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Zwakman M, Hentzen JEKR, Jonker JE, Krikke C, Lange JFM, Hofker SHS. Surgical techniques for mesenteric lengthening in ileoanal pouch surgery: a systematic review. Colorectal Dis 2023. [PMID: 36726188 DOI: 10.1111/codi.16498] [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: 07/12/2022] [Revised: 01/05/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
AIM The key to successful construction of an ileal pouch-anal anastomosis (IPAA) following proctocolectomy in patients with ulcerative colitis or familial adenomatous polyposis is the ability of the pouch reservoir to reach the anus well vascularized and without tension. The aim of this systematic review was to provide an overview of previously described different surgical lengthening techniques to achieve adequate length for a tension-free IPAA. METHOD Pubmed, Embase and Cochrane Library databases were systematically searched. Two reviewers conducted a systematic search with combinations of keywords for the surgical procedure and surgical lengthening techniques. All publications that reported one or more surgical lengthening techniques during IPAA surgery in adult patients were selected, consisting of reviews, cohort studies, case reports, human cadaver studies and expert opinions. The primary outcomes measured were the different surgical lengthening techniques and the step-by-step approach they involve that can be used during surgery to achieve adequate length for an IPAA. RESULTS Of 1577 records reviewed, 19 articles were included in this systematic review describing at least 1181 patients (i.e. one review, four retrospective studies, five human cadaver studies, two case reports and seven expert opinions). A total of six different surgical lengthening techniques with various subtechniques were found and described, consisting of pouch folding, construction of different types of pouches, stepladder incisions, skeletonization of vessels, division and ligation of mesenteric vessels and using an interposition vein graft. No prospective or randomized controlled trials were performed regarding this topic. Quality assessment showed a medium quality of the included studies. CONCLUSION Different surgical lengthening techniques are described in a step-by-step approach to create adequate mesenteric length during IPAA surgery, in patients in whom the ileal pouch cannot reach the dentate line.
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Affiliation(s)
- Marije Zwakman
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith E K R Hentzen
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jara E Jonker
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Christina Krikke
- Department of Abdominal Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Johan F M Lange
- Department of Abdominal Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Sijbrand H S Hofker
- Department of Abdominal Surgery, University Medical Center Groningen, Groningen, The Netherlands
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2
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Mankarious MM, Deutsch MJ, Jeganathan NA. Intraoperative Techniques for Gaining Ileoanal Pouch Reach. Clin Colon Rectal Surg 2022; 35:458-462. [PMID: 36591397 PMCID: PMC9797273 DOI: 10.1055/s-0042-1758136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Ileal pouch-anal anastomosis allows for reestablishing gastrointestinal continuity in patients after proctocolectomy. The technical elements of pouch creation and gaining reach into the pelvis are demanding and require a variety of surgical maneuvers to achieve a tension-free anastomosis. We present a brief review of the literature discussing various approaches aimed at improving ileal pouch reach into the low pelvis. Although these techniques are used with different frequencies, they serve as important adjuncts to the gastrointestinal surgeons' armamentarium.
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Affiliation(s)
- Marc M. Mankarious
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Michael J. Deutsch
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Nimalan A. Jeganathan
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
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3
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Saad MK, Fiani E, Saikaly E. Mesenteric Lengthening in Pouch Surgery: Review of Surgical Techniques. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1736466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractDescribed for the first time in the medical literature in 1978 by Parks and Nicholls, total proctocolectomy with ileal-pouch anal anastomosis (IPAA) is nowadays the procedure of choice for patients with ulcerative colitis in whom the medical therapy has, a selected group of patients with Crohńs disease, and for patients with familial adenomatous polyposis. Despite the advances in medical treatment regarding inflammatory bowel disease, up to 30% of patients still require surgery, and restorative proctocolectomy and IPAA are the mainstay of the surgical treatment. It is considered a demanding and technically-challenging procedure, with the main challenge being the performance of a tension-free IPAA; the main reason for failure of the tension-free anastomosis is a shortened mesentery. With particular attention to detail, sufficient length can be achieved to enable a safe anastomosis in most patients. Herein, we describe the available techniques to lengthen the mesentery of the ileal pouch to perform an easy-to-reach tension-free anastomosis.
