A 50-year-old woman with Lynch syndrome (MLH1 germline mutation) undergoes colonoscopy revealing a 3 cm right-sided colon cancer and 2 synchronous tubular adenomas in the left colon. What is the most appropriate surgical strategy?
- A Right hemicolectomy with surveillance of left-sided adenomas
- B Total or subtotal colectomy with ileorectal anastomosis ✓
- C Segmental right colectomy followed by annual colonoscopy
- D Total proctocolectomy with permanent ileostomy
Explanation
In Lynch syndrome, the entire colorectum harbors a significantly elevated lifetime risk of metachronous colorectal cancer (40–80%). When colorectal cancer is diagnosed in a Lynch syndrome patient, current guidelines recommend total or subtotal colectomy with ileorectal anastomosis to minimize the risk of a second primary, while preserving rectal function. Segmental resection with surveillance is acceptable only if the patient refuses or is unfit for extended resection. Total proctocolectomy with ileostomy is reserved for rectal involvement or sphincter compromise. Right hemicolectomy alone leaves the majority of at-risk mucosa in situ.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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