Surgical treatment of familial adenomatous polyposis: ileorectal anastomosis or restorative proctolectomy?

CONTEXT Controversy regarding the best operative choice for familial adenomatous polyposis lays between the morbidity of restorative proctocolectomy and the supposed mortality due to rectal cancer after ileorectal anastomosis. OBJECTIVES To evaluate operative complications and oncological outcome after ileorectal anastomosis and restorative proctocolectomy. METHODS Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information regarding early and late outcome were recorded. RESULTS Eighty-eight patients - 41 men (46.6%) and 47 women (53.4%) - were assisted. At diagnosis, 53 patients (60.2%) already had associated colorectal cancer. Operative complications occurred in 25 patients (29.0 %), being 17 (19.7%) early and 8 (9.3%) late complications. There were more complications after restorative proctocolectomy (48.1%) compared to proctocolectomy with ileostomy (26.6%) and ileorectal anastomosis (19.0%) (P = 0,03). There was no operative mortality. During the follow-up of 36 ileorectal anastomosis, cancer developed in the rectal cuff in six patients (16,6%). Cumulative cancer risk after ileorectal anastomosis was 17.2% at 5 years, 24.1% at 10 years and 43.1% at 15 years of follow-up. Age-dependent cumulative risk started at 30 years (4.3%), went to 9.6% at 40 years, 20.9% at 40 years and 52% at 60 years. Among the 26 patients followed after restorative proctocolectomy, it was found cancer in the ileal pouch in 1 (3.8%). CONCLUSIONS 1. Operative complications occurred in about one third of the patients, being more frequently after the confection of ileal reservoir; 2. greater age and previous colonic carcinoma were associated with the development of rectal cancer after ileorectal anastomosis; 3. patients treated by restorative proctocolectomy are not free from the risk of pouch degeneration; 4. the disease complexity and the various risk factors (clinical, endoscopic, genetic) indicate that the best choice for operative treatment should be based on individual features discussed by a specialist; 5. all patients require continuous and long-term surveillance during postoperative follow-up.