Cancer surveillance in longstanding ulcerative colitis: endoscopic appearances help predict cancer risk.

BACKGROUND AND AIMS: The risk of colorectal cancer is increased in ulcerative colitis (UC). Patients with UC have diverse colonoscopic appearances. Determining colonoscopic markers for cancer risk could allow patient risk stratification. PATIENTS AND METHODS: Following on from an earlier study which demonstrated a correlation between inflammation severity and neoplasia risk, a case control study was performed to look for colonoscopic markers of colorectal neoplasia risk in UC. Each patient with neoplasia detected between 1988 and 2002 was matched with two non-dysplastic colitic controls. Data were collected on post-inflammatory polyps, scarring, strictures, backwash ileitis, a shortened, tubular, or featureless colon, severe inflammation, and normal looking surveillance colonoscopies. RESULTS: Cases (n = 68) and controls (n = 136) were well matched. On univariate analysis, cases were significantly more likely to have post-inflammatory polyps (odds ratio (OR) 2.14 (95% confidence interval 1.24-3.70)), strictures (OR 4.22; 1.08-15.54), shortened colons (OR 10.0; 1.17-85.6), tubular colons (OR 2.03; 1.00-4.08), or segments of severe inflammation (OR 3.38; 1.41-10.13), and less likely to have had a macroscopically normal looking colonoscopy (OR 0.40; 0.21-0.74). After multivariate analysis, a macroscopically normal looking colonoscopy (OR 0.38; 0.19-0.73), post-inflammatory polyps (2.29; 1.28-4.11), and strictures (4.62; 1.03-20.8) remained significant. The five year risk of colorectal cancer following a normal looking colonoscopy was no different from that of matched general population controls. CONCLUSIONS: Macroscopic colonoscopic features help predict neoplasia risk in UC. Features of previous/ongoing inflammation signify an increased risk. A macroscopically normal looking colonoscopy returns the cancer risk to that of the general population: it should be possible to reduce surveillance frequency to five years in this cohort.

Histological categorisation of fibrotic cancer stroma in advanced rectal cancer.

BACKGROUND AND AIMS: Based on conflicting reports regarding the role of the fibrotic stromal response in cancer development--namely, that a desmoplastic reaction can favour either the host or the tumour--it is clear that the role of the stromal response is varied. We have classified the fibrotic stroma of rectal adenocarcinoma penetrating the muscularis propria, based on histologically identified stromal components. METHODS: Three categories of stroma were used: mature-when the stroma was composed of mature collagen fibres (fine and elongated fibres into multiple layers); intermediate-when keloid-like collagen was intermingled with mature fibres; and immature-consisting of a myxoid stroma in which no mature fibres were included. RESULTS: In a data set of 862 patients, 53% of patients had mature fibrotic cancer stroma, 33% had intermediate stroma, and 15% had immature stroma. Five year survival rates decreased as follows: mature stroma (80%), intermediate stroma (55%), and immature stroma (27%). The adverse tumour phenotype, tumour cell budding (conspicuous isolated cells or small clusters of cancer cells), was observed in the cancer fronts in tumours with unfavourable fibrotic stroma (p<0.0001). Based on multivariate analysis, categorised fibrotic stroma was selected as an independent prognostic parameter (hazard ratio 1.39; 95% confidence interval 1.17-1.64) together with tumour differentiation. By immunohistochemical examination, as maturation of the fibrotic stroma decreased, stromal T cells became significantly sparser. Furthermore, myofibroblasts were distributed extensively in immature fibrotic stroma compared with mature and intermediate fibrotic stroma. CONCLUSION: The morphological categorisation of fibrotic cancer stroma highlights the role of the stromal response in relation to the behaviour and host immune reactions of rectal adenocarcinoma and would be a useful tool for predicting patient prognostic outcome.

Salvage abdominal surgery in patients with a retained rectal stump after restorative proctocolectomy and stapled anastomosis.

BACKGROUND: The introduction of surgical stapling instruments has widened the use of restorative proctocolectomy. Too high a distal transection of the rectum can, however, produce a retained rectal stump, which may cause symptoms. A study of the operative and functional data in a consecutive series of patients undergoing salvage surgery for retained rectal stump was undertaken. METHODS: Twenty-five patients referred between January 1990 and September 2000 for pouch dysfunction were identified as having a retained rectal stump. Twenty-two underwent abdominoanal revision. The hospital notes were reviewed and function was assessed during outpatient visits, by postal questionnaire and by telephone interview. RESULTS: Median operating time was 225 (range 170-340) min and median hospital stay was 15 (range 8-48) days. There was no operative death. Five pouches were excised. Seventeen patients were available for functional assessment. Median follow-up was 22.5 (range 4-114) months. Median 24-h frequency before and after operation was 12 (range 4-20) and 6 (range 3-12) respectively, and median night-time frequency was 4 (range 0-8) and 0.5 (range 0-4) respectively. Fifteen patients reported marked subjective improvement in pouch function and quality of life. CONCLUSION: Major revisional surgery for symptomatic retained rectal stump after restorative proctocolectomy with stapled anastomosis was successful in 15 of 22 patients. These results are worse than the outcome following first-time restorative proctocolectomy with anastomosis constructed at the anal level. Pouch-rectal anastomosis should be avoided.

Peri-operative management of patients having external anal sphincter repairs: temporary prevention of defaecation does not improve outcomes.

