Short-term Outcome of Robot-assisted and Open IPAA: An Observational Single-center Study

Transanal ileal pouch-anal anastomosis: A systematic review and meta-analysis of technical approaches and clinical outcomes

PURPOSE

Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.

METHODS

Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.

RESULTS

Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.

CONCLUSIONS

Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.

Patient-reported Outcome Measures in Ileoanal Pouch Surgery: a Systematic Review

OBJECTIVE

To summarise frequency, type, and heterogeneity of patient-reported outcomes measures [PROMs] in papers reporting on outcomes after ileal pouch anal anastomosis [IPAA].

BACKGROUND

Prevalence of ulcerative colitis [UC] has risen in Western countries, and one in three patients requires surgery. IPAA is a frequently performed procedure for UC, and a lack of standardisation is manifest in reporting outcomes for inflammatory bowel disease [IBD] despite the clear need for inclusion of PROMs as primary outcomes in IBD trials.

METHODS

Scopus, Pubmed, and Web of Science databases were searched from January 2010 to January 2023 for studies investigating outcomes in IPAA surgery. The primary outcome was the proportion of studies reporting outcomes for IPAA surgery for UC, which included PROMs.

RESULTS

The search identified a total of 8028 studies which, after de-duplication and exclusion, were reduced to 79 articles assessing outcomes after IPAA surgery. In all 44 [55.7%] reported PROMs, with 23 including validated questionnaires and 21 papers using authors' questions, 22 different PROMs were identified, with bowel function as the most investigated item. The majority of studies [67/79, 85%] were retrospective, only 14/79 [18%] were prospective papers and only two were [2.5%] randomised, controlled trials.

CONCLUSIONS

Only half of the papers reviewed used PROMs. The main reported item is bowel function and urogenital, social, and psychological functions are the most neglected. There is lack of standardisation for use of PROMs in IPAA. Complexity of UC and of outcomes after IPAA demands a change in clinical practice and follow-up, given how crucial PROMs are, compared with their non-routine use.

Pediatric colorectal robotic surgery

Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal.

Robotic Surgery for the Ileal Pouch

BACKGROUND

A robotic approach to total colectomy/proctectomy and ileal pouch reconstruction would seem to be a sensible use of the platform's enhanced reach, visualization, and dexterity.

OBJECTIVE

The study aimed to discuss current published data for robotic ileal pouch surgery.

STUDY SELECTION

The study selection included a paucity of published data to date, representing early learning curves and case series with small numbers.

CONCLUSIONS

Current robotic platforms may offer advantages, particularly in the low pelvis beyond what is found with a laparoscopic approach.

Robotic-Assisted versus Laparoscopic Proctectomy with Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Analysis of Clinical and Financial Outcomes from a Tertiary Referral Center

Background: Robotic-assisted colorectal surgery is gaining popularity, but limited data are available on the safety, efficacy, and cost of robotic-assisted restorative proctectomy with the construction of an ileal pouch and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Methods: A retrospective study was conducted comparing consecutively performed robotic-assisted and laparoscopic proctectomy with IPAA between 1 January 2016 and 31 September 2021. In total, 67 adult patients with medically refractory UC without proven dysplasia or carcinoma underwent surgery: 29 operated robotically and 38 laparoscopically. Results: There were no differences between both groups regarding postoperative complications within 30 days according to Clavien-Dindo classification’ grades 1−5 (51.7% vs. 42.1%, p = 0.468) and severe grades 3b−5 (17.2% vs. 10.5%, p = 0.485). Robotic-assisted surgery was associated with an increased urinary tract infection rate (n = 7, 24.1% vs. n = 1, 2.6%; p = 0.010) and longer operative time (346 ± 65 min vs. 281 ± 66 min; p < 0.0001). Surgery costs were higher when operated robotically (median EUR 10.377 [IQR EUR 4.727] vs. median EUR 6.689 [IQR EUR 3.170]; p < 0.0001), resulting in reduced total inpatient profits (median EUR 110 [IQR EUR 4.971] vs. median EUR 2.853 [IQR EUR 5.386]; p = 0.001). Conclusion: Robotic-assisted proctectomy with IPAA can be performed with comparable short-term clinical outcomes to laparoscopy but is associated with a longer duration of surgery and higher surgery costs. As experience increases, some advantages may become evident regarding operative time, postoperative recovery, and length of stay. The robotic procedure might then become cost-efficient.

