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Zaman S, Mohamedahmed AYY, Abdelrahman W, Abdalla HE, Wuheb AA, Issa MT, Faiz N, Yassin NA. Minimally Invasive Surgery for Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis of Robotic Versus Laparoscopic Surgical Techniques. J Crohns Colitis 2024; 18:1342-1355. [PMID: 38466108 PMCID: PMC11324345 DOI: 10.1093/ecco-jcc/jjae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/04/2024] [Accepted: 03/08/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND We aimed to evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatory bowel disease [IBD]. METHODS Comparative studies of robotic versus laparoscopic colorectal resections in patients with IBD were included. The primary outcome was total post-operative complication rate. Secondary outcomes included operative time, conversion to open surgery, anastomotic leaks, intra-abdominal abscess formation, ileus occurrence, surgical site infection, re-operation, re-admission rate, length of hospital stay, and 30-day mortality. Combined overall effect sizes were calculated using a random-effects model and the Newcastle-Ottawa Scale was used to assess risk of bias. RESULTS Eleven non-randomized studies [n = 5566 patients] divided between those undergoing robotic [n = 365] and conventional laparoscopic [n = 5201] surgery were included. Robotic platforms were associated with a significantly lower overall post-operative complication rate compared with laparoscopic surgery [p = 0.03]. Laparoscopic surgery was associated with a significantly shorter operative time [p = 0.00001]. No difference was found in conversion rates to open surgery [p = 0.15], anastomotic leaks [p = 0.84], abscess formation [p = 0.21], paralytic ileus [p = 0.06], surgical site infections [p = 0.78], re-operation [p = 0.26], re-admission rate [p = 0.48], and 30-day mortality [p = 1.00] between the groups. Length of hospital stay was shorter following a robotic sub-total colectomy compared with conventional laparoscopy [p = 0.03]. CONCLUSION Outcomes in the surgical management of IBD are comparable between traditional laparoscopic techniques and robotic-assisted minimally invasive surgery, demonstrating the safety and feasibility of robotic platforms. Larger studies investigating the use of robotic technology in Crohn's disease and ulcerative colitis separately may be of benefit with a specific focus on important IBD-related metrics.
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Affiliation(s)
- Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | | | - Widad Abdelrahman
- Department of Colorectal and General Surgery, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Hashim E Abdalla
- Department of Colorectal and General Surgery, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ali Ahmed Wuheb
- Department of Colorectal and General Surgery, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Mohamed Talaat Issa
- Department of General Surgery, Russells Hall Hospital, Dudley Group NHS Trust, Dudley, UK
| | - Nameer Faiz
- Department of General Surgery, Russells Hall Hospital, Dudley Group NHS Trust, Dudley, UK
| | - Nuha A Yassin
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Department of Colorectal and General Surgery, University Hospitals Birmingham NHS Trust, Birmingham, UK
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Kimura H, Toritani K, Endo I. Usefulness of Hand-assisted Laparoscopic Restorative Proctocolectomy for Ulcerative Colitis in the Era of Laparoscopic Surgery - A Single-center Observational Study. J Anus Rectum Colon 2024; 8:228-234. [PMID: 39086870 PMCID: PMC11286376 DOI: 10.23922/jarc.2024-024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/16/2024] [Indexed: 08/02/2024] Open
Abstract
Objectives Hand-assisted laparoscopic surgery (HALS) combines the benefits of laparoscopic surgery with the tactile feedback from open surgery. In the current era of laparoscopic surgery, the significance of HALS as a technical transition has diminished. This study clarified the usefulness of HALS in restorative proctocolectomy (RPC) for ulcerative colitis (UC) in the era of laparoscopic surgery. Methods The 212 patients who underwent RPC with ileal pouch-anal anastomosis between 2007 and 2023 were included in this study. The patients were divided into three groups, open surgery (OS), HALS, and conventional laparoscopic surgery (LAP), and their characteristics, surgical outcomes, surgical complications, and functional outcomes were compared. Results The number of surgical techniques was OS in 21 cases, HALS in 184 cases, and LAP in 7 cases. The number of surgeons was two for OS and HALS, and four for LAP, with OS and HALS having fewer surgeons than LAP. The length of the skin incision was 13, 7, and 3 cm for OS, HALS, and LAP, respectively, and the operation times was 250, 286, and 576 minutes for OS, HALS, and LAP, respectively, with LAP having the longest operation time. The postoperative complications and function did not differ markedly among the three groups. Conclusions In RPC for UC, HALS involved fewer surgeons and a shorter operative time than LAP. Even in the era of laparoscopic surgery, HALS remains a useful option, especially when a shorter operation time is required or when the number of available surgeons is insufficient.
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Affiliation(s)
- Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kenichiro Toritani
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Itaru Endo
- Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
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Pedraza AM, Ferguson EL, Ramos-Carpinteyro R, Mikesell C, Chavali JS, Soputro N, Almassi N, Weight C, Gorgun E, Kaouk J. Managing prostate cancer after proctocolectomy and ileal pouch-anal anastomosis: feasibility and outcomes of single-port transvesical robot-assisted radical prostatectomy. World J Urol 2024; 42:368. [PMID: 38832957 DOI: 10.1007/s00345-024-05051-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 05/06/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Patients with proctocolectomy and ileal pouch-anal anastomosis (PC-IPAA) face unique challenges in managing prostate cancer due to their hostile abdomens and heightened small bowel mucosa radiosensitivity. In such cases, external beam radiation therapy (EBRT) is contraindicated, and while brachytherapy provides a safer option, its oncologic effectiveness is limited. The Single-Port Transvesical Robot-Assisted Radical Prostatectomy (SP TV-RARP) offers promise by avoiding the peritoneal cavity. Our study aims to evaluate its feasibility and outcomes in patients with PC-IPAA. METHODS A retrospective evaluation was done on patients with PC-IPAA who had undergone SP TV-RARP from June 2020 to June 2023 at a high-volume center. Outcomes and clinicopathologic variables were analyzed. RESULTS Eighteen patients underwent SP TV-RARP without experiencing any complications. The median hospital stay was 5.7 h, with 89% of cases discharged without opioids. Foley catheters were removed in an average of 5.5 days. Immediate urinary continence was seen in 39% of the patients, rising to 76 and 86% at 6- and 12-month follow-ups. Half of the cohort had non-organ confined disease on final pathology. Two patients with ISUP GG3 and GG4 exhibited detectable PSA post-surgery and required systemic therapy; both had SVI, multifocal ECE, and large cribriform pattern. Positive surgical margins were found in 44% of cases, mostly Gleason pattern 3, unifocal, and limited. After 11.1 months of follow-up, no pouch failure or additional BCR cases were found. CONCLUSION Patients with PC-IPAA often exhibit aggressive prostate cancer features and may derive the greatest benefit from surgical interventions, particularly given that radiation therapy is contraindicated. SP TV-RARP is a safe option for this group, reducing the risk of bowel complications and promoting faster recovery.
