Adenocarcinoma arising from along the rectal stump after double-stapled ileorectal J-pouch in a patient with ulcerative colitis: The need to perform a distal anastomosis

Abstract

Patients treated with restorative proctocolectomy for ulcerative colitis occasionally develop neoplasia from the rectal mucosal remnants. We report a case of a 65-year-old male who developed an adenocarcinoma from the rectal stump after a double-stapled ileorectal J-pouch for ulcerative colitis. We emphasize the need to perform the anastomosis either at the level of the dentate line or just cephalad to the anal transitional zone. Furthermore, when high-grade dysplasia at the rectum is evident, either an ileal pouch-anal anastomosis with mucosectomy or completion proctectomy with an end Brooke ileostomy should be offered. This is the second report in the literature of a carcinoma arising after use of the double-stapled ileal pouch-anal anastomotic technique.

Squamous-Cell Carcinoma Developing After an Ileoanal Pouch Procedure: Report of a Case

“…Rotholtz et al 11 reported a case of adenocarcinoma arising in the remnant of the anal transition zone after stapled IPAA. The authors emphasized the need for a low enough anastomosis to minimize the remnant, and mucosectomy and handsewn IPAA or completion proctectomy and Brooke ileostomy if any high-grade dysplasia is found in the colonic specimen.…”

Pelvic Cancer Ten Years after Restorative Proctocolectomy in Indeterminate Colitis: Report of a Case

“…The lag time between operation and the discovery of malignancy can extend from 22 months to 25 years in patients who had mucosectomies [7][8][9][11][12][13]16,18,20 and 16 months to 12 years in patients with anal transition zone-sparing procedures. 6,7,10,17,19 When the indication for surgery in long-standing IBD is cancer or dysplasia, especially involving the rectum, arguments can be made for and against mucosectomy, stapled IPAA, and even the wisdom of any pelvic pouch procedure. We do not believe that IBD-associated dysplasia at any location or early stage cancer in the colon or proximal rectum is a contraindication to RPC.…”

“…Eighteen cases of postoperative "pouch-related" cancers after restorative proctocolectomy have been reported in the literature. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Most of these cancers were discovered fairly soon after restorative proctocolectomy, and all but two were found in patients with chronic ulcerative colitis. There have been no reports of pouch-related cancer in patients with indeterminate colitis.…”

Practice Parameters for the Surgical Treatment of Ulcerative Colitis

“…Sphincter injury is minimized and the anal transition zone with its abundant supply of sensory nerve endings is preserved. Conversely, short segment inflammation 94,95 and perianastomotic zone carcinoma [96][97][98] are legitimate concerns, highlighting the importance of performing the anastomosis to the top of the anal canal. Three prospective, randomized trials have demonstrated no significant difference in perioperative complications or functional results for patients in whom a mucosectomy was performed vs. those patients in whom the proximal anal canal mucosa was preserved.…”