Ileoanal Pouch Anastomosis Research Articles

W1090 Prospective Observation of Quality of Life in Patients with Ulcerative Colitis Undergoing the Ileoanal Pouch Anastomosis

W1090 Prospective Observation of Quality of Life in Patients with Ulcerative Colitis Undergoing the Ileoanal Pouch Anastomosis

Functional outcome and quality of life after restorative proctocolectomy and ileo-anal pouch anastomosis.

Reconstructive proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The aim of our study was to evaluate the functional results of this procedure and to assess its impact upon patient quality of life (QoL). We evaluated QoL and functional results in patients who had undergone IPAA using two self-rating questionnaires: 1) Medical Outcome 36 item Health Survey (SF-36); and 2) a specific questionnaire evaluating various aspects of anorectal and urogenital function. 107 patients (median age 38 [range 17-69] years) underwent reconstructive proctocolectomy with IPAA between 1981 and 2002. Median duration of follow-up was 83 (range 4-230) months. 66 patients (61%) answered both questionnaires. Two thirds of patients have more than five bowel movements per day and one bowel movement at night. Whilst true faecal incontinence is exceptional, episodes of soiling are reported by 25% of patients. Regarding QoL in this population, the two scores of the SF-36, which summarise physical and mental health status (Physical Component Summary and Mental Component Summary) were 54.6 and 45.8, respectively (both are 50 in the general population). Our data indicate that, as measured with SF-36 questionnaire, QoL after IPAA is close to normal. However, good quality of life is not a surrogate for good functional results. Despite excellent control of continence during the day, IPAA is often associated with night time bowel movements and soiling.

Functional outcome and quality of life after restorative proctocolectomy and ileo-anal pouch anastomosis.

Reconstructive proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The aim of our study was to evaluate the functional results of this procedure and to assess its impact upon patient quality of life (QoL). We evaluated QoL and functional results in patients who had undergone IPAA using two self-rating questionnaires: 1) Medical Outcome 36 item Health Survey (SF-36); and 2) a specific questionnaire evaluating various aspects of anorectal and urogenital function. 107 patients (median age 38 [range 17-69] years) underwent reconstructive proctocolectomy with IPAA between 1981 and 2002. Median duration of follow-up was 83 (range 4-230) months. 66 patients (61%) answered both questionnaires. Two thirds of patients have more than five bowel movements per day and one bowel movement at night. Whilst true faecal incontinence is exceptional, episodes of soiling are reported by 25% of patients. Regarding QoL in this population, the two scores of the SF-36, which summarise physical and mental health status (Physical Component Summary and Mental Component Summary) were 54.6 and 45.8, respectively (both are 50 in the general population). Our data indicate that, as measured with SF-36 questionnaire, QoL after IPAA is close to normal. However, good quality of life is not a surrogate for good functional results. Despite excellent control of continence during the day, IPAA is often associated with night time bowel movements and soiling.

GENERIC SUBSTITUTES ARE NEITHER AS SAFE NOR EFFECTIVE AS BRANDED MEDICATIONS: EXPERIENCE IN MEN TREATED FOR LOWER URINARY TRACT SYMPTOMS (LUTS)

Approximately 10–20% of inflammatory bowel disease (IBD) cases are diagnosed after 60 years of age. Due to the high prevalence of conditions mimicking IBD at older age – including bowel disease associated with non-steroidal anti-inflammatory drugs, diverticulitis, and microscopic colitis – differential diagnosis of IBD among older adults is frequently delayed.Late-onset IBD is characterized by a predominance of colonic disease and an overall milder disease course; disease progression and new intestinal manifestations are rare. However, older patients are less able to tolerate inflammation and their risk of mortality from severe disease is increased.Management of late-onset IBD has been insufficiently studied since older adults are underrepresented in clinical trials and specific problems of older patients such as incontinence have not been addressed. To date, treatment generally follows the same principles as in the younger. However, older patients are at higher risk of severe adverse effects of the disease and its treatments, including bone and muscle loss, infections and lymphoma. Therefore, the safety profile of a given drug is of paramount importance in older patients with IBD. Colectomy with ileo-anal pouch anastomosis for refractory ulcerative colitis can be performed safely, although functional results may be inferior to those in middle-aged patients. To decrease mortality among older patients, a timely surgical intervention is important.Patients with late-onset IBD frequently develop colorectal carcinoma within 8 years of diagnosis; therefore, colorectal cancer screening immediately after diagnosis should be considered. Further, the clinical care of older patients with IBD needs to extend to overall health, including nutrition, vaccination, bone, muscle and mental health.

Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis

Restorative proctocolectomy with ileo pouch anal anastomosis (IPAA) is the main surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). With the advancements of minimal-invasive surgery this demanding operation is increasingly being performed laparoscopically. Therefore, the presumed benefits of the laparoscopic approach need to be systematically evaluated. To compare the beneficial and harmful effects of laparoscopic versus open IPAA for patients with UC and FAP. We searched The Cochrane IBD/FBD Group Specialized Trial Register (April 2007), The Cochrane Library (Issue 1, 2007), MEDLINE (1990 to April 2007), EMBASE (1990 to April 2007), ISI Web of Knowledge (1990 to April 2007) and the web casts of the American Society of Colon and Rectal Surgeons (ASCRS) (up to 2006) for all trials comparing open versus laparoscopic IPAA. All trials in patients with UC or FAP comparing any kind of laparoscopic IPAA versus open IPAA. No language limitations were applied. Two authors independently performed selection of trials and data extraction. The methodological quality of all included trials was evaluated to assess bias risk. Analysis of RCTs and non-RCTs was performed separately. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. Eleven trials included 607 patients of whom 253 (41%) in the laparoscopic IPAA group. Only one of the included trials was a randomised controlled trial. There were no significant differences in mortality or complications between the two groups. Reoperation and readmission rates were not significantly different. Operative time was significantly longer in the laparoscopic group both in the RCT and meta-analysis of non-RCTs (weighted mean difference (WMD) 91 minutes; 95% Confidence Interval (CI) 53 to 130). There were no significant differences between the two groups regarding postoperative recovery parameters. Total incision length was significantly shorter in the laparoscopic group, while two trials evaluating cosmesis found significantly higher cosmesis scores in the laparoscopic group. Other long-term outcomes were poorly reported. The laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable. Large high-quality trials focusing on differences regarding specific postoperative complications, cosmesis, quality of life and costs are needed.

Does Mesorectal Preservation Protect the Ileoanal Anastomosis after Restorative Proctocolectomy?

Background and aimsThe technique of rectal dissection during restorative proctocolectomy might influence the rate of septic complications. The aim of this study was to analyze the morbidity of restorative proctocolectomy in a consecutive series of patients who had rectal dissection with complete preservation of the mesorectum. Patients and methodsOne hundred thirty-one patients who had restorative proctocolectomy for chronic inflammatory bowel disease with handsewn ileopouch-anal anastomosis (IPAA) and preservation of the mesorectal tissue were analyzed by chart reviews and a follow-up investigation at a median of 85 (14–169) months after surgery. ResultsOnly one of 131 patients had a leak from the IPAA, and one patient had a pelvic abscess without evidence of leakage, resulting in 1.5% local septic complications. All other complications including the pouch failure rate (7.6%) and the incidence of both fistula (6.4%) and pouchitis (47.9%) were comparable to the data from the literature. ConclusionThe low incidence of local septic complications in this series might at least in part result from the preservation of the mesorectum. As most studies do not specify the technique of rectal dissection, this theory cannot be verified by an analysis of the literature and needs further approval by a randomized trial.

