Introduction Restorative proctocolectomy (RPC) is one of the surgical options for patients with Familial Adenomatous Polyposis (FAP). Current guidelines suggest annual endoscopic pouch surveillance as formation of adenomas and carcinomas have been reported, however the data are few and the clinical impact of these not well established.
Method We identified all FAP patients with a pouch undergoing surveillance at our institution, and retrospectively analysed our prospectively maintained polyposis database. Demographic data, details of surgery, original histopathology and follow-up pouch endoscopy reports and pathology findings were obtained.
Results We identified 388 patients with FAP who had undergone pouch surgery from 1978 to May 2016; 260 had endoscopic follow-up at our institution. 131 (50%) were male. At the time of analysis, the median age was 47 years (range 7–85), and median pouch age was 15 years (range <1–35).
Adenomatous polyps were found in 77% (200) of the ileoanal pouches. 53% (138) had cuff and 64% (166) had ileal pouch body adenomas. The time to first polyp formation was not significantly different between cuff (median 6, range 1–30 years) and pouch body (median 6, range 1–24 years), p=0.11. Pouch body adenomas developed in 47% (49/104) at 10 years and 65% (36/55) by 20 years. Cuff polyps were seen in 24% (25/104) and 27% (15/55) at 10 and 20 years respectively. The polyp count range per patient was 1–50 and 1–500 for cuff and pouch body polyps respectively.
12% (30) of cuff polyps and 5% (12) of pouch body polyps were >1 cm in size; range 10–60 mm (median 20 mm) in the cuff and 15–40 mm (median 25 mm) in the pouch body. 82% of the polyps>1 cm were treated with 1–7 (median 1) endoscopic mucosal resections. 14 patients (5%) required at least one examination under general anaesthesia for assessment and polyp resection. Pouchectomy was performed in 3% (7) for endoscopically unmanageable polyps.
High grade dysplasia/adenocarcinoma was identified in 3 cuff polyps at 4, 13 and 17 years following pouch formation. Pouchectomy was performed in all 3 cases. No pouch body cancers were identified.
Conclusion Adenomatous polyps are common in the cuff and pouch body following RPC in FAP patients. The risk of cuff and pouch body polyps increases with pouch age. Large pouch polyps often require recurrent endoscopic intervention and surgery is indicated if endoscopic removal is not feasible. High quality endoscopic surveillance is mandated.
Disclosure of Interest None Declared
- Pouch polyps