Dysplasie und Adenokarzinome im Ileum-Pouch nach restaurativer Proktokolektomie wegen Colitis ulcerosa

Purpose. Restorative proctocolectomy (RPC) is the standard surgical treatment for ulcerative colitis (UC). Restorative proctocolectomy is indicated for UC that is refractory to medical treatment, for emergency conditions, and in cases of neoplastic transformation. The procedure substantially reduces the risk of UC-associated dysplasia/neoplasia. However, after RPC surgery, even with mucosectomy, cancers of the pouch and/or the anal transitional zone (ATZ) have been reported with increasing frequency since the first report in 1984. This review highlights pouch-related dysplastic and neoplastic transformation, prevalence and adverse events, risk factors and surveillance following surgery for UC.Patients and methods. Reports in the literature on patients undergoing pouch surgery at different institutions up to May 2010 were reviewed to identify patients who developed these complications, and an attempt was made to develop a rational follow-up policy based on the available data.Results. To date, there have been 43 reported cancers of the pouch or inlet after RPC for UC: 16 from retrospective series, one from a prospective study, and 26 in case reports. A total of 30 patients underwent mucosectomy and 13 had stapled anastomoses. To date, 28 patients have been diagnosed with dysplasia after RPC for UC. Mucosectomy was performed in 27 of these and in one a stapled anastomosis was constructed without mucosectomy. In all cases reviewed, the time interval from the onset of UC to dysplasia/neoplasia was over 10 years.Conclusions. Neoplastic lesions occurring in UC patients after RPC have been shown to be absolutely inevitable. Even mucosectomy does not completely eliminate the risk. There is little evidence to support routine biopsy of the ileal mucosa or the ATZ except in patients with histological type C changes, sclerosing cholangitis, and unremitting pouchitis in the ileal mucosa. Such patients should be selected for endoscopic surveillance to detect dysplasia preceding pouch adenocarcinoma.