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Affiliation(s)
- Adriana M Pedraza
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Ethan L Ferguson
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Roxana Ramos-Carpinteyro
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Carter Mikesell
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Jaya S Chavali
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Nicolas Soputro
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Nima Almassi
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Christopher Weight
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA
| | - Emre Gorgun
- Colorectal Surgery, DDSI, Cleveland Clinic, Cleveland, OH, USA
| | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Ave, Q10, Cleveland, OH, 44195, USA.
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Maspero M, Hull TL. State of the Art: Pouch Surgery in the 21st Century. Dis Colon Rectum 2024; 67:S1-S10. [PMID: 38441240 DOI: 10.1097/dcr.0000000000003326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations. OBJECTIVE To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration. RESULTS The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications. CONCLUSIONS Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Kotze PG, Avellaneda N, Moretti RDAM, Carvello M, Tomada EP, Campos FG, Spinelli A. Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques. Dis Colon Rectum 2024; 67:S26-S35. [PMID: 38710588 DOI: 10.1097/dcr.0000000000003292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. OBJECTIVE To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. DATA SOURCE Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. STUDY SELECTION Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. INTERVENTION IPAA technique. MAIN OUTCOME MEASURES Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). RESULTS Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. LIMITATIONS A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. CONCLUSIONS Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
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Affiliation(s)
- Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Nicolas Avellaneda
- General and Colorectal Surgery Department, CEMIC University Hospital, Buenos Aires, Argentina
| | | | - Michele Carvello
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elisa Paoluzzi Tomada
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Chaouch MA, Hussain MI, Carneiro da Costa A, Mazzotta A, Krimi B, Gouader A, Cotte E, Khan J, Oweira H. Robotic versus laparoscopic total mesorectal excision with lateral lymph node dissection for advanced rectal cancer: A systematic review and meta-analysis. PLoS One 2024; 19:e0304031. [PMID: 38809911 PMCID: PMC11135705 DOI: 10.1371/journal.pone.0304031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/05/2024] [Indexed: 05/31/2024] Open
Abstract
INTRODUCTION Lateral pelvic node dissection (LPND) poses significant technical challenges. Despite the advent of robotic surgery, determining the optimal minimally invasive approach remains a topic of debate. This study aimed to compare postoperative outcomes between robotic total mesorectal excision with LPND (R-LPND) and laparoscopic total mesorectal excision with LPND (L-LPND). METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 and AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines. Utilizing the RevMan 5.3.5 statistical package from the Cochrane Collaboration, a random-effects model was employed. RESULTS Six eligible studies involving 652 patients (316 and 336 in the R-LPND and L-LPND groups, respectively) were retrieved. The robotic approach demonstrated favourable outcomes compared with the laparoscopic approach, manifesting in lower morbidity rates, reduced urinary complications, shorter hospital stays, and a higher number of harvested lateral pelvic lymph nodes. However, longer operative time was associated with the robotic approach. No significant differences were observed between the two groups regarding major complications, anastomotic leak, intra-abdominal infection, neurological complications, LPND time, overall recurrence, and local recurrence. CONCLUSIONS In summary, the robotic approach is a safe and feasible alternative for Total Mesorectal Excision (TME) with LPND in advanced rectal cancer. Notably, it is associated with lower morbidity, particularly a reduction in urinary complications, a shorter hospital stay and increased number of harvested lateral pelvic nodes. The trade-off for these benefits is a longer operative time.
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Affiliation(s)
- Mohamed Ali Chaouch
- Department of visceral and digestive surgery, Monastir University Hospital, Monastir, Tunisia
| | - Mohammad Iqbal Hussain
- Department of Robotic Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | | | - Alessandro Mazzotta
- Department of Surgery, M. G. Vannini Hospital, Istituto Figlie Di San Camillo, Rome, Italy
| | - Bassem Krimi
- Department of Surgery, Perpignan Hospital Center, Perpignan, France
| | - Amine Gouader
- Department of Surgery, Perpignan Hospital Center, Perpignan, France
| | - Eddy Cotte
- Department of Visceral Surgery, University Hospital of Lyon, University of Lyon, Lyon, France
| | - Jim Khan
- Department of Robotic Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Hani Oweira
- Department of Surgery, Universitäts Medizin Mannheim, Heidelberg University, Mannheim, Germany
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Stephens IJB, Byrnes KG, Burke JP. Transanal ileal pouch-anal anastomosis: A systematic review and meta-analysis of technical approaches and clinical outcomes. Langenbecks Arch Surg 2024; 409:153. [PMID: 38705912 PMCID: PMC11070401 DOI: 10.1007/s00423-024-03343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches. METHODS Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed. RESULTS Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence. CONCLUSIONS Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.
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Affiliation(s)
- Ian J B Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin, Ireland.
| | - Kevin G Byrnes
- Havering and Redbridge University Trust, Greater London, UK
| | - John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
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Violante T, Ferrari D, Gomaa IA, Rumer KK, D'Angelo ALD, Behm KT, Shawki SF, Perry WRG, Kelley SR, Mathis KL, Dozois EJ, Cima RR, Larson DW. Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes. J Gastrointest Surg 2024; 28:501-506. [PMID: 38583902 DOI: 10.1016/j.gassur.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.
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Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; School of General Surgery, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Ibrahim A Gomaa
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristen K Rumer
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Sherief F Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - William R G Perry
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Scott R Kelley
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Robert R Cima
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States.
