Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1621_Библиотеки_им_академика_М_И_Перельмана.pdf
148
5. Bemelman WA, Warusavitarne J, Sampietro GM, etal. ECCO-ESCP consensus on surgery for
Crohn’s Disease. J Crohns Colitis. 2018;12:1–16.
6. Lightner AL, Dattani S, Dozois EJ, Moncrief SB, Pemberton JH, Mathis KL.Pouch excision:
indications and outcomes. Color Dis. 2017;19(10):912–6.. Available from: http://www.ncbi.
nlm.nih.gov/pubmed/28387059
7. Amiot A, Gornet JM, Baudry C, Munoz-Bongrand N, Auger M, Simon M, Allez M, Cattan P,
Sarfati E, Lemann M.Crohn’s disease recurrence after total proctocolectomy with denitive
ileostomy. Dig Liver Dis. 2011;43:698–702.
8. Peyregne V, Francois Y, Gilly FN, Descos JL, Flourie B, Vignal J.Outcome of ileal pouch after
secondary diagnosis of Crohn’s disease. Int J Color Dis. 2000;15:49–53.
9. Brown CJ, Maclean AR, Cohen Z, Macrae HM, O’Connor BI, McLeod RS.Crohn’s disease
and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of fail-
ure. Dis Colon Rectum. 2005;48(8):1542–9.
10. de Oca J, Sanchez-Santos R, Rague JM, etal. Long-term results of ileal pouch-anal anastomo-
sis in Crohn’s disease. Inamm Bowel Dis. 2003;9:171–5.
11. Hyman NH, Fazio VW, Tuckson W'B, Lavery IC.Consequences of ileal pouch-anal anastomo-
sis for Crohn's disease. Dis Colon Rectum. 1991;34:653–7.
12. Grobler SP, Hosie KB, Afe E, etal. Outcome of restorative proctocolectomy when the diag-
nosis is suggestive of Crohn’s disease. Gut. 1993;34:1384–8.
13. Sagar PM, Dozois RR, Wolff BG.Long-term results of ileal pouch-anal anastomosis in patients
with Crohn‘s disease. Dis Colon Rectum. 1996;39:893–8.
14. Braveman JM, Schoetz DJ Jr, Marcello PW, etal. The fate of the ileal pouch in patients devel-
oping Crohn’s disease. Dis Colon Rectum. 2004;47:1613.
15. Tekkis PP, Heriot AG, Smith O, Smith JJ, Windsor AC, Nicholls RJ.Long-term outcomes
of restorative proctocolectomy for Crohn’s disease and indeterminate colitis. Color Dis.
2005;7:218–23.
16. American College of Gastroenterology Chronic Constipation Task Force. An evidence-based
approach to the management of chronic constipation in North America. Am J Gastroenterol.
2005;100 Suppl. 1:S1–4.
17. Milonakis E, Allan RN, Keighley MR.How does pouch construction for a nal diagnosis
of Crohn’s disease compare with ileoproctostomy for established Crohn’s proctocolitis? Dis
Colon Rectum. 2001;44:1137–42.
18. Regimbeau JM, Panis Y, Pocard M, etal. Long-term results of ileal pouch-anal anastomosis for
colorectal Crohn’s disease. Dis Colon Rectum. 2001;44:769–78.
19. Melton GB, Fazio VW, Kiran RP, etal. Long-term outcomes with ileal pouchanal anastomo-
sis and Crohn’s disease: pouch retention and implications of delayed diagnosis. Ann Surg.
2008;248:608–16.
20. Shen B, Patel S, Lian L.Natural History of Crohn’s disease in patients who underwent inten-
tional restorative proctocolectomy with ileal pouch-anal anastomosis. Aliment Pharmacol
Ther. 2010;31:745–53.
21. Grucela AL, Bauer JJ, Gorne SS, etal. Outcome and long-term function of restorative proc-
tocolectomy for Crohn’s disease: comparison to patients with ulcerative colitis. Color Dis.
2011;13:426–30.
22. Fazio VW, Kiran RP, Remzi FH, Coffey JC, Heneghan HM, Kirat HT, etal. Ileal pouch
anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg.
2013;257:679–85.
