Uneven Between-Hospital Distribution of Patient-Related Risk Factors for Adverse Outcomes of Colorectal Cancer Treatment: A Population-Based Register Study.

Purpose: The purpose of this study was to elucidate between-hospital variation in the prevalence at the time of diagnosis of patient-related risk factors for adverse outcomes of colorectal cancer (CRC) treatment. Patients and Methods: A register-based national cohort of 44,471 patients diagnosed with CRC and registered in the Danish Colorectal Cancer Group database in 2009-2018 was included in the study. Patient-related risk factors present at diagnosis were collected from national Danish registers within the areas of demography, lifestyle factors, comorbidity, participation in screening, disease-related factors and socioeconomic factors. Prediction models of short-term postoperative outcomes and mortality were modelled to examine the potential aggregated impact of patient-related risk factors on outcomes, and variations between hospitals were examined. Results: The most conspicuous variations found were for old age (75+ years), ranging from 31% (95% confidence interval (95% CI): 29-33%) to 46% (95% CI: 43-48%), Union for International Cancer Control Stage I ranging from 12% (95% CI: 10-14%) to 21% (95% CI: 19-22%), Stage IV ranging from 23% (95% CI: 21-25%) to 35% (95% CI: 34-37%) and American Society of Anesthesiologists score ≥III ranging from 18% (95% CI: 16-19%) to 40% (95% CI: 37-43%). Clinically significant variations were found in predicted probability of 30-day surgical complications which varied from 17% (95% CI: 16-17%) to 23% (95% CI: 22-23%) and 90-day postoperative mortality which varied between 3.2% (95% CI: 3-3.4%) and 5.5% (95% CI: 4.9-6%). Conclusion: Marked variation in the prevalence of patient-related risk factors for adverse outcomes of colorectal cancer treatment exists between hospitals in Denmark. It seems reasonable to take these differences into account when comparing outcomes between hospitals.

Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation.

BACKGROUND: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL. METHOD: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion. RESULTS: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04). CONCLUSION: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04766060.

Differences in treatment and survival in young and elderly patients with colorectal cancer.

INTRODUCTION: The incidence of colorectal cancer (CRC) in patients ≤ 40 years of age seems to follow an increasing trend worldwide. Previous studies have reported conflicting data on treatment intensity and survival in young patients with CRC. The aim of this study was to describe treatment and survival data in a national cohort of young Danish CRC patients in the 2001-2013 period and to compare these data with data on a national cohort of elderly patients with CRC. METHODS: In a retrospective study design, we analysed data on pre-operative management, treatment and overall survival in a national cohort of 484 young (18-40 years) and 14,647 elderly (66-75 years) CRC patients. Cox regression models were used to calculate adjusted hazard functions of overall survival. RESULTS: Surgical treatment did not differ markedly between age groups, but young patients received more oncological treatment and had a better stage-specific five-year overall survival than elderly patients. In an adjusted model, the hazard ratio for young patients with stage I-III disease was 0.67 (95% confidence interval (CI): 0.48-0.95) for colon cancer; 0.61 (95% CI: 0.37-0.99) for rectal cancer. CONCLUSION: Despite more advanced clinical stages of disease, young CRC patients had a better survival than elderly CRC patients in this national cohort. FUNDING: The study was funded by Krista og Viggo Petersens Fond; Civilingeniør Bengt Bøgh og Hustru Inge Bøghs Fond; and Arvekapitalen efter Ane Mette Nielsen til lægevidenskabelig forskning ved Vejle Sygehus. TRIAL REGISTRATION: The project was approved by DCCG (2013-03), the Danish Data Protection Agency (2008-58-0035) and the Regional Scientific Ethical Committee for Southern Denmark (S-20130079).

CT and 3 Tesla MRI in the TN Staging of Colon Cancer: A Prospective, Blind Study.

