When should a patient with a history of ulcerative colitis (UC) and multifocal dysplasia, who has undergone a restorative proctocolectomy with ileal pouch-anal anastomosis, have their pouch checked for dysplasia or cancer?

Pouch Surveillance After Colectomy for UC with Multifocal Dysplasia

Annual pouchoscopy is recommended for patients who underwent restorative proctocolectomy for ulcerative colitis with multifocal dysplasia, as preoperative dysplasia is a significant risk factor for subsequent pouch neoplasia. 1

Risk Stratification

Your patient falls into the high-risk category based on the preoperative indication of multifocal dysplasia. The evidence clearly demonstrates that:

• Preoperative dysplasia or cancer are the most significant predictors for developing pouch dysplasia after restorative proctocolectomy 1
• Patients with preoperative dysplasia have an adjusted hazard ratio of 3.62 (95% CI: 1.59-8.23) for developing pouch neoplasia compared to those without 2
• Those with preoperative cancer have an even higher risk with an adjusted hazard ratio of 13.43 (95% CI: 3.96-45.53) 2

Surveillance Protocol

Initial Surveillance

• Perform screening pouchoscopy at 1 year after surgery to assess pouch inflammation and histological activity 1
• This initial examination helps refine risk stratification beyond clinical factors alone 3

Ongoing Surveillance Schedule

• Annual pouchoscopy thereafter for patients with risk factors including preoperative neoplasia 1
• The European Crohn's and Colitis Organisation explicitly states that annual pouchoscopy is recommended in patients with risk factors such as neoplasia 1

What to Examine

During each surveillance pouchoscopy, ensure complete examination of:

• The ileal pouch mucosa 1
• The rectal cuff (if present) 1
• The anal transitional zone 1, 4

Dysplasia occurs with equal frequency in the pouch and rectal cuff/anal transitional zone 1

Biopsy Protocol

• Take biopsies from all regions of the pouch, rectal cuff, and anal transitional zone during surveillance 3
• Target any endoscopically visible lesions 1
• Consider random biopsies even in the absence of visible lesions given the high-risk status 1

Critical Timing Considerations

Important caveat: Cancers reported after IPAA typically occurred over 10 years after the onset of UC, not after surgery 1, 4. However, this does not diminish the need for annual surveillance starting at 1 year post-surgery, as dysplasia can develop earlier and precedes cancer 2.

Management of Findings

If dysplasia is detected during surveillance:

• Any grade of dysplasia without an endoscopically visible lesion requires urgent repeat chromoendoscopy by an experienced endoscopist 1
• Adenocarcinoma or high-grade dysplasia without a resectable lesion are indications for pouch excision 1
• Low-grade dysplasia requires repeat chromoendoscopy within 3 months 1

Quality Assurance

Ensure pouchoscopy reports document:

• Complete visualization of all pouch regions 3
• Specific findings in the pouch body, inlet, rectal cuff, and anal transitional zone 3
• Incomplete reporting is common (54-78% in one study) and should be avoided 3

Additional Risk Factors to Monitor

While your patient already qualifies for annual surveillance based on preoperative dysplasia, be aware that other high-risk features include:

• Primary sclerosing cholangitis 1
• Longer retained rectal cuff 1
• Type C histological changes 4, 5
• Unremitting pouchitis 4

The presence of multifocal dysplasia preoperatively places this patient in the highest risk category, and mucosectomy does not eliminate this risk 4, 2, making annual surveillance non-negotiable.