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Affiliation(s)
- Melissa Kyriakos Saad
- General Surgery Department, Saint George Hospital University Medical Center, Beirut, Lebanon
- Department of Surgery, University of Balamand, Beirut, Lebanon
| | - Elias Fiani
- Gastroenterology Department, Saint George Hospital University Medical Center, Beirut, Lebanon
- Department of Surgery, University of Balamand, Beirut, Lebanon
| | - Elias Saikaly
- General Surgery Department, Saint George Hospital University Medical Center, Beirut, Lebanon
- Department of Surgery, University of Balamand, Beirut, Lebanon
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4
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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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5
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Jaipuria J, Karimi AM, Singh A, Thapa BB, Gupta S, Sadasukhi N, Venkatasubramaniyan M, Pathak P, Kasaraneni P, Khanna A, Narayan TA, Sharma G, Rawal S. Pitcher pot neourethral modification of ileal orthotopic neobladder achieves satisfactory long‐term functional and quality of life outcomes with low clean intermittent self‐catheterization rate. BJUI COMPASS 2021; 2:292-299. [PMID: 35475302 PMCID: PMC8988529 DOI: 10.1002/bco2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 12/24/2022] Open
Abstract
Objective To describe a decade of our experience with a neo‐urethral modification of ileal orthotopic neobladder (pitcher pot ONB). Multiple investigators have reported similar modifications. However, long‐term longitudinal functional and quality of life (QOL) outcomes are lacking. Methods Prospectively maintained hospital registry for 238 ONB patients comprising a mix of open and robotic surgery cohorts from 2007 to 2017, and minimum of 2 years of follow‐up was retrospectively queried. QOL was evaluated using Bladder Cancer Index (BCI). Longitudinal trends of QOL domain parameters were analysed. List of perioperative variables that have a biologically plausible association with continence, potency, and post‐operative BCI QOL sexual, urinary, and bowel domain scores was drawn. Variables included surgery type, Body Mass Index (BMI), T and N stage, neurovascular bundle (NVB) sparing, age, and related pre‐operative BCI QOL domain score. Prognostic associations were analysed using multivariable Cox proportional hazard models and multilevel mixed‐effects modeling. Results The study comprised 80 and 158 patients who underwent open and robotic sandwich technique cohorts, respectively. Open surgery was associated with significantly higher “any” complication (40% vs 27%, P‐value .050) and “major” complication rate (15% vs 11%, P‐value .048). All patients developed a bladder capacity >400 cc with negligible post‐void residual urine, and all but one patient achieved spontaneous voiding by the end of study period (<1% clean intermittent self‐catheterization [CISC] rate). By 15 months, QOL for all three domains had recovered to reach a plateau. About 45% of patients achieved potency, and the median time to achieve day and night time continence was 9 and 12 months respectively. Lower age and NVBs spared during surgery were found to be significantly associated with the earlier achievement of potency, day and night time continence, as well as better urinary and sexual summary QOL scores. Conclusions Pitcher pot neobladder achieves satisfactory long‐term functional and QOL outcomes with negligible CISC rate. Results were superior with incremental nerves spared during surgery.
