Comparison of Postoperative Morbidity Following Total Colectomy With Ileorectal Anastomosis Vs Proctocolectomy With Ileal Pouch-Anal Anastomosis in Familial Adenomatous Polyposis

BACKGROUND: Colorectal surgery for familial adenomatous polyposis requires a balance between minimizing cancer risk, surgical risk, and quality-of-life preservation. Options include total colectomy/ileorectal anastomosis or proctocolectomy/ileal pouch-anal anastomosis. Prior studies comparing short-term postoperative outcomes are dated and mainly include laparotomies. Minimally invasive surgery is common in current practice, but there are no contemporary studies comparing postoperative outcomes between the 2 surgeries. OBJECTIVE: This study investigated postoperative outcomes including leak, obstruction, and surgical site infection after ileorectal anastomosis versus ileal pouch-anal anastomosis in familial adenomatous polyposis. DESIGN: This was a retrospective, observational cohort study. SETTINGS: This study was conducted at a single academic institution using a prospectively maintained hereditary colorectal cancer syndrome database from 2008-2023. PATIENTS: Patients with familial adenomatous polyposis who underwent index ileorectal anastomosis or ileal pouch-anal anastomosis during the study period and met inclusion criteria were selected. MAIN OUTCOME MEASURES: Main outcome measures include development of a postoperative complication, readmission, and reoperation within 30 and 90 days. RESULTS: A total of 217 patients were included – 146 (67.3%) with ileorectal anastomosis and 71 (31.7%) with ileal pouch-anal anastomosis. 85.3% had minimally invasive surgery and 14.7% had open surgery. 87.3% of ileal pouch-anal anastomosis patients had an ileostomy. No significant difference in the number of patients who developed a 30 or 90-day complication was observed. The most common 90-day complication was ileus (34.2% vs 21.2%) and most common 90-day severe complication was anastomotic leak (4.8% vs 7.0%). Patients had a higher frequency of readmission and reoperation after ileal pouch-anal anastomosis (13.0% vs 33.8% and 6.8% vs 18.3%, respectively). LIMITATIONS: This study is limited by its retrospective nature and short follow-up time. CONCLUSIONS: In the modern era, with most surgeries being done minimally invasively, and the majority of ileal pouch-anal anastomosis patients being diverted, surgeries are safe. Severe complications are uncommon and similar between groups. See Video Abstract .