23. Le Q, Melmed G, Dubinsky M, etal. Surgical outcome of ileal pouch-anal anastomosis when
used intentionally for well-dened Crohn’s disease. Inamm Bowel Dis. 2013;19:30–6.
24. Delaney CP, Fazio VW, Remzi FH, et al. Prospective, age-related analysis of surgical
results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg.
2003;238:221–8.
25. Yamamoto T, Bain IM, Allan RN, Keighley MRB.Persistent perineal sinus after proctocolec-
tomy for Crohn’s disease. Dis Colon Rectum. 1999;42:96–101.
G. Gallo and W. A. Bemelman
149
26. Li W, Stocchi L, Elagili F, Kiran RP, Strong SA.Healing of perineal wound after proctec-
tomy in Crohn’s disease patients: only preoperative perineal sepsis predict poor outcome. Tech
Coloproctol. 2017;21:715–20.
27. Murphy P, Khot Z, Vogt K, etal. Quality of life after total proctocolectomy with ileostomy or
IPAA: a systematic review. Dis Colon Rectum. 2015;58:899–908.
28. Pellino G, Sciaudone G, Selvaggi F, et al. Delayed diagnosis is inuenced by the clinical
pattern of Crohn’s disease and affects treatment outcomes and quality of life in the long
term: a cross-sectional study of 361 patients in Southern Italy. Eur J Gastroenterol Hepatol.
2015;27:175–81.
29. Dignass A, Van Assche G, Lindsay JO, et al. European Crohn’s and Colitis Organisation
(ECCO). The second European evidence-based consensus on the diagnosis and management
of Crohn’s disease: current management. J Crohns Colitis. 2010;4(1):28–62.
30. Weaver KN, Gregory M, Syal G, etal. Ustekinumab is effective for the treatment of Crohn’s
disease of the pouch in a multicenter cohort. Inamm Bowel Dis. 2019;25(4):767–74.
31. Malik T, Lee MJ, Harikrishnan AB.The incidence of stoma related morbidity—a systematic
review of randomised controlled trials. Ann R Coll Surg Engl. 2018;100(7):501–8.
15 Role ofIPAA forCrohn’s Disease
151
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_16
J. S. Scow
Division of Colon & Rectal Surgery, Department of Surgery,
The Pennsylvania State University, College of Medicine, Hershey, PA, USA
A. Merchea (
*)
Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
e-mail: Merchea.Amit@mayo.edu
16
Surgical Options forNeoplasia
Complicating Crohn’s Disease
oftheLarge Intestine
JeffreyS.Scow andAmitMerchea
Abbreviations
CC Crohn’s colitis
CD Crohn’s disease
CRC Colorectal cancer
CUC Chronic ulcerative colitis
HGD High-grade dysplasia
IBD Inammatory bowel disease
IPAA Ileal pouch-anal anastomosis
LGD Low-grade dysplasia
STC Subtotal colectomy
TAC/IRA Total abdominal colectomy/ileorectal anastomosis
TPC/EI Total proctocolectomy/end ileostomy
Introduction
Individuals with Crohn’s disease (CD) of the large intestine develop colorectal
cancer at an increased rate compared to the general population. The exact magni-
tude of increased risk is unknown. The prevalence of dysplasia at 25years has been
reported to range between 0.5% to 25% [1–5] and the risk for colorectal cancer may
be six- fold that of the general population [6–8]. Colorectal cancer in patients with
152
inammatory bowel disease (IBD) appears to develop via a pathway that deviates
from the well characterized adenoma-carcinoma sequence of sporadic colorectal
cancer and may progress rapidly, skipping steps seen with sporadic colorectal can-
cer [1, 9–14].
Currently, it is recommended by most professional organizations that patients
with Crohn’s disease involving at least one-third of the large intestine for 8 or more
years undergo surveillance colonoscopy on a regular basis with the goal of interven-
ing, either endoscopically or surgically, prior to the development of colorectal can-
cer [15–20]. Current guidelines for screening, surveillance, and treatment of
dysplasia in patients with Crohn’s disease of the large intestine have been predomi-
nantly extrapolated from observations and experience with the treatment of dyspla-
sia in patients with ulcerative colitis (UC) [21, 22] which rely on frequent surveillance
colonoscopy followed by appropriately timed total proctocolectomy and end ileos-
tomy (TPC/EI) or reconstruction with an ileal pouch-anal anastomosis (IPAA).