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Affiliation(s)
- Jiten Jaipuria
- Amity Centre for Cancer Epidemiology & Cancer Research Amity Institute of Biotechnology Amity University Uttar Pradesh Noida India
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Ahmad Mamoon Karimi
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Amitabh Singh
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Bikash Bikram Thapa
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Shashikant Gupta
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Nripesh Sadasukhi
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | | | - Preeti Pathak
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Priyatham Kasaraneni
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Ashish Khanna
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Tushar Aditya Narayan
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Girish Sharma
- Centre for Medical Biotechnology, Coordinator Amity Centre for Cancer Epidemiology & Cancer Research Amity Institute of Biotechnology Amity University Uttar Pradesh Noida India
| | - Sudhir Rawal
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
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6
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Emoto S, Hata K, Nozawa H, Kawai K, Tanaka T, Nishikawa T, Shuno Y, Sasaki K, Kaneko M, Murono K, Iida Y, Ishii H, Yokoyama Y, Anzai H, Sonoda H, Ishihara S. Risk factors for non-reaching of ileal pouch to the anus in laparoscopic restorative proctocolectomy with handsewn anastomosis for ulcerative colitis. Intest Res 2021; 20:313-320. [PMID: 33902266 PMCID: PMC9344241 DOI: 10.5217/ir.2020.00158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/12/2021] [Indexed: 11/15/2022] Open
Abstract
Background/Aims Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis and handsewn anastomosis for ulcerative colitis requires pulling down of the ileal pouch into the pelvis, which can be technically challenging. We examined risk factors for the pouch not reaching the anus. Methods Clinical records of 62 consecutive patients who were scheduled to undergo RPC with handsewn anastomosis at the University of Tokyo Hospital during 1989–2019 were reviewed. Risk factors for non-reaching were analyzed in patients in whom hand sewing was abandoned for stapled anastomosis because of non-reaching. Risk factors for non-reaching in laparoscopic RPC were separately analyzed. Anatomical indicators obtained from presurgical computed tomography (CT) were also evaluated. Results Thirty-seven of 62 cases underwent laparoscopic procedures. In 6 cases (9.7%), handsewn anastomosis was changed to stapled anastomosis because of non-reaching. Male sex and a laparoscopic approach were independent risk factors of non-reaching. Distance between the terminal of the superior mesenteric artery (SMA) ileal branch and the anus > 11 cm was a risk factor for non-reaching. Conclusions Laparoscopic RPC with handsewn anastomosis may limit extension and induction of the ileal pouch into the anus. Preoperative CT measurement from the terminal SMA to the anus may be useful for predicting non-reaching.
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Affiliation(s)
- Shigenobu Emoto
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Yasutaka Shuno
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Ishii
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
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7
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Schwartzberg DM, Remzi FH. The Role of Laparoscopic, Robotic, and Open Surgery in Uncomplicated and Complicated Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2019; 29:563-576. [PMID: 31078253 DOI: 10.1016/j.giec.2019.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The incidence of inflammatory bowel disease is increasing and despite advances in medical therapy, patients continue to require operations for complications of their disease. Minimally invasive surgical options have impacted postoperative morbidity dramatically with reduction of pain, length of stay and adhesion formation, but additionally, this population of patients are not only concerned with successful operative therapy but also the ability to return to their lifestyle and cosmetics. Laparoscopic and robotic surgery for Crohn's disease has proven to benefit patients with ileocolic or colonic disease, however complicated disease with phlegmon, abscess or fistulae is best served with a hybrid approach. Ulcerative colitis treatment has seen advancements with laparoscopic and robotic platforms, however the benefits of minimally invasive surgery must be balanced with producible and durable outcomes.
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Affiliation(s)
- David M Schwartzberg
- Department of Surgery, Inflammatory Bowel Disease Center, New York University Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 20016, USA
| | - Feza H Remzi
- Department of Surgery, Inflammatory Bowel Disease Center, New York University Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 20016, USA.
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8
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Spinelli A, Carvello M, Kotze PG, Maroli A, Montroni I, Montorsi M, Buchs NC, Ris F. Ileal pouch-anal anastomosis with fluorescence angiography: a case-matched study. Colorectal Dis 2019; 21:827-832. [PMID: 30873703 DOI: 10.1111/codi.14611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/02/2019] [Indexed: 12/12/2022]
Abstract
AIM An anastomotic leak in ileoanal pouch surgery may lead to pouch failure. Constructing a tension-free ileal pouch-anal anastomosis (IPAA) reduces this risk but can be technically challenging, balancing pouch vascularization with ileal mesenteric length and site of vessel ligation. Fluorescence angiography (FA) may help the clinician make a more balanced judgement. METHODS Thirty-two patients undergoing minimally invasive completion proctectomy with FA-guided IPAA at two academic centres were matched and compared on a 1:1 basis to a historical group undergoing the same procedure without the use of this technique. RESULTS Ligation of the ileocolic vessels was safely performed in 15/32 (47%) of FA patients compared with 5/32 (16%) of historical controls. One patient underwent intra-operative IPAA reconstruction after FA detected ischaemia. No anastomotic leak occurred with FA but there was only one in the historical controls (P = 0.31). The postoperative complication rate was similar between the two groups (P = 0.60). CONCLUSION FA is applicable to IPAA surgery and may help to reduce perfusion-related anastomotic leaks. A prospective randomized trial is warranted.
