POUCH-RELATED ADENOCARCINOMA DECADES AFTER RESTORATIVE PROCTOCOLECTOMY FOR ULCERATIVE COLITIS MIMICS ILEOANAL POUCH FAILURE

Objectives: Patients with ulcerative colitis (UC) accept a colorectal cancer risk at least 3-5 times that of the general population, but reporting of ileoanal pouch (IPAA) cancers is low. For patients who have colitis refractory to medical management, restorative proctocolectomy (RPC) with IPAA may be an option for disease control, with the intent to maintain intestinal continuity while removing at-risk tissue [1]. Here, we present a case of adenocarcinoma occurring 28 years after RPC- IPAA, a relatively rare illustration of pouch-related adenocarcinoma [2] that was indiscernible from other etiologies of pouch failure.
This is a 49-year-old male with two months of pelvic and anal pain, incomplete emptying, and poor oral intake. He underwent RPC- IPAA 28 years prior for refractory UC. Comprehensive evaluation revealed chronic anoperineal sepsis with moderate pouch anal anastomotic stricture, angulation and fibrosis, reducing the efferent limb luminal diameter to a few millimeters.
He underwent laparoscopic creation of diverting loop ileostomy as a bridge for consideration of pouch revision versus excision. Following surgery, the patient reported a small improvement in symptoms, which was worrisome. Repeat exam with biopsy showed chronic inflammation with no dysplasia. He strongly desired stoma-free living, and was offered attempt at pouch revision versus excision. At laparotomy, friable tissue in deep pelvis was clinically worrisome, and intraoperative pathologic assessment revealed adenocarcinoma. Abdominoperineal excision of the pouch, rectal cuff and anal canal was performed. Post-operatively, the patient completed oncologic staging and is being treated with adjuvant therapy.
Pouch-related cancers, although reported to be rare, should be considered when evaluating a patient with ileoanal pouch failure. When identified, pouch excision with appropriate oncologic treatment should be pursued.

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