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.
Similar content being viewed by others
REFERENCES
J Church C Burke E McGannon O Pastean B Clark (2001) ArticleTitlePredicting polyposis severity by proctoscopy: how reliable is it? Dis Colon Rectum 44 1249–54 Occurrence Handle11584194
AH Kartheuser R Parc CP Penna et al. (1996) ArticleTitleIleal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: a ten year experience Surgery 119 615–23 Occurrence Handle8650601
YR Parc S Olschwang B Desaint G Schmitt RG Parc E Tiret (2001) ArticleTitleFamilial adenomatous polyposis: prevalence of adenomas in the ileal pouch after restorative proctocolectomy Ann Surg 233 360–4 Occurrence Handle10.1097/00000658-200103000-00009 Occurrence Handle11224623
IH Wolfstein L Bat G Neumann (1982) ArticleTitleRegeneration of rectal mucosa and recurrent polyposis coli after total colectomy and ileoanal anastomosis Arch Surg 117 1241–2 Occurrence Handle7115072
RW Beart SuffixJr CR Fleming PM Banks (1982) ArticleTitleadenomas in a continent ileostomy after proctocolectomy for familial polyposis Dig Dis Sci 27 553–6 Occurrence Handle10.1007/BF01296737 Occurrence Handle7083990
SJ Stryker JA Carney RR Dozois (1987) ArticleTitleMultiple adenomatous polyps arising in a continent reservoir ileostomy Int J Colorectal Dis 2 43–5 Occurrence Handle10.1007/BF01648998 Occurrence Handle3036976
NA Shepherd JR Jass I Duval RL Moskowitz RJ Nicholls BC Morson (1987) ArticleTitleproctocolectomy with ileal reservoir: pathological and histochemical study of mucosal biopsy specimens J Clin Pathol 40 601–7 Occurrence Handle3611389
T Myrhoj S Bulow AM Mogensen (1989) ArticleTitleMultiple adenomas in terminal ileum 25 years after restorative proctocolectomy for familial adenomatous polyposis: report of a case Dis Colon Rectum 32 618–20 Occurrence Handle2544383
KP Nugent AD Spigelman RJ Nicholls et al. (1993) ArticleTitlePouch adenomas in patients with familial adenomatous polyposis Br J Surg 80 1620 Occurrence Handle8298944
JM Church JR Oakley JS Wu (1996) ArticleTitlePouch polyposis after ileal pouch-anal anastomosis for familial adenomatous polyposis: report of a case Dis Colon Rectum 39 584–6 Occurrence Handle10.1007/BF02058717 Occurrence Handle8620814
MM Bassuini PJ Billings (1996) ArticleTitleCarcinoma in an ileoanal pouch after restorative proctocolectomy for familial adenomatous polyposis Br J Surg 83 506 Occurrence Handle8665242
VM Palkar LJ deSouza P Jagannath KN Naresh (1997) ArticleTitleAdenocarcinoma arising in “J” pouch after total proctocolectomy for familial polyposis coli Indian J Cancer 34 16–9 Occurrence Handle9491657
JS Wu ES McGannon JM Church (1998) ArticleTitleIncidence of neoplastic polyps in the ileal pouch of patients with familial adenomatous polyposis after restorative proctocolectomy Dis Colon Rectum 41 552–7 Occurrence Handle9593235
MW Thompson-Fawcett VA Marcus M Redston Z Cohen RS McLeod (2001) ArticleTitleAdenomatous polyps develop commonly in the ileal pouch of patients with familial adenomatous polyposis Dis Colon Rectum 44 347–53 Occurrence Handle11289279
YR Parc S Olschwang B Desaint G Schmitt RG Parc E Tiret (2001) ArticleTitleFamilial adenomatous polyposis: prevalence of adenomas in the ileal pouch after restorative proctocolectomy Ann Surg 233 360–4 Occurrence Handle10.1097/00000658-200103000-00009 Occurrence Handle11224623
RD Valle GL de’Angelis (2001) ArticleTitlePouch adenomas after ileal pouch-anal anastomosis for familial adenomatous polyposis Dis Colon Rectum 44 456–8 Occurrence Handle11289297
