Familial adenomatous polyposis coli (FAP) may not be considered a single disease entity with standardised guidelines for operative treatment. However, prophylactic colectomy after the manifestation of polyps but prior to the development of colorectal cancer remains the most effective prevention of col-orectal cancer in FAP. The optimal timing of prophylactic surgery remains a clinical decision taken independently of mutation analysis. In the case of the classic FAP phenotype, restorative proctocolectomy and ileal pouch-anal anastomosis might be the procedure of choice. The development of reliable guidelines for attenuated FAP variants requires further evidence from clinical studies on surgical strategy and the advantages of prophylactic surgery over regular endoscopic screening with removal of polyps. A study by Winde et al.  has shown that low-dose rectal sulindac maintenance therapy is highly effective in achieving complete adenoma reversion without relapse in 87% of patients after 33 months. Rectal FAP phenotype should be crucial in the surgical decision. Colectomy with ileo-rectal anastomosis and regular chemoprevention might proceed to be a promising alternative to pouch procedures. Chemo-prevention with lower incidence of FAP-related tumours via dysplasia reversion might be possible in the future.
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