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A Decision Analysis for Rectal-Sparing Familial Adenomatous Polyposis

Total Colectomy With Ileorectal Anastomosis Versus Proctocolectomy With IPAA

Melnitchouk, Nelya, M.D., M.Sc.1,2; Saadat, Lily Victoria, M.D.1; Bleday, Ronald, M.D.1; Goldberg, Joel E., M.D., M.P.H.1,2

Diseases of the Colon & Rectum: January 2019 - Volume 62 - Issue 1 - p 27–32
doi: 10.1097/DCR.0000000000001186
Original Contributions: Colorectal Cancer
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BACKGROUND: There are different approaches for the surgical management of rectal-sparing familial adenomatous polyposis with variable impacts on both quality of life and survival.

OBJECTIVE: The aim of this study was to quantify the trade-offs between total proctocolectomy with IPAA versus total colectomy with ileorectal anastomosis using decision analysis.

DESIGN: We created a disease simulation Markov model to simulate the clinical events after IPAA and ileorectal anastomosis for rectal-sparing familial adenomatous polyposis in a cohort of individuals at the age 30 years. We used available literature to obtain different transition probabilities and health-states utilities. The output parameters were quality-adjusted life-years and life-years. Deterministic and probabilistic sensitivity analyses were performed.

SETTINGS: A decision analysis using a Markov model was conducted at a single center.

PATIENTS: Patients with rectal-sparing familial adenomatous polyposis at age 30 years were included. Rectal-sparing familial adenomatous polyposis is defined as the presence of 0 to 20 polyps that can be removed endoscopically.

MAIN OUTCOME MEASURES: Quality-adjusted life-years were measured.

RESULTS: Our model showed that the mean quality-adjusted life-years for IPAA was 25.12 and for ileorectal anastomosis was 27.12 in base-case analysis. Mean life-years for IPAA were 28.81 and 28.28 for ileorectal anastomosis. A 1-way sensitivity analysis was performed for all of the parameters in the model. None of the deterministic sensitivity analyses changed the model results across the range of plausible values. Probabilistic analysis identified that, in 86.9% of scenarios, ileorectal anastomosis had improved quality-adjusted life-years compared with IPAA.

LIMITATIONS: The study was limited by characteristics inherent to modeling studies.

CONCLUSIONS: Ileorectal anastomosis was found to be preferable for patients with rectal-sparing familial adenomatous polyposis when quality of life is taken into consideration. This model was robust based on both deterministic and probabilistic sensitivity analyses. These data should be taken into consideration when counseling patients regarding a surgical approach in rectal-sparing familial adenomatous polyposis. See Video Abstract at

1 Department of Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts

2 Center for Surgery and Public Health, Boston, Massachusetts

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Funding/Support: None reported.

Financial Disclosures: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017.

Correspondence: Nelya Melnitchouk, M.D., M.Sc., Brigham and Women’s Hospital, Department of Surgery, 75 Francis St, Boston, MA 02115. E-mail:

© 2019 The American Society of Colon and Rectal Surgeons