A 44-year-old man with familial adenomatous polyposis (FAP) has undergone colectomy with ileorectal anastomosis (IRA) at age 22. He now presents with 8 rectal polyps ranging from 5-15 mm with increasing dysplasia. KRAS mutation analysis of one polyp is positive. What is the most appropriate surgical management?
- A Completion proctectomy with ileal pouch-anal anastomosis (IPAA) ✓
- B Continue endoscopic surveillance every 6 months and ablate polyps endoscopically
- C Completion proctectomy with permanent end ileostomy
- D Celecoxib chemoprevention plus surveillance without surgery
Explanation
After IRA in FAP patients, the retained rectum remains at risk for neoplasia; approximately 10-30% require completion proctectomy within 20 years due to uncontrollable polyposis, high-grade dysplasia, or early cancer. In this patient, multiple polyps with increasing dysplasia and KRAS mutation (a marker of adenoma-carcinoma progression) mandate completion proctectomy. Ileal pouch-anal anastomosis (IPAA, or restorative proctectomy) is preferred over permanent ileostomy to maintain intestinal continuity and quality of life, provided sphincter function is adequate and there is no low rectal cancer requiring APR. Celecoxib reduces polyp burden but does not eliminate cancer risk in this setting.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.