(1) Background: Computer tomography (CT) scanning is currently the standard method for staging of colon cancer; however, the CT based preoperative local staging is far from optimal. The purpose of this study was to investigate the sensitivity and specificity of magnetic resonance imaging (MRI) compared to CT in the T- and N-staging of colon cancer. (2) Methods: Patients underwent a standard contrast-enhanced CT examination. For the abdominal MRI scan, a 3 Tesla unit was used, including diffusion weighted imaging (DWI). Experienced radiologists reported the CT and MRI scans blinded to each other and the endpoint of the pathological report. (3) Results: From 2018 to 2021, 134 patients received CT and MRI scans. CT identified 118 of the 134 tumors, whereas MRI identified all tumors. For discriminating between stage T3ab and T3cd, the sensitivity of CT was 51.1% and of MRI 80.0% (p = 0.02). CT and MRI showed a sensitivity of 21.4% and 46.4% in detecting pT4 tumors and a specificity of 79.0% and 85.0%, respectively. (4) Conclusion: Compared to CT, the sensitivity of MRI was statistically significantly higher in staging advanced T3cd and T4 tumors. MRI has the potential to be used in the treatment planning of colon cancer.

Anastomosis technique and leakage rates in minimally invasive surgery for right-sided colon cancer. A retrospective national cohort study.

PURPOSE: The aim of this study was to describe the different techniques currently used in Denmark to construct right-sided ileocolic anastomoses in minimally invasive surgery, and investigate, compare and analyse the anastomotic configurations and their anastomotic leakage (AL) rates. METHODS: This was a retrospective register-based, study design using prospectively collected data from the Danish Colorectal Cancer Group (DCCG) database. All patients aged 18 years or older with a malignant colorectal tumour in Denmark in the period of 1 February 2015 until 31 December 2019, and who had an elective, curative, minimally invasive right hemicolectomy (MIRH) with ileocolic anastomosis, were included. RESULTS: Three thousand three hundred ninety-eight patients were included. The most commonly used anastomotic approach was the extracorporeal (EC) hand-sewn anastomosis (HA) with end-to-end configuration (59%) and the second most used was the EC stapled anastomosis (SA) side-to-side configuration (20%). The latter had a higher AL rate compared with the hand-sewn technique (3.8% vs. 1.3%), and had significantly higher odds ratio (OR) (OR: 2.85, 95% CI: 1.56-4.92, p < 0.0001) for AL in the adjusted regression model. The least used technique was the end-to-side HA which also had a significantly higher OR (OR: 3.05, 95% CI: 1.30-7.15, p = 0.010) compared with the end-to-end HA. Smoking was an independent factor associated with higher OR for AL. CONCLUSION: The ileocolic end-to-end HA was the most commonly used technique and had the lowest AL rate in MIRH for colon cancer. The EC SA technique and tobacco smoking were independent risk factors for leakage of the ileocolic anastomosis.

Intracorporeal anastomosis in right hemicolectomy for colon cancer: short-term outcomes with the DaVinci Xi robot.

Intracorporeal anastomosis (IA) may improve outcomes compared with extracorporeal anastomosis (EA) in minimally invasive right colectomy. This is a prospective series of robotic right hemicolectomies (RRC) with IA from one institution. 35 consecutive patients with verified or suspected right colon cancer undergoing RRC with IA, and historic control groups of 22 RRC and 40 laparoscopic right colectomies (LRC), both with EA. Primary outcome measure was length of stay (LOS). Secondary outcome measures were 30-day complication rates, readmissions, pain scores, analgesic consumption, and specimen quality. Median LOS did not differ significantly between the groups (RRC-IA, 4 days; LRC-EA, 4 days; RRC-EA, 5 days). In-hospital surgical complications Clavien-Dindo 3 + were seen in 1, 2, and 0 patients, respectively, and 3, 5, and 3 patients were readmitted to hospital within 30 days. Median pain score was 2 in all groups on postoperative day (POD) 2. Relatively more patients in the RRC-IA group received gabapentin on POD 2 (p = 0.006), but use of other analgetics did not differ between groups. Mean specimen lengths were 31, 25 and 27 cm, respectively (RRC-IA vs. LRC-EA, p = 0.003), but mesentery width, proportion of mesocolic excisions and number of lymph nodes did not differ between the groups. RRC-IA was not associated with shorter LOS, fewer complications or better specimen quality than recent controls undergoing either RRC-EA or LRC-EA.

