While the possibility of choosing the correct surgical option is certainly related to the surgeon's skills with all the technical solutions, the possibility of having genetical markers predicting the severity of the disease would make the surgeon's task easier in proposing different solutions for different presentations of the pathology. In fact we have experienced that extra-colonic manifestations of the disease also determine other aggravating factors and that eradication of the colorectal disease does not solve the problem.
We have been able to observe how in our case histories a non-radical choice such as IRA, when associated with a severe mutation, involved a high risk of conversion or demolition of the anal sphincters so in this case the choice of an IPAA seems justified. The more radical choice becomes more difficult in cases of severe mutation and clinical features compatible with IRA, when a patient requests the preservation of the rectum or when it is impossible to detect the genetic error. In these situations, it is advisable to evaluate the case without following a fixed scheme. By educating the patient on the need for constant follow-up, the risk of degeneration appears reduced; moreover, as outlined by our experience and in the literature, it is possible to convert IRA into IPAA in the majority of the cases especially when IRA was conducted preserving all the ileum. On the other hand, if we consider mucosal polyps growth at the pouch level (as recently highlighted in the literature [14, 45]) and their possible evolution to cancer, it is easy to see that the first surgical choice appears more important considering that even a radical solution such as IPAA could not completely solve the FAP problems at the colorectal level. The laparoscopic approach can achieve an almost complete absence of visceral adhesions. This has been assessed at further operations when total colectomy had been the first surgical step of an IPAA for Ulcerative Colitis (UC). This aspect, on one hand, involves a lower risk of occlusive complications and, on the other, makes conversion to IPAA more comfortable when necessary. It is clear that the videolaparoscopic approach is appealing particularly for young people due to the reduced aesthetic damage and IRA is appealing due to the possibility of performing a single operation without ileostomic protection.
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