Adenocarcinoma of the ileostomy: the latent risk of cancer after colectomy for ulcerative colitis and familial polyposis

A case of a primary adenocarcinoma of an ileostomy is reported along with 15 other cases collected from the literature. These rare tumors are seen on the average 24 years after colectomy with ileostomy and in all cases are associated with a past history of ulcerative colitis or familial polyposis. Most of the reported cases of these tumors have appeared in the literature within the past 5 years, suggesting that there is a rising incidence of this disease corresponding to completion of a biologic latency period that began when the Brooke ileostomy was introduced for ulcerative colitis in 1951. In our case a mucinous adenocarcinoma occurred at the ileostomy site 34 years after colectomy. Adjacent to the tumor was mucosa showing colonic metaplasia and focal dysplasia. Subsequent biopsy specimens of the revised stoma showed inflammatory lesions morphologically suggestive of inflammatory (pseudo) polyps. The clinical and morphologic features in this case suggest that there is transition from ileal mucosa to colonic mucosa to colonic dysplasia to adenocarcinoma. Annual evaluation of the ileostomy for colonic metaplasia, inflammatory lesions consistent with ulcerative colitis and dysplasia, is recommended. In the presence of dysplasia, stomal revision is advised. Wide local excision is advised for adenocarcinoma.     

Cancer of ileostomy: a late complication of colectomy for ulcerative colitis

Cancer arising at an ileostomy site represents a rare late complication of total colectomy performed for ulcerative colitis. There are no more than 36 published cases in the literature. We describe a case of adenocarcinoma of the mucocutaneous junction at the ileostomy site, occurring 31 years after total colectomy for ulcerative colitis. Wide excision of the moderately differentiated adenocarcinoma was performed with refashioning of the ileostomy. Polypoid adenomas or adenocarcinomas of the ileostomy after colectomy performed for non-neoplastic conditions are extremely uncommon. Biopsies of polypoid lesions at the stoma site are recommended.     

Adenocarcinoma at the ileo-cutaneous junction following subtotal colectomy for ulcerative colitis. Case report

Adenocarcinoma of the ileo-cutaneous junction is exceedingly rare. We report a case. The clinical presentation and pathogenesis are discussed.     

Ileitis and pouchitis after colectomy for ulcerative colitis

Ileitis can occur after surgical treatment of ulcerative colitis. Following continent ileostomy or restorative proctocolectomy ileitis can become a serious clinical problem and is then known as pouchitis although this condition is yet to be clearly defined. It is likely that pouchitis is the result of an abnormal host response to a change in bacterial flora and that the nature of this host response is related to the underlying pathogenesis of ulcerative colitis. Continued study of the immunological basis of ulcerative colitis is therefore required to solve the problem of pouchitis.     

A case of ulcerative colitis relapsing at the defunctionalized colon after subtotal colectomy

A 25-year-old female with left sided ulcerative colitis underwent subtotal colectomy, and colo-anal anastomosis with diverting ileostomy by combined abdomino-sacral approach on February 14, 1985. Immediately after the operation, bleeding from the anus occurred, and one month after the operation, endoscopic examination revealed the relapse of the ulcerative colitis in the remaining colon. It was recognized, that relapse had occurred postoperatively at the nonfunctioning colon, which had been free from the disease so long as eight years since the onset of the disease. Then the relapsed colon was removed, and ileoanal anastomosis with diverting ileostomy was performed, again by combined abdomino-sacral approach. The sacral approach offered an excellent operative field and ensured the anastomosis between the small intestine and the anus.     

Identifying factors predictive of surgical-site infections after colectomy for fulminant ulcerative colitis

Surgical-site infections (SSIs) remain a major source of morbidity after colectomy for fulminant ulcerative colitis (UC). Identifying UC patients at elevated risk of developing SSIs might improve postoperative outcomes. Our goal was to identify preoperative factors, which could predict SSI development in the postoperative UC population. The records of 59 patients treated by colectomy for fulminant UC from 2004 to 2009 were retrospectively reviewed and statistically analyzed. Few differences were observed between patients who developed postoperative complications and those who did not. Twenty patients sustained a total of 27 complications, with superficial SSIs being the single most common event. Multivariate analysis identified diabetes, white blood cell count > 15 cells/mm(3), intraoperative blood loss > 200 cc, and intraoperative blood transfusion to all be independent predictors for the development of postoperative SSIs. These four factors were all able to independently predict SSIs. Postoperative UC patients with these risk factors might benefit from heightened wound surveillance or closer follow-up.     

