Laparoscopic surgery for ulcerative colitis: a review of the literature

Despite the development of new therapies, including anti-TNF alpha antibodies and immunosuppressants, a substantial proportion of patients with ulcerative colitis (UC) still require surgery. Restorative proctocolectomy with ileal-pouch anal anastomosis is the standard surgical treatment of choice for UC. With the advent of laparoscopic techniques for colorectal surgery, ileal-pouch anal anastomosis has also been performed laparoscopically. This paper reviews the history and current trends in laparoscopic surgery for UC. The accumulation of experience and improvement of laparoscopic devices have shifted the paradigm of UC surgery towards laparoscopic surgery over the past decade. Although laparoscopic surgery requires a longer operation, it provides significantly better short and long-term outcomes. The short-term benefits of laparoscopic surgery over open surgery include shorter hospital stays and fasting times, as well as better cosmesis. The long-term benefits of laparoscopy include better fecundity in young females. Some surgeons favor laparoscopic surgery even for severe acute colitis. More efforts are being made to develop newer laparoscopic methods, such as reduced port surgery, including single incision laparoscopic surgery and robotic surgery.

Trends in the surgical treatment of ulcerative colitis over time: increased mortality and centralization of care

BACKGROUND

New medical therapies available to ulcerative colitis (UC) patients have influenced operative mortality for patients requiring colectomy. We sought to examine trends in treatment and outcome for UC patients treated surgically.

METHODS

A review of 36,447 UC patients from the Nationwide Inpatient Sample was performed, comparing the pre-monoclonal antibody era (1990-1996) to the present-day era (2000-2006). Patients treated with total colectomy with ileostomy or proctocolectomy with ileal pouch were reviewed for outcome measures and practice setting (rural, urban non-teaching, urban teaching). Our main outcome measures were in-hospital mortality, length of stay, and total charges.

RESULTS

Total colectomy (n = 30,362) was performed five times more often than proctocolectomy (n = 6,085). When comparing the two study periods, mortality after total colectomy increased 3.8% to 4.6% (p = 0.0003). This difference was primarily due to increasing mortality in later years; when 1995-1996 was compared to 2005-2006, mortality increased from 3.6% to 5.6% (p < 0.0001). There were no deaths in the proctocolectomy group (p < 0.0001). The distribution by practice setting shifted over the two study periods, decreasing in rural (7.0% to 4.8%) and urban non-teaching (43.7% to 28.4%) centers, and increasing in urban teaching centers (49.3% to 66.8%). The total inflation-adjusted charges per patient increased significantly ($34,638 vs. $43,621; p < 0.0001).

CONCLUSIONS

The mortality rate after total colectomy is increasing, and the difference is accentuated in the years since widespread use of monoclonal antibody therapy. The care of these patients is being shifted to urban teaching centers and is becoming more expensive.

Thirty years of the ileal-anal pouch and beyond

Still referred to as a new surgical procedure, the ileal-anal pouch or restorative proctocolectomy is now in its 30th year. Over this time the procedure has become the standard of care for patients with ulcerative colitis and familial adenomatous polyposis who require surgery. For many patients it not only eradicates disease, but also preserves the anal sphincter, therefore enabling the patient to defecate in the normal way. Much research over the years has explored optimum surgical techniques, pouch function/capacity, pouch failure and pouch satisfaction and its long-term follow-up. This article reviews literature relating to the ileal-anal pouch and traces its journey through the past three decades, providing an overview of how the pouch has evolved and considers its future development.

Revolution and evolution: 30 years of ileoanal pouch surgery

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

Ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis: historical development and current status

In summary, the history and development of the proctocolectomy and ileal pouch-anal anastomosis has involved innovative animal and clinical research by several surgical investigators. This evolution followed the classic process of academic surgical progress: a clinical problem is identified; solutions are studied in the laboratory; and these solutions are applied back to the clinical situation with success. Dr. Sabiston's disappointment with clinical results in ulcerative colitis and familial polyposis patients led to laboratory experiments in which a new technique was shown safe in dogs. The further work of his collaborator Dr. Ravitch as well as that of Sir Alan Parks and Dr. Utsunoimya proved small-scale clinical application of the new technique. Finally, large-scale outcomes work by Dr. Fazio at the Cleveland Clinic Foundation and others has allowed further refinements to occur and has highlighted other areas to study. The work of these investigators and other has allowed lack of a permanent ostomy with satisfactory functional results in more than 95% of patients. Continued experience with these procedures has and will lead to further improvements in operative times, morbidity rates, and functional results. Although research in this area will continue, the evolution of this operation has allowed it to become the gold standard for the treatment of ulcerative colitis and familial adenomatous polyposis.

