Present Surgical Policy

At present, policy around the world is variable. Most surgeons still seem content to treat their patients with colectomy and IRA followed by regular surveillance. An increasing proportion, on the other hand, is performing restorative proctocolectomy in most of their patients and certainly on those with severe rectal polyposis. A more rational policy, perhaps, is the compromise advocated by some surgeons. If the number of polyps within 15 cm from the anal verge is less than 20, we perform a colectomy and IRA. Restorative proctocolectomy is used for patients with more than 100 rectal polyps. Patients with 20-100 polyps are treated by colectomy and IRA if the minimum time off school is desirable or if the patient can be relied upon to attend follow-up. All others in this intermediate group are advised to have a pouch. As the morbidity of restorative proctocolectomy falls and more centres gain expertise, we are sure that it will become the operation of first choice for all patients with the disease. Until then, operative treatment is likely to be governed by each surgeon's beliefs and experience coupled with the patient's attitude towards attending 6-monthly rectoscopy as well as the views of the patient's family.

In general, there are three options available to surgeon seeking to prevent patients with FAP from dying of colorectal cancer:

• proctocolectomy with ileostomy

• Colectomy with IRA

• Proctocolectomy with ileoanal reservoir.

The choice of operation should be based on clinical knowledge of the disease process and the fact that prophylactic colectomy does not necessarily cure the condition. Other considerations involve the patient's age and anatomy, the presence or absence of extra-colic manifestations and the surgeon's expertise. Over the years, debate has centred on the value of proctocolectomy and ileostomy with colectomy and IRA. This debate was further compounded by the development of the ileal reservoir procedure. Today it seems obvious that proctocolectomy and ileostomy should rarely be necessary for patients with FAP and other polyposis syndromes. Therefore, the debate now centres on the value of IRA versus proctocolec-tomy with ileoanal reservoir or restorative procto-colectomy. It is up to surgeon and the institution as to whether the approach will be "traditional" (open surgery), laparoscopically assisted, hand assisted or completely laparoscopic. Recently [29], many authors refer to good experiences with the laparo-scopic approach. It could be safe and effective treatment for selected patients with FAP. As techniques and instrumentation for laparoscopic colon surgery are perfected, this procedure will likely become an appealing option in the management of patients with FAP

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