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Surgical Management of Acute Ulcerative Colitis 261
The entire specimen is exteriorised through the
enlarged inferior low-quadrant incision. Alternative-
ly, mesenteric vessels are divided outside the
abdomen, closer to the colon, brought out through a
periumbilical or a suprapubic incision. A standard J-
pouch is constructed, the head of a circular stapler is
secured in the apex of the pouch. The abdominal
incision is sutured, and the pneumoperitoneum is re-
established. The pouch is then brought down well
oriented to the pelvic floor, the head is connected to
the pin of the stapler, which is advanced through the
anus and fired. A suction drain is positioned in the
pelvic region behind the ileal pouch. A loop ileosto-
my is usually created in the enlarged right lower
quadrant trocar site. All trocars sites are inspected,
and the parietal incisions are sutured.
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Surgical Management of Acute Ulcerative Colitis 263
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Introduction
Colorectal cancer is far from being the most common
complication of ulcerative colitis (UC), but it is the
one that has been most extensively studied, and the
literature on the subject exceeds that dealing with
other complications of the disease. Many groups of
workers have investigated the complex relationship
between ulcerative proctocolitis and cancer of the
large bowel.
Incidence
The colitic patient faces a higher risk of large-bowel
cancer than does a member of the general popula-
tion. Opinions as to how large this risk is differ great-
ly between different authors. This is hardly surpris-
ing, however, as there have been differences in the
method of collection of materials, and the duration of
the colitis has not always been taken into account [1,
2]. In facing the problem of cancer development in
longstanding ulcerative colitis, many important
issues have to be considered.
Are all patients subject to the same risk from
large-bowel cancer, or can any one group of patients
be singled out as being especially at risk? If such a
group can be identified, at what stage of their disease
are they particularly liable to develop the cancer? If
the patient’s risk group can be defined with reason-
able precision, is it possible to predict the sort of can-
cer risk which an individual patient faces? How
should these patients be followed up and how should
the surveillance programme be designed? Another
crucial issue is whether the risk of cancer is sufficient
to warrant the use of prophylactic surgery, and if so,
when should it be recommended, and with all
options present today, what form should the prophy-
lactic surgery take?
The cumulative probability of cancer for all
patients with ulcerative colitis, regardless of disease
extent, has been demonstrated to be 2 % at 10 years,
8% at 20 years and 18% at 30 years, while the overall
prevalence of colorectal cancer in any patient has
been demonstrated to be 3–4% [3]. However, there is
convincing evidence that there are colitis patients
who have an especially high risk of developing can-
cer. Investigations into the relationship between can-
cer and colitis have focussed upon the identification
of a “high-risk” group of patients and the one single
factor which does exert the most influence regarding
cancer risk in colitic patients concerns the extent of
the patient’s colitis. It seem to be quite clear that
patients who are especially at risk for development of
carcinoma are those with total or near-total involve-
ment of the colon (i.e. involvement of the whole left
half of the colon and the transverse colon as well).
There is indeed a remarkable unanimity of opinion
on this point between the various workers who have
studied the problem [4, 5, 6]. There is, additionally,
convincing evidence to show that the duration of col-
itic symptoms has a strong impact on the incidence
of cancer in those high-risk patients. In other words,
the longer the history of colitis, the greater the risk of
carcinoma.
An idea of the risk of cancer facing the individual
patient with total involvement can be gained from
the many studies that have been undertaken over the
years. Remarkably little attention has been paid to
the variation in the duration of the disease between
different patients when the incidence of cancer in UC
has been calculated. In published reports, the crude
incidence is often used. However, the use of crude
incidence to evaluate the risk of carcinoma in UC is
misleading, as it fails to correct for differences in
duration between individual patients. The figures
may thus underestimate the true incidence of carci-
noma in UC. The time factor is essential and by
employing the life-table concept much more sophis-
ticated and accurate results can be obtained. While
there is evidence to show that the cancer risk for a
patient with total involvement is low during the first
10 years of colitic symptoms, being around 0.4% per
annum, the annual risk of cancer starts to rise
sharply after this initial decade, and after 20 years of
colitis, the individual with total involvement faces an
The Cancer Risk in Longstanding Ulcerative Colitis:
Surveillance Colonoscopy and Prophylactic Surgery
Leif Hultén
266 L. Hultén
annual risk of cancer of over 5% for the remainder of
his life.