Three different computed tomography obesity indices, two standard methods, and one novel measurement, and their association with outcomes after colorectal cancer surgery.

BACKGROUND: Obesity can be measured by different indices, either as body mass index (BMI) or by more intuitive radiological measurements, and obesity has been shown to have an impact on outcome after colorectal cancer (CRC) surgery. PURPOSE: To investigate whether the thickness of the subcutaneous adipose tissue (SAT) in the abdominal wall can be used as a surrogate for the visceral fat area (VFA)-both measured on computed tomography (CT)-in prediction of short- and long-term outcomes after elective CRC surgery. MATERIAL AND METHODS: Preoperative CT scans of all patients having elective CRC surgery (stages I-III), in two consecutive years at a single-center institution, were used to measure the SAT (mm) and VFA (cm2). BMI was calculated for each patient. The three different obesity indices were used in different analyses in order to predict postoperative complications and overall survival. RESULTS: A BMI >30 kg/m2 was an independent prognostic factor in postoperative complications (odds ratio 3.2, 95% confidence interval [CI] 1.43-7.03). SAT and VFA were not able to predict complications. Patients considered visceral obese according to a high VFA (>130 cm2) had poorer survival (hazard ratio 1.53, 95% CI 1.00-2.36) compared to non-obese patients, but in the adjusted model, VFA lost its predictive power. BMI and SAT were not able to predict mortality. CONCLUSION: The novel measurement of the thickness of SAT in a preoperative setting before elective CRC surgery cannot predict either postoperative complications or overall survival; the other obesity indices had better predictive features.

Clinical characteristics and a rising incidence of early-onset colorectal cancer in a nationwide cohort of 521 patients aged 18-40 years.

BACKGROUND: The incidence of early-onset colorectal cancer (eoCRC) has been reported to increase, and patients with eoCRC seem to be diagnosed at more advanced stages compared to elderly patients. The aim of this study was to describe patient and disease characteristics, symptomatology and the incidence of eoCRC in a national cohort. MATERIALS AND METHODS: 521 eoCRC patients (≤40 years old) diagnosed with histologically verified colorectal cancer (CRC) during the years 2001-2013 were identified in national databases and compared to more than 15,000 CRC patients aged 66-75 years. Age-adjusted incidence was calculated for eoCRC patients and various sub-analyses were performed. RESULTS: More advanced stages were seen in eoCRC patients compared to elderly patients (stage II: p < 0.001, III: p = 0.01 and IV: p < 0.01). Differences were statistically significant in colon cancer, but not in rectal cancer. A significant difference in sex distribution was seen between right and left-sided tumors in the eoCRC group. The age-adjusted incidence rate increased during the study period (1.60-2.55 per 100.000), and significant annual percent changes (APC) were seen in young females (APC = 4.73) and left-sided tumor localization (including rectal cancer) (APC = 4.54), respectively. CONCLUSION: In this nationwide cohort of eoCRC patients, our results confirm that young patients are diagnosed at advanced stages, and that the incidence of eoCRC is increasing.

Screening and systematic follow-up for cardiopulmonary comorbidity in elective surgery for colorectal cancer: a randomised feasibility study.

