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We would like to thank Drs Hata, Shinagawa, and Watanabe for their interest in our article “Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study.”1Abdalla M. et al.Clin Gastroenterol Hepatol. 2017; 15: 1055-1060 e2Abstract Full Text Full Text PDF Scopus (41) Google Scholar In their letter, they proposed surveillance endoscopy of ulcerative colitis (UC) patients reconstructed with a pelvic pouch (IPAA) or an ileorectal anastomosis (IRA). Both studies referred to in the letter described the occurrence of pouch neoplasia, as opposed to the risk of rectal cancer examined in our study. Low-grade dysplasia therefore was included in both the Dutch2Derikx L.A. et al.Gastroenterology. 2014; 146: 119-128 e1Google Scholar and the Cleveland Clinic3Kariv R. et al.Gastroenterology. 2010; 139 (e1–2): 806-812Google Scholar studies, as were other types of malignancies including lymphoma, squamous cell cancer, and adenocarcinoma of the pouch itself (ie, small bowel). In the Dutch study, 4 of the 16 UC patients with an IPAA who developed an adenocarcinoma were considered recurrences and another 2 patients developed their cancer a few years after a previous pouch excision.2Derikx L.A. et al.Gastroenterology. 2014; 146: 119-128 e1Google Scholar These differences all would contribute to the somewhat higher incidence compared with our national cohort study. Interestingly enough, the Dutch group found that pouch dysplasia rarely progressed during follow-up evaluation (n = 3 patients). Indeed, 9 of 14 patients with dysplasia had regression in follow-up biopsy specimens.2Derikx L.A. et al.Gastroenterology. 2014; 146: 119-128 e1Google Scholar The patient in our national cohort happened to be from our own hospital in Linköping.4Andersson P. et al.J Crohns Colitis. 2014; 8: 582-589Google Scholar He had no history of previous colorectal cancer or dysplasia in his colorectal specimen or any known primary sclerosing cholangitis (PSC) or history of colorectal cancer in his family. Two years after his IPAA, at age 25, he developed pouchitis symptoms. Numerous endoscopies failed to identify the cause of his symptoms until an adenocarcinoma growing extraluminally at the level of the ileoanal anastomosis was seen at an examination under anesthesia. In the report from Kariv et al,3Kariv R. et al.Gastroenterology. 2010; 139 (e1–2): 806-812Google Scholar 6 of 15 patients who developed rectal cancer had gone through a mucosectomy. Taken together, one could question the value of surveillance endoscopies among all IPAA patients. Focusing on patients with IPAA who develop symptoms that could be signs of cancer may be more rational. Patients with an IPAA and a history of previous colorectal cancer should be followed up as any colorectal cancer patient. We found a high relative risk of rectal cancer among UC patients who underwent an IRA compared with the general population, with a standard incidence ratio of 8.7 (95% confidence interval, 5.6–13.4). However, the absolute risk was low, with 1.8% of IRA patients developing rectal cancer after a mean follow-up period of 8.6 years. The risk was especially high among patients with PSC, with a hazard ratio of 6.12 (95% confidence interval, 2.33–16.03).1Abdalla M. et al.Clin Gastroenterol Hepatol. 2017; 15: 1055-1060 e2Abstract Full Text Full Text PDF Scopus (41) Google Scholar A recent study from France found a similarly low risk of rectal cancer in UC patients with an IRA: 3.2% after 10 years, despite 8.5% of the IRA patients having a history of dysplasia or colon cancer before the reconstruction.5Uzzan M. et al.J Crohns Colitis. 2017; 11: 930-935Google Scholar A multivariate analysis in the same report identified PSC, inflammatory bowel disease duration, age at IRA, and history of prior adenocarcinoma of the colon as independent risk factors for rectal cancer. Thus, we completely agree with Drs Hata, Shinagawa, and Watanabe on the importance of endoscopic surveillance in UC patients restored with an IRA after subtotal colectomy. In Sweden, flexible endoscopy with multiple biopsies are proposed together with topical mesalamine treatment as well.4Andersson P. et al.J Crohns Colitis. 2014; 8: 582-589Google Scholar, 6Myrelid P. et al.J Crohns Colitis. 2015; 9: 433-438Google Scholar Furthermore, we think patients with PSC and/or a previous colon cancer should be guided toward end ileostomy, IPAA, or a continent Kock pouch as a safer oncologic alternative.4Andersson P. et al.J Crohns Colitis. 2014; 8: 582-589Google Scholar, 6Myrelid P. et al.J Crohns Colitis. 2015; 9: 433-438Google Scholar Efficacy of a Surveillance Endoscopy After an Ileorectal Anastomosis in Patients With Ulcerative ColitisClinical Gastroenterology and HepatologyVol. 16Issue 1PreviewWe read with great interest the article titled, “Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study” written by Abdalla et al.1 They investigated the risk of the development of rectal cancer after surgery in patients diagnosed with ulcerative colitis (UC) using a national cohort from Sweden and showed that the incidence of rectal cancer was not very high after both an ileal-pouch anal anastomosis (IPAA) and an ileorectal anastomosis (IRA) procedure. 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