S Cherki O Glehen V Moutardier et al. (2003) ArticleTitlePouch adenocarcinoma after restorative proctocolectomy for familial adenomatous polyposis Colorectal Dis 5 592–4 Occurrence Handle10.1046/j.1463-1318.2003.00486.x Occurrence Handle14617250
L Polese MR Keighley (2003) ArticleTitleAdenomas at resection margins do not influence the long-term development of pouch polyps after restorative proctocolectomy for familial adenomatous polyposis Am J Surg 186 32–4 Occurrence Handle10.1016/S0002-9610(03)00121-1 Occurrence Handle12842745
BC Vrouenraets P Duijvendijk Particlevan WA Bemelman GJ Offerhaus JF Slors (2004) ArticleTitleAdenocarcinoma in the anal canal after ileal pouch-anal anastomosis for familial adenomatous polyposis using a double-stapled technique: report of two cases Dis Colon Rectum 47 530–4 Occurrence Handle10.1007/s10350-003-0073-y Occurrence Handle14978621
Y Parc A Piquard RR Dozois R Parc E Tiret (2004) ArticleTitleLong-term outcome of familial adenomatous polyposis patients after restorative coloproctectomy Ann Surg 239 378–82 Occurrence Handle10.1097/01.sla.0000114216.90947.f6 Occurrence Handle15075655
IG Beveridge DJ Swain CJ Groves et al. (2004) ArticleTitleLarge villous adenomas arising in ileal pouches in familial adenomatous polyposis: report of two cases Dis Colon Rectum 47 123–6 Occurrence Handle10.1007/s10350-003-0020-y Occurrence Handle14719160
JC Hoehner AM Metcalf (1994) ArticleTitleDevelopment of invasive adenocarcinoma following colectomy with ileoanal anastomosis for familial polyposis coli. Report of a case Dis Colon Rectum 37 824–8 Occurrence Handle10.1007/BF02050149 Occurrence Handle8055729
A Herbay Particlevon J Stern C Herfarth (1996) ArticleTitlePouch-anal cancer after restorative proctocolectomy for familial adenomatous polyposis Am J Surg Pathol 20 995–9 Occurrence Handle10.1097/00000478-199608000-00008 Occurrence Handle8712299
H Vuilleumier N Halkic R Ksontini M Gillet (2000) ArticleTitleColumnar cuff cancer after restorative proctocolectomy for familial adenomatous polyposis Gut 47 732–4 Occurrence Handle10.1136/gut.47.5.732 Occurrence Handle11034594
SR Brown D Donati F Seow-Choen (2001) ArticleTitleRectal cancer after mucosectomy for ileoanal pouch in familial adenomatous polyposis: report of a case Dis Colon Rectum 44 1714–5 Occurrence Handle11711749
BS Ooi FH Remzi T Gramlich JM Church M Preen VW Fazio (2003) ArticleTitleAnal transitional zone cancer after restorative proctocolectomy and ileoanal anastomosis in familial adenomatous polyposis: report of two cases Dis Colon Rectum 46 1418–23 Occurrence Handle10.1007/s10350-004-6760-5 Occurrence Handle14530685
JA Roth T Logio (1982) ArticleTitleCarcinoma arising in an ileostomy stoma: an unusual complication of adenomatous polyposis coli Cancer 1549 2180–4
JN Primrose P Quirke D Johnston (1988) ArticleTitleCarcinoma of the ileostomy in a patient with familial adenomatous polyposis Br J Surg 75 384 Occurrence Handle2833981
V Suarez J Alexander-Williams HJ O’Connor et al. (1988) ArticleTitleCarcinoma developing in ileostomies after 25 or more years Gastroenterology 95 205–8 Occurrence Handle3371615
JF Lopez P Granger A Dupre (1991) ArticleTitleMalignant degeneration on ileostomy for rectocolonic polyposis J Chir (Paris) 128 201–3
TP Gilson LL Sollenberger (1992) ArticleTitleAdenocarcinoma of an ileostomy in a patient with familial adenomatous polyp-osis. Report of a case Dis Colon Rectum 35 261–5 Occurrence Handle10.1007/BF02051020 Occurrence Handle1310928
