Polypectomy versus proctocolectomy for adenoma patients with long-standing ulcerative colitis

Abstract

The only thing we have to fear is fear itself V Franklin Delano Roosevelt. Colorectal cancer surveillance in inflammatory bowel disease provokes both a sense of urgency and dread in most gastroenterologists. We know that patients with Crohn’s colitis and ulcerative colitis are at increased risk for colorectal cancer, although some disagreement remains on the precise risk of developing colorectal cancer with either of these conditions. Added to this is the theoretical concern that the polyp to carcinoma sequence may be accelerated or less predictable in patients with ulcerative or Crohn’s colitis, thus leading to earlier or clinically more aggressive colorectal cancer in patients without inflammatory bowel disease. Finally, a general dissatisfaction with the current tools of surveillance pervades almost every discussion of this topic. The finding of a sporadic adenoma in this bleak landscape can greatly deepen the angst. It need not be so emotionally fraught. The current management of polyps that develop in patients with colitis is strongly influenced by fear and a failure to define what it is we are seeing during the pressured moments of a surveillance procedure. To better understand where we are now with sporadic adenoma in colitis, we have much to learn from the evolution of the management of sporadic adenomas in patients without colitis during the 1970s and 1980s. The evolution of the current management algorithm for sporadic adenomas benefited greatly from the hard work of many clinicians and scientists but more importantly from coolerheaded investigators who developed a pragmatic, descriptive terminology of what was being viewed through the scope. Polyps were catalogued and categorized by size, morphology, and histology, but ultimately the conservative management of these polyps hinged on resectability. Once consensus on the resectability of a lesion was achieved, other issues of surveillance frequency, cancer risk, and need for surgery could be discussed intelligently. None of these answers were obvious at first, but most were established with time, careful observation, and experience. The first formal attempts at consensus in defining a polyp in colitis were hampered by deviating from this paradigm of discovery and surrendering to the fear and uncertainty clouding cancer risk in inflammatory bowel disease. The current taxonomy of polyps in colitis is crowded with terms such as Bnon-adenoma-dysplasia-associated lesion or mass[. In this muddled terminology, we can find the source of our current confusion and fear. We are closer to consensus on terminology than 5 years ago, but much work remains. Any definition of a polyp must hinge on its resectability before a surveillance schedule is determined or a surgeon summoned. Starting with the example of the patient without colitis, I believe that we all agree that colonoscopic polypectomy is considered to be effective for preventing colorectal cancer in these patients. Recent studies have demonstrated that even patients without colitis who are enrolled in a colonoscopic surveillance program after the identification of an adenomatous polyp are still at risk of developing colorectal cancer. And even in this relatively low-risk population (at least when compared with patients with long-standing ulcerative or Crohn’s colitis), this approach remains imperfect. Still, nobody is suggesting that we remove the colons of everybody who has been identified as having a sporadic adenoma. When one encounters an adenomatous polyp in the setting of colitis, there are several strategies that can be used. One would be to refer the patient for a total proctocolectomy. This would likely be resisted by the patient. A second, popular approach would be to perform a polypectomy, biopsy around the site (although this has never been shown to increase the yield of dysplasia it may help define resectability), and finally perform random biopsies throughout the colon. An alternative approach would be to use chromoendoscopy to better define the polyps present and enhance the yield for finding any other dysplasia in the patient. The yield for dysplasia during colonoscopy can be tripled, or even quadrupled, if one is using chromo-endoscopy techniques at the same time. The lesions should be removed and defined by the resectability and histology. The clinical definition of a dysplasia-associated lesion or mass (DALM) may need to be CONTROVERSIES IN IBD