Patients with Crohn’s disease have typically not been considered eligible for IPAA
because of Crohn’s disease’s variable nature, propensity to affect the entire GI tract,
and predilection for involvement of the anoperineal area. Current guidelines, relying
on heterogenous data, recommend TPC/EI for patients with Crohn’s disease that
develop dysplasia [15, 19]. However, some patients with rectal sparing may be candi-
dates for total abdominal colectomy with ileorectal anastomosis (TAC/IRA) if coun-
seled appropriately regarding the requirement for frequent surveillance endoscopy of
the rectum and continued potential for development of Crohn’s proctitis, rectal dys-
plasia, and possibly rectal cancer [22–27]. TAC/IRA, as opposed to TPC/EI, has the
advantage of not requiring a permanent ileostomy and does not subject a patient to the
risk of possible perineal wound healing problems and sexual dysfunction or infertility.
The aim of this chapter is to examine the published literature of the past 20years to
guide clinicians counseling patients with Crohn’s disease of the large intestine who
are facing colectomy in the setting of dysplasia. Our aim was to describe the incidence
of synchronous and metachronous neoplasia. We did not examine the risk of recurrent
Crohn’s proctitis as this is the focus of a different chapter.
Search Strategy
Relevant PICO (Population, Intervention, Comparator, Outcome) questions were
generated (Table16.1). A comprehensive literature search of the Cochrane Database
of Collected Research, EMBASE, Google Scholar, PubMed, and SCOPUS and was
performed to identify all the English language publications related to dysplasia in
Table 16.1 PICO
Patients
Intervention Comparator
Outcome
Patients with Crohn’s
colitis that develop
dysplasia requiring
resection
Total abdominal
colectomy with
ileorectal anastomosis
Total proctocolectomy
with end ileostomy
Risk of undetected
neoplasia or
recurrent neoplasia
J. S. Scow and A. Merchea
153
patients with Crohn’s disease of the large intestine for the past 20years, between
1998 and 2018. Key search terms included: colectomy, Crohn’s disease, Crohn’s
colitis, dysplasia, inammatory bowel disease, and proctocolectomy. Case reports,
chapters, and review articles were omitted. Retrospective, systematic, and prospec-
tive reviews and randomized control trials were reviewed. Meta-analyses were
reviewed for appropriateness and pertinent publications. Publications that did not
evaluate the risk of undetected or recurrent neoplasia as a primary or secondary
outcome were excluded. Studies that examined inammatory bowel disease as a
whole and did not specically delineate results for patients with Crohn’s disease
were also excluded. References of the included studies were examined for addi-
tional publications and included when criteria were met.
Results
Over the past 20years, no randomized or prospective studies evaluating the risk of
undetected or recurrent neoplasia in patients with Crohn’s disease of the large intes-
tine and dysplasia have been published. Several retrospective studies have examined
synchronous neoplasia at the time of colectomy for neoplasia and a couple of retro-
spective studies reported on metachronous neoplasia in patients with Crohn’s dis-
ease of the large intestine in patients who previously underwent procedures sparing
portions of the large intestine. Overall these are heterogenous studies with varied
inclusion/exclusion criteria, relatively few patients, and performed at large referral
centers, such that applicability to the broader population with Crohn’s disease of the
large intestine may be difcult. Additionally, colonoscopy equipment has dramati-
cally changed over the past decades as high-denition colonoscopes and monitors
have become more common and widespread since the mid-2000s. Furthermore,
chromoendoscopy has recently been recommended by several organizations to
enhance detection and endoscopic treatment of neoplasia and is becoming more
universally utilized for the evaluation of patients with IBD [16, 28, 29]. In this
review of the data, chromoendoscopy was used in only a limited number of patients.
Likely, this technique will become more widepsread to survey and manage inam-
matory bowel disease patients at risk for dysplasia in the future.
Undetected Neoplasia
Four studies investigated undetected synchronous neoplasia in patients with Crohn’s
disease of the large intestine and known dysplasia undergoing some form of colec-
tomy. Friedman examined patients (n=259) with Crohn’s disease of the large intes-
tine undergoing screening and surveillance colonoscopies (n = 1424). Patients
discovered to have dysplasia were referred for surgery (22). Patients undergoing
colectomy (extent undened in their study) for low-grade dysplasia (LGD) were
found to have high-grade dysplasia (HGD) or colorectal cancer in 54% of cases.
