Abstract

Dear Editor, Restorative proctocolectomy with creation of an ileal pouch-anal anastomosis is currently the procedure of choice for elective treatment of patients affected by ulcerative colitis with medically refractory disease, dysplasia or cancer. Although dysplastic transformation within the ileal pouch mucosa and in the rectal cuff in patients operated for ulcerative proctocolitis seems to be rare, 22 cases of adenocarcinoma adjacent to the ileo-anal anastomotic site after restorative proctocolectomy for ulcerative colitis have been described in literature so far. We report the case of a 52-year-old woman who was diagnosed with ulcerative colitis in 1980 at the age of 27. After the diagnosis, she required many hospital admissions for severe disease treated with sulphasalazine and steroids with good results. Past medical history also included a posttransfusional HCV infection treated in 2000 with interferon and ribavirin. In 2003, a colonoscopy revealed foci of adenocarcinoma and high-grade dysplasia in the descending and sigmoid colon. Consequently, the patient underwent restorative proctocolectomy with the formation of an ileal J pouch with double-stapled ileo-anal anastomosis. Histology of the surgical specimen revealed well-differentiated adenocarcinoma next to two non-invasive high-grade and low-grade lesions in the ascending colon; another welldifferentiated adenocarcinoma with necrotic areas was found in the transverse colon (G2T2N0M0). The rectum was clear of dysplasia or cancer. The phenotypic characterization of the lesions demonstrated <10% of neoplastic necrosis with no vascular nor perineural neoplastic invasion. No neoplastic lesions were found in the referred biopsy locations in the descending and sigmoid colon. Thirty-two months after the operation, a routine endoscopy showed a polipoid lesion at the anastomotic cuff in the anal transitional zone. Biopsies revealed high-grade dysplasia with foci of invasive adenocarcinoma. The patient underwent an abdominal–perineal resection with excision of the pouch and anus and formation of an end ileostomy. Surgical pathology evidenced a tubular-villous adenoma with predominant villous aspects; diffuse high-grade dysplasia and well-differentiated adenocarcinoma invading the stalk and into the submucosa of the bowel wall were demonstrated in association to a solitary ulcer and active ulcerative colitis (G1T1N0). Six months later the patient is doing well and is disease-free. Restorative proctocolectomy for patients with ulcerative colitis and co-existing colorectal cancer can be performed with a favourable prognosis and function. It is appropriate for curative intent, given that an adequate margin without tumour is obtained. Lee et al. reported three cases of adenocarcinoma after restorative proctocolectomy with a handsewn anastomosis adding to the 16, which had been previously reported. The authors noted that the overall incidence was extremely low and that the evidence to support surveillance was controversial with no clear defined dysplasia and carcinoma sequence. Factors that seemed to be related to the reported cases included a long history of antecedent ulcerative colitis (10–15 years), dysplasia or carcinoma in the original specimen, poor post-operative surveillance or severe or delayed presentation of pouchitis. Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, usually self-limiting, most common in the first 2 to 3 years post-operatively and may Int J Colorectal Dis (2007) 22:1557–1558 DOI 10.1007/s00384-006-0269-4

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