The ileo neorectal anastomosis: an experimental study on development of the surgical technique and theoretical background

Objective The keystones of surgical treatment of ulcerative colitis and familial adenomatous polyposis are resection of the diseased colon with either an ileostomy or restoration of oro-anal continuity with an ileo-anal pouch. The ileo pouch anal anastomosis however, has a 15–35% pouch-related complication rate, 10% failure rate and is accompanied by an unpredictable functional outcome. In order to reduce these unfavourable rates and to improve functional results an alternative surgical technique, the ileo neorectal anastomosis (INRA), was developed experimentally. Materials and methods In an experimental study 12 Yorkshire-Dutch landpigs had a subtotal colectomy and rectal mucosectomy. Subsequently a vascularized ileal mucosa sling was created and transposed on to the denuded rectal muscular cuff in eight. In another four animals a non-vascularized mucosa sling was transposed. The covering ileostomy was closed after 3 weeks. Repeated endoscopies, histological examinations of mucosal biopsies and rectal compliance measurements were carried out to evaluate the functional result of the neorectum. Results The surgical procedure of the INRA was technically successful in this animal study. Repeated endoscopy and histology showed complete ileal mucosa ingrowth in the neorectum without severe fibrosis in the group of animals with a vascularized sling. At follow up after 1 year no colonic metaplasia had occurred. Measurements of the neorectal reservoirs in the group of animals with a vascularized INRA procedure showed a median ‘maximum tolerated volume’ of 338 ml (range 300–410 ml). Conclusion The INRA is technically feasible and reproducible. The histologically proven survival of the vascularized ileal mucosa and development of a compliant neorectal reservoir make the INRA an interesting alternative restorative procedure. Avoidance of the pouch-related complications of the ileo pouch anal anastomosis by this procedure might herald a new era of restorative surgery.

Outcomes of the rectal remnant following colectomy for ulcerative colitis

Controversy surrounds the optimal surgical management of the distal rectal remnant during colectomy for ulcerative colitis (UC) and the potential benefit from the placement of a rectal catheter for remnant drainage. This study reviews the clinical outcomes of patients who have undergone colectomy for UC with intra-peritoneal closure of the rectal remnant. Analysis of prospective data lodged on Lothian Surgical Audit databases from patients treated in a tertiary coloproctology unit over 11 years. One hundred and fifty-nine patients were identified, the mean age was 41.9 years, 63% were men. Failure of maximal medical therapy necessitated surgery for 78.1% patients, while 12.6% had acute perforation and 11.9% had toxic megacolon. Complications included five (3.1%) stump dehiscences, eight (5.0%) intra-abdominal/pelvic collections, four (2.5%) significant wound infections, three (1.9%) small bowel obstructions and three (1.9%) deaths. Within the follow-up period, 62.3% patients had an ileo-pouch anal anastomosis (IPAA), 7.5% patients had a completion proctectomy, 10.1% patients within the series had a retained rectal remnant after 1 year follow up, the remaining patients had less than 1 year follow up. The intra-peritoneal rectal stump following colectomy for UC is associated with low rates of pelvic sepsis and a high proportion of patients successfully proceeding to IPAA.

Prophylactic Surgery for Patients with Longstanding Ulcerative Colitis. Which Option? Histopathological and Clinical Implications

Patients with longstanding chronic ulcerative proctocolitis are at risk to develop colorectal cancer Conflicting views as regards surveillance, the indications for surgery and type of preventive procedure exist. For permanent prevention of cancer development complete removal of all potential malignant colorectal mucosa has to be done. Panprocto-colectomy with a conventional ileostomy or continent ileostomy removing all colorectal mucosa should therefore eliminate further risks of colorectal cancer.Colectomy and ileorectal anastomosis is a controversial issue. While many surgeons today are reluctant to use the technique, emphasising the persistent cancer risk, others consider the operation a viable alternative when used on a selective basis. The long-term risk of cancer in the rectal stump is the main strong argument.In restorative proctocolectomy, i.e. proctocolectomy with construction of an ileopouch anal anastomosis residual rectal mucosa is left behind irrespective of technique used and is therefore at risk for cancer development. Quite a few cancers have been reported to occur in these patients but controversy exists as regards the origin of these tumours but the risk for cancer development is very low.Biopsies from ileal pouches demonstrate various histopathological changes from nearly normal mucosa, to inflammation and atrophy, inflammatory cell changes, dysplasia as well as development of carcinoma. Grading of type and atypia is a challenge to reproduce and requires the participation of experienced gastrointestinal histopathologists.

