Robotic-assisted laparoscopic "salvage" rectopexy for recurrent ileoanal J-pouch prolapse

Salvage Surgery: An Effective Therapy in the Management of Ileoanal Pouch Prolapse

BACKGROUND

Restorative proctocolectomy with IPAA is the surgical treatment of choice for patients requiring surgery for IBD and, less frequently, for other pathologies. Pouch prolapse is a rare complication that compromises pouch function and negatively affects patients' quality of life.

OBJECTIVE

This study aimed to describe our experience from a single high-volume center in this infrequent condition.

DESIGN

Restrospective cohort study of a prospectively maintained, Institutional Review Board-approved database.

SETTINGS

All consecutive eligible patients with IPAA and pouch prolapse were identified from 1990 to 2021.

PATIENTS

Patients with full-thickness prolapse treated by pouch pexy were included.

INTERVENTIONS

Pouch pexy (with/without mesh).

MAIN OUTCOME MEASURES

Success rate of pouch pexy, defined as no recurrence of prolapse.

RESULTS

A total of 4791 patients underwent IPAA; 7 (0.1%) were diagnosed with full-thickness prolapse. An additional 18 patients who underwent IPAA and had full-thickness prolapse were referred from outside institutions. Among 25 included patients, 16 (64.0%) were women, and the overall mean age was 35.6 ± 13.4 years. The time interval from initial pouch formation to prolapse was 4.2 (interquartile range, 1.1-8.5) years. Nine patients (36.0%) underwent previous treatment for prolapse. All patients presented with symptoms and physical examination compatible with full-thickness prolapse. Twenty patients (80.0%) underwent surgical pouch pexy without mesh and 5 (20.0%) had pouch pexy with mesh placement. A diverting ileostomy was performed in 1 patient (4.0%) before pouch pexy and in 8 patients (32.0%) at the time of surgical prolapse correction. After surgery, recurrent prolapse was noted in 3 patients (12.0%) at a median of 6.9 (interquartile range, 5.2-8.3) months.

LIMITATIONS

Retrospective study, small sample size thus prone to selection, and referral biases, which may limit the generalizability of our findings.

CONCLUSION

Pouch prolapse can be effectively treated with salvage surgery. Surgical intervention is safe and provides acceptable outcomes. See Video Abstract.

CIRUGA DE RESCATE UNA TERAPIA EFICAZ EN EL MANEJO DEL PROLAPSO DE LA BOLSA ILEOANAL

ANTECEDENTES:La proctocolectomía restauradora con anastomosis reservorio ileoanal es el tratamiento quirúrgico de elección para aquellos pacientes que requieren cirugía por enfermedad inflamatoria intestinal y, con menor frecuencia, por otras patologías. El prolapso de la bolsa es una complicación rara que compromete la función de la bolsa y afecta de manera negativa la calidad de vida de los pacientes.OBJETIVO:Describir nuestra experiencia de un solo centro de alto volumen en esta condición poco frecuente.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida prospectivamente aprobada por el IRB.AJUSTES/PACIENTES:Fueron identificados y elegibles de manera consecutiva todos los pacientes con anastomosis de bolsa ileoanal y prolapso de bolsa entre 1990 y 2021. Se incluyeron pacientes con prolapso de bolsa de espesor total tratados con pexia.INTERVENCIONES:Pexia de la bolsa (con/sin malla).PRINCIPALES MEDIDAS DE RESULTADO:Tasa de éxito de la pexia de la bolsa, definida como ausencia de recurrencia del prolapso.RESULTADOS:Un total de 4.791 pacientes fueron sometidos a anastomosis de bolsa ileoanal; siete (0,1%) fueron diagnosticados con prolapso de espesor total. Otros 18 pacientes con anastomosis de reservorio ileoanal fueron derivados de instituciones externas. De entre los 25 pacientes incluidos, 16 (64,0 %) eran mujeres y la edad media promedio fue de 35,6+/-13,4 años. El intervalo de tiempo desde la creación inicial de la bolsa hasta el prolapso fue de 4,2 (IQR 1,1-8,5) años. Nueve (36,0 %) pacientes fueron sometidos a tratamiento previo para el prolapso (fisioterapia n = 4, pexia de la bolsa n = 2, pexia de la bolsa con malla n = 2, resección de la mucosa n = 1). Todos los pacientes presentaron síntomas y exploración física compatibles con prolapso de espesor total. Veinte (80,0%) pacientes se sometieron a pexia de bolsa quirúrgica sin malla y cinco (20,0%) se sometieron a pexia de bolsa con colocación de malla. Se realizó una ileostomía de derivación en un (4,0%) paciente antes de la pexia de la bolsa y en ocho (32,0%) pacientes en el momento de la corrección quirúrgica del prolapso. Posterior a la cirugía, se observó prolapso recurrente en tres pacientes (12,0 %) con una mediana de 6,9 (IQR 5,2-8,3) meses.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de muestra, por lo tanto, propenso a sesgos de selección y referencia que pueden limitar la generalización de nuestros hallazgos.CONCLUSIÓN:El prolapso de la bolsa ileoanal puede tratarse de manera efectiva mediante la cirugía de rescate. La intervención quirúrgica es segura y proporciona resultados aceptables. (Traducción-Dr. Mauricio Santamaria ).

