Surveillance for neoplasia in the patient with an ileal pouch

The inflammatory bowel diseases, both ulcerative colitis and Crohn’s disease, have been suggested as significant risk factors for adenocarcinoma of the colon and small bowel. Professional guidelines have addressed endoscopic surveillance of the colon in patients with colitis [Farraye et al. (Gastroenterology 138(2):746–74, 2010); Winawer et al. (Gastroenterology 124(2):544–60, 2003); Kornbluth and Sachar (Am J Gastroenterol 105:501–23, 2010); Leighton et al. (Gastrointest Endosc 63(4):558–65, 2006); Eaden et al. (Gut 51 Suppl 5:V10, 2002); Cairns et al. (Gut;59(5):666–89, 2010); Hanauer and Meyers (Am J Gastroenterol 92(4):559–66, 1997); Colorectal cancer surveillance in inflammatory bowel disease, UpToDate. Updated 2013.], but post-proctocolectomy surveillance of the ileal pouch has been specifically addressed by only a few [Cairns et al. (Gut;59(5):666–89, 2010); Colorectal cancer surveillance in inflammatory bowel disease, UpToDate. Updated 2013]. These guidelines advocate stratifying surveillance of the ileal pouch according to risk group. Pouch dysplasia or cancer is infrequent but elevated over what would be expected [Ziv et al. (Dis Colon Rectum 37(12):1281–5, 1994); Scarpa (Br J Surg 94:534–45, 2007); Kariv (Gastroenterology 139(3):806–12, 2010); Derikx et al. (Gastroenterology 146(1):119–28, 2014)]. High-risk groups are those considered to have previous rectal dysplasia, dysplasia or cancer at time of pouch surgery, primary sclerosing cholangitis (PSC), or Type C mucosa of the pouch (persistent atrophy and severe inflammation). However, recent large cohort studies have shown that the risk of neoplasia of the pouch is increased only in patients who had colorectal neoplasia (dysplasia or cancer) prior to surgery [Ziv et al. (Dis Colon Rectum 37(12):1281–5, 1994); Scarpa (Br J Surg 94:534–45, 2007); Kariv (Gastroenterology 139(3):806–12, 2010); Derikx et al. (Gastroenterology 146(1):119–28, 2014)]. No specific protocol is currently recommended for pouch surveillance endoscopy by professional societies. In this chapter we will review in detail the relevant literature regarding prevalence of pouch neoplasia, surveillance indications, suggested protocols for pouch surveillance, and suggested management of pouch-associated dysplasia or cancer.