Total laparoscopic ileal pouch-anal anastomosis: prospective series of 82 patients

Routine diversion following delayed IPAA construction does not reduce the incidence of pouch-related sepsis or failure in patients with ulcerative colitis

AIM

The aim of this study was to compare modified 2-stage and 3-stage IPAA construction techniques to evaluate the effect of diverting loop ileostomy following completion proctectomy and IPAA for ulcerative colitis. In addition, our overall institutional experience was reviewed to describe long-term outcomes and changes in staging trends over time.

METHODS

Our institutional database was searched to identify all cases of IPAA for ulcerative colitis between 1981 and 2018. Patient, pouch and outcome characteristics were abstracted. Primary study outcomes were the incidence of primary pouch failure and pouch-related sepsis. Failure was evaluated by Kaplan-Meier estimates of survival over time. The adjusted effect of pouch stage was evaluated using multivariable Cox and logistic regression models. Exploratory analysis evaluated the effect of stage on failure in the pouch related sepsis subgroup.

RESULTS

A total of 2105 patients underwent primary IPAA over the study period. The 5, 10 and 20-year pouch survival probabilities were 95.2%, 92.7% and 86.6%. The incidence of pouch related sepsis was 12.3%. Adjusted analysis demonstrated no difference in pouch failure (HR = 0.64: 95% 0.39-1.07, p = 0.09) or post-operative sepsis (aOR = 0.79: 95% CI 0.53-1.17, p = 0.24) by stage of construction. Among patients experiencing pouch sepsis, there was no difference in Kaplan-Meier estimates of pouch survival by stage (p = 0.90).

CONCLUSIONS

Pouch related sepsis and IPAA failure did not differ between modified 2-stage and 3-stage construction techniques. Among the sub-group of patients experiencing pouch related sepsis, there was no difference in failure between groups. The results suggest diverting ileostomy may be safely avoided following delayed pouch reconstruction in appropriately selected patients.

Systematic C-reactive protein monitoring reduces hospital stay after laparoscopic ileal pouch-anal anastomosis. A comparative study of 158 consecutive patients with ulcerative colitis

AIM

C-reactive protein (CRP) is a common biomarker of inflammation which has largely been used to predict the risk of postoperative septic complications after colorectal surgery. However, no data exist concerning its potential benefit after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). The aim of this study was to evaluate a CRP-driven monitoring discharge strategy after laparoscopic IPAA for UC.

METHODS

Since 2012, 158 patients undergoing a laparoscopic IPAA for UC have been included: 66 patients (CRP group) operated since 2016 had a CRP-driven monitoring discharge on postoperative day 5 (POD 5) and were discharged on POD 6 if CRP < 100 mg/L; these patients were matched (according to age, gender, body mass index, IPAA in two or three steps) to 92 patients operated between 2012 and 2016 without any CRP monitoring (control group).

RESULTS

Median length of hospital stay was shorter in the CRP than the control group (7 vs. 9 days; P < 0.001) and discharge on POD 6 occurred more frequently in the CRP group (47% vs. 7%, P < 0.001). No difference was observed between the two groups concerning overall morbidity (P = 0.980), surgical site infection (P = 0.554), Clavien-Dindo ≥ IIIa morbidity (P = 0.523), unplanned rehospitalization (P = 0.734) and 30-day reoperation (P = 0.240).

CONCLUSION

CRP-driven monitoring discharge strategy after laparoscopic IPAA for UC is associated with a significant reduction in length of hospital stay, without increasing morbidity, reoperation or rehospitalization rates.

Management of Rectal Stump During Laparoscopic Subtotal Colectomy for Inflammatory Bowel Disease: A Comparative Cohort Study from Six Referral Centres

BACKGROUND AND AIMS

There is no consensus on the best management of the rectum after subtotal colectomy for refractory colitis complicating inflammatory bowel disease [IBD]. The objective was to evaluate the impact of rectal stump management during laparoscopic subtotal colectomy [LSTC] for IBD.

METHODS

Patients who underwent LSTC with double-end ileo-sigmoidostomy [Gr.A] or end ileostomy with closed rectal stump [Gr.B] for IBD were included from a retrospective database of six European referral centres.

RESULTS

In total, 314 patients underwent LSTC and were allocated to Gr.A [n = 102] and B [n = 212]. After LSTC, stoma-related complications occurred more frequently in Gr.A [12%] than in Gr.B [4%, p = 0.01]. Completion proctectomy with ileal pouch-anal anastomosis [IPAA] was performed as a three-stage procedure in all patients from Gr.A, and in 88 patients from Gr.B [42%; Gr.B1]. The other 124 patients from Gr.B underwent a modified two-stage procedure [58%; Gr.B2]. The second stage was performed laparoscopically in all patients from Gr.A compared with 73% of Gr.B1 [p < 0.0001] and 65% of Gr.B2 patients [p < 0.0001]. When laparoscopy was intended for 2nd stage IPAA, conversion to laparotomy occurred less frequently in Gr.A when compared with B1 [0 vs 5%, p = 0.06] or B2 [10%, p = 0.001]. When all surgical stages were included [LSCT and IPAA], cumulative stoma-related complications occurred more frequently in Gr.A [n = 19] than in Gr.B1 [n = 6, p = 0.02] and Gr.B2 [n = 6, p = 0.001].

CONCLUSION

This study suggests that both techniques of double-end ileosigmoidostomy and end ileostomy with closed rectal stump are safe and effective for rectal stump management after laparoscopic subtotal colectomy.

