Background: A considerable number of patients with inflammatory bowel disease (IBD) have refractory disease and therefore often require a subtotal colectomy with construction of an ileostomy. When pouch surgery is not appropriate this can be a definitive procedure. Due to the potential risk of pelvic nerve damage and pelvic septic complications, the rectum is often left in situ. The primary objective of this study was to assess the incidence rate of non-malignant (diversion colitis, stenosis) and malignant (dysplasia or cancer) complications of RS patients with IBD. Secondary objectives were to evaluate the management strategies after colectomy in IBD patients.
Methods: In a single tertiary referral centre, a diagnostic coding system was used to identify all patients with IBD and a history of colonic resection. Patients were stratified according to the presence of intestinal continuity (ileorectal anastomosis [IRA] and ileal pouch anal anastomosis [IPAA]) or discontinuity (ostomy with or without remaining RS). Additional demographic and clinical data were collected for patients with bowel discontinuity. Endoscopically confirmed diversion colitis, stenosis or shortening of the colon were defined as benign RS complications. Neoplasia was defined as the presence of low-grade dysplasia (LGD), high-grade dysplasia (HGD) or carcinoma in the RS.
Results: Out of 1787 patients with IBD, 352 had 1 or more colonic resections. The final anatomical status was IRA in 25 patients (7.1%), IPAA in 89 patients (25.3%) and a colo-/ileostomy in 238 patients (67.6%). In 197 patients a RS had been in situ for more than 1 year. Out of these 197 patients, 48 had UC (24.4%), 140 had CD (71.0%) and 9 had IBD-unclassified (4.6%). Sixty-nine patients were male (35.0%) and the mean age at colectomy was 38.8 years. Out of 144 patients with endoscopic follow-up, diversion colitis occurred in 115 patients (79.7%) and RS stenosis occurred in 56 (38.9%) patients. In patients with follow-up of the RS (median: 8 years, range 0–39), 5 carcinomas, 1 case of HGD and 6 cases of LGD occurred. Incidence rates were 3.0 and 7.1 per 1000 patient-years of follow-up, for cancer and all neoplasia, respectively. In 45 patients with a RS (22.8%) a completion proctectomy was performed. The main reasons for excision of the RS were treatment or prevention of carcinoma in 7 patients (15.6%) and persisting complaints of the RS such as bloody and mucopurulent rectal discharge in 31 patients (68.9%).
Conclusions: In patients with IBD and a retained RS after colectomy a high prevalence of diversion colitis and RS stenosis was observed during endoscopic follow-up. Cancer occurred in 5 out of 197 patients with an incidence rate of 3.0 per 1000 patient-years.