**2.3 Presence of high-grade dysplasia or colorectal malignancies**

The presence of high-grade dysplasia (HGD) or colorectal cancer is another indication for elective RPC with IPAA in IC.

Colorectal surveillance in UC obeys specific rules (**Figure 6**) [10], and chromoendoscopy has an essential role in dysplasias identification (**Figure 7**) [11, 12]. In UC surveillance, the chromoendoscopy allows to split the cases in visible dysplasia and invisible dysplasia (**Figure 7**) [13, 14].

**Figure 6.** *Colorectal surveillance in UC (33 biopsies allow 90% accuracy in dysplasia diagnosis).*

**Figure 7.** *Role of chromoendoscopy in dysplasia endoscopic visiblility.*

Nowadays, dysplasia management in UC takes into account the grade and number of dysplasia, whether visible or not, and the presence of primary sclerosing cirrhosis (PSC) (**Figures 8** and **9**) [11, 15, 16].

*Restorative Proctocolectomy: When to Propose and When to Avoid DOI: http://dx.doi.org/10.5772/intechopen.98987*

**Figure 8.**

*Management of visible dysplasia in ulcerative colitis.*

**Figure 9.** *Management of invisible dysplasia in ulcerative colitis.*


#### **Table 2.** *CRC risk factors in ulcerative colitis.*

In a systematic review of the literature, Fumery et al. found that among patients with UC-LGD under surveillance, the annual incidence of progression to CRC was 0.8%. Concomitant primary sclerosing cholangitis, invisible dysplasia, distal location, and multifocal LGD are high-risk features associated with dysplasia progression [17].

In UC patients with high-grade dysplasia or colorectal cancer (CRC), the colon and rectum should be removed with *en bloc* oncologic resection of lymph nodes in all colonic segments due to the high risk of multiple synchronous tumors and preoperative under staging (ECCO statement 9A) [18].

The risk of colorectal cancer in UC is increased compared with the general population (**Table 2**) [19–24]. Moreover, it is estimated to be around 18% after 30 years of UC duration [20].

Occasionally, total abdominal colectomy with ileorectal rectal anastomosis (TAC-IRA) can be considered.