However, the yearly risks accumulate, so that the
cumulative risk during a period of 5, 10, 20 or even
25 years is far higher. The cumulative risk of cancer
in such patients rises slowly at first to around 4%
after 10 years of colitic symptoms. However, after
10 years of colitis, the cumulative risk increases more
and more sharply to reach a startling level of 41–48%
after 25 years of colitic symptoms [5, 6]. Recently,
similar results have been presented, while others
demonstrate that those with total or extensive colitis
(extending proximal to the splenic flexure), colitis of
8 years or more, a family history of colorectal cancer,
primary sclerosing cholangitis and an early age of
onset of colitis have the greatest risk of developing
cancer [3, 7]. Primary sclerosing cholangitis (PSC)
occurs in about 2.5–6% of patients with UC, adding
considerable risk of cancer compared with UC in
general [7]. The mean interval from diagnosis of PSC
to dysplasia or cancer is only 2.9 years. Colorectal
cancer associated with PSC is more likely to be prox-
imal, to be diagnosed at a more advanced stage, and
to be fatal.
While patients with extensive colitis may have an
almost 20 times higher risk of cancer compared with
the general population of patients, those with left-
sided colitis may only have a four times higher risk,
and for an individual patient with a distal proctocol-
itis, the risk is very small, probably about the same as
that in the general population of the same age and sex
[4, 8].
The age of the patient at the onset of colitis is
another factor which has inspired debate. It has often
been claimed that colitic patients whose disease
began in childhood may have a particular tendency
to develop cancer [9]. One explanation that has been
put forward is that total involvement – a strong risk
factor – is far more common in patients under
20 years of age than in elderly patients. Another
important reason why patients who develop ulcera-
tive colitis as children are particularly at risk from
carcinoma, is that they are the only patients who will
live long enough to develop cancer! Patients who
develop total involvement at the age of 50 or later
already have a curtailed life expectation and will
probably not live long enough to develop cancer.
Therefore, the main factor which undoubtedly exerts
an effect upon the cancer risk for colitic patients is
the extent of the patient’s colitis.
Tumour Characteristics and Prognosis
Colitis carcinoma occurs as a rule at an earlier age
than does ordinary large-bowel cancer, the average
age incidence being 41 years, compared with about
60 years in cases of ordinary carcinoma of the colon
and rectum [9]. While most writers claim that the sit-
ing of colitis carcinomas does not differ materially
from that of ordinary large bowel carcinomas, others
have demonstrated that while approximately three-
quarters of ordinary carcinomas are concentrated in
the rectum and sigmoid, only one-quarter of the col-
itic carcinoma occurs in the rectosigmoid segment
[10]. Another notable feature of colitis carcinomas is
the high incidence of multiple primary growths
which is about four times greater than that found
with carcinoma of the colon in general. The individ-
ual growth may exhibit the gross features of an ordi-
nary colorectal cancer but may sometimes be quite
atypical, being flat and infiltrating with an ill-defined
edge or sometimes appearing rather as a relatively
inconspicuous thickening of the colon wall-like
fibrous strictures.
Colitic cancers differ even histologically from spo-
radic cancer as they are more often high grade and
mucinous or of a signet-ring cell type, and usually
they have spread extensively by the time the patient
comes to surgery [11]. Dysplasia in non-colitic can-
cers is almost always polypoid. In patients with coli-
tis, however, there are flat dysplasia (mostly invisible
to an endoscopist), raised dysplasia called DALM
(dysplasia-associated lesion or mass) and incidental
adenomas.