Lower peripouch fat area is related with increased frequency of pouch prolapse and floppy pouch complex in inflammatory bowel disease patients

BACKGROUND

Pouch prolapse is a rare pouch complication which often leads to pouch failure in inflammatory bowel disease (IBD) patients. Its exact cause remains unknown. Floppy pouch complex (FPC) was defined as the presence of any one of the following pouch disorders: pouch prolapse, afferent limb syndrome (ALS), redundant loop, and pouch folding. We aimed to explore the role of peripouch fat area in the occurrence of pouch prolapse and FPC.

METHODS

Pouch patients with available pouchoscopy and abdominal CT scans who were followed up between 2011 and 2017 in Cleveland Clinic were reviewed. Peripouch fat was measured on CT images.

RESULTS

Of the 93 included patients, 31 were females; 87 had J pouches and 6 had S pouches. The median duration of pouch was 8.0 (interquartile range [IQR] 5.0-16.5) years. A total of 18 cases (19.4%, 18/93) were identified as FPC, including 12 pouch prolapse, 5 ALS, 1 redundant loop, and 3 pouch folding. Patients with pouch prolapse had lower peripouch fat area (13.6 (9.3-18.5) vs. 27.6 (11.0-46.2)cm², P = 0.022) than those without. Patients with FPC had lower peripouch fat area (15.4 (11.4-20.6) vs. 27.6 (11.0-46.9)cm², P = 0.040) than those without. Univariate and multivariate analyses demonstrated that lower peripouch fat area, lower weight, and family history of IBD were independent predictors of pouch prolapse and FPC.

CONCLUSIONS

A lower peripouch fat area was observed in inflammatory bowel disease patients with pouch prolapse and FPC. Longitudinal studies are needed to further elucidate the role of peripouch fat in the pathogenesis of pouch prolapse and FPC.

Robotic Colorectal Surgery

The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.

Transabdominal re-do pouch surgery in pediatric patients for failed ileal pouch anal anastomosis: a case matched study

PURPOSE

Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting.

METHODS

Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared.

RESULTS

60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74 months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period.

CONCLUSION

Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.

Laparoscopic ventral pouch pexy with acellular dermal matrix (ADM)-a novel technique for the treatment of full-thickness pouch prolapse after restorative proctocolectomy and j-pouch

PURPOSE

Ileal pouch prolapse is a rare complication after j-pouch formation with an incidence of about 0.3%. However, if a pouch prolapse occurs, it can be a debilitating complication for the patient. Full-thickness pouch prolapse usually warrants surgical repair as reported by Sagar and Pemberton (Br J Surg 99(4):454-468, 2012) and Sherman et al. (Inflamm Bowel Dis 20(9):1678-1685, 2014). This report presents our first experience with laparoscopic ventral pouch pexy with acellular dermal matrix (ADM).

METHODS

With the patient in the French position, four trocars were positioned: a camera port at the level of the umbilicus, two 5-mm trocars in the right lower quadrant, and a third 5-mm trocar in the left lower quadrant. The j-pouch was mobilized ventrally and laterally to the level of the sphincter. A 4 × 16-cm piece of ADM (EPIFLEX®, POLYTECH Health & Aesthetics, Dieburg, Germany) was sutured to the levators on both sides and to the ventral pouch directly cranial of the sphincter. In the next step, the ADM was attached to the promontory. Subsequently, further sutures were placed to attach the pouch to the ADM. Finally, the ADM was sewn to the cranial vaginal pole.

RESULTS

Operating time was 249 min. The postoperative course was uneventful except for a higher stool frequency which could be managed conservatively. The patient was discharged on POD 9. At the latest follow-up (12 months after surgery), the patient was still symptom free without any sign of recurrence.

CONCLUSIONS

Laparoscopic ventral pouch pexy with ADM performed by a surgeon experienced in laparoscopic pouch surgery is a safe and effective treatment option in patients with pouch prolapse.