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Ferrari L, Nicolaou S, Adams K. Implementation of a robotic surgical practice in inflammatory bowel disease. J Robot Surg 2024; 18:57. [PMID: 38281204 DOI: 10.1007/s11701-023-01750-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/02/2023] [Indexed: 01/30/2024]
Abstract
Robotics adoption has increased in colorectal surgery. While there are well-established advantages and standardised techniques for cancer patients, the use of robotic surgery in inflammatory bowel disease (IBD) has not been studied yet. To evaluate the feasibility and safety of robotic surgery for IBD patients. Prospectively data in IBD patients having robotic resection at Guy's and St Thomas' hospital. All resections performed by a single colorectal surgeon specialised in IBD, utilising DaVinci platform. July 2021 to January 2023, 59 robotic IBD cases performed, 14 ulcerative colitis (UC) and 45 Crohn's disease (CD). Average age; CD patients 35, UC 33 years. Average Body mass index (BMI); 23 for CD and 26.9 for UC patients. In total, we performed 31 ileo-caecal resections (ICR) with primary anastomosis (18 Kono-S anastomosis, 6 mechanical anastomosis and 7 ileo-colostomy), of those 4 had multivisceral resections (large bowel, bladder, ovary). Furthermore, 14 subtotal colectomy (1 emergency), 8 proctectomy, 3 panproctocolectomy and 3 ileoanal J pouch. 18 of the 45 patients (45.0%) with Crohn's disease had ongoing fistulating disease to other parts of the GI tract (small or large bowel). ICR were performed using different three ports position, depending on the anatomy established prior to surgery with magnetic resonance images (MRI). One patient had conversion to open due to anaesthetic problems and one patient required re-operation to refashion stoma. 98.0% cases completed robotically. Median Length of hospital stay (LOS) was 7 days for CD and 7 for UC cases, including LOS in patients on pre-operative parenteral nutrition. Robotic colorectal techniques can be safely used for patients with IBD, even with fistulating disease. Future research and collaborations are necessary to standardize technique within institutions.
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Affiliation(s)
- Linda Ferrari
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK.
| | - Stella Nicolaou
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Katie Adams
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
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Clancy C, Connelly TM, Jia X, Lipman J, Lightner AL, Hull T, Steele SR, Holubar SD. Defining the safety of early ileostomy closure after ileal pouch anal anastomosis. Tech Coloproctol 2023; 27:1257-1263. [PMID: 37209279 DOI: 10.1007/s10151-023-02811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/24/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE The safety of early ileostomy reversal after ileal pouch anal anastomosis (IPAA) has not been established. Our hypothesis was that ileostomy reversal before 8 weeks is associated with negative outcomes. METHODS This was a retrospective cohort study from a prospectively maintained institutional database. Patients who underwent primary IPAA with ileostomy reversal between 2000 and 2021 from a Pouch Registry were stratified on the basis of timing of reversal. Those reversed before 8 weeks (early) and those reversed from 8 weeks to 116 days (routine) were compared. The primary outcome was overall complications according to timing and reason for closure. RESULTS Ileostomy reversal was performed early in 92 patients and routinely in 1908. Median time to closure was 49 days in the early group and 93 days in the routine group. Reasons for early reversal were stoma-related morbidity in 43.3% (n = 39) and scheduled closure in 56.7% (n = 51). The complication rate in the early group was 17.4% versus 11% in the routine group (p = 0.085). When early patients were stratified according to reason for reversal, those reversed early for stoma-related morbidity had an increased complication rate compared to the routine group (25.6% vs. 11%, p = 0.006). Patients undergoing scheduled reversal in the early group did not have increased complications (11.8% vs. 11%, p = 0.9). There was a higher likelihood of pouch anastomotic leak when reversal was performed early for stoma complications compared to routinely (OR 5.13, 95% CI 1.01-16.57, p = 0.049). CONCLUSIONS Early closure is safe but could be delayed in stoma morbidity as patients may experience increased complications.
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Affiliation(s)
- C Clancy
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - T M Connelly
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - X Jia
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A L Lightner
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - T Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S D Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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11
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Spinelli A, Foppa C, Maroli A, Sacchi M, Armuzzi A, Danese S, Bemelman W, Carvello M. Transanal transection and single-stapling techniques are associated with shorter rectal cuff and lower urgency rate after pouch surgery compared with the double-stapled approach. Surgery 2023; 174:808-812. [PMID: 37517895 DOI: 10.1016/j.surg.2023.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis is most commonly performed by double-stapling technique after rectal transection with a linear stapler. Double-stapling is increasingly criticized for the uneven longer cuffs and potential weak points. A transanal rectal transection and single-stapled anastomosis may potentially overcome the limitations of double-stapling. A single-stapled anastomosis may be accomplished through a transanal rectal transection followed by bottom-up dissection (transanal-ileal pouch-anal anastomosis) or through an abdominal, rectal dissection and subsequent transanal transection and single-stapled anastomosis. The purpose of this study is to compare short-term and functional outcomes of double-stapling versus single-stapled techniques for ileal pouch-anal anastomosis. METHODS This is a single-institution, ambidirectional study. Patients with ulcerative colitis undergoing ileal pouch-anal anastomosis between 2014 and 2021 were included in the study and allocated into 2 groups: group 1, including double stapled ileal pouch anal anastomosis, and group 2, including single-stapled-ileal pouch-anal anastomosis. The primary endpoint was the difference in functional parameters. RESULTS A total of 130 patients were included, 46 undergoing double-stapling-ileal pouch-anal anastomosis and 84 receiving single-stapled ileal pouch-anal anastomosis. Rectal-cuff length (defined as the distance between the dentate line and ileal pouch-anal anastomosis) was shorter after single-stapled compared with double-stapling ileal pouch-anal anastomosis (1.98 ± 0.21 vs 2.20 ± 0.53 cm, P = .01). Anastomotic leak rate was comparable between group 1 and group 2 (6% vs 5%, P = .69). Functional parameters were comparable except for urgency, which was lower for single-stapled compared with double-stapling ileal pouch-anal anastomosis (8%, vs 30%, P = .002). CONCLUSION Single-stapled ileal pouch-anal anastomosis was associated with a shorter rectal cuff and lower urgency than double-stapling ileal pouch-anal anastomosis. In our opinion, these results warrant a prospective multicentric trial to scrutinize and confirm these benefits on a larger scale.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy.
