Ileal adenomas more likely with ileal pouch-anal anastomosis vs. end ileostomy
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Patients with familial adenomatous polyposis with ileal pouch-anal anastomosis developed ileal adenomas more often than patients with end ileostomy after proctocolectomy, according to research published in Gastrointestinal Endoscopy.
“A (procto)colectomy is not a definitive solution in familial adenomatous polyposis however, and patients remain at risk of developing new adenomas and cancer in the remaining rectum after ileorectal anastomosis, and in the ileal pouch or rectal cuff after ileal pouch-anal anastomosis,” Arthur S. Aelvoet, MD, a research associate at Amsterdam UMC, and colleagues wrote. “As predicting the location, severity and timing of ileal adenomas following proctocolectomy is currently not possible, a better understanding of the development of adenomas in the ileal mucosa is needed.”
In a historical cohort study, Aelvoet and colleagues compared the development of ileal adenomas in 144 patients with ileal pouch-anal anastomosis (IPAA, n = 111) or end ileostomy (n = 33) who underwent surveillance endoscopies between 2001 and 2021. Outcomes of interest included the proportion of patients with ileal adenoma, adenoma location and proportion of patients undergoing surgical excision of pouch/end ileostomy.
According to study results, 72% of patients with IPAA developed ileal adenomas compared with 30% of patients with end ileostomy. At 5 years following surgery, ileal adenomas developed in 15% of patients with IPAA vs. 4% of patients with end ileostomy. After 10 and 20 years, 48% vs. 9% and 85% vs. 43%, respectively, developed ileal adenomas. The estimated median time to adenoma development was 140 months in the IPAA group (95% CI, 111-169) and 434 months in the end ileostomy group (95% CI, 180-688).
Of 2,983 adenomas detected in the IPAA group, 95% were reported in the pouch body and 5% in the pre-pouch ileum. Of the 77 adenomas detected in the end ileostomy group, 77% were at the everted site of the ileostomy and 23% were at the luminal site.
Pouch excision for extensive polyposis or pouch carcinoma occurred in 8% of patients in the IPAA group compared with 9% of patients in the end ileostomy group, who underwent excision of the ileostomy for extensive polyposis of the everted site of the ileostomy and luminal site.
After adjusting for potential confounders, researchers further reported that having an IPAA (HR = 5.22; 95% CI, 2.1-12.99), age at IPAA and use of chemopreventive agents prior to surgery were associated with ileal adenoma development.
“Patients with FAP that underwent proctocolectomy were more prone to develop ileal adenomas in the pouch than in the end ileostomy and the cumulative number of adenomas in pouches were higher as well,” Aelvoet and colleagues concluded. “IPAA is still the preferred option for most patients. However, all patients should be accurately informed about the risks of developing polyps and cancer in the pouch or end ileostomy, and advantages and disadvantages should be balanced for decision making on the type of surgery.”
They added, “We believe that the results of this study call for a further evaluation of the pathogenesis of ileal adenoma development following colectomy.”
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