itself was less than 2cm in diameter but was obviously an aggressive cancer. Since there was no evidence of distant metastasis and the lesion was in the colon where radiation would not be needed, she underwent a total proctocolectomy with mucosectomy and J-pouch-anal anastomosis. The loop ileostomy was kept in place for 6months while she underwent chemotherapy (Fig.13.6).

ancer

Cecum

Transvers colon

Sigmoid colon

Fig. 13.6 (a–c) Ulcerative colitis with cancer

Cancer

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Inactiv

ancer

Fig. 13.6 (continued)

13.7 Ulcerative Colitis withCancer

Clinical Presentation A 65-year-old man with ulcerative colitis for 30years was found to have circumferential rectal cancer located just above the dentate line on a physical exam. This patient also has chronic renal disease and diabetes.

Diagnostic Studies

tate line (see Fig.13.7b).

Surgical Findings Diffuse colitis with advanced distal rectal cancer. The patient underwent a total proctocolectomy and Brooke ileostomy (see Fig.13.7a).

Pathology Universal inactive ulcerative colitis. Deeply invasive signet ring cell

rectal cancer extending to the perirectal fat with metastasis present in three lymph nodes.

Follow-Up He required readmission following surgery for a perineal wound infec-

tion, which was drained. The perineal wound eventually healed well, and he was treated with chemotherapy and radiation.

Deeply ulcerated circumferential tumor located near the den-

ectal cancer

Rectal cancer

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Comment This patient had mild colitis with minimal symptoms. This case is another example that severity of colitis does not correlate with cancer risk. He had colitis for over 30years and unfortunately did not have regular surveillance colonoscopy. The diagnosis of this lesion was made only after it became symptomatic. At that point, the tumor was deeply invasive and circumferential, and there were several positive lymph nodes. At this location in the distal rectum, a total proctocolectomy with Brooke ileostomy was the only curative surgical procedure available (Fig.13.7).

Fig. 13.7 (a and b) Ulcerative colitis with cancer

Mild colitis

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13.8 Ulcerative Colitis withCancer inaJ-Pouch

Clinical Presentation A 42-year-old patient with ulcerative colitis since age 24. Patient underwent restorative proctocolectomy at age 29 for severe disease. Sigmoidoscopy, 12 years later, for recent onset of rectal bleeding shows a large ulcerated lesion in the J-pouch.

Diagnostic Studies Deeply ulcerated nearly circumferential tumor located in the distal J-pouch just above the anastomosis near the dentate line.

Surgical Findings Advanced distal rectal cancer. The patient underwent a total proctocolectomy and Brooke ileostomy. No evidence of metastatic disease at the time of surgery (see Fig.13.8a, b, c).

Pathology Deeply invasive poorly differentiated signet ring adenocarcinoma

invading the subserosal fat. Adjacent mucosa with low- and high-grade dysplasia. Margins of resection clear, 10 negative lymph nodes.

Follow-Up He was treated with chemotherapy and pelvic radiation following sur-

gery. Two years later, he developed recurrent disease in the pelvis and a lung nodule on a PET scan. The CEA rose to 44.5. The recurrent tumor was resistant to further systemic therapy, and the patient expired 26months after the surgery.

Comment This patient had colitis for over 5years prior to colectomy and 12years

after creation of the J-pouch with mucosectomy. Mucosectomy does not prevent cancer development after pouch surgery since it has been shown that there are residual microscopic islands of mucosa, which are then covered by the pouch. The diagnosis of this lesion was made only after it became symptomatic. At that point, the tumor was deeply invasive and nearly circumferential. Cancer after pouch surgery is uncommon; in our series, it occurs in only 1% of patients, and few are diagnosed at an early stage (Fig.13.8).

J-pouch

J-pouch cancer

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cancer

Fig. 13.8

(a–c) Ulcerative colitis with cancer in a J-pouch

286

J-pouch cancer

Fig. 13.8 (continued)

T. M. Heimann and R. J. Kurtz

Patients with Crohn’s disease are prone to develop small bowel cancer in diseased segments. These tumors usually present with symptoms of obstruction due to stricture formation. Patients undergoing strictureplasty should have a biopsy of the stricture since often the malignant nature of the narrowed segment of the bowel is not always evident at the time of surgery.

The incidence of colorectal cancer is also higher in patients with Crohn’s disease when compared to the general population. Although there is still some controversy over surveillance colonoscopy in patients with Crohn’s colitis, there is increasing evidence that the colorectal cancer risk is similar to that seen in ulcerative colitis. Patients with Crohn’s colitis and cancer should usually undergo total proctocolectomy with Brooke ileostomy since the cancer risk involves the entire colon and rectum.

14.1 Crohn’s Ileitis withCancer

Clinical Presentation A 72-year-old man with a 31-year history of Crohn’s disease. He presented with obstructive symptoms manifested by abdominal pain and 20-lb weight loss.

Diagnostic Studies Small bowel series showed a dilated ileum with an area of severe narrowing (see Fig.14.1a, e).

T. M. Heimann (*) · R. J. Kurtz Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA e-mail: Tomas.Heimann@mountsinai.org; Robert.Kurtz@mountsinai.org

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 T. M. Heimann (ed.), Atlas of Surgical Treatment of Inammatory Bowel Disease, https://doi.org/10.1007/978-3-031-62431-5_14

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Surgical Treatment Massive dilatation of ileum with annular cancer causing near-

complete obstruction and multiple proximal fecaliths. He had a small bowel resection with end-end anastomosis. Multiple liver metastasis were also present (Fig.14.1b, c, d).

Pathology Crohn’s disease of the ileum with moderately differentiated adenocar-

cinoma of the small bowel inltrating into the mesentery. Regional lymph nodes are free of tumor.

Follow-Up He initially did well and was placed on 5-FU-based chemotherapy.

Comment Small bowel cancer in Crohn’s disease is seldom diagnosed before sur-

gery. These tumors may cause obstruction, usually appearing as recurrent Crohn’s disease or may be found incidentally during resection or strictureplasty. Cancers producing symptoms of obstruction are often advanced, and the prognosis is poor. Tumors found incidentally may be resected at an earlier stage and have a better prognosis. Often these cancers appear as an area of thickening in the wall of the bowel, rather than the ulcerated appearance seen in de novo small bowel cancers (Fig.14.1).