Robotic multiquadrant colorectal procedures: A single-center experience and a systematic review of the literature

Purpose

Robotic surgery has been progressively implemented for colorectal procedures but is still limited for multiquadrant abdominal resections. The present study aims to describe our experience in robotic multiquadrant colorectal surgeries and provide a systematic review and meta-analysis of the literature investigating the outcomes of robotic total proctocolectomy (TPC), total colectomy (TC), subtotal colectomy (STC), or completion proctectomy (CP) compared to laparoscopy.

Methods

At our institution 16 consecutive patients underwent a 2- or 3-stage totally robotic total proctocolectomy (TPC) with ileal pouch-anal anastomosis. A systematic review of the literature was performed to select studies on robotic and laparoscopic multiquadrant colorectal procedures. Meta-analyses were used to compare the two approaches.

Results

In our case series, 14/16 patients underwent a 2-stage robotic TPC for ulcerative colitis with a mean operative time of 271.42 (SD:37.95) minutes. No conversion occurred. Two patients developed postoperative complications. The mean hospital stay was 8.28 (SD:1.47) days with no readmissions. Mortality was nil. All patients underwent loop-ileostomy closure, and functional outcomes were satisfactory. The literature appraisal was based on 23 retrospective studies, including 736 robotic and 9,904 laparoscopic multiquadrant surgeries. In the robotic group, 36 patients underwent STC, 371 TC, 166 TPC, and 163 CP. Pooled data analysis showed that robotic TC and STC had a lower conversion rate (OR = 0.17;95% CI, 0.04–0.82; p = 0.03) than laparoscopic TC and STC. The robotic approach was associated with longer operative time for TC and STC (MD = 104.64;95% CI, 18.42–190.87; p = 0.02) and TPC and CP (MD = 38.8;95% CI, 18.7–59.06; p = 0.0002), with no differences for postoperative complications and hospital stay. Reports on urological outcomes, sexual dysfunction, and quality of life were missing.

Conclusions

Our experience and the literature suggest that robotic multiquadrant colorectal surgery is safe and effective, with low morbidity and mortality rates. Nevertheless, the overall level of evidence is low, and functional outcomes of robotic approach remain largely unknown.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022303016.

Equivalency of short-term perioperative outcomes after open, laparoscopic and robotic ileal anal pouch anastomosis. Does procedure complexity override operative approach?

Background

Ileal pouch anal anastomosis is the treatment of choice for patients with chronic ulcerative colitis and familial adenomatous polyposis undergoing a proctocolectomy and desiring bowel continuity. It is a technically complex operation associated with significant morbidity and may be performed by an open, laparoscopic, or robotic approach. However, there is a paucity of data regarding the comparative perioperative outcomes between these 3 techniques outside of institutional studies.

Methods

The NSQIP targeted proctectomy data set was used to identify patients who underwent open, laparoscopic, and robotic ileal pouch anal anastomosis between 2016 and 2019. Thirty-day outcomes between different surgical approaches were compared using univariate and multivariable analysis.

Results

During the study period, 1,067 open, 971 laparoscopic, and 341 robotic ileal pouch anal anastomosis were performed. The most frequent indications were inflammatory bowel disease (64%), malignancy (18%), and familial adenomatous polyposis (7%). Mean age of the cohort was 43 ± 15 years with 43% female and 76% with body mass index ≤ 30 kg/m². Overall morbidity was 26.8% for the entire cohort with 4% anastomotic leak, 6% reoperation, 21% ileus, and 21% readmission rate. After adjusting for available confounders, operative approach was not associated with better short-term outcomes, including length of stay, overall morbidity, anastomotic leak, reoperation, incidence of ileus, and 30-day readmissions.

Conclusion

Ileal pouch anal anastomosis continues to be associated with significant postoperative morbidity regardless of operative approach. Patient-related advantages in terms of perioperative outcomes for laparoscopic and robotic platforms compared to open surgery are less pronounced in complex operations such as ileal pouch anal anastomosis.

