with a double-stapled ileo-anal anastomosis. Surgery 134:492–495PubMedCrossRefGoogle Scholar
  58. 58.
    Seow-Choen F, Ho YH, Goh HS (1994) The ileo-anal reservoir: results from an evolving use of stapling devices. J R Coll Surg Edinb 39:13–16PubMedGoogle Scholar
  59. 59.
    Bernstein CN (2006) Natural history and management of flat and polypoid dysplasia in inflammatory bowel disease. Gastroenterol Clin North Am 35:573–579PubMedCrossRefGoogle Scholar
  60. 60.
    Thompson-Fawcett MW, Warren BF, Mortensen NJ (1998) A new look at the anal transitional zone with reference to restorative proctocolectomy and the columnar cuff. Br J Surg 85:1517–1521PubMedCrossRefGoogle Scholar
  61. 61.
    Schmitt SL, Wexner SD, Lucas FV et al (1992) Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis. Dis Colon Rectum 35:1051–1056PubMedCrossRefGoogle Scholar
  62. 62.
    Thompson-Fawcett MW, Rust NA, Warren BF, Mortensen NJ (2000) Aneuploidy and columnar cuff surveillance after stapled ileal pouch-anal anastomosis in ulcerative colitis. Dis Colon Rectum 43:408–413PubMedCrossRefGoogle Scholar
  63. 63.
    Tsunoda A, Talbot IC, Nicholls RJ (1990) Incidence of dysplasia in the anorectal mucosa in patients having restorative proctocolectomy. Br J Surg 77:506–508PubMedCrossRefGoogle Scholar
  64. 64.
    Ziv Y, Fazio VW, Sirimarco MT et al (1994) Incidence, risk factors, and treatment of dysplasia in the anal transitional zone after ileal pouch-anal anastomosis. Dis Colon Rectum 37:1281–1285PubMedCrossRefGoogle Scholar
  65. 65.
    Brown CJ, Maclean AR, Cohen Z et al (2005) Crohn’s disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure. Dis Colon Rectum 48:1542–1549PubMedCrossRefGoogle Scholar
  66. 66.
    Shen B, Remzi FH, Lavery IC et al (2008) A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol 6:145–158PubMedCrossRefGoogle Scholar
  67. 67.
    Coull DB, Lee FD, Henderson AP et al (2003) Risk of dysplasia in the columnar cuff after stapled restorative proctocolectomy. Br J Surg 90:72–75PubMedCrossRefGoogle Scholar
  68. 68.
    Shelton AA, Lehman RE, Schrock TR, Welton ML (1996) Retrospective review of colorectal cancer in ulcerative colitis at a tertiary center. Arch Surg 131:806–810PubMedGoogle Scholar
  69. 69.
    Stählberg D, Veress B, Tribukait B, Broomé U (2003) Atrophy and neoplastic transformation of the ileal pouch mucosa in patients with ulcerative colitis and primary sclerosing cholangitis: a case control study. Dis Colon Rectum 46:770–778PubMedCrossRefGoogle Scholar
  70. 70.
    Sarigol S, Wyllie R, Gramlich T et al (1999) Incidence of dysplasia in pelvic pouches in pediatric patients after ileal pouchanal anastomosis for ulcerative colitis. J Pediatr Gastroenterol Nutr 28:429–434PubMedCrossRefGoogle Scholar
  71. 71.
    Sierra-Montenegro E, Fernández-Rivero JM, Villanueva-Sáenz E et al (2007) Quality of life after restorative proctocolectomy with ileo-anal J pouch in patients with ulcerative colitis. Cir Cir 75:449–452PubMedGoogle Scholar
  72. 72.
    Memon AA, Marks CG (1996) Stapled anastomoses in colorectal surgery: a prospective study. Eur J Surg 162:805–810PubMedGoogle Scholar
  73. 73.
    Delaini GG, Scaglia M, Colucci G, Hultén L (2005) The ileoanal pouch procedure in the long-term perspective: a critical review. Tech Coloproctol 9:187–192PubMedCrossRefGoogle Scholar
  74. 74.
    Elkowitz D, Daum F, Markowitz J et al (2004) Risk factors for carcinoma of the pelvic ileal pouch/anal canal in ulcerative colitis. Ann Clin Lab Sci 34:143–149PubMedGoogle Scholar
  75. 75.
    Nilubol N, Scherl E, Bub DS et al (2007) Mucosal dysplasia in ileal pelvic pouches after restorative proctocolectomy. Dis Colon Rectum 50:825–831PubMedCrossRefGoogle Scholar

Copyright information

© Urban & Vogel, Muenchen 2011

Authors and Affiliations

  1. 1.Department of SurgeryKorea University College of MedicineSeoulSouth Korea
  2. 2.Department of Biochemistry and Cancer BiologyMeharry Medical College School of MedicineNashvilleUSA

Personalised recommendations