Similarly, 50% of patients who underwent a colectomy for high-grade dysplasia
16 Surgical Options forNeoplasia Complicating Crohn’s Disease oftheLarge Intestine
154
were found to have colorectal cancer. This occurred despite intense surveillance
with patients undergoing a median of ve previous colonoscopies [5].
In 2012, Kiran reported on 50 patients with Crohn’s disease of the large intestine
that underwent colectomy for dysplasia. Patients with known colorectal cancer were
excluded in this report. No patient with low-grade dysplasia was found to have
colorectal cancer but 35% of patients with low-grade dysplasia were found to har-
bor undetected, synchronous, high-grade dysplasia. Of those with preoperative
diagnosis of high-grade dysplasia, 45% were found to have colorectal cancer. High-
grade dysplasia was predictive of high-grade dysplasia/colorectal cancer in 73% of
patients. Patients with low- or high-grade dysplasia were found to have multifocal
dysplasia in 32% and 36% of cases, respectively. Of the patients found to have
colorectal cancer, 40% had dysplasia remote from the cancer site [22].
Cleveland retrospectively reviewed 36 patients with inammatory bowel disease
who were undergoing surveillance colonoscopy, discovered to have dysplasia or
colorectal cancer, and then proceeded to colectomy. These 36 patients were preop-
eratively known to have 44 neoplastic lesions. Nearly one-half (47%) of the patients
had Crohn’s disease of the large intestine and the remaining had ulcerative colitis. Of
the 30 low-grade dysplasia lesions preoperatively known to exist, only 11 were iden-
tied in colectomy specimens of which one (1/11, 9%) was upgraded to high- grade
dysplasia. More signicantly, in the group operated on for low-grade dysplasia, 8
previously undiagnosed synchronous lesions were discovered (3 low-grade dyspla-
sia; 4 high-grade dysplasia; one sporadic cancer). Of patients with high-grade dys-
plasia, 5 of 6 known lesions were identied and one (1/5, 20%) was found to be
colorectal cancer. Additionally, one synchronous colorectal cancer was found in the
group with high-grade dysplasia. Eight lesions were known to be colorectal cancer
and 6 were conrmed in colectomy specimens, none of which were downgraded. In
patients with known colorectal cancer, no synchronous lesions were discovered [30].
Most recently, Eluri published a retrospective review of patients with Crohn’s
disease of the large intestine (21) who were either preoperatively known or found to
have high-grade dysplasia or colorectal cancer after “complete abdominal colec-
tomy.” All patients had at least one colonoscopy prior to operation. Four patients
were known to have high-grade dysplasia and 12 patients were known to have
colorectal cancer. At the time of colectomy, 5 patients (24%) were found to have
unknown high-grade dysplasia (4) or colorectal cancer (1) [31].
Recurrent/Metachronous Neoplasia
One study specically examined metachronous neoplasia in patients with known
neoplasia in the setting of Crohn’s disease of the large intestine undergoing segmen-
tal colectomy or subtotal colectomy (STC). Three additional studies made mention
of the development of metachronous lesions but did not extensively report on this
phenomenon. Kiran (2010) studied 240 inammatory bowel disease patients under-
going colectomy for colorectal cancer of whom 27% had Crohn’s disease of the
large intestine. The authors’ primary aim was to compare differences between ulcer-
ative colitis and Crohn’s disease of the large intestine. Not reported in their results,
J. S. Scow and A. Merchea
155
but included in the discussion of the manuscript was the comment that “…15% of
the [Crohn’s disease of the large intestine] patients who underwent segmental colon
resection, developed metachronous tumor within 4 years [32].”
Kiran (2012) then examined patients with Crohn’s disease of the large intestine
and conrmed dysplasia undergoing colectomy. The authors noted that “eleven…
patients… underwent procedures that left them at risk of developing cancer or high-
grade dysplasia in the retained colorectum during follow-up.” One (9%) of these
patients developed a metachronous rectal cancer three years after the index opera-
tion and died. The authors note that this individual had not complied with surveil-
lance recommendations [22].
