Does external beam radiation therapy to the pelvis portend worse ileal pouch outcomes? An international multi‐institution collaborative study

Abstract

Aim Short‐term morbidity and long‐term functional outcome of patients with an ileal pouch‐anal anastomosis (IPAA) exposed to pelvic external beam radiation therapy (EBRT) remains unknown. We report the largest series to date regarding the effects of pelvic EBRT on: (i) 30‐day postoperative outcomes; and (ii) long‐term functional outcome following IPAA. Method A retrospective chart review was conducted of patients who received EBRT before or after IPAA between 1980 and 2017 across three international inflammatory bowel disease referral centres. Results Nineteen patients were included. Indications for EBRT were rectal adenocarcinoma (n = 13), prostate adenocarcinoma (n = 4) or anal squamous cell carcinoma (ASCC) (n = 2). EBRT was given prior to IPAA in 12 (63%) patients and after IPAA in seven (37%). In EBRT before IPAA, patients had a median of 5 (range: 4–8) daytime bowel movements, 1 (range: 0–5) night‐time bowel movement, no daytime incontinence, and only one patient used pads at a median follow up of 25 (range: 11–163) months; one patient underwent pouch excision 15 months after IPAA. In EBRT after IPAA, patients reported a median of 8 (range: 5–10) daytime and 2 (range: 0–5) night‐time bowel movements, 80% had either daytime or night‐time incontinence and 80% used pads at a median follow up of 90 (range: 25–315) months. Conclusion Pelvic EBRT administered prior to IPAA is associated with acceptable long‐term function outcome. However, when pelvic EBRT is given to an IPAA in situ, most patients experience poor long‐term pouch function without pouch failure.

Anal Squamous Cell Carcinoma in Ulcerative Colitis: Can Pouches Withstand Traditional Treatment Protocols?

“…Of the 6 patients in our series with stage II or III ASCC, all received standard treatment protocols with EBRT and 5-fluorouracil and mitomycin chemotherapy regimens. 10,11 Consistent with the poor functional outcomes of EBRT on IPAA in the literature regarding IPAA and radiation therapy for prostate adenocarcinoma, 12–15 all 4 patients with an IPAA in situ in our series required intestinal diversion or pouch excision due to their inability to tolerate their treatment protocol. Similarly, just as EBRT is a relative contraindication to pouch formation following EBRT because of the potential for compromised pouch function in the setting of a prior EBRT, the 2 patients in our series without a pouch in situ never underwent an IPAA after their ASCC treatment.…”

“…8,9 However, in the setting ASCC, where standard of care includes external beam radiation therapy (EBRT), 10,11 EBRT may preclude pouch construction at a later date or may not be tolerated by patients with an IPAA in situ. [12][13][14][15] First, we herein report the results of a single institution's incidence of low-and high-grade squamous intraepithelial lesions (LSIL/HSIL) and ASCC for all adult patients with UC evaluated at our institution. Second, we report the patient characteristics, UC disease characteristics, HPV association, and treatment outcomes of all patients with UC diagnosed with anal neoplasia at a single institution to better understand treatment practices for this particular patient population with and without IPAA.…”

“…8,9 However, in the setting ASCC, where standard of care includes external beam radiation therapy (EBRT), 10,11 EBRT may preclude pouch construction at a later date or may not be tolerated by patients with an IPAA in situ. 12–15…”

Elective and Emergent Surgery in the Ulcerative Colitis Patient

“…Pouch function was acceptable among patients receiving neoadjuvant therapy but long-term outcomes were poor for those receiving radiation with the pouch in situ. 27 Though EBRT in the course of neoadjuvant treatment is not a contraindication to IPAA, patients should be counseled extensively on the risk of long-term function and pouch survival. Postoperative radiotherapy is contraindicated in patients with IPAA due to high risk of radiation damage leading to pouch dysfunction.…”

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis

“…[108][109][110] Given the risk of neoplasia, surveillance colonoscopy for patients with UC is endorsed by multiple societies; however, controversy persists regarding the optimal timing for initiating screening and recommended surveillance intervals. 111 Regardless of the extent of disease at initial diagnosis, patients should undergo a screening colonoscopy within 8 years of the onset of symptoms. The recommended intervals for subsequent surveillance endoscopic examinations are determined by individualized risk assessment and vary by different societies' guidelines.…”