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Matteo Sacchi
- Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), San Raffaele Hospital, Milan, Italy
| | - Willem Bemelman
- Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), San Raffaele Hospital, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
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12
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Radomski SN, Stem M, Consul M, Maturi JR, Chung H, Gearhart S, Graham A, Obias VJ. National trends and feasibility of a robotic surgical approach in the management of patients with inflammatory bowel disease. Surg Endosc 2023; 37:7849-7858. [PMID: 37620649 PMCID: PMC10543162 DOI: 10.1007/s00464-023-10333-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Research on the utilization of robotic surgical approaches in the management of inflammatory bowel disease (IBD) is limited. The aims of this study were to identify temporal trends in robotic utilization and compare the safety of a robotic to laparoscopic operative approach in patients with IBD. METHODS Patients who underwent minimally invasive surgery (MIS) for IBD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013-2021). Temporal trends of robotic utilization were assessed from 2013 to 2021. Primary (30-day overall and serious morbidity) and secondary (unplanned conversion to open) outcomes were assessed between 2019 and 2021, when robotic utilization was highest. Multivariable logistic regression was performed. RESULTS The use of a robotic approach for colectomies and proctectomies increased significantly between 2013 and 2021 (p < 0.001), regardless of disease type. A total of 6016 patients underwent MIS for IBD between 2019 and 2021. 2234 (37%) patients had surgery for UC [robotic 430 (19.3%), lap 1804 (80%)] and 3782 (63%) had surgery for CD [robotic 500 (13.2%), lap 3282 (86.8%)]. For patients with UC, there was no difference in rates of overall morbidity (22.6% vs. 20.7%, p = 0.39), serious morbidity (11.4% vs. 12.3%, p = 0.60) or conversion to open (1.5% vs. 2.1%, p = 0.38) between the laparoscopic and robotic approaches, respectively. There was no difference in overall morbidity between the two groups in patients with CD (lap 14.0% vs robotic 16.4%, p = 0.15), however the robotic group exhibited higher rates of serious morbidity (7.3% vs. 11.2%, p < 0.01), shorter LOS (3 vs. 4 days, p < 0.001) and lower rates of conversion to an open procedure (3.8% vs. 1.6%, p = 0.02). Adjusted analysis showed similar results. CONCLUSION The use of the robotic platform in the surgical management of IBD is increasing and is not associated with an increase in 30-day overall morbidity compared to a laparoscopic approach.
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Affiliation(s)
- Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Consul
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jay Rammohan Maturi
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Haniee Chung
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Gearhart
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ada Graham
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Medicine, National Capital Region, 10215 Fernwood Road, Suite 630, Bethesda, MD, 20817, USA
| | - Vincent J Obias
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Johns Hopkins Medicine, National Capital Region, 10215 Fernwood Road, Suite 630, Bethesda, MD, 20817, USA.
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13
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Church JM. The anatomy and physiology of the ileal pouch and its relevance to pouch dysfunction. Abdom Radiol (NY) 2023; 48:2930-2934. [PMID: 36853391 DOI: 10.1007/s00261-022-03721-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 03/01/2023]
Abstract
For the last 40 years, the ileal pouch-anal anastomosis has been used in patients with ulcerative colitis, familial adenomatous polyposis, and occasionally severe constipation to reconstruct the gastrointestinal tract after proctocolectomy. Although the procedure has generally been successful in helping patients avoid an ileostomy, it has come with its own set of problems. These include complications of the surgery such as fistulas and bowel obstruction, persistent inflammation of the pouch known as pouchitis, and functional problems related to the lack of expulsive peristalsis in the pouch. It is this last group of problems that is exacerbated by a poor diet, ill-advised anti-diarrheal medications, anal stenosis and pouch twists. As a consequence, patients with pouch problems are frequently referred for radiologic evaluation, with pouchography, defecation studies, and small bowel imaging commonly requested. In this review, the basic anatomy and physiology of the ileal pouch are discussed to provide a logical baseline against which to measure the anatomy of pouches and its relationship to the symptoms of pouch dysfunction.
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Affiliation(s)
- James M Church
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, Herbert Irving Pavilion, 161 Ft. Washington Ave., 8th Floor, Room 8-836, New York, NY, 10032, USA.
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14
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Hasselblatt P, Reindl W, Gauss A, Neeff H, Fusco S, Klaus J. Questions to consider when caring for patients with ulcerative colitis. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:690-700. [PMID: 36257329 DOI: 10.1055/a-1890-6015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Although the management of patients with ulcerative colitis (UC) is well defined by national and international guidelines, there are many debates and open questions related to daily care of UC patients. Here, we aimed to review topics with high clinical relevance including therapy algorithms, potential biomarkers for disease prognosis and response to therapy, the role of interventions targeting the gut microbiota, insights from head-to-head trials, novel UC medications, exit strategies, the impact of COVID19 on UC, care of patients with acute severe disease, cancer screening, and the role of surgery.
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Affiliation(s)
- Peter Hasselblatt
- Department of Medicine II, University Hospital Freiburg, Freiburg, Germany
| | - Wolfgang Reindl
- Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Annika Gauss
- University Hospital Heidelberg, Heidelberg, Germany
| | - Hannes Neeff
- Dept. of General and Visceral Surgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Stefano Fusco
- Department of Gastroenterology, Eberhard-Karls-Universität Tübingen Medizinische Fakultät, Tübingen, Germany
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15
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Panteleimonitis S, Al-Dhaheri M, Harper M, Amer I, Ahmed AA, Nada MA, Parvaiz A. Short-term outcomes in robotic vs laparoscopic ileal pouch-anal anastomosis surgery: a propensity score match study. Langenbecks Arch Surg 2023; 408:175. [PMID: 37140753 PMCID: PMC10160174 DOI: 10.1007/s00423-023-02898-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/14/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Laparoscopic ileal pouch-anal anastomosis (IPAA) surgery offers improved short-term outcomes over open surgery but can be technically challenging. Robotic surgery has been increasingly used for IPAA surgery, but there is limited evidence supporting its use. This study aims to compare the short-term outcomes of laparoscopic and robotic IPAA procedures. METHODS All consecutive patients receiving laparoscopic and robotic IPAA surgery at 3 centres, from 3 countries, between 2008 and 2019 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for gender, previous abdominal surgery, ASA grade (I, II vs III, IV) and procedure performed (proctocolectomy vs completion proctectomy). Their short-term outcomes were examined. RESULTS A total of 89 patients were identified (73 laparoscopic, 16 robotic). The 16 patients that received robotic surgery were matched with 15 laparoscopic patients. Baseline characteristics were similar between the two groups. There were no statistically significant differences in any of the investigated short-term outcomes. Length of stay trend was higher for laparoscopic surgery (9 vs 7 days, p = 0.072) CONCLUSION: Robotic IPAA surgery is safe and feasible and offers similar short-term outcomes to laparoscopic surgery. Length of stay may be lower for robotic IPAA surgery, but further larger scale studies are required in order to demonstrate this.