BACKGROUND: One third of patients with colorectal cancer (CRC) have comorbidity, which impairs their postoperative outcomes. Scoring systems may predict mortality, but there is limited evidence of effective interventions in high-risk patients. Our aim was to test a trial setup to assess the effect of extra postoperative medical visits and follow-up on 1-year mortality and other outcomes in patients with cardiopulmonary risk factors undergoing elective surgery for colorectal tumours. METHODS: Patients preoperatively screened positive for cardiopulmonary comorbidity were eligible. On postoperative day 4, they were randomised to either routine follow-up (RFU) or RFU with one extra medical visit and additional visits to the Cardiology and Respiratory Medicine Clinics 1 and 3 months postoperatively. The primary outcome measure was 1-year mortality; secondary outcome measures were length of stay (LOS), complications, and readmissions. RESULTS: Of 673 screened patients 326 (48%) were found eligible, 108 declined participation, and 198 were randomised. Postoperative medical problems and/or need for intervention were found in 15-23% of the patients at the extra medical visits. The 90-day mortality was 0 and the 1-year mortality only 2.6% with no differences between the two groups. LOS and complication rates did not differ, but there were significantly fewer readmissions in the intervention group. CONCLUSIONS: The 1-year mortality after elective CRC surgery was low, even in the presence of cardiopulmonary risk factors. There was no evidence of reduced mortality with additional medical follow-up in these patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02328365 registered 31 December 2014 (retrospectively registered).

The day of week of elective colorectal cancer surgery has no impact on mortality and morbidity.

INTRODUCTION: Recent studies have reported an asso-ciation between the day of week of surgery and post-operative mortality, meaning that patients undergoing surgery at the end of the week or during weekends may be at higher risk. The aim of this study was to investigate the influence of the day of week of surgery on mortality and morbidity rates in a national Danish cohort of patients undergoing major elective surgery for colorectal cancer. METHODS: In a register-based study design, all patients undergoing elective major surgery for colorectal cancer in Denmark during a ten-year period (2005-2014) were studied. Patients were identified in the National Colorectal Cancer Database. Any associations between short-time mortality and morbidity rates within 30 days after operation and the day of week of surgery, as well as patient characteristics, treatment data and socioeconomic data were analysed. RESULTS: We were unable to show that the day of week had a significant impact on short-term mortality or on surgical or medical complications. There was no evidence that patients undergoing surgery on Fridays had more risk factors or were more socioeconomically deprived than patients undergoing surgery from Monday to Thursday. CONCLUSIONS: The day of week of operation could not be shown to have any significant impact on the risk of post-operative surgical or medical complications or on short-term mortality in patients undergoing elective surgery for colorectal cancer in Denmark. FUNDING: none. TRIAL REGISTRATION: not relevant.

Increased serological cancer-associated biomarker levels at large bowel endoscopy and risk of subsequent primary cancer (†).

BACKGROUND: Frequently, subjects offered colonoscopy due to symptoms of colorectal neoplasia are diagnosed with diverticula. The symptoms may, however, also be related to extra-colonic neoplasia. The present retrospective study evaluated a possible association between increased levels of predefined biomarkers in subjects diagnosed with diverticula and risk of developing a primary malignant disease. METHODS: During 2004/2005, about 4509 subjects were included in a multicenter study with collection of blood samples before bowel endoscopy. The aim was to evaluate a relation between the protein biomarkers CEA, TIMP-1, CA19-9 and YKL-40 and findings at endoscopy. Diverticula were diagnosed in 1021 subjects. By 31 December 2012, subjects who had developed primary malignancy were identified retrospectively and relation between biomarker levels at endoscopy and risk of developing primary malignancy was calculated. The relation with the four biomarkers was divided into three groups: 0 = none increased; 1 = one increased and 2 = two or more increased. RESULTS: In the observation period, 148 subjects developed a primary malignant disease. Univariable analyzes of the biomarker levels showed that CEA, TIMP-1 and CA19-9 were significantly associated with development of primary malignancy. A multivariable analysis showed that increased levels were associated with development of malignancy (p < 0.0001). The 1- and 5-year cumulative risks of being diagnosed with a primary malignancy were: group 0: 1.1%/5.5%; group 1: 4.2%/10.1% and group 2: 11.4%/18.8%, respectively. CONCLUSION: Increased levels of CEA, TIMP-1 and CA19-9 at endoscopy with findings of diverticula were associated with a significantly increased risk of being diagnosed with a subsequent primary malignant disease.

Blood-based Biomarkers at Large Bowel Endoscopy and Prediction of Future Malignancies.