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Ileal anal pouch anastomosis is a technically complex operation associated with significant postoperative 30-day morbidity.

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Postoperative morbidity is similar between open, laparoscopic, and robotic approaches.

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In complex operations such as ileal anal pouch anastomosis, the short-term perioperative advantages of minimally invasive approaches may not be clinically evident.

Functional outcome and quality of life after transanal minimal invasive pouch surgery

PURPOSE

To investigate functional outcomes and quality of life (QoL) after restorative proctocolectomy (RPC) using transanal minimal invasive surgery (TAMIS).

METHOD

The study consists of two sub-studies. A cohort study comprised 98 consecutive patients, who underwent TAMIS RPC. These patients were the first at our department to undergo TAMIS RPC. We collected information about surgery, complications, postoperative morbidity and mortality ≤ 30 days, and pouch problems. Patients were also invited to participate in a case-control study in which the patients would respond to three different questionnaires, the Inflammatory Bowel Disease Questionnaire (IBDQ), the Short Form-36 General Health Questionnaire (SF-36), and questions from the Pouch Dysfunction Score. We compared the responding TAMIS RPC patients to a Danish national cohort (0-10 years from RPC, n = 514) of patients having RPC between 1980 and 2010. We compared functional outcomes and QoL.

RESULTS

Four (4%) of the TAMIS patients had an anastomotic leak; none of these required re-operation with removal of the pouch. Anastomotic leak was treated with antibiotics and drain. Out of the four leaks, only one ended up with a permanent stoma; all others had their stoma reversed successfully. The TAMIS patients had the same number of bowel movements as the patients in the Danish national cohort study. The same was seen with regard to incontinence. We had no conversions in our series of TAMIS procedures.

CONCLUSION

The TAMIS technique shows acceptable outcomes, both in regard to postoperative complications and also functional outcome and QoL.

Robotic Surgery for Ulcerative Colitis

Subtotal colectomy (STC) or total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA) performed in two or three stages remain the procedure of choice for patients with ulcerative colitis (UC). Minimally invasive laparoscopic approaches for STC and IPAA have been established for over a decade, having been shown to reduce postoperative pain, length of stay, and improve fertility. However "straight-stick" laparoscopy has ergonomic and visual disadvantages in the pelvis, which may contribute to IPAA failure. The robotic platform was developed to overcome these limitations. Robotic STC is associated with lower conversion rates and earlier return of bowel function with acceptably longer operative time (mean, 28 minutes) than laparoscopic STC. The robotic approach has also been shown in case series to be safe in urgent settings. Robotic IPAA is associated with lower blood loss and length of stay than laparoscopic IPAA. Robotic TPC/IPAA has been shown in small case series to be safe and feasible despite longer operating times.

Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis

BACKGROUND

Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA.

OBJECTIVE

The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures.

DESIGN

This was a retrospective cohort study.

SETTINGS

This study was conducted at a single tertiary care IBD center.

PATIENTS

All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks.

RESULTS

The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05).

LIMITATIONS

This study was limited by its retrospective design and evolving electronic medical charts system.

CONCLUSIONS

The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693.

LENTO Y CONSTANTE GANA LA CARRERA UN CASO SLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA

ANTECEDENTES:Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal.OBJETIVO:El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino.PACIENTES:Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas.RESULTADOS:La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución.CONCLUSIONES:La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.

Robotic Surgery in Crohn's Disease

Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.

Robotic versus laparoscopic ileal pouch-anal anastomosis (IPAA): a systematic review and meta-analysis

BACKGROUND

Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is a curative and cancer preventative procedure in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). It can be technically difficult laparoscopically, and hence the robotic platform has been suggested as a way to enable minimally invasive surgery in more patients. This systematic review examines robotic proctectomy or proctocolectomy with IPAA. A limited meta-analysis was performed on data comparing the robotic approach to laparoscopy.

METHODS

We searched MEDLINE, EMBASE and the Cochrane database for case series of robotic IPAA procedures and studies comparing the robotic to laparoscopic or open procedures. Data examined includes operating time, conversion to open, length of stay, complications, blood loss, return of bowel function, reoperation rate and functional outcomes.