Comparable perioperative outcomes, long-term outcomes, and quality of life in a retrospective analysis of ulcerative colitis patients following 2-stage versus 3-stage proctocolectomy with ileal pouch-anal anastomosis

PURPOSE

Many surgeons assume 3-stage ileal pouch-anal anastomosis (IPAA) is safer than 2-stage IPAA in patients with active ulcerative colitis (UC), although recent data suggest outcomes are comparable. This study aimed to compare perioperative complications, late complications, and functional outcomes after 2- versus 3-stage IPAA in patients with active UC.

METHODS

A retrospective review was conducted of patients who underwent 2- or 3-stage IPAA for active UC from 2000 to 2015 in a high-volume institution. Patients completed quality-of-life surveys 6 months following ileostomy reversal. Perioperative and late complications were recorded. Outcomes were compared with the Fisher exact test, and multivariable logistic regression was used to adjust for potential confounders.

RESULTS

We identified 212 patients who underwent 2- or 3-stage IPAA for active UC, of whom 157 patients (74.1%) underwent 2-stage procedures and 55 (25.9%) underwent 3-stage procedures. More patients undergoing 2-stage procedures were taking immunomodulators preoperatively (46.3% vs. 23.1%, p = 0.01), but there was no difference in use of steroids (p = 0.09) or biologic agents (p = 0.85). Three-stage procedures were more likely to be urgent (78.6% vs. 30.2%, p < 0.001). There were no differences in perioperative complications (p = 0.50), anastomotic leak (p = 0.94), pouchitis (p = 0.45), pouch failure (p = 0.46), perceived quality of life (p = 0.68), number of bowel movements per day (p = 0.27), or sexual satisfaction (p = 0.21) between the 2- and 3-stage groups.

CONCLUSIONS

Patients undergoing 2-stage compared to 3-stage IPAA for active ulcerative colitis have comparable outcomes and quality of life following ileostomy reversal. Two-stage IPAA appears to be safe and appropriate, even in high-risk patients.

Totally laparoscopic, multi-stage, restorative proctocolectomy for inflammatory bowel diseases. A prospective study on safety, efficacy and long-term results

BACKGROUND

Laparoscopic ileo-pouch-anal anastomosis (IPAA) has been reported as having low morbidity and several advantages.

AIMS

To evaluate safety, efficacy and long-term results of laparoscopic IPAA, performed in elective or emergency settings, in consecutive unselected IBD patients.

METHODS

All the patients received totally laparoscopic 2-stage (proctocolectomy and IPAA - stoma closure) or 3-stage (colectomy - proctectomy and IPAA - stoma closure) procedure according to their presentation.

RESULTS

From July 2007 to July 2016, 160 patients entered the study. 50.6% underwent a 3-stage procedure and 49.4% a 2-stage procedure. Mortality and morbidity were 0.6% and 24.6%. Conversion rate was 3.75%. 8.7% septic complications were associated with steroids and Infliximab treatment (p = 0.0001). 3-stage patients were younger (p = 0.0001), with shorter disease duration (p = 0.0001), minor ASA scores of 2 and 3 (p = 0.0007), lower inflammatory index and better nutritional status (p = 0.003 and 0.0001), fewer Clavien-Dindo's grade II complications (p = .0001), reduced rates of readmission and reoperation at 90 days (p = 0.03), and shorter hospitalization (p = .0001), but with similar pouch and IPAA leakage, compared to 2-stage patients. 8 years pouch failure and definitive ileostomy were 5.1% and 3.7%.

CONCLUSION

A totally laparoscopic approach is safe and feasible, with very low mortality and morbidity rates and very low conversion rate, even in multi-stage procedures and high-risk patients.

Perioperative outcomes and adverse events of robotic colorectal resections for inflammatory bowel disease: a systematic literature review

The purpose of this study was to assess outcome measures and cost-effectiveness of robotic colorectal resections in adult patients with inflammatory bowel disease. The Cochrane Library, PubMed/Medline and Embase databases were reviewed, using the text "robotic(s)" AND ("inflammatory bowel disease" OR "Crohn's" OR "Ulcerative Colitis"). Two investigators screened abstracts for eligibility. All English language full-text articles were reviewed for specified outcomes. Data were presented in a summarised and aggregate form, since the lack of higher-level evidence studies precluded meta-analysis. Primary outcomes included mortality and postoperative complications. Secondary outcomes included readmission rate, length of stay, conversion rate, procedure time, estimated blood loss and functional outcome. The tertiary outcome was cost-effectiveness. Eight studies (3 case-matched observational studies, 4 case series and 1 case report) met the inclusion criteria. There was no reported mortality. Overall, complications occurred in 81 patients (54%) including 30 (20%) Clavien-Dindo III-IV complications. Mean length of stay was 8.6 days. Eleven cases (7.3%) were converted to open. The mean robotic operating time was 99 min out of a mean total operating time of 298.6 min. Thirty-two patients (24.7%) were readmitted. Functional outcomes were comparable among robotic, laparoscopic and open approaches. Case-matched observational studies comparing robotic to laparoscopic surgery revealed a significantly longer procedure time; however, conversion, complication, length of stay and readmission rates were similar. The case-matched observational study comparing robotic to open surgery also revealed a longer procedure time and a higher readmission rate; postoperative complication rates and length of stay were similar. No studies compared cost-effectiveness between robotic and traditional approaches. Although robotic resections for inflammatory bowel disease are technically feasible, outcomes must be interpreted with caution due to low-quality studies.