Maser looked at the incidence of metachronous dysplasia and colorectal cancer
in 75 patients with Crohn’s disease of the large intestine who underwent segmental
or STC for dysplasia (11 patients) or colorectal cancer (64 patients). Of patients
with colorectal cancer, 39% developed metachronous colorectal cancer at an aver-
age of 6.8years after the index operation. Patients with high-grade dysplasia were
found to have developed recurrent dysplasia (low-grade dysplasia in 2 patients and
high-grade dysplasia in 3 patients) in 46%, at an average of 6.2years. Notably, none
of the patients with an index operation for high-grade dysplasia recurred with a
colorectal cancer. 50% of patients with metachronous colorectal cancer died due to
the recurrence. When comparing recurrence rates in patients with segmental resec-
tion versus STC, no signicant difference was found. This led the authors to con-
clude that, “the lack of detectable benet in doing a STC over a segmental resection
also suggests that leaving even a portion of colon behind puts a patient at risk for a
metachronous lesion [23].”
Cleveland noted in their small series that, of the subset of patients who under-
went segmental/STC, no metachronous neoplasia was identied. However, their
median follow-up and number of colonoscopies were only 6months (3months to
81months) and 2 (1–5), respectively. Furthermore, the bulk of these patients had
low-grade dysplasia (5) (Table16.2) [30].
Recommendations
Because of the high risk for undetected and metachronous neoplasia, TPC/EI should
be performed for patients with Crohn’s disease of the large intestine found to have
low-grade dysplasia, high-grade dysplasia, or colorectal cancer (strongly recom-
mendation, low quality evidence).
Based on the reviewed studies, the incidence of undetected synchronous and/or
upgraded lesions was 9–54%. Studies that investigated metachronous neoplasia
reported rates of 0–46%. TPC/EI is the procedure of choice because anything less
than total extirpation of the colon and rectum continues to subject a patient with
neoplasia to these risks. We do acknowledge caveats and exceptions that may sway
the surgeon and patient to consider, at least initially, TAC/IRA, and they include
rectal sparing and/or desire for preservation of fecundity. However, patients must be
strongly counseled about risks of retaining the colon or rectum and commit to strin-
gent follow-up, specically in the form of surveillance endoscopy.
16 Surgical Options forNeoplasia Complicating Crohn’s Disease oftheLarge Intestine
156
Table16.2 Studies examining risk of undetected neoplasia and recurrent/metachronous neoplasia in patients with CC and dysplasia
First Author
(year) Design
Patients
Results Notes
Quality of
evidenceBreakdown of patients
Friedman
(2008)
CC patients undergoing
surveillance colonoscopy
and surgery
259 Primarily a colonoscopy
surveillance study
Low
Surveillance pathology/#
undergoing surgery
LGD (at) 8
LGD (polyp) 5
HGD (at) 4
CRC 5
5/8 (63%) CRC/HGD
2/5 (40%) CRC
3/4 (75%) CRC/HGD
5/5 (100%) CRC
Kiran (2010) IBD patients undergoing
colectomy for CRC
(retrospective)
240 “…15% of the CD patients who
underwent segmental colon
resection, developed
metachronous tumor within 4
years” p334
Metachronous data only
mentioned in discussion
Very low
Crohn’s 64
Indications
HGD/CRC 84%
Colitis 4%
Mass/stricture 10%
Fistula 2%
Kiran (2012) CD & conrmed dysplasia
undergoing colectomy. Preop
CRC excluded
50 Preop:postop
LGD: 36% HGD
HGD: 45% CRC
1/11 patients with intact
rectum developed rectal
cancer 3 years after
surgery (p222)
Low
LGD 25
HGD 22
IFD 3
LGD: 32% MFD
HGD: 36% MFD
Maser (2013) MCRC after segmental or STC
for HGD or CRC in CD
75 25/64 (39%) MCRC Average time from
surgery to MCRC was
6.8 years
Low
CRC 64
HGD 11
5/11 (46%) recurrent dysplasia (no
MCRC)
J. S. Scow and A. Merchea
157
Cleveland
(2016)
IBD patients with dysplasia/CRC
diagnosed at high-denition
colonoscopy undergoing
colectomy
Patients/lesions
36/44
Upgraded pathology or
synchronous CRC
Unable to completely
separate Crohn’s patients
or determine # of
patients in each group as
# of lesions are reported
Low
Crohn’s
17 (47%)/19 (43%)
LGD: 1/11 (9%) HGD
8 SL: 3 LGD, 4 HGD, 1 SC
Ulcerative Colitis
