Table 2.

Depicts options available for the diagnosis, management, surveillance and care of patients with pouch-related adenomas after FAP preventive surgery based on a literature review.

Option/Diagnosis	Management	Note
Follow-up Surveillance Life-term endoscopic surveillance of all FAP patients after IPAA or IRA surgery along with evaluation of potential therapeutic options for pouch adenomas.	To fulgurate new and recurrent polyps and screen for the development of cancer Lifelong proctoscopy every 6 months to a year. Lifelong endoscopic pouch surveillance. Pouchoscopy is well tolerated without sedation in the clinic setting; thus recommend annual surveillance for the first 5 years following pouch construction. Endoscopy can then be done less frequently (every 3 years) in patients with no polyps or low polyp burden on initial pouchoscopies.77	The incidence of developing subsequent adenomas is time-dependent from surgery Patients who have an IRA, need a proctoscopy following surgery, to monitor the rectum Pouchoscopy is recommended to be done yearly for life, initially to look for anastomotic adenomas and then later to check for pouch adenomas. Once neoplasia is seen, appropriate treatment needs to be determined. Risk for the development of adenomas in the ATZ is higher after a stapled IPAA than after a mucosectomy with handsewn anastomosis. However, control of ATZ neoplasia results in a similar risk of cancer development. Because the stapled procedure is associated with better long-term functional outcomes than a mucosectomy, stapled IPAA is the preferable procedure for most patients with FAP.92
Adenomas < 5 mm without dysplasia	Simple monitoring with careful follow-up13,62 Nonsteroid anti-inflammatory drugs (NSAID) Chemoprophylaxis  • Sulindacor  • Celebrax	Both prophylactic surgical options do NOT cure FAP, and multiple polyps can occur in the ileal pouch mucosa, ARS and afferent ileal loop. The role of NSAID to suppress ileal pouch adenomas in FAP has been established31,68,85–90 Chemoprophylax may be used to minimize small adenoma growth but will not necessarily prevent neoplastic transformation.70,71
Adenomas > 5 mm with or without dysplasia Adenomas larger than 1 cm and/ or showing high-grad dysplasia	Endoscopic resection (polypectomy) with free margins.52 Alternatively a transanal excision of residual, adenoma-bearing ATZ, or abdominal approach may be indicated.2,13,17 Transanal polypectomy or coagulation modalities using Nd:YAG laser (25 W).90 or Argon plasma coagulation using 40 W to 50 W power setting and 1 L/min gas flow.53,64,90	Endoscopic mucosal resection (EMR) is a major therapeutic advance in the treatment of sessile and flat colorectal polyps.66,68 These patients however are at increased risk for adenoma recurrence,27,86–90 particularly there is a higher risk of development of adenomas at the anastomotic site after a bouble-stapled anastomosis.73
Uncontrollable adenomas with or without high-grade dysplasia/ or adenocarcinoma	Surgery, pouch excision (pouchectomy)65,73	Endoscopic treatment of pouch related adenomas is likely to be difficult because of the thin ileal mucosa and the way it is tethered to the submucosa and underlying muscle, reducing the options for their control to excising the entire pouch or chemoprevention.2,73 The median interval between RPC and pouch excision was 0.6 years (range, 0.2–11)73