Carcinoma Risk after Colectomy and Ileorectal Anastomosis

There is considerable controversy concerning the incidence of carcinoma following colectomy and IRA. The evidence against ileorectal anastomosis came mainly from the Mayo Clinic. Moertel et al. [24] found that in 145 patients treated by subtotal colec-tomy and IRA, there was a continuing risk of rectal cancer. This was 25% after 15 years of follow-up and 59% after 23 years. They found that women were at greater risk than men and that the incidence was markedly increased if the patient had carcinoma in the resected colon. Another factor with important clinical application was that the risk of carcinoma was considerably reduced if there were fewer than 20

polyps in the rectum compared with patients having more than 100. Some doubt has since been expressed about how many of these patients actually had a true IRA. It would appear that many underwent an ileosigmoid anastomosis, and it is unknown what influence the latter procedure might have had on the outcome, particularly since surveillance following this operation is more difficult than after a true IRA [25]. Fuel for the controversy was further supplied by reports from other centres [26]. They reported a series of 89 patients treated by a true IRA and 6-monthly surveillance. Included in this series were 47 patients followed for 10 years, 27 followed for 15 years and 13 followed for 20 years. Only two patients (2.2%) developed carcinoma, both of which were Duke's A lesions, and both patients survived. There are similar reports from other centres [27, 28] showing, that carcinoma develops in up to 6% of cases.

Making recommendations from these contradictory data, particularly at a time when restorative proctocolectomy is not fully tested, is clearly difficult. There is no doubt that there is a risk of developing carcinoma after colectomy and IRA, which relates to the number of polyps in the rectum and the presence of coexisting carcinoma. This may also be related to how much colorectum remains; there may be a geographic difference. Consequently, there has been general unease about performing colectomy and IRA in various countries.

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