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Affiliation(s)
- Sofoklis Panteleimonitis
- University of Portsmouth, School of Health and Care Professions, St Andrews Court, St Michael's road, Portsmouth, PO1 2PR, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | | | - Mick Harper
- University of Portsmouth, School of Health and Care Professions, St Andrews Court, St Michael's road, Portsmouth, PO1 2PR, UK
| | | | | | | | - Amjad Parvaiz
- University of Portsmouth, School of Health and Care Professions, St Andrews Court, St Michael's road, Portsmouth, PO1 2PR, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
- Hamad Medical Corporation, Doha, Qatar
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16
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Ethnic Disparities in Ileal Pouch Anal Anastomosis Outcomes: An ACS-NSQIP Study. J Surg Res 2023; 283:84-92. [PMID: 36395743 DOI: 10.1016/j.jss.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ileal pouch-anal anastomosis (IPAA) has become the gold standard operation performed for patients with ulcerative colitis (UC) who require colectomy for medically refractory disease or colitis-associated neoplasia. This study aims to evaluate whether differences in surgical outcomes following IPAA creation is associated with minority ethnicity using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes database. METHODS The ACS-NSQIP proctectomy-targeted data files (2016-2019) were reviewed to identify patients who underwent an IPAA creation (Current Procedural Terminology codes: 44157, 44158, 44211, and 45113). Demographic, comorbidity, perioperative characteristics, and postoperative outcomes, particularly total-morbidity, surgical site infection, and anastomotic leak, were compared for White, African-American, Hispanic, and Asian patients. Separate multivariable logistic regressions were calculated for each outcome of interest. Certain postoperative outcomes required collation to be analyzed due to low numbers, such as combining all surgical site infections (SSIs), anastomotic leak, and septic complications as "infection complications". For each regression, a P value of <0.05 was considered to be significant. RESULTS A total of 1462 patients were identified who underwent an IPAA creation. There were 1290 (88.2%) Caucasian, 66 (4.5%) African-American, 49 (3.4%) Hispanic, and 57 (3.9%) Asian patients. Minority race or ethnicity was not associated with higher odds of total morbidity, readmission, reoperation, the development of any SSI, anastomotic leak, or other septic complications as compared to White patients. African-American ethnicity was associated with higher odds of developing postoperative bleeding complications (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.15-5.21; P = 0.020) and postoperative renal dysfunction (OR 4.32, CI 1.43-13.07; P = 0.010) as compared to White patients. Elevated body mass index (BMI) was associated with higher odds of developing an SSI (OR 1.03, CI 1.00-1.06; P = 0.045), or an "infection" complication (OR 1.04, CI 1.01-1.07; P = 0.012), but was protective against bleeding complications (OR 0.94, CI 0.9-0.98; P = 0.004). Smoking was associated with higher odds of developing an SSI, anastomotic leak, or septic complications in the combined "infection" regression analysis (OR 2.02, CI 1.25-3.26; P = 0.004). In the analysis of total-morbidity, both hypertension (OR 1.64, CI 1.11-2.42; P = 0.013) and an ASA Class score >3 (OR 1.36, CI 1.03-1.79; P = 0.029) were associated with increased odds of complications. CONCLUSIONS This analysis of the ACS-NSQIP national database data suggests that ethnicity is not associated with disparities in surgical outcomes following IPAA surgery. African-American ethnicity was however associated with higher odds of developing postoperative bleeding complications and renal dysfunction as compared to White patients. Elevated BMI and smoking history are associated with an increased risk of SSI, anastomotic leak and septic complications.
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17
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Deputy M, Pitman F, Sahnan K, Miskovic D, Faiz O. An early experience in robotic ileoanal pouch surgery with robotic intracorporeal single-stapled anastomosis (RiSSA) at a tertiary referral centre. Colorectal Dis 2023. [PMID: 36806873 DOI: 10.1111/codi.16528] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023]
Abstract
AIM A robotic approach to ileal pouch-anal anastomosis (IPAA) surgery offers advantages over other approaches in terms of precision, improved access to the pelvis and less muscular fatigue for the surgeon. The integrity of the anastomosis is also fundamental to successful IPAA surgery. The robotic platform can permit intracorporeal suturing deep within the pelvis to create a single-stapled, double purse-string anastomosis, which may reduce the risk of anastomotic complications. This study describes the safety and early outcomes of robotic intracorporeal single-stapled anastomosis (RiSSA) amongst patients operated consecutively at a tertiary centre immediately before and following the pandemic. METHOD A retrospective study of prospectively collected data analysing the outcome of patients undergoing robotic IPAA between 2019 and 2022 was conducted. All procedures were performed with the da Vinci Xi Surgical System (with a hand-assisted suprapubic incision to fashion the pouch). All pouch-anal anastomoses were performed using a double purse-string, single-stapled (RiSSA) method. Demographic, clinical and outcome data were collected. RESULTS Twenty consecutive patients (nine with ulcerative colitis and 11 with familial adenomatous polyposis) were included with a median age of 25 years (range 16-52); 18 had American Society of Anesthesiologists classification II, and mean body mass index was 24 kg/m2 (range 18.1-34.3). Nine patients (eight ulcerative colitis and one familial adenomatous polyposis) had undergone prior subtotal colectomy and therefore underwent restorative proctectomy with IPAA. Eleven patients underwent restorative proctocolectomy. All procedures were completed robotically. The median length of stay was 9 days (5-49). There were no unplanned admissions to intensive care and no deaths. Three patients were readmitted following hospital discharge for (i) an ileus managed conservatively, (ii) small bowel obstruction managed conservatively and (iii) small bowel obstruction due to constriction at the stoma site necessitating surgery. There were two additional reoperations both for drain complications, one for drain removal and one for drain erosion. On mobilization of the pouch in the latter case, an anastomotic defect was observed. In total, 19/20 patients underwent RiSSA without postoperative anastomotic problems. DISCUSSION RiSSA offers a safe and feasible alternative technique to other minimally invasive approaches with low rates of anastomosis-related complications.
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Affiliation(s)
- Mohammed Deputy
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Francesca Pitman
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Leicester University Medical School, George Davies Centre, Leicester, UK
| | - Kapil Sahnan
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Danilo Miskovic
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Omar Faiz
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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18
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Abstract
Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal.
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Affiliation(s)
- Hira Ahmad
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.
