Introduction:
The historical approach to neoplasia in the setting of chronic colitis was to perform a total proctocolectomy. Recent consensus and society guidelines[1–3] suggest that when dysplastic lesions can be removed endoscopically, continued surveillance is appropriate. This is based on improvements in optical technologies and the low risk of metachronous colorectal carcinoma (CRC) in these patients [4–6]. We hypothesize that if a lesion is completely removed surgically and followed up endoscopically, metachronous CRC will be a rare occurrence. Thus, segmental resection may be offered as a definitive operation in patients with chronic colitis and localized colorectal neoplasia in whom endoscopic resection is not feasible. Retention of the distal colon/rectum is expected to result in an overall improved quality of life compared to permanent ileostomy or ileoanal J-pouch. Here we report our experience and follow-up of segmental resections for pre-operative neoplasia in patients with Crohn’s disease (CD) or ulcerative colitis (UC).
Methods:
This is a retrospective review from our tertiary inflammatory bowel disease (IBD) center of all patients who were found to have colitis-associated neoplasia on screening or surveillance colonoscopy and subsequently underwent segmental or total abdominal colectomy for this indication. Demographics and disease related information were collected. Pre-operative and surgical diagnoses of neoplasia were confirmed by expert gastrointestinal pathologists. Additionally, all surgical reports, as well as pre-and post-operative endoscopic reports were reviewed. Follow up was defined from the time of surgery (in months) until the last recorded endoscopic exam. Grade of neoplasia found during follow up was recorded.
Results:
Seventeen IBD patients who underwent segmental or total abdominal colectomy with ileorectal anastomoses due to confirmed neoplasia (11 CD and 6 UC). The median age was 64 (range 40–78y-with median disease duration of 20.5 years (range 5–46y) and 4 of the 17 patients had concurrent PSC. All patients had either no disease or endoscopically and histologically quiescent disease in the retained distal colon. 15 patients had IBD-associated low grade dysplasia. The indications for surgery were low grade dysplasia (LGD) in 11 patients (6 CD, 5 UC), high grade dysplasia in 3 patients (2 CD, 1 UC) and adenocarcinoma in 3 patients (all CD). One patient had invasion of the submucosa with no regional lymph node metastasis (pT1pN0MX), another patient had well-differentiated invasive adenocarcinoma with no regional lymph node metastasis, but pericolonic tumor deposits, vascular and perineural invasion (pT3N0 V1 MX). The third patient with adenocarcinoma had a focus of intramucosal adenocarcinoma with no lymph node involvement (pTiN0MX). Five patients (all UC) underwent sub-total colectomy with ileo-rectal anastomosis and 12 underwent segmental colectomy (11 CD, 1 UC).
The patients were followed for a median of 17 months (range 3–228) with a median of 2 follow up endoscopic exams (range 1–8), with high definition endoscopic equipment.
In follow up, 4 patients (all CD, one with concurrent PSC) were found to have LGD, one of which was thought to be a sporadic adenoma. The median time to identifying IBD related LGD post subtotal resection was 48.5 months (range 25–125 months). Two of these patients eventually underwent completion total proctocolectomy due to unresectable flat dysplasia or dysplasia in the setting of innumerable pseudopolyps (72 and 168 months). No cancers or HGD were identified during surveillance. No patients had relapse of their IBD in the period of follow up.
Discussion:
In this small observational cohort, we demonstrate the safety of segmental or total abdominal colectomy with ileorectal anastomoses in patients with IBD undergoing surgery for neoplasia. In this series of patients, subsequent active surveillance of the retained large bowel using modern optical technology appeared to be an effective management strategy. Although the small number and variable follow-up are limitations, we believe that in clinically stable patients, this approach may offer an improved quality of life without compromising cancer prevention strategies.
Footnotes
Conflict of Interest: none to declare.
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