溃疡性结肠炎的外科微创治疗

外科治疗是溃疡性结肠炎(ulcerative colitis, UC)的重要组成部分, 全结直肠切除、回肠贮袋肛管吻合术(ileal pouch-anal anastomosis, IPAA)已成为标准术式. 近年来在微创外科技术的迅猛发展与普及下, 越来越多医疗中心开展腹腔镜IPAA手术. 腹腔镜IPAA手术相比于开腹手术的在术后近、远期疗效中的优势逐渐突显, 且其安全有效性已达成共识. 目前更多更为微创的技术也陆续尝试应用于IPAA手术. 但是由于UC患者自身疾病的特点和IPAA术式的复杂性, 腹腔镜IPAA手术仍未达到标准化、规范化水平. 本文主要针对UC微创外科术后疗效和合理应用的研究进展作一述评.

Ileal Pouch-Anal Anastomosis for Dysplasia or Cancer Complicating Inflammatory Bowel Disease: Is Total Mesorectal Excision Always Mandatory? An Analysis of 36 Consecutive Patients

BACKGROUND AND AIMS

The extent of lymph node harvesting during surgery for colorectal neoplasm [dysplasia and/or cancer] complicating inflammatory bowel disease [IBD] is a matter of debate. This study aimed to assess the risk of invasive rectal cancer in patients undergoing ileal pouch-anal anastomosis [IPAA] for colonic neoplasm complicating IBD, and thus to clarify whether a systematic total mesorectal excision [TME] should be systematically performed, or not, in those patients.

METHODS

From 1998 to 2015, all patients who underwent IPAA for colorectal neoplasm complicating IBD were included. Patients with preoperatively known rectal cancer were excluded. Pathological results were compared with preoperative endoscopic results.

RESULTS

A totalof 36 patients [mean age 49 ± 14 years], comprising 10 women [31%] and 26 men [69%], underwent IPAA for colorectal neoplasm complicating IBD, with [n = 8; 22%] or without [n = 28; 78%] TME. Rectal cancer rate in pathological specimens was 0% [0/20] in patients with preoperatively known neoplasm only limited to the colon, 0% [0/8] among patients with preoperative rectal low-grade dysplasia, and 62% [5/8] among patients with preoperatively rectal high-grade dysplasia.

CONCLUSIONS

These results do not support systematic TME during IPAA for colonic neoplasm complicating IBD. Considering its association with postoperative sexual disorder, TME should be discussed only on a case-by-case basis.

Three-stage Laparoscopic Ileal Pouch-anal Anastomosis Is the Best Approach for High-risk Patients with Inflammatory Bowel Disease: An Analysis of 185 Consecutive Patients

BACKGROUND

There are very few studies and no consensus concerning the choice between two- and three-stage ileal pouch-anal anastomosis [IPAA] in inflammatory bowel diseases [IBD]. This study aimed to compare operative results between both surgical procedures.

METHODS

Only patients who underwent a laparoscopic IPAA for IBD were included. They were divided into two groups: two-stage [IPAA and stoma closure] [Group A] and three-stage IPAA [subtotal colectomy, IPAA, stoma closure] [Group B].

RESULTS

From 2000 to 2015, 185 patients (107 men, median age of 42 [range, 15-78] years) were divided into Groups A [n = 82] and B [n = 103]. Patients in Group B were younger than in Group A (39 [15-78] vs 43 [16-74] years; p = 0.019), presented more frequently with Crohn's disease [16% vs 5%; p < 0.04], and were more frequently operated in emergency for acute colitis [37% vs 1%; p < 0.0001]. Cumulative operative time and length of stay were significantly longer in Group B (580 [300-900] min, and 19 [13-60] days) than in Group A (290 [145-490] min and 10 [7-47] days; p < 0.0001). Cumulative postoperative morbidity, delay for stoma closure, and function were similar between the two groups. Long-term morbidity was similar between Group A [13%] and Group B [21%; p = 0.18].

CONCLUSIONS

Our study suggested that postoperative morbidity was similar between two- and three-stage laparoscopic IPAA. It suggested that the three-stage procedure is probably safer for high-risk patients [ie in acute colitis].

Emergency total proctocolectomy in an uninsured patient with Familial Adenomatous Polyposis Syndrome and acute lower gastrointestinal hemorrhage in a community hospital: A case report

•

FAP is initially managed with genetic testing, followed by yearly colonoscopy from 10 to 40 years of age.

•

Once diagnosed, total proctocolectomy with ileal-J pouch to anal anastomosis is recommended.

•

The ultimate treatment for FAP patients presenting with acute lower GI hemorrhage and hemodynamic compromise is unclear.

•

This is the first literature report of an emergency total proctocolectomy for lower GI hemorrhage in an uninsured patient with FAP in a community hospital.

•

It is essential to monitor the ileo-anal anastomosis with anoscopy.

Introduction

Rectal bleeding is the most common symptom of Familial Adenomatous Polyposis (FAP). This case investigates the efficacy of emergency surgery for FAP with total proctocolectomy end ileostomy for recurrent lower gastrointestinal (GI) hemorrhage in an uninsured patient in a 266-bed community hospital. The optimal treatment for FAP with acute lower GI hemorrhage and hemodynamic compromise unresponsive to conservative management is unclear.

Presentation of case

A 41-year-old uninsured African American man with no past medical or family history presented to the emergency department with hematochezia lasting three days. A clinical diagnosis of FAP made on colonoscopy with biopsies revealed villous and tubulovillous adenomas without dysplasia. After blood products resuscitation, an emergency total proctocolectomy with end ileostomy was performed. A staged ileal J pouch to anal anastomosis and creation of protective loop ileostomy was performed months later after securing state funding. A final loop ileostomy reversal occurred six weeks later. His self reported quality of life is improved.