| | - Donald B Shaul
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, California; Voluntary Associate Professor of Surgery, University of California, Irvine, USA
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Castaño Llano R, Molina Meneses SP, Puerta JD, Escobar RM, Salazar Ochoa S, Puerta JE, Barreiro-de Acosta M. Ileal reservoir-associated complications in ulcerative colitis versus familial adenomatous polyposis: Impact on patient quality of life. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:39-47. [PMID: 35605822 DOI: 10.1016/j.gastrohep.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/04/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Proctocolectomy with ileal reservoir is the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. OBJECTIVES To evaluate long-term postoperative complications (1994-2019) in patients operated for familial adenomatous polyposis (FAP) and ulcerative colitis (UC) and the degree of satisfaction with the procedure. METHODS Observational study based on the analysis of a retrospective database with prospective follow-up in 115 consecutive patients: 79 with UC and 36 with FAP. A total of 88 patients were followed up, 60 with UC and 28 with PFA. RESULTS 48 males (54.4%) with a mean age of 44.8 ± 10.6 years were evaluated. Indications for surgery were intractable disease in 54 patients (47%), dysplasia/cancer in 43 (37%), severe bleeding in 4 (4%) and perforation in 3 (3%). A proctectomy and mucosectomy of the rectal stump was performed in 67 (76.1%), and a double stapling technique in 21. A protective ileostomy was performed in all patients with UC and FAP. No differences were found in early complications between the two groups. Late complications showed a higher rate of reservoritis in UC patients compared to FAP (44.9 vs. 14.3%, p = 0.001), with more refractory reservoritis in the UC group (13.3 vs. 0%, p = 0.04) with no differences in bowel obstruction, strictures, or anastomotic fistulas. Overall satisfaction and adaptation were considered good in 87% of UC patients and only 57% in the FAP group (p < 0.01). CONCLUSIONS Proctocolectomy with ileal reservoir has comparable morbidity and mortality, except for the higher rate of reservoritis in patients with a history of UC, despite this contingency there is a better quality of life and greater acceptance of surgery in UC patients than in FAP patients.
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Affiliation(s)
- Rodrigo Castaño Llano
- Grupo de Gastrohepatología, Universidad de Antioquia, Instituto de Cancerología, Las Américas-AUNA, Medellín, Antioquia, Colombia
| | | | - Juan Darío Puerta
- Clínica las Américas, Docencia en Cirugía, Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia
| | | | | | | | - Manuel Barreiro-de Acosta
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Digestivo, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU), Santiago de Compostela, A Coruña, España
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20
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Robotic Surgery for the Ileal Pouch. Dis Colon Rectum 2022; 65:S37-S40. [PMID: 35867639 DOI: 10.1097/dcr.0000000000002549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND A robotic approach to total colectomy/proctectomy and ileal pouch reconstruction would seem to be a sensible use of the platform's enhanced reach, visualization, and dexterity. OBJECTIVE The study aimed to discuss current published data for robotic ileal pouch surgery. STUDY SELECTION The study selection included a paucity of published data to date, representing early learning curves and case series with small numbers. CONCLUSIONS Current robotic platforms may offer advantages, particularly in the low pelvis beyond what is found with a laparoscopic approach.
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21
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Role of robotic approach in ileal pouch–anal anastomosis (IPAA): A systematic review of the literature. J Robot Surg 2022; 17:941-947. [DOI: 10.1007/s11701-022-01490-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/06/2022] [Indexed: 11/17/2022]
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22
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Robotic-Assisted versus Laparoscopic Proctectomy with Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Analysis of Clinical and Financial Outcomes from a Tertiary Referral Center. J Clin Med 2022; 11:jcm11216561. [PMID: 36362789 PMCID: PMC9657553 DOI: 10.3390/jcm11216561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Robotic-assisted colorectal surgery is gaining popularity, but limited data are available on the safety, efficacy, and cost of robotic-assisted restorative proctectomy with the construction of an ileal pouch and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Methods: A retrospective study was conducted comparing consecutively performed robotic-assisted and laparoscopic proctectomy with IPAA between 1 January 2016 and 31 September 2021. In total, 67 adult patients with medically refractory UC without proven dysplasia or carcinoma underwent surgery: 29 operated robotically and 38 laparoscopically. Results: There were no differences between both groups regarding postoperative complications within 30 days according to Clavien-Dindo classification’ grades 1−5 (51.7% vs. 42.1%, p = 0.468) and severe grades 3b−5 (17.2% vs. 10.5%, p = 0.485). Robotic-assisted surgery was associated with an increased urinary tract infection rate (n = 7, 24.1% vs. n = 1, 2.6%; p = 0.010) and longer operative time (346 ± 65 min vs. 281 ± 66 min; p < 0.0001). Surgery costs were higher when operated robotically (median EUR 10.377 [IQR EUR 4.727] vs. median EUR 6.689 [IQR EUR 3.170]; p < 0.0001), resulting in reduced total inpatient profits (median EUR 110 [IQR EUR 4.971] vs. median EUR 2.853 [IQR EUR 5.386]; p = 0.001). Conclusion: Robotic-assisted proctectomy with IPAA can be performed with comparable short-term clinical outcomes to laparoscopy but is associated with a longer duration of surgery and higher surgery costs. As experience increases, some advantages may become evident regarding operative time, postoperative recovery, and length of stay. The robotic procedure might then become cost-efficient.
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Lee GC, Bhama AR. Minimally Invasive and Robotic Surgery for Ulcerative Colitis. Clin Colon Rectal Surg 2022; 35:463-468. [PMID: 36591398 PMCID: PMC9797258 DOI: 10.1055/s-0042-1758137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Significant advancements have been made over the last 30 years in the use of minimally invasive techniques for curative and restorative operations in patients with ulcerative colitis (UC). Numerous studies have demonstrated the safety and feasibility of laparoscopic and robotic approaches to subtotal colectomy (including in the urgent setting), total proctocolectomy, completion proctectomy, and pelvic pouch creation. Data show equivalent or improved short-term postoperative outcomes with minimally invasive techniques compared to open surgery, and equivalent or improved long-term bowel function, sexual function, and fertility. Overall, while minimally invasive techniques are safe and feasible for properly selected UC patients, surgeons must remember to abide by the principles of high-quality proctectomy and pouch creation and convert to open if necessary.
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Affiliation(s)
- Grace C. Lee
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Anuradha R. Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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24
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Gul F, Kazmi SNH, Abbas K. The future of robotic surgery for inflammatory bowel diseases. Ann Med Surg (Lond) 2022; 81:104476. [PMID: 36060440 PMCID: PMC9433598 DOI: 10.1016/j.amsu.2022.104476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/18/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - Khawar Abbas
- Corresponding author. Department of Surgery, Rawalpindi Medical University, Rawalpindi, Pakistan.
