Surgical Options

Provenzale et al. [9] proposed prophylactic colectomy for patients with a long-standing colitis or at risk of developing CRC; this approach should prevent the need of emergency colectomy. In a comparative study of about 17 different strategies, including no colonoscopic surveillance, surveillance at varying intervals and prophylactic proctocolectomy with ileal pouch-anal anastomosis, Provenzale showed that for a 30-year-old patient with pancolitis for 10 years, prophylactic colectomy would increase life expectancy by 2-10 months compared with surveillance and by 1.1-1.4 years compared with no surveillance. Surveillance would improve life expectancy by 7 months to 1.2 years compared with no surveillance.

However, when proposing this approach to the patients we should consider that restorative procto-colectomy is a major surgical procedure. The global rate of success is 95% with a morbidity of 13-59% and a post-operative complication rate of 30-50% [18-24].

Obviously, in the presence of a diagnosed CRC a total colectomy is mandatory.

In patients with rectal cancer and UC the stage could determine the best surgical option (Table 4). In patients with stage 1-2, restorative proctocolectomy is the procedure of choice because the disease is not advanced. Surgical technique, however, is quite different because an extramesorectal approach must be chosen with a high ligation of mesenteric vessels instead of an intramesorectal dissection.

Moreover, if the choice for the type of rectal dissection in patients with a diagnosed rectal cancer is clear, in the case of prophylactic proctocolectomy in males younger than 50 years and with the presence of high-grade dysplasia, an extramesorectal excision should be carefully chosen.

The rate of genito-urinary dysfunction in males after anterior resection for cancer is 0-49% [25]; this is an acceptable rate in the presence of a certain cancer but for a prophylactic surgery it should be carefully evaluated. The rate of impotence after rectal excision for inflammatory bowel disease is lower than after excision for rectal cancer ranging from 0-25% [25-30]. The incidence of sexual dysfunction increases with age and when a mesorectal plane is preferred to close rectal plane of dissection [25].

Another important issue is the role of transanal mucosectomy. Mucosectomy theoretically eliminates the risk of neoplastic transformation in the remaining anal canal epithelium. O'Connell et al. [31] showed that even after endo-anal mucosectomy, residual of rectal mucosa remains in the denudated muscle cuff in up to 14% of the patients and in up to 7% of patients at anastomosis.

Tsunoda et al. [32] studied the incidence of dys-

Table 4. Cancer and surgical options

Stage

Procedure

1-2

Restorative proctocolectomy

(2)-3

Proctocolectomy+ileostomy

4

Segmental colectomy

plasia in the mucosal strippings from the anorectal stump of patients operated on with restorative proc-tocolectomy for UC or familial adenomatous polypo-sis. On 118 operative specimens (8 CRC on UC) 87.5% of patients with cancer showed dysplasia on the colonic mucosal compared with only 4.5% of those without cancer. Anal mucosa of patients with CRC showed dysplasia in 25% of the cases compared with only 0.9% of those without cancer. Moreover, colonic dysplasia was present in 26.3% of the patients with a long-standing colitis (more than 10 years from the diagnosis) compared with 2.6% of those with less than 10 years of disease; a similar trend was observed for dysplasia in the anal mucosa (7.9 vs. 0%).

However, since the first description of the doublestapled technique restorative proctocolectomy [33], there is still controversy over the risk of dysplasia and residual disease.

The pros for the preservation of the anal transitional zone (ATZ) are that it is technically easy and seems to improve function with a low rate of septic complication and sepsis-related pouch excision compared with the handsewn technique [34]. Reilly et al. [35], in a prospective randomised trial, showed that 64% of the handsewn group experienced occasional or frequent episodes of faecal incontinence compared with 38% of the stapled group with higher anal canal resting pressure (49.4 vs. 78.3 mmHg, p<0.05) and squeeze pressure (144 vs. 195 mmHg, p<0.06) in the stapled group. However, other randomised trials have failed to find functional differences between the two techniques [36, 37].

On the other hand, mucosectomy decreases the risk of dysplasia. At a follow-up of 10 years after restorative proctocolectomy, the incidence of dysplasia was 5% [38].

The risk of developing a CRC on ATZ is very low. In the literature there are four cases of adenocarcino-ma arising along the rectal stump after double-stapled pouch in patients with UC [39,40].

A correct approach is to routinely perform a mucosectomy, if a restorative proctocolectomy is performed in the presence of CRC or dysplasia; in all other cases a stapled restorative proctocolectomy is safe and a yearly digital examination with ATZ biopsy should be performed. If a dysplasia is found, a transanal mucosectomy with ileal pouch advancement is advocated [41, 42]. Functional results after restorative proctocolectomy for rectal cancer in UC are the same compared with that observed in patients without cancer.

Gorfine et al. [43] studied 45 patients with CRC on UC (14 rectal location) which underwent restorative proctocolectomy. Thirty-six of the 39 patients still alive (92%) had a functioning pelvic pouch.

Remzi and Preen [44] showed 26 rectal cancers in

1850 patients with UC (1.4%). These patients underwent a restorative proctocolectomy with mucosectomy and the oncological and functional results were good, with a five-year survival of 78% and a good to excellent pouch function at a follow-up ranging from 1 to 17 years.

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