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Affiliation(s)
- A Spinelli
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - M Carvello
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy
| | - P G Kotze
- Colorectal Surgery Unit, Cajuru University Hospital, Catholic University of Paraná, Curitiba, Brazil
| | - A Maroli
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy
| | - I Montroni
- Colorectal Surgery Unit, Humanitas Research Hospital, Rozzano, Italy
| | - M Montorsi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of General Surgery, Humanitas Research Hospital, Milan, Italy
| | - N C Buchs
- Service of Visceral Surgery, Department of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - F Ris
- Service of Visceral Surgery, Department of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
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Carvello M, Sacchi M, Maroli A, Sharif A, Kotze P, Spinelli A. Redo pouch and re-stapled anastomosis after intra-operative detection of pouch ischaemia by fluorescence angiography - a video vignette. Colorectal Dis 2019; 21:374-375. [PMID: 30624850 DOI: 10.1111/codi.14550] [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: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 02/08/2023]
Affiliation(s)
- M Carvello
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - M Sacchi
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - A Maroli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - A Sharif
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - P Kotze
- Colorectal Unit, Department of Surgery, Pontifícias Universidade Católica (PUC-PR), Curitiba, Brazil
| | - A Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
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Comparison of Mesenteric Lengthening Techniques in IPAA: An Anatomic and Angiographic Study on Fresh Cadavers. Dis Colon Rectum 2018; 61:979-987. [PMID: 29994960 DOI: 10.1097/dcr.0000000000001133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The IPAA technique restores anal functionality in patients who have had the large intestine and rectum removed; however, 1 of the most important reasons for pouch failure is tension on the anastomosis. OBJECTIVE The aim of this study was to compare technical procedures for mesenteric lengthening used for IPAA to reduce this tension. DESIGN After randomization, 4 different techniques for mesenteric lengthening were performed and compared on fresh cadavers. SETTING This was a cross-sectional cadaveric study. MAIN OUTCOME MEASURES In the first group (n = 5), stepladder incisions were made on the visceral peritoneum of the mesentery of the small intestine. In the second and third groups, the superior mesenteric pedicle was divided, whereas the ileocolic pedicle (n = 7) or marginal vessels (n = 6) were preserved during proctocolectomy. In the fourth group (n = 7), the superior mesenteric pedicle was cut without preserving any colic vessels. Mesenteric lengthening was analyzed. Angiography was performed to visualize the blood supply of the terminal ileum and pouch after mesenteric lengthening. RESULTS Average mesenteric lengthening was 5.72 cm (± 1.68 cm) in group 1, 3.63 cm (± 1.75 cm) in group 2, 7.03 cm (± 3.47 cm) in group 3, and 7.29 cm (± 1.73 cm) in group 4 (p = 0.011 for group 2 when compared with the others). LIMITATIONS The study was limited by nature of being a cadaver study. CONCLUSIONS Stepladder incisions through superior mesenteric pedicle trace are usually sufficient for mesenteric lengthening. In addition, division of the superior mesenteric pedicle with either a preserving marginal artery or without preserving ileocolic and marginal arteries leads to additional mesenteric lengthening.
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Abstract
INTRODUCTION An IPAA is the preferred operative approach for restoration of intestinal continuity in patients with ulcerative colitis and familial adenomatous polyposis. As minimally invasive approaches have become more widely adopted, their use in IPAA has also become increasingly commonplace. Laparoscopy has the same limitations during the proctectomy portion as seen in operations for rectal cancer, including dissection in the mid-to-lower rectum attributed to angles created by bony confines of the deep pelvis and lack of visibility when constructing the anastomosis. Robotic surgery provides improved 3-dimensional and high-definition visualization of the pelvis and multiple degrees of freedom, which greatly enhance performance during the proctectomy and construction of the anastomosis. TECHNIQUE In the setting of a previous subtotal colectomy, the ileostomy site is taken down and stapled across. A 15-mm balloon trocar is placed in the site to achieve insufflation, and the robotic ports are placed horizontally just above the umbilicus. The lateral mesenteric attachments are mobilized laparoscopically, then the J-pouch is constructed through the ostomy site. The J-pouch is placed back into the abdomen with the anvil in place, and the proctectomy is performed after docking the robot. The rectum is stapled with the robotic stapler and exteriorized from the ileostomy site, and the anastomosis is constructed under direct robotic visualization. RESULTS In addition to the potential ergonomic advantages, the maneuverability and visualization in the pelvis during the proctectomy and construction of the anastomosis are reported by many surgeons to be improved as compared with laparoscopy, especially in male or obese patients. CONCLUSIONS A robotic approach during the proctectomy and IPAA offers significant advantages to a laparoscopic approach, expanding our armamentarium of minimally invasive surgical techniques to IPAA.