Total colectomy and ileorectal anastomosis for ulcerative colitis

The pros and cons of total colectomy and ileorectal anastomosis for ulcerative colitis are discussed based on the author's experience and on the collective results with this operation at St. Mark's Hospital, London, over a 20-year period. Its chief merits are that it is easy to perform, carries a low operative mortality and morbidity, and, when it works well, usually affords excellent anorectal function. It has 2 main disadvantages: in a proportion of cases it proves unable to control the disease because of continuous or recurrent activity of the residual proctitis, and occasionally a carcinoma may develop in the rectal stump. But patients who have failed with it can easily be salvaged, as a rule, by proceeding to a proctectomy and ileoanal anastomosis (or ileostomy). As for the risk of cancer arising in the rectum, fortunately, this can now be largely contained by regular follow-up attendances, at which rectal biopsies are taken to look for evidence of the premalignant change of severe epithelial dysplasia, a precaution that is absolutely essential after this operation. Important points in the technique of ileorectal anastomosis are emphasized, and the suitability of the operation for colitis in various clinical settings is examined.

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Resumen Las ventajas y desventajas de la colectomía total y anastomosis ileorrectal para colitis ulcerosa son discutidos por el autor con base en su experiencia personal y los resultados colectivos con esta operación en el St. Mark's Hospital de Londres en un período de 20 años. Sus méritos principales incluyen la facilidad de ejecución, la baja mortalidad y morbilidad operatorias, y el hecho de que, cuando funciona bien, provee una excelente función anorrectal. Posee 2 desventajas principales: en un cierto nÚmero de casos no se logra el control de la enfermedad debido a actividad continuada o recurrente de la proctitis residual y, ocasionalmente, se puede desarrollar un carcinoma en el muñón rectal. Pero en los pacientes en quienes falla la operación se puede emprender fácilmente una proctectomía con anastomosis ileonal (o ileostomía). En cuanto al riesgo de cancer en el recto residual, afortunadamente ésto puede ser bastante bien controlado mediante un seguimiento regular que incluye biopsias rectales para detectar la alteración premaligna que es la displasia epitelial severa. Este tipo de seguimiento constituye una precaución absolutamente esencial después una vez realizada esta operación.Se hace énfasis sobre aspectos importantes de la técnica de anastomosis ileorrectal y se analiza la indicación para este tipo de procedimiento en las diferentes condiciones clínicas.

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Résumé Les facteurs pour ou contre la colectomie totale complétée par une anastomose iléo-rectale pour traiter la colite ulcéreuse sont discutés par l'auteur en fonction de sa proper expérience et des résultats obtenus par cette opération au St. Mark's Hospital de Londres au cours d'une période de 20 ans. Les mérites principaux de l'intervention sont la simplicité de sa réalisation, le taux faible de la morbidité et de la mortalité, les résultats excellents de la fonction ano-rectale en général. Elle présente cependant 2 inconvénients majeurs: dans un certain nombre de cas, elle est incapable de contrÔler totalement l'affection car des lésions rectales continuent à évoluer ou récidivent après une accalmie; dans quelques cas un cancer peut se développer au niveau du rectum. Cependant dans le premier cas les malades peuvent Être traités efficacement en procédant à la protectomie et à la constitution d'un réservoir iléo-anal (ou à une iléostomie). Quant au risque de cancer du rectum, il peut maintenant Être supprimé en suivant attentivement ces opérés et en procédant sans hésiter à la biopsie de toute zone suspecte pour dépister une dysplasie épithéliale marquée qui constitue une lésion pré-cancéreuse.Les détails techniques importants de la constitution d'un réservoir iléo-anal pour traiter la colite ulcéreuse sont soulignés et les possibilités de sa réalisation dans différentes organisations sont étudiées.