Because of the active nature of these colitic
growths and the delay that often attends their diag-
nosis, many of them may have reached an advanced
inoperable or incurable stage by the time they come
to surgery. In the treatment of established colitis car-
cinomas, if the growth is operable, the ideal is pan-
proctocolectomy since more limited resections are
very liable to be followed by the development of fur-
ther carcinomas in the remaining colon or rectum
[11].While reasonably good results may sometimes
be achieved after surgery, the average 5-year survival
rate is less than after idiopathic cancer [12].
The Justification for Prophylactic Surgery
The high cancer risk and dubious prognosis is dis-
quieting and it automatically raises the question as to
the advisability of prophylactic excisional surgery.
Over the years, the opinion has been sharply divided
as to the justification for this step. While some
authors consider that the cancer risk does not neces-
sarily justify an increased use of colectomy [13, 14]
others advocate preventive surgery for all patients
with a 10-year history of ulcerative colitis and total
involvement of the colon and rectum [4, 5, 6]. Still
others go even further and recommend surgery for
The Cancer Risk in Longstanding Ulcerative Colitis: Surveillance Colonoscopy and Prophylactic Surgery 267
all patients with a radiologically abnormal colon four
or more years after the onset of disease [15]. Howev-
er, even in patients with longstanding colitis, elective
proctocolectomy, with its inherent mortality and
morbidity, cannot be justified on the basis of cancer
prevention in patients whose colitis is restricted to
the distal half of the colon. However, in the group of
patients with total or subtotal involvement of the
colon with a colitic history of 10 or more years, a very
strong case can clearly be argued for elective surgery
on the basis of cancer prevention alone. In such
patients, the risk of cancer with continued conserva-
tive treatment is so high as to completely outweigh
the hazards of prophylactic surgery.
Cancer Screening and Colonoscopy Surveillance
In the past, the indication for prophylactic colectomy
for patients with longstanding ulcerative colitis was
mainly based on the disease history and the clinical
risk factors mentioned above. Today, with the avail-
ability of colonoscopy and the recognition of the dys-
plasia–precancer–cancer sequence, surveillance
colonoscopy with serial colonoscopic examinations
and mucosal biopsies is thought to allow for a more
adequate individual assessment of the cancer risk
and firm recommendation for surgery before the
development of cancer. Thus, it is stated that pro-
phylactic surgery should be reserved for patients
whose biopsy findings are indicative of heightened
cancer risk based on the joint interpretation by the
clinician and the pathologist.
Surveillance Guidelines
Guidelines have recently been published by authors
from different expert centres [16–19]. Since duration
and anatomic extent of the ulcerative colitis have
been shown to be the two strong and independent
risk factors regarding the development of cancer,
special attention to these variables is crucial in the
practice of surveillance. The UK guidelines for sur-
veillance in ulcerative colitis [19] state that surveil-
lance colonoscopy should preferably be performed in
disease remission, it should be performed in all
patients after 8–10 years of disease to clarify disease
extent, and regular surveillance should begin after
8–10 years in those with pancolitis and after
10–15 years in those with left-sided colitis. Given that
cancer risk increases with the duration of disease, the
interval between colonoscopies should decrease in
line with increased disease duration. In the second
decade of disease, colonoscopy should be carried out
every 3 years, in the third decade every 2 years and
every year in the fourth decade. Based on the fact that
interval cancers can develop within 2 years after an
examination, patients with extensive (or left-sided)
colitis who have a negative result should begin sur-
veillance within 1–2 years. With a negative surveil-
lance colonoscopy, subsequent examinations should
be performed every 1–2 years. With two negative
examinations, the next surveillance examination may
be performed in 1–3 years until colitis has been pres-
ent for 20 years.
