Surveillance

Dysplastic epithelium may be a marker for coexisting malignancy, and provides the rationale for surveillance. The optimal surveillance strategy remains controversial [45]. Surveillance colonoscopy in IBD is advocated for early diagnosis of neoplasia, but is imperfect because some patients develop cancer despite surveillance. In effect, a few reports have shown conflicting results and these studies suggest that surveillance leads to the detection of early-stage cancer in only a minority of patients and a significant number of patients develop cancer at an advanced stage despite surveillance.

The American Gastroenterological Association (AGA) recommends that colonoscopic surveillance should begin after 8 years in patients with pancolitis and 15 years in patients with colitis involving the left colon. Colonoscopy should be repeated every 1-2 years.

The American College of Gastroenterology (ACG) recommends annual surveillance colonoscopy beginning after 8-10 years of disease. Multiple biopsies should be obtained at regular intervals. The finding of definite dysplasia is an indication for colectomy. Patients whose biopsies are indefinite for dysplasia should undergo repeat surveillance colonoscopy at a shorter interval.

The American Society for Gastrointestinal Endoscopy (ASGE) recommends that patients with UC who have pancolitis should begin surveillance colonoscopy after 8 years of disease. Four biopsies should be obtained every 10 cm from the cecum to the rectum. In addiction, any suspicious lesions or masses should be biopsied. Colonoscopy should be repeated every 1-3 years. The finding of carcinoma or high-grade dysplasia is an indication for colecto-my. Colectomy is also indicated for any degree of dysplasia associated with lesion or mass. However, in patients in whom colectomy is not feasible or is unacceptable, frequent surveillance, every 3-6 months, is considered an acceptable alternative. For patients with left-sided colitis, the ASGE recommends that surveillance should begin after 15 years of disease. Surveillance is not indicated in ulcerative proctitis. In CD, the risk of colorectal cancer is increased only in regard to Crohn's colitis. Surveillance colonoscopy and biopsy for dysplasia should be offered to patients with longstanding disease. Furthermore, a reduction in mortality due to surveillance has not yet been established.

On the other hand, prophylactic colectomy is a method to prevent the development of CRC in IBD. The development of the stapling of the ileal pouchanal anastomosis with preservation of the anal transitional zone is an important advancement in surgical treatment, but remains controversial because of concerns about the potential risk of dysplasia and cancer. The risk factor for carcinoma is inflammation in the small intestinal and rectal mucosa. Pouchitis is the most frequent late complication and clearly related to a worse outcome. The etiology of pouchitis remains unknown. Possible causes are fecal stasis resulting in bacterial overgrowth and infection [46], microbial imbalance [47], production of volatile fatty acids, ischemia [48], oxygen-free radical injury [49], nitric oxide [50] and deprivation of short chain fatty acids [51]. Penna et al. [52] reported a strong correlation between primary sclerosing cholangitis and pouchitis, suggesting a common link in their pathogenesis. Teixeira et al. [53] showed that pouchitis was more frequent in patients with extra-intestinal manifestations. Acute pouchitis was more frequent than chronic pouchitis described by others.

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