Quality of life in patients undergoing ileal pouch-anal anastomosis at the University of Cincinnati

BACKGROUND

In 1978, Drs. Fischer and Martin were among the first to preserve anorectal continence and create a pelvic reservoir in adult patients, in what has become the ileal pouch-anal anastomosis (IPAA).

METHODS

Here we review our institutions' experience with 379 of these procedures from 1978 to present. To assess the specific health concerns of patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP) and determine the effects of IPAA on health-related quality of life, we evaluated patients with the SF-36, the Rating Form of Inflammatory Bowel Disease Patient Concerns (RFIPC), time trade-off questions, and a gamble question.

RESULTS

IPAA patients did not differ from the general population in seven of eight general health categories assessed by the SF-36. When compared with the UC population as a whole using the RFIPC they had reduced concerns in almost all areas. In addition, time trade-off and gamble questions indicated that these patients, as a group, are willing to accept a significant risk of dying in order to achieve their results of the IPAA.

CONCLUSIONS

This high level of satisfaction has led to the referral of patients who would not have otherwise considered a procedure requiring permanent ileostomy.

The ileal pouch anal anastomosis: past, present, and future

The modern era of ileal pouch anal anastomosis began just over 20 years ago. Several areas remain controversial, including patient selection, surgical technique, use of a temporary diverting ileostomy, aging sphincters, complications, and postoperative management. This article reviews current controversies concerning ileal pouch anal anastomoses and our approach to managing patients who undergo this complicated procedure.

Current trends in restorative proctocolectomy: introduction of an ultrasonically activated scalpel

PURPOSE

We evaluated the usefulness of an ultrasonically activated scalpel (Harmonic Scalpel) for mucosal proctocolectomy and ileal J-pouch-anal anastomosis.

METHODS

Seventy-four patients with ulcerative colitis (70 patients) and familial adenomatous polyposis (4 patients) underwent mucosectomy using the Harmonic Scalpel since 1997. We compared the clinical and functional results with those of the monopolar electrocoagulator (forceps coagulation technique, 86 patients with colitis and 7 with polyposis).

RESULTS

We performed graduated mucosal proctectomy by using the Harmonic Scalpel. The operative time (Harmonic Scalpel, 42 minutes vs. forceps coagulation technique, 85 minutes) and blood loss (Harmonic Scalpel, 33 ml vs. forceps coagulation technique, 86.8 ml) were significantly reduced by this method. The Harmonic Scalpel enabled restorative proctocolectomy by the synchronous approach within three hours. The functional results and complications were not significantly different between the two groups.

CONCLUSION

The Harmonic Scalpel shortened the operative time, decreased blood loss, and was useful for restorative proctocolectomy in our study.

[Changes in colitis surgery. II: Corrective interventions and conversion operations]

Over a period of 9 years in 48 patients already operated on for ulcerative colitis secondary surgical interventions had to be planned. 25 patients had an ileostomy (IS), 10 a Kock-pouch (KP), 11 an ileoanal pouch (IAP) and 2 an ileorectal anastomosis (IRA). Whereas in 4 patients only the subjective wish for another procedure with better quality of life predominated, in 44 patients (91.7%) also objective, sometimes multiple indications for reoperation existed. In 37 patients main indications were complications or dysfunctions of the preexisting procedures, combined with the need for further resection of the colitis in 6 of them. Resection of the residual colitis was the main indication in the remaining 7 patients. The aim of the reoperation in all patients was both complete elimination of the eventually persisting colitis and restoration of quality of life in the best way wished or possible. Our of 25 IS 3 remained, 3 were reconstructed, 17 were converted to KP and 2 to IAP. Out of 10 KP one remained and in 9 corrective surgery of the nipple valve was performed. Out of 11 IAP 2 had to be resected with construction of IS, 5 were converted to KP and 4 were corrected. Two IRA were converted to IAP. The rate of early complications was 8.3% (n = 4), lethality was zero. Late complications occurred in 13 cases (27.1%) and were associated ten times with KP. Complications of KP decreased with time to zero due to technical modifications. They could always be corrected restoring function. Since only one KP had to be resected due to severe pouchitis, KP was an important secondary procedure for 31 out of 48 patients also in the long-term course ensuring both complete elimination of colitis and good quality of life owing to voluntary fecal control.

[Changes in colitis surgery. I: Is there a standard in primary surgical treatment?]