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Ohira G, Miyauchi H, Narushima K, Kagaya A, Mutou Y, Saitou H, Hayano K, Matsubara H. Predicting difficulty in extending the ileal pouch to the anus in restorative proctocolectomy: investigation of a simple predictive method using computed tomography. Colorectal Dis 2017; 19:O34-O38. [PMID: 27943576 DOI: 10.1111/codi.13575] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/27/2016] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to assess the ability of preoperative axial computed tomography (CT) to predict surgical difficulty in bringing the ileal pouch to the level of the anus during restorative proctocolectomy (RPC). METHOD Patients who underwent RPC with an ileal pouch-anal anastomosis (or ileal pouch-anal canal anastomosis) in our institution between January 2008 and April 2014 were enrolled. The patients were divided into two groups, including those in whom CT indicated potential difficulty in extending the pouch downwards (extension difficult (ED) group) and patients with no CT evidence of potential difficulty (normal group). The groups were compared for clinical factors and the thickness of the slices of CT showing the root of the superior mesenteric artery, the point of communication of the ileocaecal artery with the marginal artery (tICA) and the anal verge (AV). Receiver-operating characteristic analysis was performed, and a cut-off value was calculated for predicting the degree of difficulty in bringing the ileal pouch down to the anal canal. RESULTS Thirty-four patients were entered in the study. The ED group included significantly taller patients and more with familial adenomatous polyposis than the normal group. The distance between tICA and AV was significantly longer in the ED group, with a cut-off of 21 cm giving a sensitivity of 100% and a specificity of 83.3%. CONCLUSION The distance between tICA and AV measured by axial CT can be a useful predictor for the difficulty in bringing the ileal pouch down to the anus during RPC.
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Affiliation(s)
- G Ohira
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - H Miyauchi
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - K Narushima
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - A Kagaya
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Y Mutou
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - H Saitou
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - K Hayano
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - H Matsubara
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Management of Challenging Urethro-ileal Anastomosis During Robotic Assisted Radical Cystectomy with Intracorporeal Neobladder Formation. Eur Urol 2015; 69:704-709. [PMID: 26463317 DOI: 10.1016/j.eururo.2015.09.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/23/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Robotic assisted radical cystectomy (RARC) is increasingly being adopted, but intracorporeal neobladder formation remains a challenging procedure limited to selected centers. Common challenges with intracorporeal neobladder formation relate to fashioning a tension-free urethro-ileal anastomosis. In this paper, we describe a series of maneuvers to overcome these challenges that we believe will be of great utility to surgeons performing intracorporeal neobladder. OBJECTIVE To describe maneuvers to overcome challenges during intracorporeal urethro-ileal anastomosis formation and to report postoperative outcomes for patients in whom these maneuvers were used. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of medical records of patients who underwent RARC with intracorporeal neobladder performed by one surgeon (G.-P.H.) at our tertiary center from January 2012 to February 2015 in which at least one additional maneuver was required beyond preservation of urethral length, removal of the sigmoid colon from the pelvis, and careful ileal loop selection. The primary end point was 90-d complications. Follow-up ranged from 6 to 36 mo, and 16 patients had at least 1-yr follow-up. SURGICAL PROCEDURE RARC with intracorporeal neobladder formation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Clinical and operative data collected from a prospectively maintained, institutional review board-approved database. Maneuvers used during intracorporeal urethro-ileal anastomosis were recorded. Descriptive statistics were used to evaluate postoperative outcomes. RESULTS AND LIMITATIONS Nineteen patients met the inclusion criteria. Mean operative time was 486 min (standard deviation: 112 min) with median hospitalization of 7 d (interquartile range: 7-9 d). Seven patients (36.8%) experienced a complication, with one (5.3%) major complication thought to be unrelated to surgery. No open conversions were required. There was no 90-d mortality. CONCLUSIONS Our stepwise approach can help overcome challenges of urethro-ileal anastomosis during intracorporeal neobladder formation. PATIENT SUMMARY When performing intracorporeal neobladder formation, challenges are often encountered in fashioning the urethro-ileal anastomosis. We describe a series of maneuvers that, when used in a stepwise manner, help overcome these challenges.