19 (53%)/25 (57%)
HGD: 1/5 (20%) CRC
1 SL: 1 CRC
LGD 30 lesions
HGD 6 lesions
CRC 8 lesions
No metachronous neoplasia in 7
patients undergoing segmental/
STC
Eluri (2017) IBD undergoing colectomy with
HGD or CRC in postop specimen
70
Crohn’s 21
5/21 (24%) undetected HGD/CRC All patients had prior
surveillance colonoscopy
Low
Abbreviations: CC Crohn’s colitis, CD Crohn’s disease, CRC colorectal cancer, CUC chronic ulcerative colitis, HGD high grade dysplasia, IBD inammatory
bowel disease, IFD indenite for dysplasia, LGD low grade dysplasia, MCRC metachronous colorectal cancer, MFD multifocal dysplasia, SC sporadic cancer,
SL synchronous lesions, STC subtotal colectomy
16 Surgical Options forNeoplasia Complicating Crohn’s Disease oftheLarge Intestine
158
Personal View
In accordance with current guidelines, TPC/EI is our recommendation for patients
with Crohn’s disease of the large intestine and neoplasia because of the very real
risk of undetected synchronous neoplasia and the lifetime risk of metachronous
neoplasia with preservation of the colon and/or rectum [19]. As outlined above, in
both scenarios the risk is real and unacceptably high for the average patient.
However, we acknowledge that there are strong arguments against TPC/EI, at least
as the initial operation. Any resectional procedure performed for Crohn’s disease
must be done by a surgeon cognizant of the fact the patient will still be at risk of
sequelae of this disease even when the entire colon and rectum has been resected.
Recently, international consensus guidelines from the Surveillance for Colorectal
Endoscopic Neoplasia Detection and Management in Inammatory Bowel Disease
Patients (SCENIC) were published and endorsed by multiple, international gastro-
enterologic and endoscopic societies. These guidelines recommend complete endo-
scopic removal of polypoid and nonpolypoid dysplasia followed by further
surveillance colonoscopy. For patients with invisible dysplasia, chromoendoscopy
with a high denition endoscope is recommended [28]. Critics have pointed out that
these guidelines are awed for three reasons: current poor adherence to endoscopic
screening/surveillance guidelines, very low quality evidence, and signicant risk of
synchronous and metachronous neoplasia as demonstrated by the aforementioned
studies [5, 22, 23, 30–33].
Ideally, prospective, randomized studies will be performed to more denitively
answer the questions of the relative roles of surveillance colonoscopy, endoscopic
resection, and colectomy, including what extent of resection is appropriate. Until
the data are more complete, patients should be counseled on the risks of synchro-
nous and metachronous neoplasia and the options available for treatment. One study
demonstrated that patients are reticent to agree to colectomy unless the risk of
colorectal cancer is 72% [34]. Other than dysplasia [13], risk factors for an increased
risk of colorectal cancer in patients with Crohn’s disease of the large intestine
include young age at diagnosis, duration of disease [7], extent of disease [4], chronic
inammation [35], and concomitant primary sclerosing cholangitis [36]. These risk
factors must be considered when counseling patients about options for the treatment
of neoplasia in the setting of Crohn’s disease of the large intestine.
Ultimately, the best procedure is one that accounts for the risk of undetected
synchronous neoplasia, future metachronous neoplasia, and the patient’s goals and
ability to comply with future surveillance. Factors that may play a role in this deci-
sion include: age of the patient, capability to care for and cultural perceptions of an
ostomy, desire for children, presence of anoperinal disease, rectal involvement, risk
factors for colorectal cancer, and type of work. One of many plausible scenarios
would be to perform a TAC/IR in a female of child-bearing age with rectal sparing
while planning to perform regular surveillance endoscopy and a completion proc-
tectomy with creation of an end ileostomy when child bearing is complete. While
procedures less than TPC/EI may be feasible and appropriate in certain circum-
stances, our practice is to recommend TPC/EI in accordance with current surgical
J. S. Scow and A. Merchea