Dysplasia at the Anal Transition Zone after IPAA

 

 Buy Article Permissions and Reprints

Abstract

Ileal pouch-anal anastomosis is a popular way of reconstruction the gastrointestinal tract after total proctocolectomy for ulcerative colitis. The pouch-anal anastomosis is usually stapled, which requires the preservation of a small amount of upper anal canal and lower rectum. This includes the anal transition zone (ATZ), a surprisingly small and irregular ring of tissue at and just above the dentate line. The ATZ and rectal cuff is prone to inflammation and neoplasia, particularly in patients who had a colon cancer or dysplasia at the time their large bowel was removed. This high-risk group needs ATZ/rectal cuff surveillance before and after the surgery. Those without colorectal dysplasia preoperatively are at low risk of developing ATZ/rectal cuff dysplasia postoperatively and follow-up can be more relaxed. Treatment of ATZ dysplasia is difficult and may mean mucosectomy, pouch advancement, pouch removal, or a redo pelvic pouch.

Publication History

Article published online:
28 December 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

• References

• 1 Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. BMJ 1978; 2 (6130): 85-88
  CrossrefPubMedGoogle Scholar
• 2 Lovegrove RE, Constantinides VA, Heriot AG. et al. A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg 2006; 244 (01) 18-26
  CrossrefPubMedGoogle Scholar
• 3 Lee CHA, Kalady MF, Burke CA. et al. Incidence and management of rectal cuff and anal transitional zone neoplasia in patients with familial adenomatous polyposis. Dis Colon Rectum 2021; 64 (08) 977-985
  CrossrefPubMedGoogle Scholar
• 4 Fenger C. The anal transitional zone. Acta Pathol Microbiol Immunol Scand, A, Suppl 1987; 289: 1-42
  PubMedGoogle Scholar
• 5 Thompson-Fawcett MW, Warren BF, Mortensen NJ. A new look at the anal transitional zone with reference to restorative proctocolectomy and the columnar cuff. Br J Surg 1998; 85 (11) 1517-1521
  CrossrefPubMedGoogle Scholar
• 6 Fenger C. The anal transitional zone. Location and extent. Acta Pathol Microbiol Scand [A] 1979; 87A (05) 379-386
  PubMedGoogle Scholar
• 7 Fenger C, Knoth M. The anal transitional zone: a scanning and transmission electron microscopic investigation of the surface epithelium. Ultrastruct Pathol 1981; 2 (02) 163-173
  CrossrefPubMedGoogle Scholar
• 8 Fenger C, Lyon H. Endocrine cells and melanin-containing cells in the anal canal epithelium. Histochem J 1982; 14 (04) 631-639
  CrossrefPubMedGoogle Scholar
• 9 Kariv R, Remzi FH, Lian L. et al. Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology 2010; 139 (03) 806-812 , 812.e1–812.e2
  CrossrefPubMedGoogle Scholar
• 10 Horio Y, Uchino M, Bando T. et al. Incidence, risk factors and outcomes of cancer of the anal transitional zone in patients with ulcerative colitis. J Crohn's Colitis 2020; 14 (11) 1565-1571
  CrossrefPubMedGoogle Scholar
• 11 Liu ZX, Liu XL, Patil DT. et al. Clinical significance of indefinite for dysplasia on pouch biopsy in patients with underlying inflammatory bowel disease. J Gastrointest Surg 2012; 16 (03) 562-571
  CrossrefPubMedGoogle Scholar
• 12 Lightner AL, Vaidya P, Vogler S. et al. Surveillance pouchoscopy for dysplasia: Cleveland Clinic Ileoanal Pouch Anastomosis Database. Br J Surg 2020; 107 (13) 1826-1831
  CrossrefPubMedGoogle Scholar
• 13 Block M, Börjesson L, Willén R. et al. Neoplasia in the colorectal specimens of patients with ulcerative colitis and ileal pouch-anal anastomosis - need for routine surveillance?. Scand J Gastroenterol 2015; 50 (05) 528-535
  CrossrefPubMedGoogle Scholar
• 14 Ziv Y, Fazio VW, Sirimarco MT, Lavery IC, Goldblum JR, Petras RE. Incidence, risk factors, and treatment of dysplasia in the anal transitional zone after ileal pouch-anal anastomosis. Dis Colon Rectum 1994; 37 (12) 1281-1285
  CrossrefPubMedGoogle Scholar
• 15 Remzi FH, Fazio VW, Delaney CP. et al. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years. Dis Colon Rectum 2003; 46 (01) 6-13
  CrossrefPubMedGoogle Scholar
• 16 Wu XR, Kirat HT, Kalady MF, Church JM. Restorative proctocolectomy with a handsewn IPAA: S-pouch or J-pouch?. Dis Colon Rectum 2015; 58 (02) 205-213
  CrossrefPubMedGoogle Scholar
• 17 Kiran RP, Kochhar GS, Kariv R. et al. Management of pouch neoplasia: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2022; 7 (09) 871-893
  CrossrefPubMedGoogle Scholar