INCIDENTAL DYSPLASIA DURING TOTAL PROCTOCOLECTOMY WITH ILEOANAL POUCH: IS IT ASSOCIATED WITH WORSE OUTCOMES?
Marianna Maspero*, Ana Otero Pineiro, Olga Lavryk, Stefan D. Holubar, Jeremy M. Lipman, Emre Gorgun, David Liska, Hermann Kessler, Michael Valente, Scott Steele, Tracy L. Hull
Cleveland Clinic, Cleveland, OH
Background: Patients with inflammatory bowel disease (IBD) are at increased risk of colorectal cancer. In cases of invisible or non-endoscopically resectable dysplasia found at colonoscopy, total proctocolectomy with ileal pouch anal anastomosis can be offered with good long-term oncological outcomes and pouch survival, however, little is known regarding cancer-related outcomes when dysplasia is found incidentally after surgery. We hypothesized incidental colorectal dysplasia is associated with worse oncologic outcomes compared to dysplasia diagnosed preoperatively.
Methods: Using our prospectively collected pouch registry, we identified patients who had a) preoperative dysplasia or b) dysplasia found only after colectomy. Patients with cancer preoperatively or after colectomy were excluded. Included patients were divided into three groups: ONLYPRE (+preoperative biopsy, negative final pathology), PREFINAL (+preoperative biopsy and final pathology), and ONLYFINAL (negative preoperative biopsy, +final pathology. Long-term pouch survival in the three groups was assessed with survival analysis.
Results: In total, 517 patients were included: ONLYPRE = 125, PREFINAL = 254, ONLYFINAL = 137. No demographic differences were observed between groups. The preoperative diagnosis was ulcerative colitis in the majority of cases. In patients with a positive preoperative biopsy, the concordance between preoperative biopsy and final pathology was 49% (Figure 1a). After a median follow-up of 12 years (IQR 3 – 21), there were no differences in overall, disease-free or pouch survival between groups (Figure 1b, c, d). Cancer/dysplasia developed in 11 patients: 3 (2%) in the ONLYPRE, 5 (2%) in the PREPOST, and 3 (2%) in the ONLYPOST group (Table 1). Oncologically, one required redo pouch (ONLYPRE group), while 4 required pouch excision: 1 (1%) In ONLYPRE, 1 (0.5%) in the PREPOST, and 2 (2%) in the ONLYPOST group (p = 0.24). Only one cancer-related death occurred in the entire cohort (ONLYPRE group). Disease-free survival at 10 years was 98% for ONLYPRE, 98% for PREPOST, and 98% for ONLYPOST (p = 0.968). Pouch survival at 10 years was 96% for ONLYPRE, 99% for PREPOST, and 97% for ONLYPOST (p = 0.236).
Conclusion: An ileoanal pouch in the setting of IBD-associated dysplasia, regardless of when it is diagnosed, confers exceptionally good long-term outcomes. The incidental finding of dysplasia during proctocolectomy does not seem to be associated with worsened outcomes compared to preoperatively diagnosed dysplasia.
Table 1. Diagnosis and management of patients with cancer/dysplasia development after pelvic pouch
Figure 1. Pathology and long-term outcomes after pelvic pouch for dysplasia. a) Concordance between preoperative biopsy and final pathology; b) Overall survival; c) Disease free survival; d) Pouch survival
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