Colectomy and Ileorectal Anastomosis IRA

Conflicting results have been presented as regards the indications for colectomy with IRA for ulcerative colitis. Although many surgeons today are still reluctant to use the technique, emphasising not only the persistent cancer risk but also the poor function [32-34], others consider the operation a viable alternative when used selectively in patients without signs of mucosal dysplasia and whose rectum is not severely affected by inflammation or fibrosis [35-37]. The colectomy and IRA procedure for a condition that almost invariably involves an inflamed rectum certainly seems illogical. Apart from poor function, there is a significant risk of cancer development in the chronically inflamed mucosa. It is often argued that a substantial proportion of IRA patients - maybe even half of them - will have their rectum excised eventually due to persistent or relapsing proctitis [38]. However, in many cases, the proctitis often settles spontaneously or after local treatment or recurs periodically. Thus, the patient may enjoy reasonably good general health and bowel function. Therefore, even if 40-50% of the patients will ultimately require rectal excision, roughly half of the patients will continue to enjoy a satisfactory result and many of those who finally fail, have been able to postpone a major operation (IPAA) or an abdominal stoma for several years. Therefore, the time "bought" by IRA will get many young people through their formative years of education, allowing them to plan for a family and a professional career. However, the long-term risk of cancer in the rectal stump is the main strong argument that has been put forward against the use of this operation - a risk that increases with the duration of the disease and with the passage of time after the colectomy. The cumulative probability of cancer development approaches 5 and 15% after a 20 and 30-year observation, respectively [34, 39]. A very important predictive factor is the presence of severe dysplasia in the rectum or carcinoma of the colon at the time of surgery [40]. Bearing this in mind, the risk of rectal cancer should therefore be low in patients with a short antecedent disease history and in those without mucosal dysplasia in the colon/rectum. As regular well-designed colonoscopic surveillance is considered justified for the control of patients with longstanding panproctocolitis - in whom the cancer risk is 3-4 times higher - similar guidelines [19] should be quite appropriate and safe for surveillance of patients with an IRA. In other words, by using a meticulous follow-up system for patients with IRA, it should be possible to identify patients who are at a particular risk and urge them to undergo prophylactic rectal excision.

The controversy regarding colectomy and IRA and the place of this procedure in the treatment of UC has been characterised in the past by personal prejudices and overzealous condemnation of the technique by several of the more prominent experts on colorectal surgery [38]. Employed on a selective basis, IRA should a safe procedure with low mortality and morbidity and good prospects for success as a prophylactic procedure in many patients with longstanding ulcerative colitis. However, before surgery, the patients must be fully informed of any inconveniences and risks associated with the procedure, and, most importantly, they must be prepared to submit to lifelong endoscopy surveillance.

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