Discussion

Lower GI hemorrhage from FAP unresponsive to blood products may require emergency total proctocolectomy and end ileostomy with a staged ileal J pouch to anal anastomosis, which can be done in a community acute care hospital for an uninsured patient.

Conclusion

A total proctocolectomy is feasible in the emergency setting in an uninsured patient with lower GI bleeding and FAP. A staged ileal J pouch-anal anastomosis is easier to justify to the hospital compared to a staged completion colectomy with proctectomy. It is essential to monitor the ileo-anal anastomosis with anoscopy.

Risk Factors for the Development of Desmoid Tumor After Colectomy in Patients with Familial Adenomatous Polyposis: Multicenter Retrospective Cohort Study in Japan

BACKGROUND

Desmoid tumor (DT) is the primary cause of death in patients with familial adenomatous polyposis (FAP) after restorative proctocolectomy. This study aimed to identify risk factors for DT in a Japanese population.

METHODS

Clinical data for 319 patients with FAP undergoing first colectomy from 2000 to 2012 were reviewed retrospectively.

RESULTS

Two hundred seventy-seven FAP patients were included in this study. Thirty-nine (14.1 %) patients developed DT. Occurrence sites were the intraperitoneal region in 25 (64.1 %) cases, intraperitoneal region and abdominal wall in three (7.7 %), and abdominal wall in nine (23.1 %). The mean period from surgery to DT development was 26.3 months (range 4-120 months). Gender (female vs. male, p = 0.03), age at surgery (>30 vs. ≤30 years, p = 0.02), purpose of surgery (prophylactic vs. cancer excision, p = 0.01), and surgical procedure (proctocolectomy [ileoanal anastomosis (IAA), ileoanal canal anastomosis (IACA), total proctocolectomy (TPC)] vs. total colectomy [ileorectal anastomosis, partial colectomy]; p = 0.03) significantly influenced the estimated cumulative risk of developing DT at 5 years after surgery. Conversely, approach (laparoscopic vs. open, p = 0.17) had no significant effect on the increased risk of DT occurrence. In multivariate analysis, female gender, with a hazard ratio of 2.2 (p = 0.02,) and proctocolectomy (IAA, IACA, TPC), with a hazard ratio of 2.2 (p = 0.03), were independent risk factors for DT incidence after colectomy.

CONCLUSIONS

Female gender and proctocolectomy (IAA, IACA, TPC) were independent risk factors for developing DT after colectomy in patients with FAP.

Safety, feasibility, and short-term outcomes in 588 patients undergoing minimally invasive ileal pouch-anal anastomosis: a single-institution experience

PURPOSE

A laparoscopic approach to proctocolectomy and ileal pouch-anal anastomosis (IPAA) in patients with chronic ulcerative colitis and familial adenomatous polyposis has grown in popularity secondary to reports of small series demonstrating short-term patient benefits. Limited data exist in large numbers of patients undergoing laparoscopic ileal pouch-anal anastomosis (L-IPAA). We aimed to analyze surgical outcomes in a large cohort of patients undergoing L-IPAA.

METHODS

From a prospectively maintained surgical database, 30-day surgical outcome data were reviewed for all L-IPAA performed for chronic ulcerative colitis and familial adenomatous polyposis from 1999 to 2012. Demographics, operative approach, and operative and postoperative complications were analyzed.

RESULTS

A total of 588 L-IPAA ileal pouch-anal anastomoses were performed predominantly for chronic ulcerative colitis (93.9 %). The mean age was 36.2 years, and 54.3 % were male, with a mean BMI of 24.1 kg/m(2). Three-stage operations were performed in 17.7 %. The mean operating time of the patients excluding 3-stage operation was 269.4 min. Minimally invasive techniques included hand-assist in 55 % and straight laparoscopy in 45 %. Conversion to open occurred in 8.8 %. Median length of stay was 5 days. There was no mortality. Complications occurred in 36.9 % of patients: Clavien grade I (17.5 %), grade II (72.8 %), and grade III (9.7 %). Analysis of the grouped data over time demonstrated a statistically significant reduction in operative time (p < 0.001) and an increase in the ratio of hand-assisted over straight laparoscopy (p = 0.001).

CONCLUSIONS

Minimally invasive IPAA performed using either a laparoscopic or hand-assisted technique is safe, can be performed with low conversion rates, and confers beneficial perioperative outcomes.

Restorative Proctocolectomy and Ileal Pouch-anal Anastomosis

OBJECTIVES

To assess mortality after restorative proctocolectomy (RPC) and determine the influencing factors with a specific focus on institutional caseload and surgical approach in France.

BACKGROUND

RPC is an uncommonly performed and demanding procedure; case volume may exert a significant influence on outcome.

METHODS

Data of all patients who underwent RPC in France between 2009 and 2012, including demographics, diagnosis, procedures, mode of admission, discharge, and hospital type were collected.

