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Surgical considerations in FAP-related pouch surgery: Could we do better?

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Abstract

The ileoanal pouch has become the standard restorative procedure of choice for patients with the classical phenotype in FAP (familial adenomatous polyposis) and also for ulcerative colitis (UC). Whilst we tend to encounter descriptive analyses comparing functional outcome, fertility and quality of life (QOL) between series in literature, there may be an urgent need to discuss the subtle technical modifications that may be pivotal for improving long-term QOL in FAP patients. Our aim is to review the current literature and discuss the aspects of ileal pouch-anal anastomosis that may require specific reevaluation for FAP. Surgical strategies aimed at minimizing post-interventional desmoid growth is one of the most important aspects. For this study, the following topics of interest were selected: Timing of surgery, IRA or ileoanal pouch for classical FAP, laparoscopic or conventional surgery, TME or mesenteric dissection, preservation of the ileocolic vessels, handsewn or double-staple anastomosis, shape and size of pouch, protective ileostomy, Last and definitely not least: how to manage desmoid plaques or desmoids at the time of prophylactic surgery. For the depicted technicalities of the procedure, a review of recent literature was performed and evaluated. For the topics selected, only sparse reference in literature was identified that was focused on the specific condition situation of FAP. Almost all pouch literature focusses on the procedural aspects, and FAP patients are always a very minor number. Therefore it becomes obvious that the specific entity is not adequately taken into account. This is a serious bias for identification of important steps in the procedure that may be beneficial for patients with either of the diseases. The results of this study demonstrate that several technical differences for construction of ileoanal pouches in FAP patients deserve more attention and prospective evaluation—perhaps even randomized trials. The role, importance and potential benefit or deterioration of outcome in most of the discussed technicalities remains unclear to date. Significant differences between the underlying diseases (UC and FAP) have not been taken into consideration, such as specifically the management of precursor desmoid lesions at the time of prophylactic surgery as well as prevention of desmoid tumors. Several of the aspects discussed in this paper should be prospectively evaluated in larger and exclusive series of FAP patients.

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References

  1. Bodmer WF, Bailey CJ, Bodmer J, Bussey HJ, Ellis A, Gorman P, Lucibello FC, Murday VA, Rider SH, Scambler P (1987) Localization of the gene for familial adenomatous polyposis on chromosome 5. Nature 328(6131):614–616

    Article  CAS  PubMed  Google Scholar 

  2. Bisgaard ML, Fenger K, Bulow S, Niebuhr E, Mohr J (1994) Familial adenomatous polyposis (FAP): frequency, penetrance, and mutation rate. Hum Mutat 3(2):121–125

    Article  CAS  PubMed  Google Scholar 

  3. Ganschow P, Pfeiffer U, Hinz U, Leowardi C, Herfarth C, Kadmon M (2010) Quality of life ten and more years after restorative proctocolectomy for patients with familial adenomatous polyposis coli. Dis Colon Rectum 53(10):1381–1387

    Article  PubMed  Google Scholar 

  4. Guillem JG, Smith AJ, Calle JP, Ruo L (1999) Gastrointestinal polyposis syndromes. Curr Probl Surg 36(4):217–323

    Article  CAS  PubMed  Google Scholar 

  5. Aretz S, Vasen HF, Olschwang S (2015) Clinical utility gene card for: familial adenomatous polyposis (FAP) and attenuated FAP (AFAP). Eur J Hum Genet 19(7):1476–5438

    Google Scholar 

  6. Ishikawa H, Mutoh M, Iwama T, Suzuki S, Abe T, Takeuchi Y, Nakamura T, Ezoe Y, Fujii G, Wakabayashi K, Nakajima T, Sakai T (2016) Endoscopic management of familial adenomatous polyposis in patients refusing colectomy. Endoscopy 48(01):51–55

    PubMed  Google Scholar 

  7. Schneider R, Schneider C, Dalchow A, Jakobeit C, Möslein G (2015) Prophylactic surgery in familial adenomatous polyposis (FAP)-a single surgeon’s short- and long-term experience with hand-assisted proctocolectomy and smaller J-pouches. Int J Colorectal Dis 30(8):1109–1115