RESULTS

Five non-randomised studies compared robotic to laparoscopic techniques; one compared robotic to open surgery and three case series are included. Operating time was significantly longer in robotic cases. Estimated blood loss was significantly less in three of four studies which reported this; hospital stay was significantly less in two. There were nonsignificant reductions in complications and readmission rates. Pooled analysis of four papers with adequate data showed a nonstatistically significant trend to less complications in robotic procedures. Three studies assessed functional and quality of life outcomes, with little difference between the platforms.

CONCLUSIONS

Available data suggests that the robotic platform is safe to use for IPAA procedures. There is minimal evidence for clinical advantages, but with little data to base decisions and significant potential for improvements in technique and cost-effectiveness, further use of the platform for this operation is warranted. It is vital that this occurs within an evaluation framework.

[Minimally invasive and robot-assisted surgery for chronic inflammatory bowel disease : Current status and evidence situation]

The majority of cases of inflammatory bowel disease (IBD) can be treated by minimally invasive surgery. The advantages of standard laparoscopic approaches compared to open surgery with respect to short-term and long-term outcome parameters have been adequately proven with evidence level 1 for ileocecal resection in Crohn's disease. For many other indications there are at least several larger registry or case-control studies that have shown advantages for laparoscopy. For robot-assisted surgery the feasibility has principally been demonstrated for IBD, whereby at least for ulcerative colitis limited data suggest comparable results to the standard laparoscopic approach. Single port approaches have so far not been able to demonstrate any relevant advantages in IBD surgery. Major advantages for transanal minimally invasive surgery (TAMIS) for performing restorative proctocolectomy could not be demonstrated in two larger case-controlled studies but it was at least shown to be a comparable alternative to standard laparoscopy. Overall, it seems unlikely that the recently described new laparoscopic approaches will result in measurable advantages for the patient in comparison to standard laparoscopy as the access trauma is not significantly changed. In general, the indications to perform minimally invasive surgery must always be based on the basic principles of IBD surgery and contraindications have to be considered in individual cases as the advantages of laparoscopic approaches are levelled out in the long run.

A systematic review and meta-analysis of outcomes after elective surgery for ulcerative colitis

AIM

Approximately 20%-30% of patients with ulcerative colitis (UC) will undergo surgery during their disease course, the vast majority being elective due to chronic refractory disease. The risks of elective surgery are reported variably. The aim of this systematic review and meta-analysis is to summarize the outcomes after elective surgery for UC.

METHODS

A systematic review was conducted that analysed studies reporting outcomes for elective surgery in the modern era (>2002). It was prospectively registered on the PROSPERO database (ref: CRD42018115513). Searches were performed of Embase and MEDLINE on 15 January 2019. Outcomes were split by operation performed. Primary outcome was quality of life; secondary outcomes were early, late and functional outcomes after surgery. Outcomes reported in five or more studies underwent a meta-analysis of incidence using random effects. Heterogeneity is reported with I² , and publication bias was assessed using Doi plots and the Luis Furuya-Kanamori index.

RESULTS

A total of 34 studies were included (11 774 patients). Quality of life was reported in 12 studies, with variable and contrasting results. Thirteen outcomes (eight early surgical complications, five functional outcomes) were included in the formal meta-analysis, all of which were outcomes for ileal pouch-anal anastomosis (IPAA). A further 71 outcomes were reported (50 IPAA, 21 end ileostomy). Only 14 of 84 outcomes received formal definitions, with high inter-study variation of definitions.

CONCLUSION

Outcomes after elective surgery for UC are variably defined. This systematic review and meta-analysis highlights the range of reported incidences and provides practical information that facilitates shared decision making in clinical practice.

Successful patient-oriented surgical outcomes in robotic vs laparoscopic right hemicolectomy for cancer - a systematic review

AIM

Minimally invasive surgical approaches for cancer of the right colon have been well described with significant patient and equivalent oncological benefits. Robotic surgery has advanced in its ability to provide multi-quadrant abdominal access, leading the surgical community to widen its application outside of the pelvis to other abdominal compartments. Globally it is being realized that a patient's surgical episode of care is becoming the epicentre of cancer treatment. In order to establish the role of robotic surgery in a patient's episode of care, 'successful patient-oriented surgical' parameters in right hemicolectomy for malignancy were measured. The objective was to examine the rates of successful patient-oriented surgical outcomes in robotic right hemicolectomy (RRH) compared to laparoscopic right hemicolectomy (LRH) for cancer.