RESULTS

One thousand one hundred sixty-six RPCs were performed in 237 centers (mean: 1.65 procedure/year/center). Rate of laparoscopic procedures was 47.1% (n = 549). Mortality reached 1.5% (n = 17). Independent factors for mortality were ageless than 45 years (odds ratio, OR = 3.9) and surgery in a center performing less than 3 RPC per year (OR = 3.2). Centers performing less than 3 RPC per year represented 89% of all centers, accounted for 37% (n = 431) of all patients and represented 70.6% of all deaths (n = 12). Underlying pathology exerted a significant effect on mortality; mortality rate after "classical" indications (polyposis and inflammatory bowel disease) was 0.7% (8/1078) and was 16.7% (9/54) for "nonclassical" indications (peritonitis, carcinomatosis, and so on) (P < 0.0001). Nonclassical diagnoses were observed more frequently in centers performing less than 3 RPC per year [40/412 (7.3%) vs 24/720 (3.3%), P = 0.0027]. A laparoscopic approach was associated with a low mortality rate on univariate analysis (0.7% vs 1.2%, P = 0.05), a shorter hospital stay (15.8 ± 0.6 vs 17.8 ± 0.55, P = 0.0053) and more frequently performed in experienced centers ≥3 RPC/year (50.8% vs 40.7%, P = 0.0009).

CONCLUSIONS

Mortality after RPC in centers performing 3 or less RPC per year was significantly higher, and accounted for more than half of all deaths. In France, consolidating all RPCs to higher volume centers may lead to better outcomes.

Prevalence of laparoscopic surgical treatment and its clinical outcomes in patients with familial adenomatous polyposis in Japan

BACKGROUND

Laparoscopic surgery is becoming the preferred technique for most colorectal interventions. This study aimed to clarify the time trend of surgical treatment for familial adenomatous polyposis (FAP) and its relevance to clinical outcomes in Japan over a 13-year period.

METHODS

This was a multicenter retrospective cohort study comprising 23 specialist institutions for colorectal disease and a cohort of 282 FAP patients who underwent total colectomy or proctocolectomy during 2000-2012. Patient clinical backgrounds and surgical outcomes were compared between the first and second halves of the study period.

RESULTS

The proportion of surgical types adopted over the entire study period was 46, 21, 30, and 3 % for ileoanal anastomosis (IAA), ileoanal canal anastomosis, ileorectal anastomosis, and permanent ileostomy, respectively. FAP patients undergoing laparoscopic surgery have increased since 2008 and reached 74 % in the past 3 years. In particular, the number of patients undergoing laparoscopic proctocolectomy with IAA increased approximately four-fold from the first to the second half of the study period. A laparoscopic approach was increasingly used in patients with coexisting colorectal malignancies. Despite this trend, surgical results of the laparoscopic approach between the two study periods showed similar morbidity, pouch operation and stoma closure completion rates. No postoperative mortality was observed in this series, and laparoscopic surgery was comparable to open surgery in terms of stoma closure rate, incidence of intra-abdominal/abdominal desmoid tumors, and postoperative survival rate in both study periods.

CONCLUSION

Laparoscopic approach is increasingly being adopted for prophylactic FAP surgery in Japan and may provide clinically acceptable practical outcomes.

Hand-assisted hybrid laparoscopic-robotic total proctocolectomy with ileal pouch--anal anastomosis

PURPOSE

Few studies have reported minimally invasive total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We herein report a novel hand-assisted hybrid laparoscopic-robotic technique for patients with FAP and UC.

METHODS

Between February 2010 and March 2014, six patients underwent hand-assisted hybrid laparoscopic-robotic total proctocolectomy with IPAA. The abdominal colectomy was performed laparoscopically with hand assistance through a transverse suprapubic incision, also used to fashion the ileal pouch. The proctectomy was carried out with the da Vinci Surgical System. The IPAA was hand-sewn through a trans-anal approach. The procedure was complemented by a temporary diverting loop ileostomy.

RESULTS

The mean hand-assisted laparoscopic surgery (HALS) time was 154.6 (±12.8) min whereas the mean robotic time was 93.6 (±8.1) min. In all cases, a nerve-sparing proctectomy was performed, and no conversion to traditional laparotomy was required. The mean postoperative hospital stay was 13.2 (±7.4) days. No anastomotic leakage was observed. To date, no autonomic neurological disorders have been observed with a mean of 5.8 (±1.3) bowel movements per day.

CONCLUSIONS

The hand-assisted hybrid laparoscopic-robotic approach to total proctocolectomy with IPAA has not been previously described. Our report shows the feasibility of this hybrid approach, which surpasses most of the limitations of pure laparoscopic and robotic techniques. Further experience is necessary to refine the technique and fully assess its potential advantages.

Laparoscopic approach for inflammatory bowel disease is a real alternative to open surgery: an experience with 574 consecutive patients

OBJECTIVE

This study aimed to report a 14-year experience of laparoscopic approach for inflammatory bowel disease (IBD), including complicated and recurrent cases.

BACKGROUND

Feasibility of laparoscopic approach for IBD surgical management has been questioned.

METHODS

From 1998 to 2012, all patients undergoing colorectal resection for IBD were prospectively enrolled. Adjusted risks of conversion and severe postoperative morbidity after laparoscopic resection were computed, according to a multivariate regression logistic model.

RESULTS

A total of 790 consecutive resections for IBD were performed on 633 patients. Laparoscopic approach was performed in 574 (73%) procedures, including 286 ileocecal resections (48%), 118 subtotal colectomies (19%), 134 ileal pouch-anal anastomoses (21%), 23 segmental colectomies (8%), and 18 abdominoperineal resections (4%). A total of 145 (25%) complex laparoscopic procedures were performed, considered as such because of iterative surgery for IBD recurrence (n = 66, 12%) or because of intra-abdominal-abscess or fistula (n = 93, 16%). Conversion to laparotomy occurred in 67 procedures (12%). Postoperative death occurred in 1 patient (0.2%). Severe postoperative morbidity occurred in 66 laparoscopic procedures (13%). Splitting the study in 5 time periods, the rate of laparoscopic procedures significantly increased from 42% in period 1 to 80% in period 5 (P < 0.001). With time, the rate of complex procedures performed laparoscopically significantly increased (P = 0.023), whereas both mean adjusted risks of conversion and severe postoperative morbidity significantly decreased (P < 0.001).