     

Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis

A case of adenocarcinoma arising in a 39-year-old patient after restorative proctocolectomy is reported. The patient underwent an ileal pouch-anal anastomosis with double-stapled technique for severe ulcerative colitis 18 years earlier, without evidence of associated neoplasm or dysplasia in operative specimen. After endoscopic diagnosis of adenocarcinoma, the patient was submitted to excision of the pouch and permanent ileostomy, followed by combined radiotherapy and chemotherapy. Pathology showed an AJCC stage III moderately differentiated mucinous adenocarcinoma. The patient died 24 months after the operation, due to cancer progression. There are 50 reported cases in the indexed medical literature of carcinoma arisen after ileal pouch-anal anastomosis for ulcerative colitis. Twenty-five out of these arose after mucosectomy and hand-sewn anastomosis, and 25 after stapling technique. Furthermore, in 48% of the patients, dysplasia or cancer was already present at the time of the colectomy. The increase of reported cases suggests a routine long-term endoscopic surveillance in patients with long-standing ileal pouches, especially in presence of dysplasia or cancer in the proctocolectomy specimen.     

Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: a case-matched study

OBJECTIVE: The aim of the study was to evaluate feasibility and safety of restorative proctectomy with ileal pouch anal anastomosis (IPAA) through a Pfannenstiel incision after prior laparoscopic colectomy. METHODS: Seventeen patients who underwent restorative proctectomy after laparoscopic emergency colectomy for ulcerative colitis (UC) were prospectively evaluated. Results were compared with results of a group of 21 case matched patients that had restorative proctectomy and IPAA via a midline incision in the same period. RESULTS: Median operation time was longer, although not significantly, in patients who had a restorative proctectomy through a pfannenstiel (186 min) compared to a restorative proctectomy through a midline incision (158 min). Procedure related complications were comparable between the groups, respectively, 1 of 17 patients in the pfannenstiel group and 3 of 21 patients in the median laparotomy group. Median hospital stay in the pfannenstiel group was 10 days and in the midline group 12 days. CONCLUSIONS: After laparoscopic assisted emergency colectomy for ulcerative colitis, restorative proctectomy is feasible and can be performed safely through a Pfannenstiel incision.     

A retrospective study reviewing the fate of the rectum after total abdominal colectomy and end ileostomy in patients with ulcerative colitis

Aim

The objective of this study was to review the fate of the rectal stump following total colectomy for ulcerative colitis and evaluate the risk of rectal cancer.

Methods

A review of operative and pathological databases identified 103 patients who had undergone total abdominal colectomy for ulcerative colitis between 1987 and 2008. Those who had synchronous colorectal cancer at the time of operation were excluded from study.

Results

Twenty of the 103 patients did not proceed with further surgery, most of whom are under regular surveillance of the remaining stump. Ten patients were lost to follow-up. Seventy-three patients were finally included in the study: forty-three patients had been submitted to proctectomy and ileoanal pouch surgery with a success rate of 86%, 28 to proctectomy and ileostomy, and two patients to ileorectal anastomosis.

Conclusion

These data suggest that after a total colectomy, the majority of patients proceed with restorative pouch surgery with encouraging results and for the most part, good quality of life, while a significant number of patients prefer to proceed with completion proctectomy. For those who decide to retain the rectal stump, the incidence of rectal cancer is sufficiently high as to require regular surveillance.     

Medical management of ulcerative colitis and indications for colectomy

Contemporary medical management of ulcerative colitis is surveyed. The most valuable drugs are corticosteroids, which may be administered orally, by injection, or topically (as enemas); and sulphasalazine (Azulfidine^®) for oral or topical use. Other agents such as immunosuppressive drugs and disodium cromoglycate may also have a small role in management. In addition, in very ill patients, intravenous fluid and electrolyte replacement, blood transfusion, or parenteral nutrition may be required. Suitable regimens of medical treatment for mild, moderate, and severe attacks of colitis are outlined as well as the indications for surgery. The best choice of medication for maintenance therapy is also considered. The risk of malignant change in long-standing colitis is discussed with particular reference to the method of containing this risk during continued conservative management by regular proctoscopic and colonoscopic biopsies to detect the premalignant condition of severe epithelial dysplasia.