JA Johnson Suffix3rd DS Talton GV Poole (1993) ArticleTitleAdenocarcinoma of a Brooke ileostomy for adenomatous polyposis coli Am J Gastroenterol 88 1122–4 Occurrence Handle8391212
N Lux J Wedell M Busch H Calker Particlevan (1993) ArticleTitleAdenocarcinoma of the ileostomy after total proctocolectomy in familial polyposis. A case report and synthesis of previously published cases [in German] Chirurg 64 416–8 Occurrence Handle8392459
T Iizuka T Sawada K Hayakawa M Hashimoto H Udagawa G Watanabe (2002) ArticleTitleSuccessful local excision of ileostomy adenocarcinoma after colectomy for familial adenomatous polyposis: report of a case Surg Today 32 638–41 Occurrence Handle10.1007/s005950200116 Occurrence Handle12111524
FH Remzi JM Church J Bast et al. (2001) ArticleTitleMucosectomy vs. stapled ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: functional outcome and neoplasia control Dis Colon Rectum 44 1590–6 Occurrence Handle11711729
P Duijvendijk Particlevan HF Vasen L Bertario et al. (1999) ArticleTitleCumulative risk of developing polyps or malignancy at the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis J Gastrointest Surg 3 325–30 Occurrence Handle10.1016/S1091-255X(99)80075-4 Occurrence Handle10481126
B Malassagne C Penna R Parc (1995) ArticleTitleAdenomatous polyps in the anal transitional zone after ileal pouch-anal anastomosis for familial adenomatous polyposis: treatment by transanal mucosectomy and ileal pouch advancement Br J Surg 82 1634 Occurrence Handle8548224
K Schulmann W Schmiegel (2004) ArticleTitleCapsule endoscopy for small bowel surveillance in hereditary intestinal polyposis and non-polyposis syndromes Gastrointest Endosc Clin N Am 14 149–58 Occurrence Handle10.1016/j.giec.2003.10.014 Occurrence Handle15062388
FM Giardello SR Hamilton AJ Krush et al. (1993) ArticleTitleTreatment of colonic and rectal adenomas with sulindac in familial adenomatous polyposis N Engl J Med 328 1313–6 Occurrence Handle10.1056/NEJM199305063281805 Occurrence Handle8385741
M Cruz-Correa LM Hylind KE Romans SV Booker FM Giardiello (2002) ArticleTitleLong-term treatment with sulindac in familial adenomatous polyposis: a prospective cohort study Gastroenterology 122 641–5 Occurrence Handle10.1053/gast.2002.31890 Occurrence Handle11874996
F Tonelli R Valanzano L Messerini F Ficari (2000) ArticleTitleLong-term treatment with sulindac in familial adenomatous polyposis: is there an actual efficacy in prevention of rectal cancer? J Surg Oncol 74 15–20 Occurrence Handle10.1002/1096-9098(200005)74:1<15::AID-JSO4>3.0.CO;2-Z Occurrence Handle10861602
G Winde KW Schmid W Schlegel et al. (1995) ArticleTitleComplete reversion and prevention of rectal adenomas in colectomized patients with familial adenomatous polyposis by rectal low-dose sulindac maintenance treatment Dis Colon Rectum 38 813–30 Occurrence Handle10.1007/BF02049838 Occurrence Handle7634976
G Steinbach PM Lynch RK Phillips et al. (2000) ArticleTitleThe effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis N Engl J Med 342 1946–52 Occurrence Handle10874062
Author information
Authors and Affiliations
Additional information
Reprints are not available.
About this article
Cite this article
Church, J. Ileoanal Pouch Neoplasia in Familial Adenomatous Polyposis: An Underestimated Threat. Dis Colon Rectum 48, 1708–1713 (2005). https://doi.org/10.1007/s10350-005-0057-1
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10350-005-0057-1