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Anal Transitional Zone Neoplasia in Patients with Familial Adenomatous Polyposis After Restorative Proctocolectomy and IPAA: Incidence, Management, and Oncologic and Functional Outcomes
source: Diseases of the colon and rectum
authors: Ozdemir Y, Kalady M F, Aytac E, Kiran R P, Erem H H, Church J M, Remzi F Hsummary/abstract:
BACKGROUND : Restorative proctocolectomy and IPAA in patients with familial adenomatous polyposis may leave residual anal transitional zone mucosa that is prone to neoplasia.
OBJECTIVE : The aim of this study was to evaluate the long-term control of neoplasia at the IPAA, the functional outcomes, and the influence of anastomotic technique on these results.
DESIGN : : This research is a retrospective cohort study from a prospective database.
SETTING : The investigation took place in a high-volume specialized colorectal surgery department.
PATIENTS : Patients with familial adenomatous polyposis who underwent IPAA between 1983 and 2010 were included.
MAIN OUTCOME MEASURES : The primary outcomes measured were functional outcomes, quality of life, and the incidence of neoplasia in the anal transitional zone.
RESULTS : Eighty-six patients underwent mucosectomy and 174 underwent stapled anastomosis with mean 155 ± 99 and 95 ± 70 months follow-up. Eighteen patients (20.9%) in the mucosectomy group and 59 patients (33.9%) in the stapled group developed anal transitional zone adenomas (p = 0.03). One of 86 (1.2%) patients undergoing mucosectomy and 3 of 174 (1.7%) patients undergoing stapled anastomosis developed cancer in the anal transitional zone (p > 0.05). Three of these patients underwent an abdominoperineal resection, but one who refused abdominoperineal resection underwent transanal excision with neoileoanal anastomosis. Patients undergoing a mucosectomy had a significantly higher rate of anastomotic stricture, but other complications were similar. Incontinence, seepage, and pad usage were higher in the mucosectomy group. Cleveland global quality-of-life score was 0.8 ± 0.2 in patients with handsewn anastomoses and 0.8 ± 0.3 in patients with a stapled anastomoses (p > 0.05).
LIMITATIONS : This study was limited by its nonrandomized retrospective design.
CONCLUSIONS : Risk for the development of adenomas in the anal transitional zone is higher after a stapled IPAA than after a mucosectomy with handsewn anastomosis. However, control of anal transitional zone neoplasia results in a similar risk of cancer development. Because the stapled procedure is associated with better long-term functional outcomes than a mucosectomy, stapled IPAA is the preferable procedure for most patients with familial adenomatous polyposis.organization: Cleveland Clinic
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