To obtain 90% sensitivity for the detection of dys-
plasia in patients with extensive disease, a minimum
of 33 biopsies is suggested, taking 4 biopsies for every
10 cm around the colon. In those with less extensive
microscopic disease, four quadrant biopsies taken
from the proximal extent of disease and every 10 cm
distally would be satisfactory. The commonly fol-
lowed guideline is that any diagnosis of high-grade
dysplasia (and low-grade dysplasia when associated
with a DALM) should lead to consideration of colec-
tomy, while low-grade dysplasia in flat mucosa
should not be an indication for colectomy but for
continuous surveillance with colonoscopy. The issue
is controversial. While DALM or cancer in such cases
has been proved to occur in more than half the
patients at 5 years [20] other authors [21] considered
low-grade dysplasia (unrelated to a DALM) less
alarming and not sufficiently reliable as a marker to
justify prophylactic colectomy.
Careful comparative studies by experienced
pathologists show evidence that surveillance and
screening programmes may carry a significant rate of
histological error due to interobserver variation
between the gastrointestinal pathologists when grad-
ing dysplasia in ulcerative colitis [22].
The Efficacy of Surveillance
There is evidence showing that colonoscopic surveil-
lance may detect precancerous dysplasia and early
treatable cancer. Thus, some studies indicate that
patients with cancers detected by surveillance tend to
be at a curable stage while patients not adhering to
surveillance are most likely to die from cancer [23].
Other studies, however, are less convincing [24],
showing evidence that only very few of the malignan-
cies found were treatable cancers detected by true
surveillance colonoscopy and with only a marginally
better success rate. There seems in fact to be no direct
evidence that endoscopic surveillance reduces cancer
mortality in inflammatory bowel disease [25], and a
review reported on in the Cochrane Central Register
of Controlled Trials presents a similar message [18].
Although cancers tend to be detected at an earlier
stage and has a correspondingly better prognosis in
268 L. Hultén
patients who are undergoing surveillance, lead-time
bias seems to contribute substantially to this appar-
ent benefit; and there is no clear evidence that sur-
veillance colonoscopy prolongs survival in patients
with extensive colitis. Nevertheless, there seems to be
consensus that a surveillance programme should
offer colonoscopy to patients with extensive ulcera-
tive colitis of 8 years duration and to those with less
extensive disease of 15 years duration. Surveillance
colonoscopy should be performed every 3 years for
10 years, every 2 years for 10 and then annually
including at least four biopsies taken every 10 cm
around the colon with careful biopsy of any macro-
scopic lesion.
Surveillance and its Limitations
Mucosal dysplasia documented by surveillance
colonoscopy used clinically to identify the “high
risk” patients has proven to have significant limita-
tions. Sampling error, presence of acute mucosal
inflammation, differences in pathological interpreta-
tion (observer variations) and variable patient com-
pliance are factors that might interfere with the diag-
nostic accuracy.
The reliability of dysplasia as a precursor of cancer
is poor [22]. The histological interpretation is often
subjective and of doubtful diagnostic value and the
decision making resulting from its discovery will,
therefore, often be doubtful. The grading of dyspla-
sia, differentiation between true dysplastic changes
and active inflammatory changes and differentiation
between DALM and “sporadic” adenomas constitute
the dilemma for the pathologist. Moreover, an
important obstacle to an accurate assessment of dys-
plasia is an active mucosal inflammation that may
result in cytological changes that are hard to distin-
guish from dysplasia.
Because dysplasia is focal and patchy, it may not
even be detected by extensive colonoscopic biopsies,
and established cancers may be missed entirely. Thus,
there is evidence showing that a significant fraction of
patients may have colorectal cancer in the absence of
dysplasia at the colonoscopic surveillance, although
this may at least in part be attributable to inadequate
surveillance [26]. Based on such observations, the
authors claimed that if proctocolectomy is recom-
mended only upon detection of either high-grade dys-
plasia or dysplasia of any grade, a large proportion of
patients may already have an established cancer at the
time of surgery. It is obvious that there are practical
limitations to the theoretical concept that dysplasia
surveillance can reliably serve as a marker for malig-
nant degeneration. The authors also emphasised that
failure to operate on high-risk patients – i.e. those
with pancolitis, those with duration of disease more
than 10 years and those with disease presenting dur-
ing childhood – while waiting for dysplasia to be dis-
covered by surveillance colonoscopy will invite a high
risk of developing concomitant colorectal cancer.
