EP827 - Saving the sphincter: Revision of Ileal Pouch with Adenocarcinoma Following Proctocolectomy for Ulcerative Colitis.

Purpose/Background: Adenocarcinoma of the ileal pouch is a rare but serious phenomenon following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) in the setting of ulcerative colitis (UC). We report such a case, highlighting the key aspects of successful surgical management and emphasizing the importance of routine surveillance.

Methods/Interventions: A 46 year-old male with history of UC, diagnosed at 16 years old, underwent a total proctocolectomy with ileoanal pouch at age 19 for intractable symptoms not resolving with clinical managment. After surgery, the patient became lost to follow up. The patient later presented with abdominal cramping and loose/watery bowel movements to a gastroenterologist. The gastroenterologist performed a pouchoscopy that revealed pouchitis and a solitary polyp, which was biopsied. Pathology from the biopsy showed high grade dysplastic glands in a background of ulceration and necroinflammatory debris, highly suspicious for adenocarcinoma. The patient was subsequently referred to colorectal surgery. The surgeon performed an additional pouchoscopy, which showed a lesion at the afferent limb pouch inlet area. At this point, surgery was recommended to remove the lesion and revise the pouch, and the patient was agreeable. A pre-operative magnetic resonance image (MRI) of the pelvis showed no evidence of malignancy extending into the peri-pouch tissue. The patient underwent a diagnostic laparoscopy to rule out metastasis. After no metastasis was found, a laparotomy was performed involving extensive lysis of adhesions, high ligation of the ileocolic artery, pouch excision, mucosectomy, small bowel resection. After the pouch was excised, the pelvis was irrigated with 40% alcohol diluted with saline to avoid tumor contamination. After irrigation, a new J pouch was created followed by a hand-sewn ileal pouch anal anastomosis and creation of a loop ileostomy. The patient recovered well postoperatively.

Results/Outcomes: Final pathology of the specimen showed focal intramucosal adenocarcinoma with multifocal high-grade and low-grade dysplasia in a background of chronic active enteritis/chronic inflammatory bowel disease. Resection margins were negative for dysplasia or malignancy.

Conclusion/Discussion: Restorative proctocolectomy with IPAA is the gold standard of treatment for UC that is refractory to medical management. Though rare, neoplastic transformation of the pouch is a serious complication, requiring excision of the pouch, possible end ileostomy or in some few cases meticulous mucosectomy with pouch recreation and hand-sewn anastomosis, avoiding a permanent ostomy. Our report examines a case of adenocarcinoma of the pouch 30 years after restorative proctocolectomy with IPAA who was lost to follow up. This case highlights the importance of routine endoscopic surveillance in UC patients following proctocolectomy with IPAA even in patients with no evidence of dysplasia or cancer at the time of the initial surgery. Additionally, this case describes an alternative management that maintains sphincter function and avoids an end ileostomy, which is the outcome of the few previously published case reports.