CONCLUSIONS

Laparoscopic approach is a safe and effective alternative to open surgery for IBD management. With growing experience, the rate of laparoscopic complex procedures increased, whereas adjusted risks of conversion and severe postoperative morbidity significantly decreased.

A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study

OBJECTIVE

To assess the infertility rate after laparoscopic ileal pouch-anal anastomosis (IPAA).

BACKGROUND

Total proctocolectomy with IPAA is known to be associated with postoperative infertility in open surgery, which may be caused by pelvic adhesions affecting the fallopian tubes. However, fertility after laparoscopic IPAA has never been assessed.

METHODS

All patients who underwent a total laparoscopic IPAA between 2000 and 2011 and were aged 45 years or less at the time of operation and 18 years or more at the time of data collection were included. The patients answered a fertility questionnaire by telephone. All demographic and perioperative data were prospectively collected. The results were compared with those of controls undergoing laparoscopic appendectomy.

RESULTS

Sixty-three patients were included. The mean age at the time of surgery was 31 ± 9 years (range 14-44). IPAA was performed for ulcerative colitis in 73% of the cases and familial adenomatous polyposis in 17%. The mean follow-up after IPAA was 68 ± 33 months (range 6-136). Fifty-six patients answered the questionnaire (89%). Half of them already had a child before IPAA. Fifteen patients attempted pregnancy after IPAA, of which 11 (73%) were able to conceive, resulting in 10 ongoing pregnancies and 1 miscarriage. The global infertility rate was 27%. There was no difference in fertility over time compared with the 14 controls who attempted pregnancy during the same period (90% vs 86% at 36 months, P = 0.397).

CONCLUSIONS

The infertility rate appears to be lower after laparoscopic IPAA than after open surgery.

Surgical management of IBD--from an open to a laparoscopic approach

Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.

Laparoscopic surgery for inflammatory bowel disease--the experience in China

BACKGROUND

The incidence of inflammatory bowel disease (IBD) has risen rapidly in China over the last 15 years. Increasing numbers of people with IBD require surgery during their lifetime, but few reports of IBD in Eastern populations have been described to date. The aim of this study was to assess the short-term effects of the laparoscopic surgery for IBD in Chinese patients.

MATERIALS AND METHODS

From February 2010 to March 2012, 35 patients with IBD underwent laparoscopic operations and the clinical data obtained for these patients were reviewed.

RESULTS

Patients with Crohn's disease (CD) (N = 21) and ulcerative colitis (UC) (N = 14) underwent laparoscopic surgery. In the CD group, the mean age was 37.4 years. Two patients (9.5%) required conversion to an open procedure. The median length of postoperative hospitalization was 9 (7-40) days. Overall morbidity was 26.3% and no patients required re-operation. In the UC group, the mean age was 55.2 years. The conversion rate was 14.3% (2/14). The median time to regular diet was 4 (3-10) days and the median length of postoperative hospitalization was 8 (7-25) days. Four patients developed postoperative complications and one patient developed ileostomy retraction requiring urgent operative intervention to rebuild the stoma.

CONCLUSIONS

Laparoscopic surgery in patients with IBD can be accomplished safely and with reasonable operative times, conversion rates and morbidity rates. The main advantages of the laparoscopic approach are rapid recovery, improved cosmesis, less postoperative pain, and patient satisfaction.

Total laparoscopic approach for the treatment of right colon cancer: a technical critique

BACKGROUND AND AIMS

Total laparoscopic surgery is not a new concept, but it is not preferred generally for right colectomy. The aim of the study is to evaluate the outcomes, which are related with surgical technique after total laparoscopic right colectomy (TLRC) and laparoscopic-assisted right colectomy (LARC) for right colon cancer in 30 consecutive patients.

MATERIALS AND METHODS

Thirty patients with right colon cancer, half of which were treated with TLRC and half of which were treated with LARC, were compared with regard to patient demographics, operative and postoperative data, histopathologic findings, follow-up data, and the complications related to the surgical technique.

RESULTS

There were 16 men and 14 women, median age was 63 years (range 41-86) with a body mass index (BMI) of 27 kg/m2 (range 20-33). There were no differences between the groups for BMI, harvested lymph node number, or distal and radial margins. The length of the incision and the length of the postoperative stay was shorter in the TLRC group (p=0.000). Overall complications were higher in the LARC group than in the TLRC group (p=0.014). The median follow-up was 28 months (range 5-99). In the late period, two patients in the LARC group were reoperated on. The cause of reoperation was internal herniation in one patient due to ileal twisting and incisional hernia in the other one.

CONCLUSION

Our preliminary data indicate that TLRC could result in better outcomes for right colon cancer patients than LARC.

Benefits of a straight laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis: a retrospective case-matched study

PURPOSES

The aim of this study was to evaluate the benefit of straight laparoscopic restorative proctocolectomy (sLRP) with ileal pouch anal anastomosis for ulcerative colitis (UC).

METHODS

Twenty patients underwent sLRP or open restorative proctocolectomy. The 2 groups were retrospectively well matched with respect to sex, body mass index, and American Society of Anesthesiologists' score.

RESULTS

The median operative time was longer in the sLRP group (P=0.0003). The median operative blood loss was significantly less in the sLRP group (P=0.0054). The median analgesic drug usage during the first 7 days after surgery was lower in the sLRP group (P=0.038). There were no differences in morbidity rates and long-term functional outcome measures between the groups.

