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Preservation of the Anal Transition Zone in Ulcerative Colitis. Long-Term Effects on Defecatory Function

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

The anal transition zone (ATZ) after ileal pouch anal anastomosis (IPAA) for ulcerative colitis is considered at risk for dysplasia and persistent or recurrent disease activity. The long-term fate of the ATZ and the effects of histologic changes on defecatory function are not well-known.

Methods

To evaluate the inflammatory and preneoplastic changes of the ATZ in patients without preoperative dysplasia, yearly biopsies of the ATZ were obtained and functional results recorded on a questionnaire/diary. Histologic changes were correlated with simultaneous assessment of defecatory function.

Results

Between 1992 and 2006, 225 patients underwent a stapled IPAA. A total of 238 successful biopsies of the ATZ were performed. There was no dysplasia found. Acute inflammation was noted in 4.6%, chronic inflammation in 84.9%, and normal mucosa in 10.5% of cases. Patients with chronic inflammation reported an average of 6.2 ± 1.7 bowel movements/day and 93.2% of them were able to delay a bowel movement for at least 30 min. The presence of chronic ATZ inflammation did not seem to have a negative impact on function, with 96.1% of patients reporting perfect continence, and only 5.3% using protective pads.

Conclusions

Preservation of the ATZ in selected patients is safe and offers excellent long-term functional results. New onset dysplasia was not noted. Chronic inflammation had limited clinical impact. Presence of ATZ inflammation in a total of 89.5% of patients warrants life-long surveillance with biopsies.

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Abbreviations

ATZ:

Anal transition zone

IPAA:

Ileal pouch anal anastomosis

RPC:

Restorative proctocolectomy

UC:

Ulcerative colitis

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Acknowledgment

This study was funded in part by the University of Chicago Cancer Research Foundation (UCCRF) Auxiliary Board Research Support Grant (A.F.).

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Authors and Affiliations

  1. Department of Surgery, University of Chicago, Chicago, IL, USA

    Alessandro Fichera, Laura Ragauskaite, Mark T. Silvestri, Nicholas M. Elisseou, Michele A. Rubin & Roger D. Hurst

  2. Department of Surgery, Weill Medical College of Cornell University, New York, NY, USA

    Fabrizio Michelassi

  3. Department of Surgery, MC 5031, University of Chicago Hospitals, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA

    Alessandro Fichera

Authors
  1. Alessandro Fichera
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  2. Laura Ragauskaite
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  3. Mark T. Silvestri
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  4. Nicholas M. Elisseou
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  5. Michele A. Rubin
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  6. Roger D. Hurst
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  7. Fabrizio Michelassi
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Correspondence to Alessandro Fichera.

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Discussion

Thomas Ullman, M.D. (New York, NY): Thank you to my surgical colleagues out here. As a gastroenterologist, it is always a bit intimidating to be in a room with surgeons, but I am happy to be here this morning.

Dr. Fichera's report here really I think puts the nail in the coffin of using hand-sewn anastomoses for patients who are dysplasia-free. He reports really excellent functional results, with about 5% of patients with episodes of leakage at night and the requirement of wearing pads. I think that quite clearly the functional outcomes are so outstanding in this group that it really almost dogmatically now is the operation of choice when it is available for these patients.

The dysplasia and neoplasia story in general really does require even greater follow-up than we have here. These patients were followed for a median of 33 months, and it will be curious to see, as I hope Dr. Fichera will be doing by following these patients into the future, what the true neoplastic potential is. With that in mind and with my 1-minute limitation, I had a couple of brief questions for Dr. Fichera.

The first question is, among these patients who had regularly scheduled anoscopies, how many of them in the intervals in between went on to develop episodes of cuffitis or even pouchitis? And I will leave these here in note form for you when we get to them all.

And then secondly, I wanted to know how many of these patients were truly at risk for the development of neoplasia over time? Specifically, how many patients had colitis for more than 8 years or sclerosing cholangitis or a family history of colorectal cancer?

Finally, what would you speculate ought to be the appropriate interval for dysplasia surveillance in this group?

Alessandro Fichera, M.D. (Chicago, IL): Thank you, Tom, for your comments and questions. The incidence of cuffitis has been reported by us in the past, and it is slightly lower than what has been reported in another series from the Cleveland Clinic. As I speculate in the manuscript, the fact that we do strive to keep a very short anal transition zone probably is responsible for our findings. A series from 1995 collecting patients going back to the 1970s is clearly different that a series from the late 1990s and forward. Our incidence overall of cuffitis including patients that had cuffitis in between the biopsies is approximately 10%. To answer your second question regarding patients at risk of developing cancer or dysplasia in the anal transition zone, in our previously reported experience the main indication for surgery was failure of medical management. Patients with dysplasia or long-standing disease, per se, were approximately 30 to 33% of the entire group.

Now, based on these findings, we changed our follow-up protocol. Obviously, patients will be followed forever, but rather than having them come back every year for a biopsy, and that was a big deterrent for them to come and have a biopsy, we are moving to a 3-year interval: Baseline of 1 year, if obviously we find no dysplasia, we wait 3 years from that, making this into a big event every 3 years rather than an every-year occurrence that really was not very appealing to our patient population.

Susan Galandiuk, M.D. (Louisville, KY): The reading of dysplasia, especially in the field of chronic inflammation, can be very difficult. Did you for purposes of this study have several pathologists review all your specimens for uniformity?

Dr. Fichera: Often patients relocate and we have often biopsies sent to us from outside institutions. Those biopsies were all reviewed by our dedicated pathologists. Furthermore, every biopsy is reviewed as a group at our inflammatory bowel disease conference every other week. So they were reviewed by two or three pathologists.

Bryan M. Clary, M.D. (Durham, NC): Using the same questionnaire, have you compared these results with your patients who underwent a hand-sewn anastomosis?

Dr. Fichera: That is exactly what we are going to do next. In a previous report, you noticed that the hand-sewn patients obviously have a longer follow-up. The series now is shifting more toward more stapled patients. So the comparison will be not totally fair, but that is the next step now that we have identified that the majority of stapled patients indeed have chronic inflammation. And another point is a lot of these normal mucosa patients eventually shift to chronic inflammation over time. So there is clearly a big group of patients with chronic inflammation. Those are the ones, as you are suggesting, that should be compared with the hand-sewn patients.

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Fichera, A., Ragauskaite, L., Silvestri, M.T. et al. Preservation of the Anal Transition Zone in Ulcerative Colitis. Long-Term Effects on Defecatory Function. J Gastrointest Surg 11, 1647–1653 (2007). https://doi.org/10.1007/s11605-007-0321-x

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