Urogenital Complications of Crohn's Disease

Urogenital complications in Crohn's disease is a very narrow, specific area for consideration. The most frequent conditions that fall under this rubric include fistulous disease involving the genitourinary tract, nephrolithiasis, intrinsic renal diseases associated with Crohn's disease, and considerations in those who have had surgical procedures that alter normal pelvic anatomy. Fistulas involving the ureters, urinary bladder, and vagina are discussed. Nephrolithiasis is commonly in the form of calcium oxalate and uric acid, and is a well-known complication of Crohn's disease secondary to multiple mechanisms. Intrinsic renal disease is relatively rare and includes interstitial nephritis, amyloidosis, IgA nephropathy, and obstructive uropathy. Women who have undergone ileopouch anal anastomosis procedures are at risk for sexual dysfunction, dyspareunia, and decreased fecundity.

Do Patient Preferences Influence Decisions on Treatment for Patients With Steroid-Refractory Ulcerative Colitis?

Patients with steroid-refractory ulcerative colitis face a difficult treatment decision between colectomy and therapy with infliximab or cyclosporine. The aim of this study was to understand how individual patient preferences for the various treatment outcomes influence the optimal treatment decision for a given patient. A Markov model was used to simulate treatment with total colectomy with an ileo pouch-anal anastomosis (TC/IPAA), cyclosporine (CSA), infliximab (INFLX), and infliximab followed by cyclosporine for treatment failures (INFLX-->CSA). Utility weights for treatment outcomes were elicited from 48 patients using both time trade-off and visual rating scale methods. Preference sets were applied to the model to identify the therapy that maximized quality-adjusted life years (QALYs) for each patient. Sensitivity analyses were performed to assess model robustness. Optimal treatment was highly variable among patients (INFLX-->CSA = 42%, 20/48; TC/IPAA = 37%, 18/48; CSA = 21%, 10/48; INFLX = 0%, 0/48). However, when average preference weights from our sample were applied to the model, medical treatments were superior to TC (CSA = .26 QALYs gained vs TC/IPAA; INFLX-->CSA = .25 QALYs gained vs TC/IPAA). Patient preferences have a clear impact on the optimal treatment for steroid-refractory ulcerative colitis. Although averaged preferences support the use of medical interventions, a third of individual patients may benefit most from proceeding directly to colectomy. Failure to fully assess individual preferences may result in suboptimal treatment for these patients.

Discrimination is not impaired by excision of the anal transition zone after restorative proctocolectomy.

Anal sensation has been assessed using a constant current stimulator in 21 patients after restorative proctocolectomy (15 J pouch, 6 W pouch). The anal transition zone (ATZ) has been excised in 15 patients but preserved in 6. Results were compared with 14 age- and sex-matched patients with ulcerative colitis (UC) and 14 controls. Median threshold values in the lower, mid and upper zones of the anal canal in pouch patients were: 6.8 mA, greater than 15.0 mA and greater than 15.0 mA respectively compared with 3.9 mA (P less than 0.01), 5.7 mA (P less than 0.01) and 11.4 mA (P less than 0.01) in UC and 3.5 mA (P less than 0.01), 4.2 mA (P less than 0.01) and 11.4 mA (P less than 0.01) in controls. The mid and upper zone threshold anal sensation was significantly lower when the ATZ had not been removed and except in the lower zone did not differ from UC or controls (median threshold sensations when ATZ was preserved were: lower zone, 5.8 mA; mid zone, 5.5 mA; upper zone, 7.5 mA). Paired studies in eight patients showed that excision of the ATZ was associated with a significant impairment in anal sensation (mid zone: 5.7 versus greater than 15.0 mA, P less than 0.05; upper zone: 7.5 versus greater than 15.0 mA, P less than 0.05) whereas no change in anal sensation was recorded when the ATZ was preserved. Despite these physiological changes, no clinical benefit could be identified in patients in whom the ATZ was preserved. Discrimination was normal in all except one patient. The incidence of soiling, nocturnal incontinence and failure to defer defaecation for more than 1 h was recorded in 3/15 patients (20 per cent) whose ATZ had been removed, compared with 1/6 patients (17 per cent) in whom the ATZ had been preserved. We conclude that excision of the ATZ does not eliminate the ability to discriminate and does not increase the risk of impaired continence after ileo-pouch anal anastomosis.

