A 45-year-old patient with Lynch syndrome (MLH1 mutation) is found to have a 2 cm sigmoid colon cancer and a synchronous 1 cm ascending colon adenoma with high-grade dysplasia. What is the most appropriate surgical strategy?
- A Total abdominal colectomy with ileorectal anastomosis (IRA) ✓
- B Sigmoid colectomy with endoscopic removal of the ascending colon adenoma
- C Subtotal colectomy leaving the rectum and right colon in situ
- D Laparoscopic sigmoid colectomy followed by annual colonoscopy surveillance
Explanation
In Lynch syndrome (hereditary non-polyposis colorectal cancer, HNPCC), the cumulative metachronous colorectal cancer risk approaches 45% at 10 years after segmental resection. Total abdominal colectomy with ileorectal anastomosis (IRA) is recommended when the cancer is not rectal, as it significantly reduces metachronous cancer risk. This is especially important in younger patients with Lynch syndrome with confirmed mismatch repair gene mutations. Segmental resection with surveillance is only appropriate if the patient declines extended resection after counselling about the high metachronous risk.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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