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Bianchi G, Gavriilidis P, Martínez-Pérez A, de’Angelis GL, Uzzan M, Sobhani I, Coccolini F, Schena CA, Carra MC, Spinoglio G, de’Angelis N. Robotic multiquadrant colorectal procedures: A single-center experience and a systematic review of the literature. Front Surg 2022; 9:991704. [PMID: 36061042 PMCID: PMC9428340 DOI: 10.3389/fsurg.2022.991704] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Robotic surgery has been progressively implemented for colorectal procedures but is still limited for multiquadrant abdominal resections. The present study aims to describe our experience in robotic multiquadrant colorectal surgeries and provide a systematic review and meta-analysis of the literature investigating the outcomes of robotic total proctocolectomy (TPC), total colectomy (TC), subtotal colectomy (STC), or completion proctectomy (CP) compared to laparoscopy. Methods At our institution 16 consecutive patients underwent a 2- or 3-stage totally robotic total proctocolectomy (TPC) with ileal pouch-anal anastomosis. A systematic review of the literature was performed to select studies on robotic and laparoscopic multiquadrant colorectal procedures. Meta-analyses were used to compare the two approaches. Results In our case series, 14/16 patients underwent a 2-stage robotic TPC for ulcerative colitis with a mean operative time of 271.42 (SD:37.95) minutes. No conversion occurred. Two patients developed postoperative complications. The mean hospital stay was 8.28 (SD:1.47) days with no readmissions. Mortality was nil. All patients underwent loop-ileostomy closure, and functional outcomes were satisfactory. The literature appraisal was based on 23 retrospective studies, including 736 robotic and 9,904 laparoscopic multiquadrant surgeries. In the robotic group, 36 patients underwent STC, 371 TC, 166 TPC, and 163 CP. Pooled data analysis showed that robotic TC and STC had a lower conversion rate (OR = 0.17;95% CI, 0.04–0.82; p = 0.03) than laparoscopic TC and STC. The robotic approach was associated with longer operative time for TC and STC (MD = 104.64;95% CI, 18.42–190.87; p = 0.02) and TPC and CP (MD = 38.8;95% CI, 18.7–59.06; p = 0.0002), with no differences for postoperative complications and hospital stay. Reports on urological outcomes, sexual dysfunction, and quality of life were missing. Conclusions Our experience and the literature suggest that robotic multiquadrant colorectal surgery is safe and effective, with low morbidity and mortality rates. Nevertheless, the overall level of evidence is low, and functional outcomes of robotic approach remain largely unknown.
Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42022303016.
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Affiliation(s)
- Giorgio Bianchi
- Unit of general surgery, CARE Department, Henri Mondor University Hospital, Créteil, France
- Department of medicine and surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Paschalis Gavriilidis
- Department of surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University, Valencia, Spain
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
- Correspondence: Gian Luigi de'Angelis
| | - Mathieu Uzzan
- Department of Gastroenterology, APHP-Henri Mondor University Hospital, Creteil, France
| | - Iradj Sobhani
- Department of Gastroenterology, APHP-Henri Mondor University Hospital, Creteil, France
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, Creteil, France
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Carlo Alberto Schena
- Unit of general surgery, CARE Department, Henri Mondor University Hospital, Créteil, France
| | | | - Giuseppe Spinoglio
- IRCAD Faculty Member Robotic and Colorectal Surgery-IRCAD, Strasbourg, France
| | - Nicola de’Angelis
- Unit of general surgery, CARE Department, Henri Mondor University Hospital, Créteil, France
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, Creteil, France
- University Paris-Est, UPEC, Créteil, France
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Olortegui KS, Graham A, Hyman N. Staging Considerations for the Ileal Pouch-Anal Anastomosis. J Gastrointest Surg 2022; 26:1531-1536. [PMID: 35469035 DOI: 10.1007/s11605-022-05317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Affiliation(s)
| | - Ada Graham
- University of Chicago Medical Center, Chicago, IL, USA
| | - Neil Hyman
- University of Chicago Medical Center, Chicago, IL, USA
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Opoku D, Hart A, Thompson DT, Tran C, Suraju MF, Chang J, Boatman S, Troester A, Goffredo P, Hassan I. Equivalency of short-term perioperative outcomes after open, laparoscopic and robotic ileal anal pouch anastomosis. Does procedure complexity override operative approach? Surg Open Sci 2022; 9:86-90. [PMID: 35719413 PMCID: PMC9201005 DOI: 10.1016/j.sopen.2022.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/02/2022] [Accepted: 05/14/2022] [Indexed: 02/07/2023] Open
Abstract
Background Ileal pouch anal anastomosis is the treatment of choice for patients with chronic ulcerative colitis and familial adenomatous polyposis undergoing a proctocolectomy and desiring bowel continuity. It is a technically complex operation associated with significant morbidity and may be performed by an open, laparoscopic, or robotic approach. However, there is a paucity of data regarding the comparative perioperative outcomes between these 3 techniques outside of institutional studies. Methods The NSQIP targeted proctectomy data set was used to identify patients who underwent open, laparoscopic, and robotic ileal pouch anal anastomosis between 2016 and 2019. Thirty-day outcomes between different surgical approaches were compared using univariate and multivariable analysis. Results During the study period, 1,067 open, 971 laparoscopic, and 341 robotic ileal pouch anal anastomosis were performed. The most frequent indications were inflammatory bowel disease (64%), malignancy (18%), and familial adenomatous polyposis (7%). Mean age of the cohort was 43 ± 15 years with 43% female and 76% with body mass index ≤ 30 kg/m2. Overall morbidity was 26.8% for the entire cohort with 4% anastomotic leak, 6% reoperation, 21% ileus, and 21% readmission rate. After adjusting for available confounders, operative approach was not associated with better short-term outcomes, including length of stay, overall morbidity, anastomotic leak, reoperation, incidence of ileus, and 30-day readmissions. Conclusion Ileal pouch anal anastomosis continues to be associated with significant postoperative morbidity regardless of operative approach. Patient-related advantages in terms of perioperative outcomes for laparoscopic and robotic platforms compared to open surgery are less pronounced in complex operations such as ileal pouch anal anastomosis. Ileal anal pouch anastomosis is a technically complex operation associated with significant postoperative 30-day morbidity. Postoperative morbidity is similar between open, laparoscopic, and robotic approaches. In complex operations such as ileal anal pouch anastomosis, the short-term perioperative advantages of minimally invasive approaches may not be clinically evident.