Soluble cancer-related protein biomarker levels may be increased in subjects without findings at large bowel endoscopy performed due to symptoms associated with colorectal cancer. The present study focused on a possible association between increased biomarker levels in such subjects and subsequent development of malignant diseases. In a major study of 4,990 subjects undergoing large bowel endoscopy, 691 were without pathology and comorbidity. Plasma levels of TIMP-1, CEA, CA19-9, and YKL-40 were determined in samples collected just before endoscopy and compared with subsequent development of a malignant disease within a period of 7-8 years. The upper 90% limits of the reference levels of every single protein were used to differentiate between normal and increased levels. The levels were separated into three groups: 0, none of the biomarkers increased; 1, one biomarker increased; 2, two or more biomarkers increased. A total of 43 subjects developed a primary malignant disease in the observation period. Univariatly, increase of all four biomarkers was significantly associated with subsequent development of a malignant disease. A multivariate analysis showed that increased biomarker levels were associated with subsequent development of a malignant disease (P = 0.002). The cumulative risk of developing malignant disease within the first 5 years after endoscopy was group 0, 3.3%; group 1, 5.8%; group 2, 7.8%. It is concluded that increased levels of plasma TIMP-1, CEA, CA19-9, and serum YKL-40 at large bowel endoscopy without findings may be associated with an increased risk of developing a subsequent malignant disease.

Serum YKL-40 in risk assessment for colorectal cancer: a prospective study of 4,496 subjects at risk of colorectal cancer.

The aim of the present study was to test the hypothesis that high serum YKL-40 associates with colorectal cancer in subjects at risk of colorectal cancer. We measured serum YKL-40 in a prospective study of 4,496 Danish subjects [2,064 men, 2,432 women, median age 61 years (range, 18-97)] referred to endoscopy due to symptoms or other risk factors for colorectal cancer. Blood samples were collected just before large bowel endoscopy. Serum YKL-40 was determined by ELISA. Serum YKL-40 was higher (P < 0.0001, unadjusted for confounding covariates) in subjects diagnosed with colon cancer (median 126 µg/L, 25%-75%: 80-206 µg/L) and rectal cancer (104, 72-204 µg/L) compared with subjects with adenoma (84, 53-154 µg/L), other nonmalignant findings (79, 49-138 µg/L), and no findings (62, 41-109 µg/L). Serum YKL-40 independently predicted colorectal cancer [OR, 1.53; 95% confidence interval (CI), 1.40-1.67; AUC = 0.68, P < 0.0001]. Restricting the analysis to subjects with no comorbidity increased the OR for serum YKL-40 to predict colorectal cancer (OR, 1.82; 1.58-2.08; AUC = 0.73, P < 0.0001). Combining serum YKL-40 and CEA demonstrated that both were significant [(YKL-40, OR, 1.27; 95% CI, 1.16-1.40); (CEA, OR, 1.92; 1.75-2.10; AUC = 0.75, P < 0.0001; OR for a 2-fold difference in marker level)]. Multivariable analysis (YKL-40, CEA, age, gender, body mass index, and center) showed that serum YKL-40 was a predictor for colorectal cancer in individuals without comorbidity (OR, 1.25; 95% CI, 1.05-1.40; P = 0.012), whereas this was not the case for those with comorbidity (OR, 0.98; 95% CI, 0.84-1.14; P = 0.80). In conclusion, high serum YKL-40 in subjects suspected of colorectal cancer and without comorbidity associates with colorectal cancer. Determination of serum YKL-40 may be useful in combination with other biomarkers in risk assessment for colorectal cancer. Cancer Epidemiol Biomarkers Prev; 24(3); 621-6. ©2015 AACR.

Biomedical informatics as support to individual healthcare in hereditary colon cancer: the Danish HNPCC system.