OBJECTIVE: To determine whether there was any detectable difference in outcomes of external anal sphincter repair depending on whether patients were managed routinely with a covering stoma, a constipating dietary regimen or a laxative dietary regimen in the early postoperative period. PATIENTS AND METHODS: A consecutive retrospective series of 299 anal sphincter repairs undertaken on 286 patients within a single institution was studied. Patients were divided into three groups depending on the peri-operative regimen followed: routine use of a covering stoma (group 1), routine use of a postoperative constipating dietary regimen (group 2) and routine use of a laxative dietary regimen (group 3). Choice of peri-operative regimen depended on surgeon preference alone. Short-term outcomes (length of stay, complications) and long-term outcomes (functional reported degree of continence, anal ultrasound and physiology test results) were assessed in relation to peri-operative group as well as aetiology of sphincter damage. RESULTS: Short-term results (complications of surgery) were obtainable in all patients; long-term results were available for 89% of patients. Length of stay was similar for all 3 groups (excluding re-admission for stoma closure). Complication rates were not significantly different between the three groups. Functional improvement in continence was reported by 68% of group 1, 69% of group 2 and 79% of group 3 (differences not statistically significant). An anatomical sphincter defect was detected postoperatively in 8% of patients in group 1, 9% in group 2 and 7% of group 3. Poorer outcomes were achieved in older patients and in patients with previous ileo-anal pouch formation. Early faecal impaction and repair breakdown were independently associated with poor long-term outcomes. CONCLUSIONS: Neither routine use of a covering stoma nor a postoperative constipating regimen produced better results following external anal sphincter repair than did the use of a postoperative laxative regimen which encouraged early passage of loose stool without the need for straining.

Clinicopathological characteristics of colorectal carcinoma complicating ulcerative colitis.

This study examined three features associated with colorectal carcinoma complicating ulcerative colitis: (a) the distribution of 157 cancers in 120 patients with ulcerative colitis treated at St Mark's Hospital between 1947 and 1992; (b) the frequency at which dysplasia was found at a distance from the tumour in 50 total proctocolectomy specimens in which an average of 27 histology blocks were reviewed, and (c) the five year survival rate according to Dukes's stage and participation in a surveillance programme. Of 157 carcinomas, 88 (56%) occurred in the rectosigmoid, 19 (12%) in the descending colon or splenic flexure, and 50 (32%) in the proximal colon. Among the 120 patients, the rectum or sigmoid colon contained cancer in 81 (67.5%). Dysplasia was detected in 41 of 50 reviewed proctocolectomy specimens (82%). Dysplasia distant to a malignancy occurred in 37 (74%); two were classified indefinite, probably positive, 19 were low grade, and 16 were high grade; in 18 specimens there was an elevated dysplastic lesion. Survival was related to the Dukes's stage: about 90% of patients with Dukes's A or B cancer were alive at five years. The five year survival of 16 patients in whom cancer developed during surveillance was 87% compared with 55% of 104 patients who did not participate in surveillance (p = 0.024).

Factors affecting the outcome of endoscopic surveillance for cancer in ulcerative colitis.

BACKGROUND/AIMS: Cancer surveillance in patients with ulcerative colitis is of unproven benefit. This study assesses the efficacy and analyzes factors limiting the success of a surveillance program during a 21-year period in 332 patients with ulcerative colitis to the hepatic flexure and disease duration exceeding 10 years. METHODS: Clinical assessment and sigmoidoscopy with biopsy was undertaken yearly. Colonoscopy and biopsy every 10 cm throughout the colon was performed every 2 years or more often if dysplasia was found. Only biopsy specimens reported as showing dysplasia were reviewed. RESULTS: Surveillance contributed to detection of 11 symptomless carcinomas (8 Dukes A, 1 Dukes B, and 2 Dukes C), but 6 symptomatic tumors (4 Dukes C and 2 disseminated) presented 10-43 months after a negative colonoscopy. Dysplasia without carcinoma was confirmed in 12 symptomless patients who underwent colectomy. The 5-year predictive value of low-grade dysplasia for either cancer or high-grade dysplasia was 54% using current criteria. CONCLUSIONS: Surveillance identified some patients at a curable stage of cancer or with dysplasia. Limiting factors were failure to include patients with presumed distal colitis, biennial colonoscopy, the number of biopsy specimens at each colonoscopy, and variation in histological identification and grading of dysplasia.

The first 10 years' experience of restorative proctocolectomy for ulcerative colitis.

Between 1976 and 1985, 110 patients had restorative proctocolectomy or proctectomy for ulcerative colitis and 103 were followed up until death or February 1992. There was one postoperative and one late death related to surgery. The cumulative probability of pouch failure was 12% at five years: half of the failures occurred within one year. The commonest reasons were perianal/pelvic sepsis and probable Crohn's disease. The cumulative probability of readmission, excluding that for ileostomy closure, was 68% at five years. There were 152 operations carried out during readmissions. These included 44 laparotomies. Function was assessed in 80 patients at a mean of 99.3 months after ileostomy closure. For 66 patients with spontaneous evacuation, average minimum diurnal frequency was 3.8, maximum 4.9, with 35 evacuating at night. One patient experienced major continence problems, 30 had minor leaks, and 49 were completely continent. Postoperatively, five patients gave birth to nine babies, four had renal stones, two myasthenia gravis, and two severe anaemia: seven had pre or postoperative thyroid dysfunction.