P417 Ileal pouch-anal anastomosis for dysplasia or cancer complicating inflammatory bowel disease: should a total mesorectal excision always be performed? An analysis of 39 consecutive patients.
L. Maggiori*1, C. Coton1, X. Tréton2, Y. Bouhnik2, Y. Panis1
1Beaujon Hospital, Colorectal Surgery, Clichy, France, 2Beaujon Hospital, Gastroenterology, Clichy, France
Updated S-ECCO guidelines in patients undergoing a restorative coloproctectomy with ileal pouch-anal anastomosis (IPAA) for colorectal dysplasia or cancer complicating inflammatory bowel disease (IBD) state that an extensive lymph node dissection, including a total mesorectal excision (TME), should always be performed, even in the absence of preoperatively known rectal cancer and despite the risk of postoperative sexual disorders. This study aimed to compare the oncological outcomes of patients who underwent IPAA for colorectal neoplasm complicating IBD with or without TME.
From 1998 to 2014, all patients who underwent an IPAA for neoplasm complicating an IBD were included. This population was split in 2 groups: IPAA with TME and IPAA without TME.
39 consecutive patients were enrolled (10 women, 29 men, with a mean age of 51 [27-77] years), including 24 (62%) restorative coloproctectomies and 15 (38%) completion proctectomies performed after previous subtotal colectomy. Surgical dissection included a proctectomy with TME in 14 (36%) patients and without TME in 25 (64%) patients.
In the TME group, indication for surgery included colonic dysplasia (n=1, 7%), rectal dysplasia (n=6, 43%), colonic cancer (n=1, 7%), and rectal cancer (n=6, 43%). In the no TME group, indications included colonic dysplasia (n=14, 56%), rectal dysplasia (n=9, 35%), unlocated dysplasia (n=1, 4%), and colonic cancer (n=1, 4%).
Among the 8 patients from the TME group without preoperatively know rectal cancer, pathologic examination of the specimen showed rectal dysplasia in 3 patients and pT1 rectal cancer in 3 patients (pTisN0R0, pT1sm2N0R0, and pT1sm3N0R0). In the 25 patients from the no-TME group, pathologic examination of the specimen showed rectal dysplasia in 6 patients and rectal cancer in 2 patients: 1 with high grade dysplasia but associated with a cystic lesion in the muscular layer (genuine pT2N0 (0/10)? Or proctitis cystica profunda?) and 1 pT2N0 (0/37) R0.
After a mean follow-up of 53 months [2-124], cancer recurrence was observed in 4 patients from the TME group and in no patient from the no-TME group.
These results do not support systematic TME during IPAA surgery for colorectal dysplasia or colonic cancer complicating IBD. Considering its demonstrated association with postoperative sexual disorders, TME should be discussed on a case-by-case basis during multidisciplinary team meetings.