Total proctocolectomy followed by ileal pouch-anal anastomosis (IPAA) is currently the gold standard in the treatment of familial adenomatous polyposis (FAP) and ulcerative colitis (UC). At our institution, we always tend to favor endoanal mucosectomy (EAM) followed by handsewn anastomosis at the dentate line, while other centers prefer double-stapled anastomosis, considering this technique without EAM to be superior in terms of functional outcomes. This study’s objective was to evaluate the relevance of EAM regarding the functional outcomes and neoplastic risk control in those patients who had been treated at our institution since 1986.
We reviewed the medical records of 166 consecutive patients treated by IPAA for FAP (n=57) or UC (n=109) at our institution. The following parameters were specifically investigated: functional assessments at follow-up visits, pathological results of the EAM resection specimen, and findings of the ileal pouch endoscopic monitoring.
The median stool frequency of patients was 5.8 (IQR: 1-17) per 24h and 1.0 at nighttime (IQR: 0-7). In our series, 82% of patients had perfect daytime continence, 57% perfect nighttime continence, and 23% less than one nocturnal incontinence episode per week. Moreover, 76% of patients had less than one urgency episode per week, and 54% did not suffer from urgency at all. In FAP patients, dysplasia or cancer was detected in 73% of EAM specimens (94% of low-grade dysplasia (LGD), one in situ carcinoma, and one invasive carcinoma). In UC patients, only one EAM specimen presented LGD. None of our patients with FAP or UC developed cancer in the ileal pouch or anal canal after a median follow-up of 114 months (24-331) and 60 months (4-237), respectively. In UC patients, endoscopic monitoring did not reveal any adenomas in the pouch. In FAP patients, 43% developed LGD after a median follow-up of 86 months (9-283), and one patient (2.1%) showed high-grade dysplasia (HGD) after 216 months of follow-up.
Even though we systematically perform EAM, our functional results are as satisfying as in the literature, except for nocturnal continence. However, most incontinent patients did not report more than one incontinence episode per week. The high prevalence of dysplasia as well as the presence of two carcinomas on specimens from our FAP patients are major arguments in favor of performing EAM in these patients. In UC patients, dysplasia was much less prevalent. The findings made during endoscopic monitoring do currently not discredit the efficiency of our EAM policy. However, this monitoring must be continued to detect the development of pouch dysplasia and the emergence of cancer on an islet of residual colonic mucosa.
1 Unité de Chirurgie Colorectale, Cliniques universitaires Saint-Luc, Bruxelles, Belgique
2 Service d’Anatomie Pathologique, Cliniques universitaires Saint-Luc, Bruxelles, Belgique
3 Service d’Hépato-gastro-entérologie, Cliniques universitaires Saint-Luc, Bruxelles, Belgique