The largest criticism about stapled IPAA is the risk of leaving in situ a 1- to 2-cm-long columnar cuff of mucosa above the anal transitional zone (ATZ) area, with symptomatic sequelae and the potential for neo-plastic transformation over time [24, 52]. The risk of a dysplasia in the ATZ/columnar mucosa may be connected with the stage of illness, follow-up duration and UC or FAP diagnosis. Risk is 25% if the proctocolectomy specimen shows cancer, 10% if there is concomitant dysplasia. In patients with FAP, the risk of adenoma is 4-12% and of dysplasia 10-12% . Considering that the risk of cancer onset after ileorectal anastomosis is 15-20% after 30 years since surgery , a theoretical risk of 2% after 30 years since surgery was calculated for the ATZ/columnar residual mucosa both in patients with UC and FAP. Neoplastic risk does not disappear after mucosectomy because in ileoanal pouches removed because of complications, residual islands of columnar mucosa between the reservoir serosa and the rectal muscular cuff were found in 20% of cases ; moreover, most carcinomas that occurred following IPAA were in patients who underwent mucosectomy [53, 54]. Recent investigations with a minimum fol low-up of 10 years gave rather reassuring data, as development of dysplasia in the residual columnar mucosa was found in 0-4.5% of cases [53-55]. Evidence from examining doughnuts and mucosectomy specimens does not support the argument for routine mucosectomy, except for FAP patients with extensive rectal involvement and high-risk genotype and CU patients with associated dysplasia or cancer . All other cases would be better served by sparing the anal canal mucosa due to functional improvement [11, 14], even if some controversy on this topic persists [7,17, 25]. Regardless, it is advisable to perform an annual endoscopic biopsy follow-up [53, 55]. Endoscopic and histologic markers of an inflammation of the columnar mucosa were found in 35% and 50-75% of patients. Clinical symptoms affected only 15% of patients and did not compromise reservoir function .
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