Current Evidence

Whilst it is clear that the ideal surgical intervention for FAP would involve minimal colorectal malignancy risk, whilst obtaining a good functional outcome, quality of life, and low post-operative morbidity; it is unclear from the literature as to which of the IPAA and IRA techniques best offer this, and in which patients. This chapter aims to systematically review and present the existing comparative literature on IPAA as compared to IRA for the primary treatment of FAP, using meta-analytic techniques where appropriate. The specific questions that we aim to answer are:

• does one technique carry significantly less early post-operative morbidity (bowel obstruction, haemorrhage, intra-abdominal sepsis, anastomot-ic separation, wound infection and need for reoperation within 30 days) than the other?

• How does the functional outcome compare between the two techniques with regards to stool frequency, urgency, night defecation, inconti nence, pad requirement and need for anti-diar-rhoeal medication?

• Is there a significant difference in the dietary restrictions and social dysfunction between IRA and IPAA techniques?

• How does male and female sexual dysfunction compare between the two techniques?

• What are differences between IPAA and IRA in the incidence of long-term complications (anastomotic stricture, perianal irritation, intra-abdominal desmoid formation and cancer in the pouch/rectum)? Please note that where appropriate meta-analysis of these outcomes has been performed in line with recommendations from the Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUORUM) guidelines [38, 39]. Statistical analysis for categorical variables has been carried out using the odds ratio as the summary statistic. This ratio represents the odds of an adverse event occurring in the IPAA group compared with the IRA group. An odds ratio of less than one favours the IPAA group, and the point estimate of the odds ratio is considered statistically significant at the p<0.05 level if the 95% confidence interval does not include the value one. For continuous variables such as bowel frequency per 24-h period, statistical analysis has been carried out using the weighted mean difference (WMD) as the summary statistic [40]. For studies that presented continuous data as means and range values, the standard deviations (SD) have been calculated using statistical algorithms and checked using "bootstrap" resampling techniques. Thus all continuous data have been standardised for analysis.

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