Proctocolectomy and ileoanal pouch anastomosis without conservation of a rectal muscular cuff.

The technique of proctocolectomy and formation of an ileal reservoir with ileoanal anastomosis is well described. It is believed that the conservation of a rectal muscular cuff is necessary for continence but no data are available to support this contention. The aims of this study were to describe the clinical and physiological aspects of continence after proctocolectomy and ileal J pouch anastomosis without conservation of a rectal muscular cuff. Eighteen consecutive patients (mean age 37.3 years, 16 ulcerative colitis, two familial polyposis) who underwent proctocolectomy and ileoanal anastomosis on the dentate line were studied 6 months after closure of the loop ileostomy. The 18 patients and eight controls underwent: (a) anal manometry; (b) determination of maximum tolerable volume (MTV); (c) liquid continence test (infusion of NaCl at 60 ml/min for 25 min) with simultaneous measurement of ileal reservoir pressure. The volume evacuated during 5 min after the continence test was also measured. The frequency of bowel actions was (mean +/- s.e.m.) 5.3 +/- 0.4 per 24 h (nocturnal 1.14 +/- 0.26). Seventeen of 18 patients (94 per cent) had normal continence and defaecation; one patient was incontinent. A decrease in resting anal canal pressure (102.5 +/- 4 versus 47.5 +/- 6 cmH2O) was observed after ileoanal anastomosis. A rectoanal inhibitory reflex was elicited in one of the 18 patients (6 per cent). Patients were able to retain 1023 +/- 68 ml saline during the liquid continence test. The percentage evacuation of the ileal reservoir was 61 +/- 4.5 per cent. Correlations were found (P = 0.05) between daily stool frequency and the volume of saline retained during the liquid continence test. It is concluded that conservation of a rectal muscular cuff is not necessary for the achievement of good clinical results.

The ileoanal pouch procedure in the long–term perspective: a critical review

An ileo-pouch anal anastomosis (IPAA) has become the gold standard procedure for ulcerative colitis and familial adenomatous polyposis. Clinical results on the pelvic pouch procedure have often been encouraging; when confronted with the different surgical options, the majority of patients select IPAA as the best operation. However, even if IPAA is a great innovation, it is by no means the first choice for all patients. For patients old enough to join in a responsible discussion, the pros and cons of the various operations must be carefully described; the choice of surgical procedure must meet the patient's wishes and appear soundly based to the surgeon. The young age of most patients has to be considered and a long follow-up time is required to establish whether and, if so, to what extent the operation may adversely impact the patient's continence, sex life, fertility, and quality of life. The risk of cancer transformation in the residual rectal mucosa in the muscular or columnar cuff is another important factor that may influence the eventual decision. This article critically reviews our experience and the literature.

Laparoscopic Total Abdominal Colectomy in the Acute Setting

We report results from a single surgeon's 10-year team experience with laparoscopic total abdominal colectomy. We review our series, which includes a large subgroup of ill, high-risk patients with acute colitis requiring urgent surgery. From 1993 to 2003, we performed 65 laparoscopic total abdominal colectomies. All patients referred for total abdominal colectomy were offered the laparoscopic approach. We prospectively collected the following data on all patients: demographics, surgical indications, preoperative status, duration of surgery, intraoperative blood loss, operative complications, length of stay, subsequent operations, patient satisfaction, and lessons learned from our team experience. Preoperative diagnoses included ulcerative colitis (n=55), Crohn's colitis (n=3), colonic inertia (n=4), and familial adenomatous polyposis (n=3). Among the patients with inflammatory bowel disease, 70% of cases were performed on ill patients, refractory to medical management, requiring urgent surgery. This subgroup was managed with laparoscopic total abdominal colectomy and Brooke ileostomy, with ileoanal pouch anastomosis deferred. Operative times were long, ranging from 6 to 11 hours. Mean intraoperative blood loss was 200 ml. Mean length of stay was 4.3 days and ranged from 2 to 13 days. There were no conversions to open surgery and there were no deaths. Complications occurred in 12% of patients and included intra-abdominal abscess (n=2), wound infection (n=3), stoma stenosis (n=1), and incisional hernia (n=2). Postoperative patient satisfaction was high. Subsequent operations, including restorative proctectomy, were also performed laparoscopically. Laparoscopic total abdominal colectomy is technically challenging and requires a team approach but offers patients significant benefit in length of stay and surgical recovery. This operation can be effectively used with minimal morbidity in difficult, ill patients requiring urgent surgery.