    Article  PubMed  Google Scholar 

  8. van Duijvendijk P, Slors JF, Taat CW, Oosterveld P, Vasen HF (1999) Functional outcome after colectomy and ileorectal anastomosis compared with proctocolectomy and ileal pouch-anal anastomosis in familial adenomatous polyposis. Ann Surg 230(5):648–654

    Article  PubMed  PubMed Central  Google Scholar 

  9. Vasen HF, van der Luijt RB, Slors JF, Buskens E, de Ruiter P, Baeten CG, Schouten WR, Oostvogel HJ, Kuijpers JH, Tops CM, Meera KP (1996) Molecular genetic tests as a guide to surgical management of familial adenomatous polyposis. Lancet 348(9025):433–435

    Article  CAS  PubMed  Google Scholar 

  10. Penna C, Kartheuser A, Parc R, Tiret E, Frileux P, Hannoun L, Nordlinger B (1993) Secondary proctectomy and ileal pouch-anal anastomosis after ileorectal anastomosis for familial adenomatous polyposis. Br J Surg 80(12):1621–1623

    Article  CAS  PubMed  Google Scholar 

  11. Bjork J, Akerbrant H, Iselius L, Svenberg T, Oresland T, Pahlman L, Hultcrantz R (2001) Outcome of primary and secondary ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum 44(7):984–992

    Article  CAS  PubMed  Google Scholar 

  12. von Roon AC, Tekkis PP, Lovegrove RE, Neale KF, Phillips RK, Clark SK (2008) Comparison of outcomes of ileal pouch-anal anastomosis for familial adenomatous polyposis with and without previous ileorectal anastomosis. Br J Surg 95(4):494–498

    Article  Google Scholar 

  13. Moertel CG, Hill JR, Adson MA (1970) Surgical management of multiple polyposis. The problem of cancer in the retained bowel segment. Arch Surg 100(4):521–526

    Article  CAS  PubMed  Google Scholar 

  14. Bess MA, Adson MA, Elveback LR, Moertel CG (1980) Rectal cancer following colectomy for polyposis. Arch Surg 115(4):460–467

    Article  CAS  PubMed  Google Scholar 

  15. Church JM, Xhaja X, Warrier SK, LaGuardia L, O’Malley M, Burke C, Kalady MF (2014) Desmoid tumors do not prevent proctectomy following abdominal colectomy and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum 57(3):343–347

    Article  PubMed  Google Scholar 

  16. Parks AG, Nicholls RJ (1978) Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 2(6130):85–88

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Utsunomiya J, Iwama T, Imajo M, Matsuo S, Sawai S, Yaegashi K, Hirayama R (1980) Total colectomy, mucosal proctectomy, and ileoanal anastomosis. Dis Colon Rectum 23(7):459–466

    Article  CAS  PubMed  Google Scholar 

  18. Taylor BM, Beart RW Jr, Dozois RR, Kelly KA, Phillips SF (1983) Straight ileoanal anastomosis v ileal pouch–anal anastomosis after colectomy and mucosal proctectomy. Arch Surg 118(6):696–701

    Article  CAS  PubMed  Google Scholar 

  19. Nyam DC, Brillant PT, Dozois RR, Kelly KA, Pemberton JH, Wolff BG (1997) Ileal pouch-anal canal anastomosis for familial adenomatous polyposis: early and late results. Ann Surg 226(4):514–519

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Dozois RR, Kelly KA, Welling DR, Gordon H, Beart RW Jr, Wolff BG, Pemberton JH, Ilstrup DM (1989) Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis. Ann Surg 210(3):268–271

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Olsen KO, Juul S, Bulow S, Jarvinen HJ, Bakka A, Bjork J, Oresland T, Laurberg S (2003) Female fecundity before and after operation for familial adenomatous polyposis. Br J Surg 90(2):227–231

    Article  CAS  PubMed  Google Scholar 

  22. Rajaratnam SG, Eglinton TW, Hider P, Fearnhead NS (2011) Impact of ileal pouch-anal anastomosis on female fertility: meta-analysis and systematic review. Int J Colorectal Dis 26(11):1365–1374

    Article  PubMed  Google Scholar 

  23. Slors JF, den Hartog Jager FC, Trum JW, Taat CW, Brummelkamp WH (1989) Long-term follow-up after colectomy and ileorectal anastomosis in familial adenomatous polyposis coli. Is there still a place for the procedure? Hepatogastroenterology 36(2):109–112