METHODS

A systematic search of MEDLINE (Ovid: 1946-present), PubMed (NCBI), Embase (Ovid: 1966-present) and Cochrane Library was conducted using PRISMA for parameters of successful patient-oriented surgical outcomes in RRH and LRH for malignancy alone. The parameters measured included postoperative ileus, anastomotic complication, surgical wound infection, length of stay (LOS), incisional hernia rate, conversion to open, margin status, lymph node harvest and overall morbidity and mortality.

RESULTS

There were 15 studies which included 831 RRH patients and 3241 LRH patients, with a median age of 62-74 years. No study analysed the concept of successful patient-oriented surgical outcomes. There was no significant difference in the incidence of postoperative ileus, with less time to first flatus in RRH (2.0-2.7 days, compared with 2.5-4.0 days, P < 0.05). Anastomotic leak rate in one study reported a significant increase in LRH compared to RRH (P < 0.05, 0% vs 8.3%). Significantly decreased LOS following RRH was outlined in six studies. One study reported a significantly higher rate of incisional hernias following LRH with extracorporeal anastomoses compared to RRH with intracorporeal anastomoses. Overall rates of conversion to open surgery were less with RRH (0%-3.9% vs 0%-18%, P < 0.001, 0.05). One study outlined significantly higher rates of incomplete resection with an open right hemicolectomy compared with minimally invasive laparoscopic and robotic resections, with positive margin rates of 2.3%, 0.9% and 0% respectively (P < 0.001). Two studies reported significantly higher lymph node harvest in RRH (P < 0.05). Overall morbidity and 30-day mortality were comparable in both approaches.

CONCLUSION

Thirty-day morbidity and mortality were comparable between the two approaches, with patients undergoing RRH having lower anastomotic complications, increased lymph node harvest, and reduced LOS, conversion to open and incisional hernia rates in a number of studies. There are limited data on surgical approach and impact on quality of life and what patients deem successful surgical outcomes. There is a further need for a randomized controlled trial examining successful patient-oriented outcomes in right hemicolectomy for malignancy.

Entirely Robot-assisted Total Colectomy/Total Proctocolectomy Compared With a Laparoscopic Approach

PURPOSE

Previous robot-assisted total colectomy/total proctocolectomy (TC/TPC) has been mostly confined to completion proctectomy combined with open or laparoscopic colon dissection. This study describes an integrative method of entirely robot-assisted maintaining anatomical dissection with single docking and one-off arm placement.

MATERIALS AND METHODS

Twenty patients who underwent robot-assisted TC/TPC and 36 who underwent laparoscopic procedures at the Asan Medical Center (Seoul, Korea) were enrolled.

RESULTS

Mean operation time was ∼1 hour longer in the robot-assisted than in the laparoscopic group (P=0.003), due primarily to the extra time required for instrument installation and more frequent transient ileal diversion. Three patients (8%) in the laparoscopic group required conversion to open surgery, compared with none in the robot-assisted group. Rates of postoperative adverse events did not differ in the 2 groups (P=0.063). Short (8 cm) ileal pouches were applied to all patients who underwent robot-assisted TPC/ileal-pouch anal anastomosis, but to one patient who underwent laparoscopic surgery. There were no discrepancies of mean daily bowel movement between patients with short and long ileal pouches 6 months after surgery (P=0.694), showing 5 times per day (range: 1 to 10).

CONCLUSION

The advantages of the boom system and motion-sensitive table were successfully utilized to integrate anatomical dissection with the multiquadrant procedures of TC/TPC, with none of these patients requiring conversion to open surgery. Refinement of these techniques may overcome some of the technical and time-related and cost-related concerns of the robotic approach.

