Dysplasia of the anal transitional zone after heal pouch-anal anastomosis - Results of prospective evaluation after a minimum of ten years
Dysplasia of the anal transitional zone after heal pouch-anal anastomosis - Results of prospective evaluation after a minimum of ten years
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DOI：
10.1007/s10350-004-6488-2
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发表时间：
2003-01-01
影响因子：
3.9
通讯作者：
Lavery, IC
中科院分区：
文献类型：
--
作者：
Remzi, FH;Fazio, VW;Lavery, IC
目得：由于担心发育不良和癌症的潜在风险，保留肛门移行区的回肠贮袋-肛门吻合术的吻合仍然存在争议。肛门移行区发育不良手术后10年或更长时间的自然病程和最佳治疗方法尚不清楚。本研究确定了肛门移行区发育不良的风险和保守治疗肛门移行区发育不良的结果，回肠袋-肛门吻合术后至少随访10年。方法：研究了1986年至1990年期间接受保留肛门移行区的吻合器回肠贮袋-肛门吻合术治疗炎症性肠病的共计289例患者。纳入了接受保留肛门移行区回肠袋-肛门吻合术的患者，这些患者在术后至少10年进行了连续肛门移行区活检研究（n = 178）。中位随访时间为130个月（范围：120-157）。结果：8例患者术后4 ~ 123个月（中位数，9个月）发生肛门移行区发育不良。与性别、年龄、术前病程或结肠炎程度无关，但肛门移行区发育不良的风险与术前诊断或直肠结肠切除术标本中的癌症或发育不良显著相关。异型增生在2例患者中为高级别，6例为低级别。2例低度异型增生患者。在两次或多次检测到低度异型增生后，进行了完整的粘膜切除术和会阴袋前移，并进行了新回肠袋-肛门吻合术。1例两次高度异型增生的患者接受了完全粘膜切除术，但这在技术上不可行。在密切的术后监测下，进行了部分粘膜切除术和肛门移行区活检。活检显示发育不良呈阴性。第二个最近诊断为高度异型增生的患者在麻醉下进行了检查，肛门移行区活检阴性，并将密切监测。在研究期间，未发现肛门移行区的癌症。其他4例轻度异型增生患者（1或2次）接受了预期治疗，中位时间为119个月（范围：103-133），无异型增生。结论：吻合器回肠贮袋-肛门吻合术后肛门移行区发育不良不常见，通常具有自限性。在至少10年的随访中，保留肛门移行区不会导致肛门移行区癌症的发生。建议进行长期监测，以监测发育不良。如果重复活检证实持续性发育不良，建议进行粘膜切除术伴会阴袋前移和新回肠袋-肛门吻合术。
PURPOSE: Stapling of the ileal pouch-anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years' follow-up after ileal pouch-anal anastomosis. METHODS: A total of 289 patients undergoing anal transitional zone-sparing stapled ileal pouch-anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow-up was 130 (range, 120-157) months. RESULTS: Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low-grade dysplasia. on two or more occasions after detection of low-grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo-ileal pouch-anal anastomosis. One patient with high-grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high-grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low-grade dysplasia on I or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103-133) months. CONCLUSIONS: Anal transitional zone dysplasia after stapled ileal pouch-anal anastomosis is infrequent and is usually self-limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo-ileal pouch-anal anastomosis is recommended.