Original article Surveillance pouchoscopy for dysplasia: Cleveland Clinic Ileoanal Pouch Anastomosis Database A. L. Lightner 1 , P. Vaidya 1 , S. Vogler 1 , J. McMichael 2 , X. Jia 4 , M. Regueiro 3 , T. Qazi 3 , S. R. Steele 1 and J. Church 1 Departments of 1 Colorectal Surgery, 2 General Surgery and 3 Gastroenterology, Digestive Disease Surgical Institute, and 4 Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA Correspondence to: Professor A. L. Lightner, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA (e-mail: lightna@ccf.org) Background: No formal guidelines exist for surveillance pouchoscopy following ileal pouch–anal anas- tomosis (IPAA) for ulcerative colitis. Methods: All adults who had previously had IPAA for ulcerative colitis, and underwent a pouchoscopy between 1 January 2010 and 1 January 2020, were included. Results: A total of 9398 pouchoscopy procedures were performed in 3672 patients. The majority of the examinations were diagnostic (8082, 86⋅0 per cent; 3260 patients) and the remainder were for rou- tine surveillance (1316, 14⋅0 per cent; 412 patients). Thirteen patients (0⋅14 per cent of procedures) were found to have biopsy-proven neoplasia at the time of pouchoscopy; seven had low-grade dysplasia (LGD) (0⋅07 per cent; all located in the anal transition zone), none had high-grade dysplasia (HGD) and six (0⋅06 per cent) had invasive adenocarcinoma (4 in anal transition zone and 6 in pouch). Of the six patients with adenocarcinoma, four had neoplasia at the time of proctocolectomy (2 adenocar- cinoma, 1 LGD, 1 HGD); all six were symptomatic with anal bleeding or pelvic pain at the time of pouchoscopy, had a negative surveillance pouchoscopy examination within 2years of diagnosis of ade- nocarcinoma, had palpable masses on digital rectal examination, and had visible lesions at the time of pouchoscopy. Conclusion: Surveillance pouchoscopy is not recommended in asymptomatic patients because signifcant neoplasia following IPAA for ulcerative colitis is rare. Paper accepted 26 May 2020 Published online 20 July 2020 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.11811 Introduction Between 15 and 30 per cent of patients with ulcerative colitis eventually require a colectomy for medically refrac- tory disease or neoplasia 1–4 . The procedure of choice for restoration of intestinal continuity has been restorative proctocolectomy using an ileal pouch–anal anastomosis (IPAA). This operation allows removal of at-risk diseased mucosa while maintaining favourable long-term function and good quality of life 5,6 . However, the IPAA has cre- ated a novel type of intestinal physiology that involves faecal stasis in the small intestine and the new disease of pouchitis. One of the main concerns with chronic infammation in the colon is progressive mucosal dyspla- sia that leads to cancer. Similarly, for those caring for patients with an IPAA, the risk of dysplasia development in the mucosa of the ileal pouch has been a source of concern 7 . This is related to the unknown response of the ileal mucosa to chronic exposure to stool, with unknown levels of colonic bacteria, and the observation that most patients had a certain degree of pouch infammation. Early studies of patients with an IPAA fuelled this concern by reporting that pouch histology showed infammation and villous atrophy, changes initially labelled as colonic metaplasia. Pouch surveillance with random biopsies became rou- tine in the early years, but it has become apparent that dysplasia and cancer are rare 8,9 . A review 10 of pouch surveillance guidelines from various societies revealed heterogeneous and inconsistent recommendations. Not surprisingly, survey data have demonstrated that physi- cians also disagree about the need for pouch surveillance and the necessary screening interval, making surveillance practice patterns highly variable 11 . There is a natural © 2020 BJS Society Ltd BJS 2020; 107: 1826–1831 Published by John Wiley & Sons Ltd Downloaded from https://academic.oup.com/bjs/article/107/13/1826/6139494 by guest on 10 October 2022