# Adenoma and carcinoma in the anal transitional zone following hand-sewn versus stapled ileal pouch-anal anastomosis in familial adenomatous polyposis

## TL;DR

This study compares surgical techniques for treating familial adenomatous polyposis and finds stapled surgery has faster operation times and better function but higher adenoma recurrence.

## Contribution

The study provides new comparative data on oncological and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis in FAP patients.

## Key findings

- Stapled IPAA had shorter operative times and better anorectal function compared to hand-sewn IPAA.
- Stapled IPAA showed higher 5-year adenoma recurrence rates but no cancer progression.
- Hand-sewn IPAA had two cancer cases during long-term follow-up.

## Abstract

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is the standard surgical treatment for familial adenomatous polyposis (FAP) in our institution. Stapled and hand-sewn IPAA differ in the amount of retained rectal mucosa, influencing both adenoma risk and functional outcomes. In this retrospective cohort study, we compared oncological and functional outcomes between the two techniques. Consecutive patients with FAP who underwent RPC with IPAA at Seoul National University Hospital between 1994 and 2022 were included. The ATZ adenoma and cancer occurrence, operative time, and anorectal functional outcomes were compared between hand-sewn and stapled anastomosis groups. The cumulative incidence risk of adenoma recurrence was compared using the log-rank test. 89 patients were analyzed: 32 underwent hand-sewn and 57 underwent stapled IPAA. Median follow-up was 100 months in the stapled group and 79 months in the hand-sewn group. Stapled IPAA was associated with shorter operative time (220.6 vs. 332.9 min, p < 0.001), lower diverting ileostomy rate (78.9% vs. 96.9%, p = 0.027), and lower Wexner incontinence scores (1.54 vs. 3.43, p = 0.009). Adenomas or carcinomas at the ATZ were identified in 29.2% of patients, with a higher 5-year adenoma recurrence in the stapled group (20.1% vs. 3.2%, p = 0.02). Most adenomas were successfully managed endoscopically, with no cancer progression in the stapled group. Two cancers occurred in the hand-sewn group during long-term follow-up. Stapled IPAA offers advantages in operative efficiency and anorectal function, with higher adenoma recurrence manageable under surveillance. These findings suggest stapled IPAA may be a reasonable surgical option for FAP when coupled with diligent follow-up.