Surgery in presence of dysplasia in IBD

Abstract

Patients with longstanding ulcerative colitis (UC) and Crohn’s disease have an increased risk of developing colorectal cancer. Dysplasia can be defined as neoplastic intraepithelial change, paralleling the location of neoplasia, arising from chronic inflammation, divided in different grades from low to high grade. Different types of dysplasia have been described in UC such as “flat dysplasia”, DALM or ALM. The management of dysplasia and cancer associated with UC has been strongly influenced by the considerable progress in the surgical treatment of the disease that has taken place in the last decades. The presence of dysplasia modifies the surgical attitude in sphincter-saving procedures such as ileorectal and ileoanal anastomosis where colonic mucosa is left in situ. With the stapled-anastomosis few centimeters of colonic mucosa (1-2 cm) are left in site below ileo-anal anastomosis with a risk of malignant degeneration. The hand-sewn IPAA with mucosectomy reduces the risk of retained colonic mucosa below the anastomosis, but does not allow complete removal of columnar epithelium with its potential evolution to a malignant state. Conclusions: in case of preoperative diagnosis of dysplasia we strongly recommend an oncologic resection of the specimen with TME, ligation at the origin of all the vascular pedicles and a extended lymphadenectomy.