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14
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Cserni T, Cervellione RM, Hajnal D, Varga G, Kubiak R, Rakoczy G, Kaszaki J, Boros M, Goyal A, Dickson A. Alternative ileal flap for bladder augmentation if mesentery is short. J Pediatr Urol 2015; 11:64.e1-6. [PMID: 25824877 DOI: 10.1016/j.jpurol.2014.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/07/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE To date the clam ileocystoplasty is the preferred method of bladder augmentation in children when the urodynamic problem is non-compliance and/or detrusor overactivity. The key to this technique is the incision of the bladder wall deep into the pelvis down to the trigone in order to avoid a diverticulum like neobladder and to provide adequate margin for augmentation. The detubularised ileum flap therefore has to reach to the bottom of the divided bladder on a reliable vascular pedicle without significant tension. A short ileal mesentery caused by previous surgery, peritonitis, peritoneal dialysis or ventriculo-peritoneal shunt may complicate surgery and compromise outcome. We hypothesized we can rely on the communication of the intramural vessels within the intestine and can detubularise the ileum adjacent to the mesentery rather than along the antimesenteric line and this could be combined with ligation of some vasa recta (VR) in order to create alternative ileum flaps, which reach further into the pelvis. Our aim was to assess the viability of the alternative flaps detubularised along the paramesenteric line and measure how many VR could be sacrificed beyond the tertiary arcades. MATERIALS AND METHODS After ethical approval adjacent ileal segments were detubulirased along the antimesenteric line (Group 1) and along the paramesenteric line (Group 2) in 5 minipigs in general anaesthesia. Ligation of 0,1,2,3 and 4 VR has been performed starting from the free end of the segments. The length of the ileal flaps was recorded. The microcirculation of flap edges was detected by in vivo microscopy using orthogonal polarising spectral imaging (Cytoscan A/R Cytometrics, PA, USA). Clam ileocystoplasty was performed with the ileum detubularised along the paramesenteric line without ligation of VR. Specimens of the augmented bladder were obtained after 4 weeks and stained with Hematoxilin + Eosin. RESULTS No alteration in capillary red blood cell velocity (RBCV) and perfusion rate (PR) was observed after paramesenteric detubularisation. The flaps in Group 2 reached 20.25 ± 0.5 mm longer vs. CONTROL This is 98% of the mean bowel width (20.5 ± 0.57 mm) measured in the animals. Ligation of each VR further increased the length of both flaps (mean: 10.59 ± 3.18 mm) however ligation of more than 2 VR gradually decreased the microcirculation in both groups. All animals augmented with alternative flap survived, there was no urine leak or suture break down. Histology confirmed viable bowel flaps. CONCLUSION Paramesenteric detubularisation of the ileum is fully tolerated and results in longer reaching ileal flap vs. CONTROL Only limited ligation of VR is tolerated. DISCUSSION This study showed the first time that clam ileocystoplasty is feasible with ileal flap detubularised along the paramesenteric line. The use of the animal model and the relative short postoperative observation are the main limitations of this study.
