Adenocarcinoma arising from a long-standing Kock pouch

Abstract

Dear Editor: Ulcerative colitis (UC) is a chronic inflammatory bowel disease involving the all colon and rectumwith different extent. It is well known and widely accepted that surgical treatment is necessary to manage refractory forms and severe clinical symptoms and to prevent colonic cancer. The risk of primary colonic cancer is higher the longer interval fromUC diagnosis has passed. Proctocolectomy represents the surgical choice for these patients, and until development of ileal pouch anal anastomosis (IPAA), the continent Kock pouch has represented the only continent solution that, avoiding the formation of terminal ileostomy, has improved patient’s quality of life. Because of its relatively common complications, mainly associated to a loss of function due to nipple valve slippage, Kock pouch has been afterwards supplanted by IPAA that restores the bowel continuity maintaining the physiological sphincters function. We would like to report a new case of a primary adenocarcinoma arising from a long-standing Kock pouch in a 56-yearold woman. She had a proctocolectomy with pouch formation in 1985 for severe pancolitis in ulcerative colitis associated to erythema nodosum. Despite medical treatments and a previous diverting ileostomy, she experienced a progressive deterioration of her clinical symptoms confirmed by endoscopic and histological findings. At the time of surgery, a severe inflammation involved the all rectum. Therefore, a proctocolectomy wasmandatory. The restorative proctocolectomywith an IPAA was avoided because of patient’s pelvic floor weakness. Due to her high motivation of having a better body image and quality of life, a continent Kock ileostomy was given avoiding a terminal ileostomy. The histopathology report on surgical specimen confirmed the diagnosis of ulcerative colitis without dysplasia or cancer. Since the operation, the pouch function has always been satisfactory without any complications; therefore, she has never had pouch revision nor endoscopic surveillance. Twenty-eight years later, the patient complained of mild discomfort at the stoma site and difficulty in pouch intubating associated to bloating, abdominal tenderness, and need of Valsalva to empty the pouch. The stoma was not explorable because of a retracted and tender distal area. It admitted just the tip of the fifth finger and the exploration was painful. A little polypoid lesion (1.5×1×0.5 cm) was noted on the right side of the mucocutaneous junction of the stoma. Clinical examination was otherwise unremarkable. Excision biopsy under local anesthesia was performed, and the histology revealed high-grade dysplasia with focal area of intestinal type mucinous adenocarcinoma with dermal infiltration (CK 20+ and CD X2+). Imaging by CT, MRI, and PET-TC scanning showed a concentric thickening of 6 mm of the distal part of the stoma characterized by high metabolic activity. There was no suspicion of regional node involvement or evidence of metastases. Blood tests and neoplastic markers were negative. An excision of the pouch together with 10 cm distal ileum segment was performed. The pouch appeared dilated, but otherwise normal and no abnormalities of the valves were obvious. Macroscopically, the tract of the exteriorized bowel showed a thick retracting area with a reduced compliance of the ileum wall. Nodules enlargement were also noted at the time of surgery. An end ileostomy was fashioned on the contralateral side of the abdomen as oncologically I. Giannini (*) Department of Emergency and Organ Transplantation, General Surgery and Liver transplantation Unit, University Aldo Moro of Bari, Policlinico. Piazza G Cesare, 11, 70124 Bari, Italy e-mail: ivanagi83@yahoo.it