The Danish HNPCC register is a publically financed national database. The register gathers epidemiological and genomic data in HNPCC families to improve prognosis by screening and identifying family members at risk. Diagnostic data are generated throughout the country and collected over several decades. Until recently, paper-based reports were sent to the register and typed into the database. In the EC cofunded-INFOBIOMED network of excellence, the register was a model for electronic exchange of epidemiological and genomic data between diagnosing/treating departments and the central database. The aim of digitization was to optimize the organization of screening by facilitating combination of genotype-phenotype information, and to generate IT-tools sufficiently usable and generic to be implemented in other countries and for other oncogenetic diseases. The focus was on integration of heterogeneous data, elaboration, and dissemination of classification systems and development of communication standards. At the conclusion of the EU project in 2007 the system was implemented in 12 pilot departments. In the surgical departments this resulted in a 192% increase of reports to the database. Several gaps were identified: lack of standards for data to be exchanged, lack of local databases suitable for direct communication, reporting being time-consuming and dependent on interest and feedback.

Plasma TIMP-1 and CEA in detection of primary colorectal cancer: a prospective, population based study of 4509 high-risk individuals.

OBJECTIVE: The combination of plasma tissue inhibitor of metalloproteinases-1 (TIMP-1) and carcinoembryonic antigen (CEA) may be valuable biomarkers for early detection of colorectal cancer (CRC). A prospective, population based study was performed to validate this hypothesis. MATERIAL AND METHODS: Individuals (n = 4509) referred for large bowel endoscopy due to symptoms of CRC were prospectively included. Baseline data and concurrent diseases were recorded. The primary endpoint was detection of CRC and findings at examinations were recorded using International Classification of Diseases-10 codes. Plasma was obtained before endoscopy and TIMP-1 and CEA levels were determined after the inclusion of all individuals. RESULTS: Findings were based on sigmoidoscopy in 1766 and colonoscopy in 2743 individuals. Colon cancer (CC) was detected in 184 and rectal cancer in 110 individuals. Ten individuals with other cancers, 856 with adenomas and 1176 with non-neoplastic findings were also detected. The biomarker levels were increased in a variety of diseases including CRC compared to individuals without any findings at endoscopy. A multivariable analysis demonstrated that both markers were significant and independent detectors of CRC. Combining both biomarkers, independent contributions from each (TIMP-1, odds ratio (OR) = 1.8 (95% confidence interval (CI): 1.4-2.2), p < 0.0001; CEA < 5 ng/ml, OR = 1.6, 1.3-1.9, or ≥ 5 ng/ml, OR = 2.3, 95% CI: 1.9-2.7 (p < 0.0001)) were obtained. Subgroup analysis of individuals examined by colonoscopy with CC as the endpoint showed that combining both biomarkers, independent contributions from each (TIMP-1, OR = 2.5, 95% CI: 1.8-3.4, p < 0.0001; CEA < 5 ng/ml, OR = 1.4, 95% CI: 1.1-1.8, and CEA ≥ 5 ng/ml, OR = 2.3, 95% CI: 1.8-3.0 (p < 0.0001)) were obtained. CONCLUSIONS: This prospective validation study supports the use of the combination of plasma TIMP-1 and CEA protein measurements as a potential aid in early detection of CRC and specifically of CC.

[Chronic ileus following iatrogenic reversal of the small intestine]. / Kronisk ileus efter iatrogen reversering af tyndtarmen.

We report a case of inadvertent reversal of the entire small intestine leading to severe complications and long-standing ileus. The clinical diagnosis was confirmed by magnetic resonance imaging and laparotomy. The patient was cured by surgical re-reversal of the bowel. Care should be taken to mark the bowel ends when multiple simultaneous bowel resections are performed.

Adenocarcinoma arising from the rectal stump eleven years after excision of an ileal J-pouch in a patient with ulcerative colitis: report of a case.

Adenocarcinomas in relation to the ileal J-pouch after restorative proctocolectomy for ulcerative colitis have been recently reported with increasing frequency. All previously reported cases have occurred in patients with their ileal pouch in situ. We report a case of adenocarcinoma in the anal canal 11 years after removal of a failed ileal J-pouch. Mucosectomy had been performed at the restorative proctocolectomy. The anus had been left in place at the pouch excision because of severe fibrosis in the pelvis. If it is decided to remove an ileal pouch permanently, a total abdominoperineal excision should be performed, particularly in patients with risk factors for cancer development.