How Can Diagnostic Accuracy be Improved?
It is possible that new molecular markers in conjunc-
tion with histologic dysplasia will improve the sensi-
tivity of the surveillance and biopsy approach. Can-
cer surveillance may also be improved by better
selection of patients for inclusion in surveillance pro-
grammes, using markers other than dysplasia to pre-
dict cancer. Molecular genetic research may produce
better ways of selecting patients at greatest risk [27].
It may also produce a better premalignant marker
than dysplasia and it can help in distinguishing col-
itic dysplasia from other entities. Chromoendoscopy
can improve the detection of dysplasia and may also
be helpful in distinguishing colitic neoplasia from
non-colitic neoplasia. Dye spraying of the colonic
mucosa during colonoscopy (chromoendoscopy)
combined with high-resolution colonoscopy using a
magnifying colonoscope is another measure used to
increase the detection rate of neoplastic lesions in
patients with colitis [28, 29]. Many of these new
methods may be promising but no technique has yet
been convincing or has entered into routine clinical
practice.
Last but not the least, it should be emphasised
that, apart from a highly skilled endoscopist and
histopathologist, for a program of surveillance to be
efficient, it also has to rely on both the physician’s
and patient’s compliance. There should be regular
call back for all participating patients so that no
patients are lost in follow-up.
Even then, cancer surveillance does not totally
eliminate the risk of cancer. Despite many successful
results, one must question as to whether colonoscopy
surveillance, arguably efficacious for special clinic
populations, is truly effective even in the community
at large. In other words, will the results obtained
from careful clinical trials – produced under ideal
conditions – be reproducible when deployed in rou-
tine clinical practice? For example, it has been esti-
mated, as a “best-case” scenario, that colonoscopic
surveillance may decrease the incidence of cancer
from 7–8% down to 0.5–1% and the author claims
that no actual program is likely to enjoy such success.
Therefore, “at risk” ulcerative colitis patients who are
averse to take this cancer risk and who cannot accept
the imperfect and in many respects inconvenient
nature of colonoscopic surveillance, should be rec-
ommended for prophylactic colectomy.
The Cancer Risk in Longstanding Ulcerative Colitis: Surveillance Colonoscopy and Prophylactic Surgery 269
Prophylactic Surgery: What Are the Options?
Panproctocolectomy and Ileostomy (PI)
For prevention of cancer development in patients
with ulcerative proctocolitis, complete removal of all
potential malignant colorectal mucosa has to be
done. Before the advent of the surgical options of our
days, panproctocolectomy with construction of a
conventional ileostomy was the standard procedure
for cancer prophylaxis in patients with longstanding
ulcerative colitis. Such an operation eliminates fur-
ther risks of colorectal cancer and no surveillance
should be needed. Although cancer in the ileostomy
in these patients has been demonstrated to occur
many years after surgery, this is probably a different
state of affairs [31]. Bowel metaplasia may occur
where gut contents come into regular contact with
the squamous epithelium of the skin, which is an
important step in the development of these rare
tumours, as is also true in some cases of adenocarci-
noma of the oesophagus. Ileostomy cancer develops
at the mucocutaneous junction of the ileostomy, and
chronic irritation caused by trauma and/or chemical
agents from stoma appliances or adhesives may be
factors in its unclear etiology.
