From the Guidelines
Yes, patients with an ileal pouch-anal anastomosis (IPAA) should undergo regular surveillance for cancer, particularly if they had underlying ulcerative colitis or familial adenomatous polyposis prior to their surgery.
Rationale for Surveillance
The rationale for surveillance is that despite removal of the colon and rectum, the risk of neoplasia is not completely eliminated. Inflammation in the pouch (pouchitis) and the presence of any remaining rectal mucosa can lead to dysplasia and potentially cancer over time.
Surveillance Recommendations
For most patients, endoscopic surveillance of the pouch (pouchoscopy) should be performed annually starting 8-10 years after the initial diagnosis of inflammatory bowel disease, as recommended by the AGA clinical practice update on endoscopic surveillance and management of colorectal dysplasia in inflammatory bowel diseases 1.
Biopsy Protocol
During surveillance, multiple biopsies should be taken from the pouch body, inlet, and any remaining rectal cuff (if present).
Risk Factors
Patients with additional risk factors such as primary sclerosing cholangitis, a history of colorectal dysplasia or cancer, or a strong family history of colorectal cancer may require more frequent surveillance, typically every 6 months, as suggested by the european evidence based consensus for endoscopy in inflammatory bowel disease 1.
Importance of Early Detection
Early detection through regular surveillance allows for timely intervention and improved outcomes. Patients should be informed that while the absolute risk of pouch neoplasia is relatively low (1-4%), lifelong surveillance remains important for early detection.
Key Considerations
- The cumulative incidence of cancers of the pouch and cuff is lower than the lifetime CRC risk in the general population, but surveillance is still crucial for early detection and intervention 1.
- The presence of dysplasia in the original colectomy specimen and associated PSC are significant predictors for the development of pouch dysplasia 1.
- Annual pouchoscopy is recommended in patients with risk factors such as neoplasia and primary sclerosing cholangitis 1.
- No specific pouch follow-up protocol is required in asymptomatic patients without risk factors 1.
From the Research
Surveillance of Ileal Pouch-Anal Anastomosis for Cancer
- The decision to surveil an ileal pouch-anal anastomosis (IPAA) for cancer is based on the risk of developing dysplasia or cancer in the pouch or retained rectal mucosa 2, 3, 4.
- Studies have shown that the risk of neoplasia is higher in patients with ulcerative colitis who undergo ileorectal anastomosis (IRA) compared to those who undergo IPAA 2.
- However, cases of adenocarcinoma in the ileal pouch have been reported, highlighting the importance of regular follow-up with pouchoscopy and random biopsies in patients with long-standing inflammation of the ileal mucosa 4.
- Risk factors for carcinoma in the pelvic ileal pouch/anal canal include dysplasia, p53 overexpression, labeling index, and aneuploidy 3.
- Surveillance endoscopy has been shown to be effective in detecting dysplasia/cancer at an early stage, particularly in patients with IRA 2.
- The cumulative incidence of neoplasia after IPAA is minimal, but it is still important to consider surveillance, especially in patients with a history of dysplasia or cancer 2, 5, 6.
- The type of surgery, such as stapled IPAA, may also impact the risk of cancer and the effectiveness of surveillance 6.
Recommendations for Surveillance
- Regular follow-up with pouchoscopy and random biopsies is recommended for patients with long-standing inflammation of the ileal mucosa 4.
- Surveillance endoscopy should be considered for patients with a history of dysplasia or cancer, particularly those with IRA 2, 6.
- The frequency and duration of surveillance should be individualized based on the patient's risk factors and history of disease 3, 5.
- Close long-term follow-up is recommended for patients with cancer/dysplasia to detect possible recurrence early 6.