Deciding on an IRA vs. IPAA for FAP

Ileorectal anastomosis (IRA)

Ileal pouch-anal anastomosis (IPAA), mucosectomy and handsewn anastomosis

Ileal pouch-anal anastomosis (IPAA), stapled anastomosis

Indications

<20 rectal adenomas

Young patient

High desmoid risk

Woman

>20 rectal adenomas

Older patient

Low desmoid risk

Adenomas in ATZ

>20 rectal adenomas

Older patient

Low desmoid risk

ATZ clear of adenomas

Contraindication

Rectal cancer

Uncontrollable rectal polyposis

Fecal incontinence

Obese

High desmoid risk

Fecal incontinence

Obese

High desmoid risk

ATZ adenomas

Advantages

No ileostomy

Low complications

Good bowel function

Low risk of desmoid disease

Minimal risk of rectal cancer

Per anal defecation

No urgency

Low risk of ATZ neoplasia

Minimal risk of rectal cancer

Per anal defecation

No urgency

Minimal seepage/incontinence

Disadvantages

Risk of rectal cancer

Temporary stoma

Higher complication rate, both early and late

Abnormal bowel function with seepage and incontinence

High risk of desmoid disease

Risk of ATZ polyps and cancer

High risk of ATZ neoplasia

Table 30.2

The outcomes of ileorectal anastomosis and ileal pouch-anal anastomosis: a literature review

Study	Variable	IRA	IPAA	P
Campos et al. (2009) N = 88 1977–2006	Complications Cancer	19.0 % 16.6 %	48.1 % 3.8 %	0.03
Gunter et al. (2003) N = 151 1970–2000
Soravia et al. (1999) n = 131 1980–1997	Anastomotic leak Bowel obstruction Function	3 % 15 % Less nighttime stooling, better continence, less skin irritation	12 % 24 %	0.21 0.58
Bjork et al. (2001) n = 131 1984–1996	Complications Function	26 % Less night time stooling, better continence, less skin irritation	40 %	<0.05
Vasen et al. (2001)	Cancer	Risk of death from cancer 12.5 % by age 65	Increase in life expectancy by 1.8 years
Koskenvuo et al. (2014)	Secondary proctectomy Anus preservation rate during secondary proctectomy Cancer rate	39/140 49 % 24 % at 30 years
Niewenhuis et al. (2009)	Secondary proctectomy by genotype Attenuated Intermediate Severe	10 % 39 % 61 %
Ko et al.	Bowel movements per day Leakage Pads usage Perianal skin problems Food avoidance Inability to distinguish gas	5.2 0 0 7 % 43 % 7 %	7.5 43 % 17 % 33 % 80 % 37 %	<0.05 0.01 <0.01 <0.01 <0.01 <0.01
Wuthrich	Soiling >6 bowel movements/24 h		25 % 67 %

References

Ripa R, Bisgaard ML, Bulow S, Nielsen FC. De novo mutations in familial adenomatous polyposis (FAP). Eur J Hum Genet. 2002;10:631–7.CrossRefPubMed

Kartheuser AH, Parc R, Penna CP, Tiret E, Frileux P, Hannoun L, Nordlinger B, Loygue J. Ileal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: a ten-year experience. Surgery. 1996;119(6):615–23.CrossRefPubMed

Koskenvuo L, Renkonen-Sinisalo L, Jarvinen HJ, Lepisto A. Risk of cancer and secondary proctectomy after colectomy and ileorectal anastomosis in familial adenomatous polyposis. Int J Colorectal Dis. 2014;29:225–30.CrossRefPubMed

Church J, Burke C, McGannon E, Pastean O, Clark B. Risk of rectal cancer in patients after colectomy and ileorectal anastomosis for familial adenomatous polyposis: a function of available surgical options. Dis Colon Rectum. 2003;46:1175–81.CrossRefPubMed

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