From the Guidelines
Patients with an ileal pouch-anal anastomosis (IPAA) in the UK should undergo annual surveillance with pouchoscopy if they have high-risk factors such as prior colorectal cancer or dysplasia, or primary sclerosing cholangitis, as recommended by the most recent guidelines 1.
Key Points to Consider
- The risk of neoplasia in pouches is extremely small, but it increases with longer pouch duration, particularly beyond 10 years post-surgery 1.
- Patients with high-risk factors, such as prior colorectal dysplasia or cancer, or primary sclerosing cholangitis, should undergo annual surveillance pouchoscopy 1.
- The procedure involves taking 4 random biopsies from different quadrants of the pouch and additional targeted biopsies of any suspicious areas.
- The surveillance aims to detect dysplasia or adenocarcinoma that may develop in the pouch mucosa over time.
- Patients without risk factors may not require surveillance, but individualized surveillance intervals should be considered 1.
Rationale for Surveillance
- The ileal mucosa in the pouch undergoes colonic metaplasia when exposed to fecal stasis, potentially leading to similar neoplastic changes as seen in the original diseased colon.
- Regular surveillance allows for early detection and intervention if concerning changes are found, which can improve morbidity, mortality, and quality of life outcomes.
Important Considerations
- Patients should be informed that while the absolute risk of pouch neoplasia is low, regular surveillance is still important for early detection and intervention.
- The British Society of Gastroenterology recommends surveillance every 5 years for those without risk factors, but individualized surveillance intervals should be considered 1.
From the Research
Pouch Surveillance Guidelines in the UK
There are no specific guidelines mentioned in the provided studies for pouch surveillance in the UK. However, the studies provide information on the importance of surveillance and the risks associated with pouch-related dysplasia and adenocarcinoma.
Risk Factors and Surveillance
- The risk of pouch-related dysplasia and adenocarcinoma is higher in patients with a preoperative diagnosis of ulcerative colitis (UC)-associated dysplasia or cancer 2, 3.
- Surveillance endoscopy with biopsy is recommended for patients at risk, such as those with a preoperative diagnosis of UC-associated neoplasia 3.
- The time interval for routine endoscopic surveillance is not clearly defined, but it is recommended to perform pouchoscopy at 1 year postoperatively to refine risk-stratification based on clinical factors alone 4.
- Patients with histological type C changes, sclerosing cholangitis, and unremitting pouchitis in the ileal mucosa should be selected for endoscopic surveillance to detect dysplasia preceding pouch adenocarcinoma 2.
Current Practices in Ileal Pouch Surveillance
- There is a lack of universally accepted guidelines regarding surveillance of UC patients after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) 4.
- A retrospective cohort study found that 35% of patients had never undergone pouchoscopy for any indication, and 70% had never undergone pouchoscopy with surveillance as the specific indication 4.
- The study also found that patients under the care of surgeons appeared more likely to undergo surveillance, but rates of incomplete reporting were higher among surgeons than gastroenterologists 4.
Diagnosis and Management of Dysplasia and Cancer
- The diagnosis and management of dysplasia and cancer of the ileal pouch in patients with underlying inflammatory bowel disease are challenging due to the lack of clear guidelines and the rarity of pouch neoplasia 3.
- The main risk factor for pouch neoplasia is a preoperative diagnosis of UC-associated dysplasia or cancer, and mortality associated with pouch cancer, once diagnosed, appears to be high 3.
- Surveillance endoscopy with biopsy is the current gold standard for surveillance, but it is not clear how often it should be performed 3.