    CAS  PubMed  Google Scholar 

  24. Gozzetti G, Poggioli G, Marchetti F, Laureti S, Grazi GL, Mastrorilli M, Selleri S, Stocchi L, Di SM (1994) Functional outcome in handsewn versus stapled ileal pouch-anal anastomosis. Am J Surg 168(4):325–329

    Article  CAS  PubMed  Google Scholar 

  25. Gemlo BT, Belmonte C, Wiltz O, Madoff RD (1995) Functional assessment of ileal pouch-anal anastomotic techniques. Am J Surg 169(1):137–141

    Article  CAS  PubMed  Google Scholar 

  26. Tuckson W, Lavery I, Fazio V, Oakley J, Church J, Milsom J (1991) Manometric and functional comparison of ileal pouch anal anastomosis with and without anal manipulation. Am J Surg 161(1):90–95

    Article  CAS  PubMed  Google Scholar 

  27. Bülow S, Bülow C, Nielsen TF, Karlsen L, Moesgaard F (1995) Centralized registration, prophylactic examination, and treatment results in improved prognosis in familial adenomatous polyposis. Results from the Danish Polyposis Register. Scand J Gastroenterol 30(10):989–993

    Article  PubMed  Google Scholar 

  28. Warrier S, Kalady M (2012) Familial adenomatous polyposis: challenges and pitfalls of surgical treatment. Clin Colon Rectal Surg 25(2):83–89

    Article  PubMed  PubMed Central  Google Scholar 

  29. Croner R, Brueckl W, Reingruber B, Hohenberger W, Guenther K (2005) Age and manifestation related symptoms in familial adenomatous polyposis. BMC Cancer 5:24

    Article  PubMed  PubMed Central  Google Scholar 

  30. Gordon P, Nivatongs S (2007) Principles and practice of surgery for the colon, rectum and anus, 3rd edn. CRC Press, Boca Raton

    Book  Google Scholar 

  31. Debinski H, Love S, Spigelman A, Phillips R (1996) Colorectal polyp counts and cancer risk in familial adenomatous polyposis. Gastroenterology 110(4):1028–1030

    Article  CAS  PubMed  Google Scholar 

  32. Spigelman AD, Talbot IC, Williams AD et al (1989) Upper gastrointestinal cancer in patients with familial adenomatous polyposis. Lancet 2:783–785

    Article  CAS  PubMed  Google Scholar 

  33. Lynch P, Morris J, Wen S, et al. (2016) A proposed staging system and stage-specific interventions for familial adenomatous polyposis. Gastrointestinal Endoscopy (GIE). doi:10.1016/j.gie.2015.12.029

  34. Stelzner F (2006) Homingareale bei erblichen, synchronen und metachronen Rektokolonkrebsen. Chirurg 77:1056–1060

    Article  CAS  PubMed  Google Scholar 

  35. Koskenvuo L, Renkonen-sinisalo L, Järvinen H, Lepistö A (2014) Risk of cancer and secondary proctectomy after colectomy and ileorectal anastomosis in familial adenomatous polyposis. Int J Colorectal Dis 29:225–230

    Article  CAS  PubMed  Google Scholar 

  36. Bonjer J, Deijen C, Abis G et al (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372:1324–1332

    Article  CAS  PubMed  Google Scholar 

  37. Indar A, Efron J, Young-Fadok T (2009) Laparoscopic ileal pouch-anal anastomosis reduces abdominal and pelvic adhesions. Surg Endosc 23:174–177

    Article  PubMed  Google Scholar 

  38. Bartela S, D`Hoore A, Cuesta M, Bensdorp A, Lucas G, Bemelmann W (2012) Significantly increased pregnancy rates after laparascopic proctectomy: a cross-sectional study. Ann Surg 256(6):1045–1048 (1528–1140)

    Article  Google Scholar 

  39. Fajardo A, Dharmarajan S, George V, Hunt S, Birnbaum E, Fleshman J, Mutch M (2010) Laparoscopic versus open 2-stage ileal pouch: laparoscopic approach allows for faster restoration of intestinal continuity. J Am Coll Surg 211(3):377–383