Increased cytokine transcripts in pouchitis reflect the degree of inflammation but not the underlying entity

After ileopouch anal anastomosis (IPAA), 10-40% of patients with ulcerative colitis (UC) but only 5% of patients with familial adenomatous polyposis (FAP) develop pouchitis. Immunoregulatory abnormalities might be of importance in the pathogenesis of the disease. Therefore, we characterized cytokine and chemokine transcripts in inflamed and non-inflamed pouches in patients with UC compared to those with FAP and Crohn's disease (CD). Mucosal biopsies were taken from 87 patients with IPAA [UC (n=70), CD (n=8) or FAP (n=9)]. Patients with active ileal CD (n=14), active UC (n=17) and non-inflammatory conditions (n=12) served as controls. The expression of 20 gene transcripts was quantified using real-time polymerase chain reaction. Pro-inflammatory cytokines and chemokines are significantly increased in IPAA patients with acute pouchitis. This increase is independent of the underlying disease (UC or CD) and reflects the degree of inflammation. A good correlation between pouchitis activity (using the Pouchitis Disease Activity Index) and the MRP-14, interleukin-8, macrophage inflammatory protein-2alpha and matrix metalloproteinase-1 transcripts was observed. Our data support the view that pouchitis reflects an inflammatory process that is different from that of underlying inflammatory bowel diseases, as the cytokine and chemokine patterns in pouchitis are neither typical of CD nor of UC, but maybe due to bacterial intestinal microflora overgrowth in the pouch lumen. Quantification of transcript levels allows an estimation of the extent of mucosal inflammation and may become helpful in the evaluation of the disease, especially in clinical trials.

Techniques d’anastomoses iléoanales avec réservoir

Complete proctocolectomy with ileoanal pouch anastomosis is the gold standard for the treatment of familial adenomatous polyposis and ulcerative colitis. In Crohn’s disease, this technique may be considered for selected patients free of anal or small bowel lesions. The two main techniques used for ileoanal anastomosis are the manual anastomosis following mucosectomy (Parks’ procedure, the reference technique), and the stapled anastomosis, the most used procedure worldwide. A third technique exists also, consisting in rectal eversion with section on the dentate line (Hautefeuille procedure); this technique avoid conservation of the anal transitional zone in stapled ileoanal anastomosis, and the risk of incomplete mucosectomy associate with Parks’ procedure. Finally, it is possible today to perform this intervention by laparoscopic approach, provided the operating team has the required training.

The risk of dysplasia and cancer in the ileal pouch mucosa after restorative proctocolectomy for ulcerative proctocolitis is low: A long‐term term follow‐up study