CONCLUSIONS

An sLRP for UC has the advantage over an open restorative proctocolectomy of better short-term outcomes, and both groups have similar long-term outcomes. This procedure is acceptable for minimally invasive surgery in patients with UC.

Laparoscopic surgery for ulcerative colitis

Laparoscopic techniques have become increasingly used in the treatment of ulcerative colitis: in experienced hands, they are safe and feasible. Recovery advantages have not been consistently demonstrated and functional results have been comparable to open surgery. Other possible benefits and costs issues have also been inconsistent. Further investigation on the role of laparoscopic surgery for ulcerative colitis with larger populations and longer follow-up with a focus on recovery parameters, quality of life, and costs are needed.

Surgical outcomes of laparoscopic colorectal resections for familial adenomatous polyposis

BACKGROUND

Acceptance of extended laparoscopic colon resections is still controversial besides the growing experience over the years.

AIM

The aim of this study was to evaluate the postoperative outcomes of laparoscopic colorectal resections exclusively for familial adenomatous polyposis patients.

METHODS

Patient data, surgical procedures and operative outcomes from 49 patients submitted to total proctocolectomy (TPC) or total abdominal colectomy (TAC) from 1997 to 2009 were prospectively analyzed.

RESULTS

There were 18 (36.7%) men and 31 (63.3%) women, with a median age of 31.1 years. Surgical procedures consisted of 3 TPC with ileostomy (6.1%), 30 restorative TPC with ileoanal anastomosis (61.2%), and 16 TAC with ileorectal anastomosis (32.6%). Only 1 patient (2.0%) required open conversion. No patient required blood transfusion. Median operating time was 289, ranging from 150 to 400 minutes. Twelve patients (24.5%) presented complications and only 1 (2.0%) died. Overall complication rates were similar after TAC or TPC (31.2% vs. 21.2%; P=0.4). Reoperations were necessary in 7 cases (14.3%), and the median length of hospital stay was 6.2 days (3 to 16). The comparison of 2 consecutive groups of patients over time revealed a little improvement in surgery duration (301 to 276 min; P=0.16), but relevant reduction in morbidity (32% vs. 16.6%; P=0.2) and reoperation rates (20% vs. 8.3%; P=0.4), besides the absence of statistical difference.

CONCLUSIONS

Laparoscopic TPC and TAC represent an interesting alternative approach for young and motivated familial adenomatous polyposis patients. When performed by experienced surgeons, they provide excellent short-term outcome regarding immediate recovery, morbidity, and cosmesis.

Feasibility of laparoscopic restorative proctocolectomy without diverting stoma

AIM

Restorative proctocolectomy performed before the advent of laparoscopy had evolved to frequently omit a diverting stoma. Our aim was to assess the impact of a diverting stoma on postoperative outcomes following laparoscopic restorative proctocolectomy.

METHOD

Data on all patients undergoing a laparoscopic restorative proctocolectomy at our institution were prospectively collated in a database.

RESULTS

Between November 2004 and February 2010, 71 patients (38 females) underwent laparoscopic restorative proctocolectomy. Indications included familial adenomatous polyposis (n=34), ulcerative colitis (n=35), indeterminate colitis (n=1) and Lynch syndrome (n=1). Laparoscopic restorative proctocolectomy was performed as a one-stage procedure in 49 patients, and after a sub-total colectomy in 22. Seven patients in each group underwent the formation of a diverting stoma. Nine patients required conversion to open surgery. Sixteen patients experienced at least one postoperative complication. The postoperative morbidity was 29% (n=4/14) and 21% (n=12/21) in patients with and without a stoma (p=0.8), and the rate of fistula was 21% and 5%, respectively (p=0.08). Seven percent of patients with a stoma and 16% without stoma had an intra-abdominal collection (p=0.7). Nine patients required reoperation. The reoperation rate was not influenced by the presence or absence of a diverting stoma.

CONCLUSION

Laparoscopic restorative proctocolectomy can be performed safely without a diverting stoma in selected patients.

Surgical management of ulcerative colitis

INTRODUCTION

Surgery is the only curative option in the treatment of ulcerative colitis. Despite advances in the medical management surgery is required in about a third of patients.

SURGICAL MANAGEMENT

In the acute setting surgery is indicated when medical treatment fails to improve an episode of acute severe colitis. The intervention of choice is a staged colectomy with end ileostomy and preservation of the rectal stump in the first instance. Indications for elective surgery are failure of medical therapy and malignant transformation. The surgical options include conventional proctectomy with ileostomy or a Kock's continent ileostomy and colectomy with an ileorectal anastomosis. The current gold standard is restorative proctocolectomy with ileal pouch-anal anastomosis. Most frequently the technique includes a J pouch with a stapled anastomosis and temporary faecal diversion with a loop ileostomy. Laparoscopic pouch surgery is a feasible and safe option with an excellent cosmetic result.

CONCLUSIONS

Although the morbidity remains significant after surgery, the quality of life is good with a satisfactory long-term functional outcome.

