“Cuffitis” and inflammatory changes in the columnar cuff, anal transitional zone, and ileal reservoir after stapled pouch-anal anastomosis

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Abstract
During the past eight to ten years most surgeons have adopted the double-stapled technique to accomplish the pouch-anal anastomosis in restorative proctocolectomy for ulcerative colitis. Little attention has been focused on the functional implications of retaining a segment of diseased columnar mucosa in the upper anal canal. The aim of this study was to investigate clinically significant inflammation in the columnar cuff. In all, 113 patients were studied and 715 biopsies were performed during a 2.5-year period. Biopsy specimens were taken from two or three sites, including the columnar cuff, ileal pouch, and anal transitional zone. Acute and chronic inflammation was scored for biopsy specimens from all three sites and compared with endoscopic assessment and pouch function. In the columnar cuff acute histologic inflammation was found in 13 percent of patients, and in 9 percent this was symptomatic during follow-up and was accompanied by evidence of endoscopic inflammation. Most patients had mild inflammation in the cuff that persisted over time. Inflammation in the pouch, pouch frequency, and anastomotic height were not related to columnar cuff inflammation. Cuffitis is a cause of pouch dysfunction after a double-stapled restorative proctocolectomy. We propose a triad of diagnostic criteria, including symptoms and endoscopic and histologic inflammation.