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28
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A prospective analysis of the postoperative and long-term functional outcomes of a novel technique to perform rectal transection during laparoscopic restorative proctectomy and ileal pouch-anal anastomosis. Tech Coloproctol 2022; 26:583-590. [PMID: 35292864 DOI: 10.1007/s10151-022-02611-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Laparoscopic ileal pouch-anal anastomosis (IPAA) technique is not standardized. An irregular division of the rectum could result in poor functional outcomes and residual diseased mucosa. The aim of the study was to develop a new technique for performing the rectal transection via a laparoscopic approach, and to compare the outcomes of this technique with those of the open surgery IPAA. METHODS This prospective study included all patients who underwent restorative proctectomy (following a previous subtotal colectomy) for ulcerative colitis in October 2017-November 2020. Rectal division was performed using a 30 mm open linear stapler which was applied laparoscopically across the distal rectum. Postoperative and functional outcomes, length of anal stump and completeness of mucosal removal were compared. Only the patients who had their ileostomy reversed by 31 December 2020 and, therefore, a minimum follow-up of 6 months from the ileostomy closure, were included in the analysis of the functional outcomes and quality of life. RESULTS There were 207 patients (161 laparoscopic, 46 open). Median age was 43 (18-77) years and 85 patients (41.1%) were male. Major complications (9.3 vs. 8.7%, p = 0.89) including anastomotic leaks (3.7 vs 4.4%, p = 0.84) were similar after laparoscopic and open IPAA. Patients reported a comparable number of bowel movements during the day (6 vs. 7, p = 0.21) and at night (2 vs. 2, p = 0.66), and a similar rate of episodes of incontinence during the previous 6 months (3.7 vs. 4.3%, p = 0.75). The mean Cleveland Global Quality of Life score was also similar (0.79 vs. 0.74, p = 0.35). CONCLUSION Our technique is safe and reproducible, and replicates the results of the open IPAA, while maintaining the advantages of minimally invasive surgery and avoiding any kind of anal manipulation which could result in poor long-term functional outcomes.
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Alsafi Z, Snell A, Segal JP. Prevalence of 'pouch failure' of the ileoanal pouch in ulcerative colitis: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:357-364. [PMID: 34825957 PMCID: PMC8803821 DOI: 10.1007/s00384-021-04067-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The ileoanal pouch (IPAA) provides patients with ulcerative colitis (UC) that have not responded to medical therapy an option to retain bowel continuity and defecate without the need for a long-term stoma. Despite good functional outcomes, some pouches fail, requiring permanent diversion, pouchectomy, or a redo pouch. The incidence of pouch failure ranges between 2 and 15% in the literature. We conducted a systematic review and meta-analysis aiming to define the prevalence of pouch failure in patients with UC who have undergone IPAA using population-based studies. METHODS We searched Embase, Embase classic and PubMed from 1978 to 31st of May 2021 to identify cross-sectional studies that reported the prevalence of pouch failure in adults (≥ 18 years of age) who underwent IPAA for UC. RESULTS Twenty-six studies comprising 23,389 patients were analysed. With < 5 years of follow-up, the prevalence of pouch failure was 5% (95%CI 3-10%). With ≥ 5 but < 10 years of follow-up, the prevalence was 5% (95%CI 4-7%). This increased to 9% (95%CI 7-16%) with ≥ 10 years of follow-up. The overall prevalence of pouch failure was 6% (95%CI 5-8%). CONCLUSIONS The overall prevalence of pouch failure in patients over the age of 18 who have undergone restorative proctocolectomy in UC is 6%. These data are important for counselling patients considering this operation. Importantly, for those patients with UC being considered for a pouch, their disease course has often resulted in both physical and psychological morbidity and hence providing accurate expectations for these patients is vital.
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Affiliation(s)
| | - Alice Snell
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
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30
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Ashburn JH. Operative indications and options in ulcerative colitis. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Ashitomi Y, Oshio H, Yano M, Okazaki S, Motoi F. Laparoscopic Proctocolectomy With Transanal Total Mesorectal Excision for Ulcerative Colitis. Cureus 2021; 13:e19720. [PMID: 34934583 PMCID: PMC8684528 DOI: 10.7759/cureus.19720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/06/2022] Open
Abstract
Transanal total mesorectal excision (TaTME) refers to endoscopic retrograde total mesorectal excision and is becoming increasingly popular worldwide. TaTME improves surgical manipulation and minimizes the risk of local recurrence of rectal cancer by ensuring circumferential resection margins. TaTME is mainly indicated for patients in whom transabdominal approaches are expected to be technically challenging. We extended the indications for TaTME to include surgery for ulcerative colitis lesions that might be cancerous in the rectum. Here, we report a case of proctocolectomy with TaTME for ulcerative colitis. A 38-year-old woman who was receiving treatment for ulcerative colitis underwent a biopsy for random samples from the transverse colon to the rectum. Histopathological findings revealed noninvasive dysplasia with p53 overexpression, suggestive of cancer. We extended the indication of TaTME to surgery for ulcerative colitis. We formed two surgical teams and performed laparoscopic proctocolectomy with TaTME simultaneously. This simultaneous operation reduced the duration of the procedures in the present case. The patient was discharged without any complications and underwent loop ileostomy closure four months postoperatively. The patient recovered without significant loss of the anal sphincter function and is doing well four months after the second surgery. We propose laparoscopic proctocolectomy with TaTME to be conducted simultaneously by two teams as a safe and effective technique that is associated with a shorter operation time than that reported previously. Additionally, TaTME was useful in confirming the appropriate dissection layer as well as in surgical manipulation. Hence, TaTME could serve as a useful therapeutic option for ulcerative colitis surgery.
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Affiliation(s)
- Yuya Ashitomi
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
| | - Hiroshi Oshio
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
| | - Mitsuhiro Yano
- Department of Surgery, Nihonkai General Hospital, Yamagata, JPN
| | - Shinji Okazaki
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
| | - Fuyuhiko Motoi
- First Department of Surgery, Yamagata University, Faculty of Medicine, Yamagata, JPN
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Liu S, Eisenstein S. State-of-the-art surgery for ulcerative colitis. Langenbecks Arch Surg 2021; 406:1751-1761. [PMID: 34453611 PMCID: PMC8481179 DOI: 10.1007/s00423-021-02295-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/11/2022]
Abstract
Ulcerative colitis (UC) is an autoimmune-mediated colitis which can present in varying degrees of severity and increases the individual’s risk of developing colon cancer. While first-line treatment for UC is medical management, surgical treatment may be necessary in up to 25–30% of patients. With an increasing armamentarium of biologic therapies, patients are presenting for surgery much later in their course, and careful understanding of the complex interplay of the disease, its management, and the patient’s overall health is necessary when considering he appropriate way in which to address their disease surgically. Surgery is generally a total proctocolectomy either with pelvic pouch reconstruction or permanent ileostomy; however, this may need to be spread across multiple procedures given the complexity of the surgery weighed against the overall state of the patient’s health. Minimally invasive surgery, employing either laparoscopic, robotic, or transanal laparoscopic approaches, is currently the preferred approach in the elective setting. There is also some emerging evidence that appendectomy may delay the progression of UC in some individuals. Those who treat these patients surgically must also be familiar with the numerous potential pitfalls of surgical intervention and have plans in place for managing problems such as pouchitis, cuffitis, and anastomotic complications.
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Affiliation(s)
- Shanglei Liu
- Department of Surgery, UC San Diego Health System, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA
| | - Samuel Eisenstein
- Department of Surgery, UC San Diego Health System, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA.
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