Incisionless Laparoscopic Total Proctocolectomy with Ileal J-Pouch Anal Anastomosis

Minimally invasive surgery continues to evolve. Recent innovations have included single-incision access, robotic technology, and natural orifice dissection and/or specimen extraction. Many argue that there is minimal patient benefit to these advanced techniques. We report 39 patients undergoing laparoscopic ileal J-pouch anal anastomosis surgery, 17 of whom did not have a separate specimen extraction incision (Group 1). The specimen for this group was extracted through the circular incision made for the ileostomy; the pouch was constructed extracorporeally and returned to the abdomen through the stoma site. For the remaining 22 patients, a suprapubic Pfannenstiel incision was made (Group 2). No hand-assistance was used for either group. Group 1 showed a 45-minute reduction in operative time, a 1-day reduction in hospital stay, and a reduction in complications. Although these differences are modest, it shows that minimally invasive surgery is an evolving process. Small modifications may translate into significant advantages.

Robotic-assisted laparoscopic surgery for restorative proctocolectomy with ileal J pouch-anal anastomosis

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for chronic ulcerative colitis (CUC). Robotic-assisted laparoscopic surgery (RALS) has been shown to have its greatest merits in colorectal procedures involving the pelvis. The aim of this study was to evaluate the safety and feasibility of RP with IPAA using an innovative robotic technique. A total of five consecutive patients underwent RALS RP with IPAA between August 2008 and February 2010. Patient demographics, intraoperative parameters, and postoperative outcomes were tabulated and assessed. Surgery was indicated for medically intractable CUC in three patients (60%), CUC-related dysplasia in one patient (20%) and CUC-related adenocarcinoma in one patient (20%). An ileal pouch-anal anastomosis was successful in all five cases. The mean operative time was 330 min and estimated blood loss was 200 cc. There were no intraoperative complications or conversions. The mean length of hospital stay was 5.6 days and no patients developed major postoperative complications. RALS is an innovative technique offering technical and visual advantages to the colorectal surgeon and can be offered for those who are seeking restorative proctolectomy for chronic ulcerative colitis.

Laparoscopic colectomy and restorative proctocolectomy for familial adenomatous polyposis

BACKGROUND

Familial adenomatous polyposis (FAP) is a dominantly inherited syndrome. Risk of cancer begins to increase after age 20 years if not treated. The purpose of this study was to evaluate the feasibility and short- and long-term outcomes after laparoscopic prophylactic surgery for FAP.

METHODS

Fifty-five patients with FAP were identified through the Hereditary Colorectal Tumor Registry from 2003 to 2009. Patients with laparoscopic total colectomy (TC)/IRA or proctocolectomy (TPC)/ileal pouch-anal anastomosis IPAA were included. Patients with previous colon or abdominal major surgery, malignancy, and desmoids before surgery were excluded. Main outcomes were: 30 days anastomotic leak and pouch failure; long-term desmoids and malignant recurrence.

RESULTS

Of the 55 patients, 32 were men, median age was 28 years, and mean body mass index was 23. Median follow-up time was 36 (range, 5-77) months. Forty-four patients had laparoscopic TC/IRA and ten had laparoscopic TPC/IPAA. One patient was converted to open surgery and received an open TPC/IPAA. Incision length was 7 (range, 5-14) cm. Anastomotic leak was 3 (5.4%: 2 laparoscopic and 1 open), and pouch failure was 0. Median postsurgical length of stay was 7 (range, 4-24) days. Desmoids occurred in three patients (5.4%), and there was no malignant recurrence within the follow-up period. Pathology revealed severe dysplasia in ten patients and adenocarcinoma in nine (8 laparoscopic and 1 open). Long-term small-bowel obstruction was 2 (3.6%). One mortality due to liver metastases occurred at 24 months.

CONCLUSIONS

Laparoscopic prophylactic treatment of FAP appears to be safe and feasible and may be an appealing alternative to open surgery. If the goal of prophylactic FAP surgery is to avoid cancer occurrence, laparoscopic surgery could be an important advancement.

Ileal reservoir with ileo-anal anastomosis: long-term complications

Coloproctectomy with ileo-anal anastomosis (CP-IAA) has been in use for 30 years. This intervention is the standard technique when surgery is indicated for familial adenomatous polyposis (FAP) and for ulcerative colitis (UC). Although the surgery is safe with mortality of less than 1%, it is associated with a morbidity of 18-70%. We thought a literature review about long-term complications would be enlightening. Pouchitis is the most common complication; it occurs in 70% of patients over 20 years follow-up; small bowel obstruction affects 25% of patients and pelvic sepsis occurs in 20-30% within 10 years. CP-IAA can impact the patient's sexual life due to erectile and ejaculatory dysfunction, dyspareunia, and incontinence of stool during sexual intercourse. Nevertheless, patients with long-standing UC describe an overall improvement in their sexual function after surgery. The failure rate varies from 3.5 to 15%; major causes of failure are sepsis, unrecognized Crohn's disease, and poor functional results. Cases of dysplasia and cancer have been reported in the reservoir, but more particularly when there is retained colonic glandular mucosa. The transitional zone should be monitored whenever there are risk factors for colon neoplasia. The relatively high morbidity of CP-IAA should not overshadow the good functional results of this technique.

Very low stapling of the anal canal in laparoscopic ileal pouch-anal anastomosis

Performing a double-stapled ileal pouch-anal anastomosis requires very low stapling of the anal canal. However, this laparoscopic procedure is often difficult to perform. We describe here a transanal method of everting the rectum, which allows easier transection under visual control and a sufficiently low anastomosis. Once the entire colon and rectum have been dissected out at laparoscopy, a plastic tube is introduced per anum and advanced into the mid sigmoid. The rectum is then divided at the level of the rectosigmoid junction by an endostapler, which also attaches the plastic tube to the rectum. The colon specimen is removed by a small incision at the chosen stoma site. Gentle traction on the plastic tube at the perineum everts the rectal tube. The anal canal is then transected at the desired level relative to the dentate line.