    Article  PubMed  Google Scholar 

  40. Ganschow P, Treiber I, Hinz U, Leowardi C, Büchler M, Kadmon M (2015) Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP)—a critical issue. Langenbecks Arch Surg 400:213–219

    Article  PubMed  Google Scholar 

  41. Ballantyne GH, Pemberton JH, Beart RW, Jr Wolff B G, Dozois RR (1985) Ileal J pouch-anal anastomosis. Current technique. Dis Colon Rectum 28:197–202

    Article  CAS  PubMed  Google Scholar 

  42. Thirlby RC (1995) Optimizing results and techniques of mesenteric lengthening in ileal pouch-anal anastomosis. Am J Surg 169(5):499–502

    Article  CAS  PubMed  Google Scholar 

  43. Warrier S, Kalady M (2012) Familial adenomatous polyposis: challenges and pitfalls of surgical treatment. Clin Colon Rectal Surg 25(2):83–89

    Article  PubMed  PubMed Central  Google Scholar 

  44. Parks AG, Nicholls RJ (1978) Proctocolectomy without ileostomy for ulcerative colitis. BMJ 2:85–88

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Heald R, Allen D (1986) Stapled ileo-anal anastomosis: a technique to avoid mucosal proctectomy in the ileal pouch operation. Br J Surg 73(7):571–572

    Article  CAS  PubMed  Google Scholar 

  46. Kirat H, Remzi F, Kiran R, Fazio V (2009) Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients. Surgery 146:723–730

    Article  PubMed  Google Scholar 

  47. Lewis LG, Kuzu A, Sagar PM, Holdswirth PJ, Johnston D (1994) Stricture at the pouch-anal anastomosis after restorative proctocolectomy. Dis Colon Rectum 37:120–125

    Article  CAS  PubMed  Google Scholar 

  48. Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH, Nicholls RH, Fazio VW, Tekkis PP (2006) A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy. A meta-analysis of 4,183 patients. Ann Surg 1:18–26

    Article  Google Scholar 

  49. Block M, Börjesson L, Lindholm E, Öresland T (2009) Pouch design and long-term functional outcome after ileal pouch-anal anastomosis. 2009 Br J Surg 96:527–532

    CAS  PubMed  Google Scholar 

  50. Sagar PM, Lewis W, Holdsworth PJ, Johnston D (1992) One-stage restorative proctocolectomy without temporary defunctioning ileostomy. Dis Colon Rectum 35:582–588

    Article  CAS  PubMed  Google Scholar 

  51. Sugarman HJ, Newsome HH (1994) Stapled ileoanal anastomosis without a temporary ileostomy. Am J Surg 167:58–66

    Article  Google Scholar 

  52. Mori L, Vita M, Razzetta F, Meinero P, DÀmbrosio G (2013) Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile? Dis Colon Rectum 56(1):29–34

    Article  PubMed  Google Scholar 

  53. Durno C, Monga N, Bapat B, Berk T, Cohen Z, Gallinger S (2008) Does early colectomy increase desmoid risk in familial adenomatous polyposis? Clin Gastroenterol Hepatol 6(2):215–219

    Article  Google Scholar 

  54. Sturt N, Clark S (2006) Current ideas in desmoid tumours. Fam Cancer 5(3):275–285 (discussion 87–288)

    Article  PubMed  Google Scholar 

  55. Hartley J, Church J, Gupta S, McGannon E, Fazio V (2004) Significance of incidental desmoids identified during surgery or familial adenomatous polyposis. Dis Colon Rectum 47(3):334–338 (discussion 339–340)

    Article  CAS  PubMed  Google Scholar 

  56. Quast D, Schneider R, Burdzi, E, Hoppe S, Möslein G (2015) Long-term outcome of sporadic and FAP-associated desmoid tumors treated with high-dose selective estrogen receptor modulators and sulindac: a single-center long-term observational study in 134 patients. Fam Cancer, published online Aug 4

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  1. Center for Hereditary Tumors, HELIOS-Klinikum Wuppertal, University Hospital Witten-Herdecke, Heusnerstr. 40, 42283, Wuppertal, Germany

    Gabriela Möslein

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Möslein, G. Surgical considerations in FAP-related pouch surgery: Could we do better?. Familial Cancer 15, 457–466 (2016). https://doi.org/10.1007/s10689-016-9904-6

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