LAUSR

endoscopic downstaging of colorectal polyp burden in patients with familial adenomatous polyposis (FAP) in a multicenter, prospective, interventional study. After 5 years, 90.4% of patients with intact colon remained without surgical intervention and 83.9% of those who had 10cm or more residual large bowel did not require further surgical intervention. The authors conclude that their approach “could have the potential to be a useful means of preventing colorectal cancer without implementing colectomy.” This raises interesting questions about the role of endoscopy in the management of FAP and perhaps can be seen to challenge the paradigm of surgical management of this condition, in all except those with a very mild polyp burden. Before the development of safe anesthesia, surgery in FAP was reserved for cases with colorectal cancer (CRC); CRC was the main cause of death, occurring usually in the fifth decade of life. With the advent of safe prophylactic surgery, life expectancy rose dramatically almost to the level of the general population [2]. For those with an intact large bowel, any management strategy will need to be compared with the undoubted benefit of such surgical intervention, the key outcome being CRC prevention. For those who have already undergone colectomy and ileorectal anastomosis (IRA) or indeed a subtotal colectomy, the end points include not only CRC but also need for secondary proctectomy.