Colectomy and Ileorectal Anastomosis (IRA)
Conflicting results have been presented as regards
the indications for colectomy with IRA for ulcerative
colitis. Although many surgeons today are still reluc-
tant to use the technique, emphasising not only the
persistent cancer risk but also the poor function
[32–34], others consider the operation a viable alter-
native when used selectively in patients without signs
of mucosal dysplasia and whose rectum is not severe-
ly affected by inflammation or fibrosis [35–37]. The
colectomy and IRA procedure for a condition that
almost invariably involves an inflamed rectum cer-
tainly seems illogical. Apart from poor function,
there is a significant risk of cancer development in
the chronically inflamed mucosa. It is often argued
that a substantial proportion of IRA patients – maybe
even half of them – will have their rectum excised
eventually due to persistent or relapsing proctitis
[38]. However, in many cases, the proctitis often set-
tles spontaneously or after local treatment or recurs
periodically. Thus, the patient may enjoy reasonably
good general health and bowel function. Therefore,
even if 40–50% of the patients will ultimately require
rectal excision, roughly half of the patients will con-
tinue to enjoy a satisfactory result and many of those
who finally fail, have been able to postpone a major
operation (IPAA) or an abdominal stoma for several
years. Therefore, the time “bought” by IRA will get
many young people through their formative years of
education, allowing them to plan for a family and a
professional career. However, the long-term risk of
cancer in the rectal stump is the main strong argu-
ment that has been put forward against the use of this
operation – a risk that increases with the duration of
the disease and with the passage of time after the
colectomy. The cumulative probability of cancer
development approaches 5 and 15% after a 20 and
30-year observation, respectively [34, 39]. A very
important predictive factor is the presence of severe
dysplasia in the rectum or carcinoma of the colon at
the time of surgery [40]. Bearing this in mind, the
risk of rectal cancer should therefore be low in
patients with a short antecedent disease history and
in those without mucosal dysplasia in the colon/rec-
tum. As regular well-designed colonoscopic surveil-
lance is considered justified for the control of
patients with longstanding panproctocolitis – in
whom the cancer risk is 3–4 times higher – similar
guidelines [19] should be quite appropriate and safe
for surveillance of patients with an IRA. In other
words, by using a meticulous follow-up system for
patients with IRA, it should be possible to identify
patients who are at a particular risk and urge them to
undergo prophylactic rectal excision.
The controversy regarding colectomy and IRA
and the place of this procedure in the treatment of
UC has been characterised in the past by personal
prejudices and overzealous condemnation of the
technique by several of the more prominent experts
on colorectal surgery [38]. Employed on a selective
basis, IRA should a safe procedure with low mortali-
ty and morbidity and good prospects for success as a
prophylactic procedure in many patients with long-
standing ulcerative colitis. However, before surgery,
the patients must be fully informed of any inconven-
iences and risks associated with the procedure, and,
most importantly, they must be prepared to submit
to lifelong endoscopy surveillance.
Restorative Proctocolectomy: Ileo Pouch-Anal
Anastomosis (IPAA)
The interest in IRA may well have declined with the
advent of proctocolectomy and the ileo pouch-anal
anastomosis (IPAA). IPAA or restorative procto-
colectomy, i.e. construction of a reservoir of distal
ileum and an ileo pouch-anal anastomosis is the cur-
rent most popular option for surgical treatment of
ulcerative proctocolitis. There is no stoma or need
for an external bag and the normal route of defeca-
tion is preserved, i.e. a normal body image. It has
270 L. Hultén
become the first choice operation to be recommend-
ed around the world. In the conventional technique,
colectomy is combined with endoanal mucous proc-
tectomy and the ileal pouch is hand-sewn to the
pectinate line. In the currently most popular tech-
nique the abdominal dissection is carried out down
to the levator muscle, the rectum is severed at this
level and the ileal pouch is connected to the rectal
stump by a stapling device. In analogy to the tradi-
tional total proctocolectomy procedure, it has been
considered a curative and cancer-prophylactic pro-
cedure since all diseased mucosae are completely
removed. At first sight, restorative proctocolectomy
therefore seems to be an unmistakable opportunity;
however, recent results imply that the IPAA proce-
dure may not be the panacea it was thought to be. It
is a demanding operation with a high potential for
complications even in an experienced surgeon’s
hands and the functional results are sometimes far
from perfect [41]; even its place as a cancer-prophy-
lactic procedure may in fact be in question. An
increasing number of cancers have been reported in
these patients and the incidence is expected to rise as
the length of follow-up increases [42].
