Staged Approaches to Restorative Proctocolectomy with Ileoanal Pouch-When and Why?

Management of ulcerative colitis in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease updated in 2023

Ulcerative colitis (UC) is a chronic inflammation of the gastrointestinal tract and is characterized by alternating periods of inflammation and remission. Although UC incidence is lower in Taiwan than in Western countries, its impact remains considerable, demanding updated guidelines for addressing local healthcare challenges and patient needs. The revised guidelines employ international standards and recent research, emphasizing practical implementation within the Taiwanese healthcare system. Since the inception of the guidelines in 2017, the Taiwan Society of Inflammatory Bowel Disease has acknowledged the need for ongoing revisions to incorporate emerging therapeutic options and evolving disease management practices. This updated guideline aims to align UC management with local contexts, ensuring comprehensive and context-specific recommendations, thereby raising the standard of care for UC patients in Taiwan. By adapting and optimizing international protocols for local relevance, these efforts seek to enhance health outcomes for patients with UC.

The suspended ileal loop for difficult Hartmann's reversal

BACKGROUND

Hartmann's reversal can be complicated by the presence of dense adhesions in the upper part of the abdominal cavity, difficulties in freeing the splenic flexure with the risk of splenic tears, a lack of sufficient colonic length, the risk of ureteral lesion, or the risk of lesions of the vascular arcade.

METHODS

We propose a technique which consists of interposing an adapted segment of ileal loop between the end of the proximal colon and the rectum to restore intestinal continuity.

RESULTS

Two patients had Hartmann procedure, the first for a Hinchey stage 4 perforated diverticulitis and the second for a colorectal fistula due to ischemia of the proximal colonic segment. Hartmann's reversal was expected to be difficult, so a suspended ileal loop was used. The outcomes were uneventful, and functional results were satisfactory.

CONCLUSIONS

A suspended ileal loop could be used as a salvage procedure in some cases of potentially difficult Hartmann's reversal.

Laparoscopic vs open restorative proctectomy after total abdominal colectomy for ulcerative colitis or familial adenomatous polyposis

PURPOSE

Randomized controlled trials (RCTs) demonstrated that a laparoscopic approach provides short-term benefits, such as reduced blood loss and a shorter hospital stay, in patients who undergo rectal surgery. On the other hand, a few RCTs investigating proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) suggested limited advantages of laparoscopic surgery over open surgery. A substantial proportion of patients with UC or FAP may undergo staged operations with IPAA, but no study has compared the two approaches for proctectomy with IPAA after total abdominal colectomy.

METHODS

We examined 61 consecutive patients with UC or FAP who underwent proctectomy with IPAA after colectomy in our hospital. Patients were divided into the Lap group (n = 37) or the Op group (n = 24) according to surgical approach. Patient background and outcomes, such as operative time, blood loss, first bowel movement, postoperative complications, and pouchitis, were compared between these groups.

RESULTS

One patient required conversion to open surgery in the Lap group. The median volume of blood loss was 90 mL in the Lap group and 580 mL in the Op group (p < 0.0001). The Lap group showed a shorter time to first bowel movement than the Op group (median: 1 vs 2 days, p = 0.0003). The operative time, frequencies of postoperative complications, and accumulation rate of pouchitis were similar between the two groups.

CONCLUSIONS

Laparoscopic surgery was beneficial for patients undergoing restorative proctectomy in terms of blood loss and bowel recovery without increasing the operative time or rate of complications.