Mucosectomy vs. stapled ileal pouch - Anal anastomosis in patients with familial adenomatous polyposis - Functional outcome and neoplasia control

PURPOSE: The tradeoff of neoplasia control for better function represented by a stapled ileal pouch-anal anastomosis is still controversial in patient s with familial adenomatous polyposis. We compared outcomes after mucosecto my and hand-sewn ileal pouch-anal anastomosis with those after stapled ilea l pouch-anal anastomosis in 119 patients with familial adenomatous polyposi s who underwent surgery since 1983. METHODS: Age, gender, length of follow- up, complications, quality of life, incontinence, urgency, nighttime and da ytime seepage, pad usage, necessity of ileostomy, and incidence of adenomas developing in pouch and anal transitional zone were recorded. RESULTS: The re were 42 mucosectomy and 77 stapled patients who were followed up for an average of 5.8 and 3.6 years, respectively, with endoscopic surveillance. T here was one postoperative death in the stapled group that prohibited long- term followup. Nine of 42 mucosectomy patients developed pouch adenomas vs. 8 of 76 in the stapled group. Six of 42 patients developed adenomas in the mucosectomized anal transitional zone in the mucosectomy group. Twenty-one of 76 patients developed adenomas in the anal transitional zone in the sta pled group. All were managed with local procedures or further surveillance. One of 76 patients developed cancer in the residual low rectum; this requi red further resection. Patients with stapled anastomosis had better outcome s in every category. Differences in incontinence, daytime and nighttime see page, pad usage, and avoidance of ileostomy were statistically significant. All patients with mucosectomy required ileostomy vs. only 40 of 77 patient s with stapled anastomosis. CONCLUSION: Familial adenomatous polyposis pati ents with stapled ileal pouch-anal anastomosis have better functional outco me and can avoid temporary diversion. This should be balanced against a 28 percent incidence of adenomas in the anal transitional zone.