Background: Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become a standard surgical treatment for patients with UC. Although long-term functional outcomes of the IPAA are good in the large majority of patients, they still have risks of anastomotic failure, pelvic sepsis and developing pouchitis. On the other hand, total colectomy with ileorectal anastomosis (IRA) requires less complex techniques with lower complication rate that has been considered as a treatment of choice for a selected group of UC patients. Among these two surgical procedures, patients who underwent IRA have a higher risk of developing neoplasia than those who underwent IPAA, and the incidence of rectal cancer was reported in up to 18% after IRA.
The aim of this study was to clarify the cumulative rate of developing neoplasia after IRA and IPAA. Additionally we describe the clinical course of patients who developed neoplasia after IRA and IPAA.
Methods: We evaluated 131 UC patients who underwent either IPAA or IRA in our institution between 1965 and 2016 by reviewing medical and endoscopic records. All patients underwent surveillance colonoscopy at least once after surgery. We retrospectively reviewed for the development of neoplasia based on endoscopic and pathological findings. The cumulative rate of developing neoplasia was calculated using the Kaplan-Meier method. The clinical features and clinical course of patients who developed neoplasia after IRA or IPAA were retrospectively reviewed.
Results: Among 131 patients, 31 patients underwent IRA and 100 patients underwent IPAA. A total of 392 endoscopy sessions were conducted after IRA and 673 pouchoscopy sessions were conducted after IPAA. There were no statistic differences between IRA group and IPAA group for sex, age at onset, or age at surgery. Since we perform IPAA for UC patients who develop neoplasia, there were statistical difference between IRA group and IPAA group in the surgical indication. A total of seven patients were detected with neoplasia during postoperative surveillance colonoscopy. Among them neoplasia was found in six of 31 patients in IRA group and in one of 131 patients in IPAA group. In IRA group high-grade dysplasia was detected in three cases and low-grade dysplasia in three cases from the retained rectum at the time of surveillance colonoscopy. Neoplasia were detected more frequently in the IRA group than in the IPAA group. The cumulative rate of developing neoplasia after IRA at 10 and 20 years was 7.4% and 18.6% respectively.
Conclusions: Cumulative incidence of neoplasia after IRA in UC patients was 18.6% after 20 years. IRA should be performed in selected patients and strict surveillance colonoscopy with biopsies is important.