Some of the rare complications reported in patients with an ileopouch anal anastomosis (IPAA) after coloectomy for chronic ulcerative colitis are dysplasia and carcinoma. The supposed pathway is for the ileal pouch mucosa to go through adaptational changes then is to progress through the phases of chronic pouchitis, dysplasia and subsequently to adenocarcinoma. In many of these studies however, the dysplasia-cancer sequence is inconclusive since the carcinoma might have developed from the ileal mucosa itself or from residual viable rectal mucosa left behind. The purpose of this study was therefore to study the long-term ileal mucosal adaptation patterns and the incidence and grading of dysplasia in the ileal pouch mucosa in patients previously operated on for ulcerative proctocolitis. Forty-five patients who had been operated on with an IPAA (25 males/20 females), with a median age of 54 years (range 34-76), were invited for clinical examination and pouch endoscopy including mucosal biopsies. The duration of their colitis until surgery was median 6 years (range 1-28) and the time median interval from start of disease until time of follow up 24.8 years (range 17-46). Three independent pathologists from two different centres reviewed sequential mucosal biopsies taken from separate sites of the pouch for dysplasia and mucosal adaptation patterns. The type C pattern with a severe inflammation in lamina propria together with severe atrophy of villi, sometimes with ulceration and granulation tissue, was observed by the two pathologists from one centre in 15 of 45 (33.3%) patients and in 11 (24.4%) of 45 by the third pathologist, respectively. As regards dysplasia one pathologist group evaluated 2/45 (4.4%) cases as low-grade dysplasia while the third pathologist considered one of these cases as indefinite for dysplasia and one as reactive. There was in this respect full agreement between the two centres in 43 (95.6%) of 45 cases. Neither high-grade dysplasia nor invasive carcinoma was diagnosed. Dysplastic transformation within the ileal pouch mucosa in patients operated for ulcerative proctocolitis is rare even after a long follow-up. These results are reassuring for both patients and surgeons. There seem to be no solid grounds to support routine surveillance for dysplasia in the ileal pouch mucosa in these patients. The surveillance for neoplastic changes in the remaining muscular/epithelial cuff is a separate issue however.

Familial Adenomatous Polyposis

Familial adenomatous polyposis is an inherited, autosomal-dominant syndrome that is caused by a germline mutation of the adenomatous polyposis gene (APC). The syndrome is characterized by the development of hundreds to thousands of adenomatous polyps in the colon and rectum with nearly all patients developing colorectal cancer if prophylactic surgery is not performed. Benign extracolonic manifestations are seen with this syndrome and include upper gastrointestinal polyps, desmoids, epidermoid cysts, osteomas, and congenital hypertrophy of the retinal pigment epithelium (CHRPE). Malignant extracolonic manifestations have also been associated with this syndrome. The most common sites of extracolonic cancers that develop in these patients are duodenal, thyroid, brain, and liver. Prophylactic surgery should be performed shortly after the diagnosis of polyposis. Surgical options include total proctocolectomy with end ileostomy, total colectomy with ileorectal anastomosis, or total proctocolectomy with ileopouch anal anastomosis. The literature is reviewed with regard to these different procedures. Genetic testing has evolved over the past decade to play a key role in identifying at-risk individuals and assisting in recommendations made to these patients and their families with regard to screening, surgical treatment, and surveillance.

Malignancies in inflammatory bowel disease

The risk of luminal gastrointestinal tract, hepatobiliary tract, and non-gastrointestinal tract cancers in inflammatory bowel disease remains of great interest. The purpose of this review is to report on studies published in 2002 that have addressed several important questions related to the biology, natural history, and risk factors for colonic and extracolonic cancers. Two studies reported conflicting results on the natural history of low-grade dysplasia in patients with ulcerative colitis. Other investigators focused on the safety of medications used to treat inflammatory bowel disease, one noting no increased risk of cancer with azathioprine, another suggesting that anti-tumor necrosis factor therapy may increase the risk of lymphoma. Studies of patients after total proctocolectomy and ileoanal pouch anastomosis suggest that these patients continue to have a small risk of bowel cancer. A novel observation from studies focusing on the subgroup of patients with inflammatory bowel disease and primary sclerosing cholangitis was the identification of an increased risk of pancreatic cancer. Finally, many investigators continue to pursue potential biomarkers of malignancy for use in inflammatory bowel disease cancer surveillance programs. These studies have added to our knowledge of the risk of malignancy in inflammatory bowel disease and have set the stage for future long-term studies to better delineate the risk of lymphoma with the use of anti-tumor necrosis factor therapy and the fate of low-grade dysplasia in flat mucosa. Clinical application of potential biomarkers of malignancy in inflammatory bowel disease cancer surveillance is anticipated in the near future.