[Robotic Assisted Proctocolectomy with Ileal Pouch-Anal Anastomosis in a Case of Suspected Hereditary Polyposis]

BACKGROUND

Various forms of hereditary polyposis have been described in the literature. Classical familial adenomatous polyposis (FAP) is a rare, autosomal dominantly inherited disease which is caused by a germline mutation in the adenomatous polyposis coli gene (APC). Patients with this diagnosis successively develop multiple polyps of the colon. Left untreated, FAP almost inevitably leads to malignant transformation.

INDICATION

We present the case of a 37-year-old patient with histologically confirmed, stenotic adenocarcinoma of the descending colon and an initially suspected hereditary polyposis due to multiple polyps in the descending and sigmoid colon.

METHODS

The video describes the preoperative imaging as well as endoscopic findings and demonstrates the technique of a two-stage, robotically assisted proctocolectomy with ileal pouch-anal anastomosis (IPAA) and the creation of a temporary loop ileostomy.

CONCLUSIONS

With respect to the surgical treatment of classic FAP, restorative proctocolectomy (RPC) with ileal J-pouch construction can be regarded as an established standard procedure, despite controversy regarding various technical aspects. Minimally invasive strategies should be considered as an equivalent option compared to conventional techniques.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

The Role of Laparoscopic, Robotic, and Open Surgery in Uncomplicated and Complicated Inflammatory Bowel Disease

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.

Short-term postoperative outcomes following robotic versus laparoscopic ileal pouch-anal anastomosis are equivalent

BACKGROUND

Minimally invasive approaches have become the standard of care for ileal pouch-anal anastomoses (IPAA). There are few reports comparing outcomes following a laparoscopic versus robotic approach. Our aim was to determine if there were any differences in the 30-day postoperative outcomes following IPAA performed laparoscopically versus robotically.

METHODS

A retrospective chart review of all laparoscopic and robotic IPAA performed between January 1, 2015 and June 30, 2018 was carried out. Patients included were adult patients who underwent a proctectomy and IPAA utilizing either a laparoscopic or robotic approach. Data collected included patient demographics, operative variables, and 30-day postoperative outcomes.

RESULTS

A total of 132 patients had a minimally invasive IPAA; 58 were performed laparoscopically and 74 robotically. Less than half the patients were female (n = 55; 41.7%) with a median age of 37 years (range 18-68 years). The majority of patients had a diagnosis of ulcerative colitis (n = 103; 78.0%) with medically refractory disease (n = 87; 65.9%). A greater proportion of patients in the laparoscopic cohort had a prolonged length of stay (n = 27; 46.6% versus n = 18; 24.3%; p < 0.001) and a two-stage approach (n = 56; 96.6% versus n = 37; 50%; p < 0.001), but there were no differences in the rates between the laparoscopic versus robotic cohorts of superficial surgical site infection (6.9% versus 6.8%; p = 0.99), peripouch abscess (15.5% versus 6.8%; p = 0.11), anastomotic leak (6.9% versus 2.7%; p = 0.21), pelvic abscess (15.5% versus 6.8%; p = 0.11), and pelvic sepsis (15.5% versus 6.8%; p = 0.11), readmission (24.1% versus 17.6%; p = 0.35) or reoperation (6.9% versus 5.4%; p = 0.72). On multivariable analysis, only male sex remained predictive of prolonged length of stay, and a robotic approach trended toward a decreased rate of prolonged length of stay.

CONCLUSIONS

Laparoscopic and robotic IPAA have equivalent postoperative morbidity underscoring the safety of the continued expansion of the robotic platform for pouch surgery.

The Current Role of Robotics in Colorectal Surgery

PURPOSE OF REVIEW

Despite the growth in laparoscopic surgery, comparable oncological outcomes, and reduced complication rates, the majority of colorectal surgery is still performed via an open approach. Reasons for this may include technical difficulties associated with operating in narrow spaces such as in the pelvis and inadequate experience. Robotic surgery provides potential solutions to some of these challenges. This review will summarize the state of the literature regarding robotic colorectal surgery.