Chronic inflammation in the ileal mucosa (pouch-
itis) is a frequent complication in continent ileosto-
my and has proved subsequently to be so even in the
pelvic pouch (IPAA)[43]. A case of adenocarcinoma
in the continent ileostomy [44] and sporadic reports
of dysplasia in the ileal pouch mucosa, have current-
ly appeared in the literature, suggesting that the mor-
phological transformation of the ileal pouch mucosa
might eventually result in cellular dysplasia and
eventually carcinoma [45, 46]. The atrophic colon-
like mucosa in the ileal pouch is hypothetically con-
sidered a potentially premalignant condition with
risk of subsequent development of advanced neo-
plastic transformation. It has been suggested that
dysplasia and aneuploidy, as demonstrated by these
authors, reflect a different pathway of an atrophic
mucosa-dysplasia carcinoma sequence. However, the
results from long-term studies, both on continent
ileostomy patients and subsequently on IPAA
patients, are reassuring [47, 48]. The overall inci-
dence of mucosal dysplasia in the ileal pouch mucosa
proved to be low and no case of high-grade dysplasia
or carcinoma was observed. Considering an observa-
tion time of an average of 30 years in these studies,
and the comparatively large series of patients, these
results imply that dysplastic and neoplastic transfor-
mation within the ileal pouch mucosa is extremely
rare regardless of the type of adaptation and the risk
for epithelial dysplasia in the ileal pouch mucosa to
progress into cancer seems to be very low.
The published reports on cancer that develops in
the IPAA patients operated on for ulcerative colitis,
reflect a quite different issue, however [42, 48]. Irre-
spective of the technique used, IPAA leaves residual
rectal mucosa behind and dysplasia in these rectal
mucosal remnants with subsequent cancer develop-
ment has proved to be a procedural risk, reflecting
the continuous risk of malignant transformation in
the chronically inflamed rectal mucosa. Thus, it has
been demonstrated that even after a careful macro-
scopically complete mucosectomy, islands of rem-
nants of rectal mucosa are left behind in about 20%
of the cases [49], and in the alternative technique
where the ileal pouch is stapled to the top of the anal
canal, varying amounts of rectal mucosa as well as
the anal transitional zone mucosa remain preserved.
The rectal stump may even include part of the lower
rectum in technically demanding cases. Thus, there is
a potential risk for malignant development in the
islands of mucosa remaining between the muscular
cuff and ileal mucosa or in the retained mucosa in the
anal transitional zone, the so-called residual epithe-
lial cuff after the stapled technique. Moreover, it is
convincingly demonstrated that this risk is impend-
ing in patients with a long history of antecedent
ulcerative colitis, and with the diagnosis of dysplasia
or cancer in the operative specimen at the time of
colectomy [42, 48]). Therefore, although there are
reports suggesting that an IPAA is a successful surgi-
cal approach for ulcerative colitis patients with coex-
isting colorectal cancer [50], it is doubtful if such an
approach should be recommended.
Although some colorectal surgeons may question
the need for routine surveillance for cancer in the
IPAA patients [51], these observations imply that
despite the fact that the cancer risk after IPAA may
well be less than after the IRA procedure, a similar
endoscopy surveillance is still justified. A close fol-
low-up in all IPAA patients should be emphasised,
with special attention focussed on those with a long
antecedent disease history and those with dysplasia
or cancer in the original specimen. In this context, it
should be emphasised that the dysplasia or early can-
cer that arises from the residual rectal tissue in the
muscular cuff after mucosectomy may not be easily
detectable and endoscopy surveillance with deep
random biopsies of the anal canal mucosa should be
recommended.
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