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Affiliation(s)
- T Cserni
- Department of Paediatric Urology, Royal Manchester Children's Hospital, UK; Institute for Surgical Research, University of Szeged, Hungary.
| | - R M Cervellione
- Department of Paediatric Urology, Royal Manchester Children's Hospital, UK; Institute for Surgical Research, University of Szeged, Hungary.
| | - D Hajnal
- Institute for Surgical Research, University of Szeged, Hungary.
| | - G Varga
- Institute for Surgical Research, University of Szeged, Hungary.
| | - R Kubiak
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, UK.
| | - G Rakoczy
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, UK.
| | - J Kaszaki
- Institute for Surgical Research, University of Szeged, Hungary.
| | - M Boros
- Institute for Surgical Research, University of Szeged, Hungary.
| | - A Goyal
- Department of Paediatric Urology, Royal Manchester Children's Hospital, UK.
| | - A Dickson
- Department of Paediatric Urology, Royal Manchester Children's Hospital, UK.
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15
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Wu XR, Kirat HT, Xhaja X, Hammel JP, Kiran RP, Church JM. The impact of mesenteric tension on pouch outcome and quality of life in patients undergoing restorative proctocolectomy. Colorectal Dis 2014; 16:986-94. [PMID: 25141985 DOI: 10.1111/codi.12748] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 05/15/2014] [Accepted: 06/04/2014] [Indexed: 12/13/2022]
Abstract
AIM The study aimed to establish a method for the measurement of mesenteric tension after ileal pouch-anal anastomosis (IPAA) and to evaluate the impact of tension on clinical outcome and quality of life. METHODS All consecutive patients undergoing an open IPAA from July 2008 to October 2009 were prospectively enrolled. After the creation of the anastomosis, mesenteric tension was estimated by the surgeon in the operating room on a 10-point scale (1, least tension; 10, most tension). The association was analysed between mesenteric tension defined as low (1-2), medium (3-7) and high (8-10) and postoperative complications and quality of life (Cleveland Clinic Global Scale). RESULTS A mesenteric tension score was obtained in 134 patients (71 men, 53.0%). Median age was 38.5 (29.3-47.0) years. Fifty-six patients (41.8%) had a low, 59 (44.0%) a medium and 19 (14.2%) a high degree of mesenteric tension. Patients with a high mesenteric tension had a shorter anal transitional zone, a longer distance from the upper border of the symphysis pubis to the apex of the small bowel loop designated for the ileoanal anastomosis, a thinner abdominal wall at the stoma site and a longer distance from the pouch to the ileostomy. The proportion of patients with high mesenteric tension was less after stapled anastomosis. On long-term follow-up, patients with high mesenteric tension were more likely to suffer from anastomotic stricture and pouch failure. Pouch function was not influenced by mesenteric tension. CONCLUSION High mesenteric tension after IPAA is adversely associated with postoperative complications and pouch survival.
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Affiliation(s)
- X-R Wu
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Dauser B, Riss S, Stopfer J, Herbst F. Bridging the gap with an ileocolonic graft after extensive colorectal resections. World J Surg 2011; 36:186-91. [PMID: 22072431 DOI: 10.1007/s00268-011-1337-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Ileocecal interposition (ICI) for first-line reconstruction after low anterior colorectal resection was introduced by von Flüe and Harder in 1994 (Dis Colon Rectum 37:1160-1162, 1994). We report our experience using this technique to bridge colonic gaps after significant loss of bowel length. PATIENTS AND METHODS Between 1999 and 2009 the left-sided colon was too short for traditional isoperistaltic reconstruction in six patients treated in our hospital. Reasons for extensive bowel loss were a deficient (n = 3) or torn (n = 1) marginal artery with ischemia or repeat colorectal resections (n = 2). An ICI was done to bridge the gap and enable restoration of intestinal continuity. RESULTS No patient died. Whenever performing a coloanal anastomosis (4/6) a loop ileostomy was raised. One patient with colonic diversion experienced graft-related complications: ischemic colitis of the interposed colonic segment, anastomotic stenosis, and a presacral sinus were observed and managed nonoperatively. Subsequent closure of the stoma was possible in all cases. A median Vaizey incontinence score of 9 (range: 4-14) was recorded in the patient with coloanal anastomosis. The average number of bowel movements per day was 1.5 (range: 0.5-6). CONCLUSIONS When the descending colon does not reach the rectal stump or anal canal in reoperative cases or after vascular complication, ICI is a useful salvage procedure resulting in good bowel function.
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Affiliation(s)
- B Dauser
- Department of Surgery, St. John of God Hospital, Johannes von Gott Platz 1, 1020 Vienna, Austria
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