RECENT FINDINGS

The most consistent benefit of robotic surgery is decreasing operative conversions, specifically in rectal cancer. In partial colectomies, there is evidence to support quicker return to bowel function. Oncologic outcomes compared to the laparoscopic approach are equivalent. Robotic surgery provides solutions to the challenges posed by laparoscopy, including wristed instruments, ease of intracorporeal suturing, and ergonomic advantages. Randomized trials to evaluate peri-operative outcomes will be important. If robotics is able to facilitate conversion of open colectomies to their minimally invasive equivalent, robotics may end up proving to be advantageous in the peri-operative and post-operative period. Continued studies are warranted.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Short-term outcomes of robotic-assisted right colectomy compared with laparoscopic surgery: A systematic review and meta-analysis

To assess the clinical efficacy and safety of robotic-assisted right colectomy (RRC) with conventional laparoscopic right colectomy (LRC) by performing a systematic review and meta-analysis of the published studies. All published literature for comparative studies reporting preoperative outcomes of RRC and LRC were searched. We searched the databases included Cochrane Library of Clinical Comparative Trials, MEDLINE, Embase, Web of Science and Chinese Biomedical Database (CBM) from 1973 to 2018. The censor date was up to January 2018. Operative time, estimated blood loss, length of hospital stay, conversion rates to open surgery, postoperative complications, and related outcomes were evaluated. All calculations and statistical tests were performed using Stata 12.0 software. A total of 7769 patients with colon cancer enrolled in 13 trials were divided into a study group (n = 674) and a control group (n = 7095). Meta-analysis suggested significantly greater length of hospital stay in the LRC group [MD = -0.85; 95% CI: -1.07 to -0.63; P < 0.00001]. Robotic surgery was also associated with a significantly lower complication rate [OR = 0.73; 95% CI: 0.52 to 1.01; P = 0.05]. There were statistically significant differences between the groups in estimated blood loss [MD = -16.89; 95% CI: -24.80 to -8.98; P < 0.00001] and the rate of intraoperative conversion to open surgery [OR = 0.34, 95% CI: 0.15 to 0.75; P = 0.008)], but these differences were not clinically relevant. The recovery of bowel function in two groups is no significant differences [MD = -0.58, 95% CI: -0.96 to -0.20, P = 0.0008]. However, operation times [MD = 43.61, 95% CI: 39.11 to 48.10, P < 0.00001] were longer for RRC than for LRC. Compared to LRC, RRC was associated with reduced estimated blood loss, reduced postoperative complications, longer operation times. Recovery of bowel function and other perioperative outcomes were equivalent between the two surgeries.

Robotic Platform for an IPAA

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.

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.

Primary fecal diversion and bowel dysfunction in restorative proctocolectomy for ulcerative colitis: a nationwide cross-sectional study

PURPOSE

The aim of this study was to explore the effects of primary fecal diversion on the risk of pouch dysfunction.

METHODS

Patients operated with an ileal pouch-anal anastomosis in Denmark in 2000-2010 were identified and validated bowel function questionnaires retrieved from a cross-sectional study. Multivariate logistic regression analysis was performed to determine the effect of primary fecal diversion on pouch dysfunction. A diagnostic or procedural code for intraabdominal abscesses and fistulas, occurring within 1 year after pouch creation, and anastomotic leakage or extremely early-onset pouchitis within 30 days of surgery defined a pelvic complication.

RESULTS

The questionnaire response rate was 85.6% (504 of 589), with no relevant differences in clinical characteristics between responders and non-responders. Pelvic complications, pouch failure, and death prior to the questionnaire date were more common for patients without primary fecal diversion. Among patients without primary fecal diversion, the prevalence of pouch dysfunction was 48% (95% CI: 34-62%), compared to 30% (95% CI: 26-35%) for those with [adjusted odds ratio = 2.23 (95% CI: 1.20-4.14)]. This difference was primarily caused by a higher risk of 'urgency', 'incomplete emptying', and a higher number of bowel movements per day.

CONCLUSION

Omission of primary fecal diversion in ileal pouch-anal anastomosis for ulcerative colitis may have a negative impact on bowel function. Prospective studies are warranted to elaborate these findings and to determine causality with pelvic complications.

Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care

AIM

Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes.

METHOD

Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed.

RESULTS

In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06).

CONCLUSION

IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

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.