Diagnosis and management of floppy pouch complex

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for patients with refractory ulcerative colitis, colitis-associated dysplasia or familial adenomatous polyposis. There are various pouch disorders and associated complications. Floppy pouch complex is defined as the presence of pouch prolapse, afferent limb syndrome, enterocele, redundant loop and folding pouch on pouchoscopy, gastrografin pouchogram or defecography. Common clinical presentation includes dyschezia, bloating, abdominal pain, straining or the sense of incomplete evacuation. Each disorder has its own unique endoscopic, radiographic and manometry findings. A range of therapeutic options are available for the management of the various causes of a pouch.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA)

BACKGROUND

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.

METHODS

The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.

RESULTS

Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.

CONCLUSIONS

Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Robotic colorectal surgery

INTRODUCTION

Minimally invasive surgery has many potential benefits, and the application of recently developed robotic technology to patients with colorectal diseases is rapidly gaining popularity.

QUALITY AND OUTCOMES

However, the literature evaluating such techniques, including the outcomes, risks, and costs, is limited. In this review, we evaluate and summarize the existing information, calling attention to areas where future investigation should occur.

Robotic-assisted single-incision laparoscopic partial cecectomy

BACKGROUND

Single-incision laparoscopic surgery is an emerging approach in the field of minimally invasive colon and rectal surgery. This modality utilizes a 'scarless' incision concealed within the umbilicus, and results in improved cosmesis with the potential for reduced trauma, pain and length of hospital stay. However, unique technical challenges have curbed its adaptation. Robotic-assisted technique may help overcome these limitations when applied to the single-incision approach.

METHODS

A robotic-assisted single-incision laparoscopic partial cecectomy was performed using the da Vinci robot and the GelPOINT access device. Modifications of the robotic set-up were utilized to optimize the technique. The robotic instruments were crossed below the abdominal wall to minimize internal conflict and maximize range of motion. Control of the robotic arms was reassigned on the robotic console to create a more intuitive surgical approach. The robotic camera was rotated and positioned vertically to reduce external conflict and enhance visualization.

RESULTS

Robotic-assisted single-incision laparoscopic partial cecectomy was performed in a 53 year-old male without complication or need for conversion. The procedure required 120 min with an estimated blood loss of < 50 ml. Pathology revealed a sessile tubular adenoma of the cecum. The length of hospital stay was 2 days and no complications were encountered. The patient returned with a well-healed 2.5 cm incision and no postoperative complications at 6 weeks follow-up.

CONCLUSIONS

With appropriate modifications, robotic-assisted single-incision laparoscopic surgery may be applicable as a minimally invasive modality for partial colectomy. Further studies are warranted to establish the safety, efficacy, benefits, and limits of this technique.

Robotic-assisted laparoscopic surgery for recurrent diverticulitis: experience in consecutive cases and a review of the literature

BACKGROUND

Robotic-assisted laparoscopic surgery has recently gained enthusiasm for application in colorectal surgery. We present the safety and feasibility of using the da Vinci® robotic system for the surgical treatment of sigmoid diverticulitis.

METHODS

Between August 2008 and November 2009, robotic-assisted laparoscopic anterior rectosigmoid resection (RALS-AR) for diverticulitis was performed in 24 consecutive patients. Demographic data, intraoperative parameters, and postoperative outcomes were assessed.

RESULTS

RALS-AR was performed in 14 male (58.3%) and 10 female (41.7%) patients with a diagnosis of recurrent diverticulitis. The mean patient age and BMI were 49.8 ± 9.3 years (range = 30-62 years) and 29.9 ± 6.3 kg/m(2) (range = 15.9-46.9 kg/m(2)), respectively. Disease stratification identified 15 cases of uncomplicated (62.5%) and 9 cases of complicated (37.5%) disease. The procedures required 14.1 ± 6.7 min (range = 6-30 min) for robotic docking, 100.5 ± 31.0 min (range = 50-180 min) for surgeon console time, and 224.2 ± 47.1 min (range = 150-330 min) for the total operative time. Robotic docking and surgeon console time represented 51.9% of the total operative time. A primary colorectal anastomosis was fashioned with avoidance of colostomy in all patients. There were no significant intraoperative complications, and none of the procedures required conversion to open, hand-assisted, or conventional laparoscopic technique. The length of hospital stay was 3.4 ± 2.6 days (range = 2-14 days), and the postoperative complication rate was 12.5% (n = 3). There were no anastomotic leaks, secondary surgical interventions, or hospital readmissions.

CONCLUSIONS

Robotic-assisted laparoscopic technique is a safe and feasible option for the surgical treatment of diverticulitis. The approach may be offered to patients with uncomplicated or complicated disease, and it results in a short hospital stay and low complication rate.