A 40-year-old man with FAP who has undergone prophylactic proctocolectomy now develops upper GI symptoms. Endoscopy reveals multiple duodenal polyps with Spigelman stage IV. What is the recommended management?
- A Pancreaticoduodenectomy (Whipple procedure) ✓
- B Endoscopic surveillance every 6 months
- C COX-2 inhibitor (celecoxib) for polyp regression
- D Duodenotomy and local excision of all polyps
Correct answer: A. Pancreaticoduodenectomy (Whipple procedure)
Explanation
The Spigelman staging system classifies periampullary duodenal polyposis in FAP: Stage IV (maximum score 12) indicates an approximately 36% risk of duodenal cancer within 10 years. At Spigelman stage IV, pancreaticoduodenectomy (Whipple) is recommended as it removes the high-risk mucosa. Endoscopic surveillance is insufficient at this stage, and duodenotomy with polypectomy cannot adequately address the diffuse field of high-risk mucosa.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.