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The C-seal: A Biofragmentable Drain Protecting the Stapled Colorectal Anastomosis from Leakage
Published on: November 4, 2010
Twenty-year-old stapled pouches for ulcerative colitis without evidence of rectal cancer: implications for
Jorge Silva-Velazco1, Luca Stocchi, Xian-rui Wu
11Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio 2Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio.
Background:
The risk of anal transition zone dysplasia/cancer after stapled IPAA for ulcerative colitis might be cumulative over time.
Objective:
The purpose of this work was to assess the long-term incidence and risk factors of anal transition zone dysplasia.
Design:
This was a retrospective study from a prospectively maintained database.
Settings:
The study was conducted at a tertiary referral center.
Patients:
Participants included those in our surveillance program of serial anal transition zone biopsies after stapled IPAA from 1986 to 1992.
Main Outcome Measures:
Anal transition zone dysplasia was the main measured outcome.
Results:
Of 532 patients, 285 had 2 or more anal transition zone surveillance biopsies, including 73 with ≥20 years of regular follow-up. No adenocarcinoma was detected, and 15 patients died of unrelated causes after a median follow-up of 13.4 years (range, 2.9-19.5 years) without dysplasia. The estimated survival rates at 10, 15, and 20 years were 99.6% (95% CI, 96.9-99.9), 98.9% (95% CI, 95.7-99.7), and 92.6% (95% CI, 86.5-96.0). The estimated rates of anal transition zone dysplasia based on the 9 patients were 2.9% (95% CI, 1.5-5.7) and 3.4% (95% CI, 1.8-6.4) at 10 and 15 years. No new-onset dysplasia was identified beyond 125 months. Postoperative anal transition zone dysplasia was significantly associated with both preoperative and pathology findings of colorectal dysplasia (p < 0.001 for each) or cancer (p = 0.025 and p <0.001) and was managed expectantly or with mucosectomy (5 and 4 patients), depending on the number of positive biopsies and degree of dysplasia. Continued surveillance after detection of anal transition zone dysplasia showed no evidence of recurrent dysplasia during a median follow-up of 125 months (range, 9-256 months).
Limitations:
Approximately half of the eligible patients were excluded from the analysis because of insufficient follow-up.
Conclusions:
Long-term follow-up data corroborate the use of stapled IPAA for ulcerative colitis. Future studies should assess whether a less intensive surveillance strategy is safe 10 years after surgery.
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