Incidence and Management of Rectal Cuff and Anal Transitional Zone Neoplasia in Patients with Familial Adenomatous Polyposis.

BACKGROUND Rectal cuff and anal transitional zone neoplasia is an increasing challenge in patients with familial adenomatous polyposis who have undergone restorative proctocolectomy. Its real incidence, range of severity, and treatment efficacy are poorly documented. OBJECTIVE We sought to document the evolution of rectal cuff and anal transitional zone neoplasia and describe its management. DESIGN Retrospective cohort study collecting prospectively recorded data. SETTINGS Hereditary colorectal cancer group in a large academic medical center. PATIENTS All patients undergoing primary restorative proctocolectomy at this institution. INTERVENTIONS Surveillance pouchoscopy and treatment of rectal cuff/anal transitional zone neoplasia. MAIN OUTCOME MEASURES The presence and the severity of rectal cuff/anal transitional zone neoplasia. Excision by cautery, snare, mucosectomy or redo pouch. RESULTS A total of 165 patients were included: 52% were male (86/165) with median age at restorative proctocolectomy of 31.0 years (SD 12.8). In 117/165 the proctocolectomy was their first operation and in 48/165 it followed a colectomy. 83% (137/165) had stapled anastomosis, 17% had mucosectomy with hand sewn (HS) anastomosis. 14% of patients (23/165) were treated with sulindac at some point during their surveillance. Median follow-up was 10.1 years (IQR: 4.5, 17.2) and the median number of pouchoscopies per patient was 4. (IQR: 2, 8) 78/165 (47.3%) developed rectal cuff/anal transitional zone adenomas, more in the stapled group (52.3%; 72/137) than the hand-sewn group (21.4%; 6/28) (p<0.005). Median time to adenoma was 4.5 years (IQR: 2.4, 8.9). Three patients developed cancer under surveillance and in 3 other cancers developed when screenings lapsed. 5 patients developed symptomatic anal stenosis secondary to repeated surgeries (median of 9 procedures; range 2 -10). LIMITATIONS Lack of Quality of Life measurement in patients who developed rectal cuff/anal transitional zone neoplasia. CONCLUSIONS Rectal cuff/anal transitional zone adenomas are more common than previously reported. Mild polyposis can be controlled endoscopically, but repeated procedures in higher stage are associated with risk of anal stenosis. Compliance with surveillance is essential to avoid cancer. See Video Abstract at http://links.lww.com/DCR/B594.