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Resumen Se revisa el manejo medico contemporáneo de la colitis ulcerativa. Las drogas de mayor valor terapéutico son los corticosteroides, que pueden ser administrados por vía oral, por vía parenteral, o por vía tópica (en forma de enemas); y la sulfasalazina (Azulfidine^®) que es de administración oral o tópica. También otros agentes tales como drogas inmunosupresoras y el cromoglicato disódico pueden tener un rol menor. Además, pacientes muy graves pueden requérir reemplazo de líquidos y electrolitos, transfusión de sangre, o nutrición parenteral.Se delinean regímenes adecuados de tratamiento médico para episodios leves, moderados, y severos de colitis, y se definen las indicaciones para cirugía. Así mismo, se considera la medicación de mejor escogencia para terapia de mantenimiento.Se discute el riesgo de malignidad en colitis de larga evolución, con referencia particular al método de controlar tal riesgo en el curso de manejo conservador continuado mediante biopsias proctoscópicas y colonoscópicas regulares para la detección de alteraciones premalignas y de severa displasia epitelial.

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Résumé Le traitement médical actuel de la colite ulcéreuse est apprécié. Les médicaments les plus efficaces sont les cortico-stéroides qui peuvent Être administrés par voie orale, par voie parentérale et par voie locale (sous forme de lavements), et la sulphasalazine (Azulfidine^®) par voie orale ou locale. D'autres agents, tels que les médicaments immuno-suppresseurs et le disodium cromoglycate, peuvent jouer un rÔle d'appoint. En outre, chez les malades en mauvais état il peut Être nécessaire d'avoir recours au rétablissement de l'équilibre hydro-électrique par voie intra-veineuse, à la transfusion sanguine ou à l'alimentation parentérale.Les modalités thérapeutiques médicales adéquates qui doivent Être employées pour traiter respectivement les attaques discrètes, moyennes ou sévères de colite sont indiquées ainsi que les indications de la chirurgie. Est également envisagé le meilleur traitement médical d'entretien.Le risque de dégénérescence maligne de la colite ulcéreuse de longue durée est également pris en considération en insistant sur la méthode à observer pour le prévenir au cours du traitement conservateur, méthode qui a recours régulièrement à la proctoscopie et à la colonoscopie qui permettent de déceler la lésion pré-cancéreuse que constitue une dysplasie épithéliale marquée.

     

Volvulus of an ileal pouch-rectal anastomosis after subtotal colectomy for ulcerative colitis: report of a case

Ileal J-pouch rectal anastomosis is a commonly performed procedure for patients who have undergone subtotal colectomy for ulcerative colitis or familial adenomatous polyposis without rectal involvement. We herein report the case of a patient with ileal pouch volvulus that developed 15 years after subtotal colectomy for ulcerative colitis. A 62-year-old female visited our emergency room with complaints of abdominal pain and nausea that had persisted for 12 h. Abdominal radiography and contrast-enhanced computed tomography detected segmental distention of the small intestine around the staples. We diagnosed volvulus of the ileal pouch-rectal anastomosis and performed emergency laparotomy. We released the volvulus and performed pouchpexy. The patient was discharged on postoperative day 10, and recurrence of the volvulus has not been observed for 5 months since the procedure was performed. Our study indicates that an early diagnosis and intervention are needed to avoid serious complications, such as pouch necrosis and perforation, in such cases.     

Single-incision laparoscopic total abdominal colectomy for refractory ulcerative colitis

Background  

A three-stage restorative proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for the particularly debilitated patient with medically refractory ulcerative colitis (UC). Laparoscopic surgery has been shown to offer several advantages over the open approach in this setting. Single-incision laparoscopic surgery is an emerging minimally invasive strategy representing a truly scarless procedure for the first surgical step, namely, the total abdominal colectomy (TAC).