Ziv Y, Fazio V W, Sirimarco M T, Lavery I C, Goldblum J R, Petras R E
Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio 44195.
Dis Colon Rectum. 1994 Dec;37(12):1281-5. doi: 10.1007/BF02257797.
Preservation of the anal transitional zone (ATZ) after restorative proctocolectomy and stapled ileal pouch-anal anastomosis (IPAA) for ulcerative colitis is controversial.
To evaluate the incidence, risk factors, and treatment options for dysplasia and/or cancer after restorative proctocolectomy and stapled IPAA.
We reviewed the records of all 254 patients operated on for ulcerative colitis who had a restorative proctocolectomy, stapled IPAA, and annual postoperative biopsies of ATZ. Follow-up studies included an annual questionnaire and physical examination.
During a follow-up of 2.3 +/- 1.4 (mean +/- standard deviation) years, low-grade dysplasia was found in eight patients (3.1 percent), 16 (median: range, 6-56) months after surgery. Repeated biopsies revealed dysplasia in only two of eight patients, and completion mucosectomy was performed. Dysplasia in ATZ was associated with a preoperative (P = 0.02) or postoperative (P = 0.04) pathologic diagnosis of ulcerative colitis with concurrent dysplasia or cancer. No association (P > 0.05) was found between dysplasia and the following: age, sex, preoperative length of disease, use of a double-stapled versus single-stapled technique, or anastomotic distance from the dentate line.
Incidence of low-grade dysplasia in ATZ was low. Restorative proctocolectomy with total mucosectomy of the anal canal and handsewn IPAA is recommended for patients with preoperative diagnosis of ulcerative colitis and concurrent cancer or dysplasia. Frequent follow-up with biopsies is recommended for patients with incidental finding of cancer or high-grade dysplasia after restorative proctocolectomy and stapled IPAA with preservation of ATZ. For persistent or recurrent low-grade dysplasia, we recommend a completion mucosectomy.
对于溃疡性结肠炎患者，在进行保留肛门移行区（ATZ）的结直肠切除回肠储袋肛管吻合术（IPAA）后，ATZ的保留存在争议。
评估保留肛门移行区的结直肠切除回肠储袋肛管吻合术后发育异常和/或癌症的发生率、危险因素及治疗选择。
我们回顾了254例接受溃疡性结肠炎手术患者的记录，这些患者均接受了保留肛门移行区的结直肠切除回肠储袋肛管吻合术及术后每年一次的ATZ活检。随访研究包括每年一次的问卷调查和体格检查。
在平均2.3±1.4（均值±标准差）年的随访期间，8例患者（3.1%）在术后16（中位数：范围6 - 56）个月发现低度发育异常。重复活检显示8例患者中仅2例存在发育异常，遂进行了根治性黏膜切除术。ATZ发育异常与术前（P = 0.02）或术后（P = 0.04）溃疡性结肠炎伴发育异常或癌症的病理诊断相关。发育异常与以下因素无关联（P>0.05）：年龄、性别、术前病程、双吻合器与单吻合器技术的使用、或吻合口距齿状线的距离。
ATZ低度发育异常的发生率较低。对于术前诊断为溃疡性结肠炎并伴有癌症或发育异常的患者，建议行肛管全黏膜切除的保留肛门移行区的结直肠切除回肠储袋肛管吻合术。对于保留ATZ的结直肠切除回肠储袋肛管吻合术后偶然发现癌症或高度发育异常的患者，建议频繁进行活检随访。对于持续或复发的低度发育异常，我们建议行根治性黏膜切除术。