In a 15 years period surgery of ulcerative colitis expanded from ileostomy (IS) via Kock's pouch (KP) and ileoanal pouch (IAP) to ileorectal anastomosis (IRA). Interactions between availability of methods and frequency of operations are investigated retrospectively in order to establish an optimal primary procedure. With an overall amount of 80 operations the yearly operative frequency raised in correlation to the introduction of continence reconstructive procedures. As a consequence of this fact history of disease was shortened to less than 8 year and global colitis-associated morbidity markedly decreased. For patients readiness to undergo operation Kock's pouch was only important at the beginning (n = 9/11.3%). Most decisive was IAP (n = 49/61.3%) which could be realized last even in an one-stage-procedure with better early results due to improved patients conditions and simplified technical modifications. IRA (n = 7/8.8%) played only a limited role in the last years for selected patients, whereas IS (n = 15/18.8%) kept reserved for contraindications to reconstructive surgery. For all procedures operative complications decreased from 46.1% (12/26) to 11.0% (6/54) and lethality to 0%. Late complications were related to proctectomy (nerve damage) and construction of IAP (pouchitis in 34.8% and defunctioning of the pouch in 10.4%), whereas IRA was free of specific morbidity so far. Surgery of ulcerative colitis is characterized today by restoration of anal continence. The advantage of the changed surgical concept lies within the ability to perform colectomy at an earlier stage of the disease. Safe construction of IAP is the most important technical progress. Early operation of colitis and late morbidity of pouch justify (preliminary) IRA. Thus, surgical standard in colitis-surgery is defined more individually.

[Development of ileal J-pouch anal anastomosis]

The practical procedures of ileoanal anastomosis (IAA) has developed through the two independent lines of thinking. The one idea involved pooling of the intestinal content in an ileal reservoir as S-shaped pelvic pouch by Parks. The other was the concept of rectal mucosal replacement by Peck who grafted a ileal mucosal segment within the totally denuded preserved rectal cuff. The author followed on the later concept and constructed an laterally anastomosed antiperistaltic looped ileum with which the pouch was able to joint directly to the anus in a side to end fashion to form a structure similar to the natural rectal ampulla and always spontaneously evacuable. Currently most of the surgeons in the world who perform IAA use the technique of the J pouch and in the present department, IAA has been performed on 150 patients with UC and 120 with FAP during the last 13 years and the number of these patients is ever increasing. These evidences suggest the operation that has been established is the superior above the other alternative techniques of proctocolectomy.

Causes of failure and life expectancy of the ileoanal pouch

180 ileoanal pouches constructed over 10 years and followed for at least 2 years (154 for Inflammatory Bowel Disease (IBD) and 26 for Familial Adenomatous Polyposis (FAP)) were reviewed. 23 pouches have been excised to date, 8 remain defunctioned (pouch failure FAP 7.7%, IBD 18.8%). The reasons for excision were: ischemia (n = 6), pelvic sepsis (n = 5), severe stenosis (n = 3), underlying Crohn's disease (n = 3), poor function (n = 5) and fistula (n = 1). The reasons for defunction were: Crohn's disease (n = 1), pelvic sepsis (n = 5) and ileoanal stenosis (n = 2). The projected overall pouch survival rate (Life table analysis) at 5 years was 81% (confidence interval 74-87%). Beyond 7 years, the figures to calculate survival became unreliable (small numbers). There was a significant association between pouch failure and pelvic sepsis (Fisher's exact test P < 0.0001) and between failure and fistula formation (P < 0.02). Multiple regression analysis showed pelvic sepsis and recurrent pouchitis to be independent factors of pouch failure. Pouch failure can occur many years after initial operation. Long-term follow up is recommended.

Changing referral patterns for surgical treatment of ulcerative colitis

OBJECTIVE

To determine whether referral patterns for surgical treatment among patients with chronic ulcerative colitis have changed in recent years, especially in view of the introduction of a new operation, the ileal pouch-anal anastomosis (IPAA).

MATERIAL AND METHODS

Between January 1976 and December 1986, 981 patients underwent proctocolectomy at Mayo Clinic Rochester. Brooke ileostomy (N = 300), colectomy with ileorectal anastomosis (N = 33), proctocolectomy with Kock pouch (N = 180), or ileal pouch-anal anastomosis (IPAA) (N = 468) was performed. The indications for surgical intervention were categorized as emergent or elective, the latter including intractability, cancer, and cancer prophylaxis. For analysis, the duration from diagnosis of disease to operation, indications for surgical treatment, and types of operation were subdivided into pre-IPAA era (before 1981) and post-IPAA era (from 1981 onward) for the entire group and for distant versus local patients.

RESULTS

More continence-preserving operations were done in 1981 and thereafter (76%) than before 1981 (46%). In the later segment of the study period in comparison with before 1981, fewer operations were done for emergent reasons (4% versus 8%) and a greater percentage of operations were done for elective indications, especially intractability (74% versus 61%). With the advent of IPAA in 1981, patients underwent operation sooner after the diagnosis was made (7.4 years versus 8.6 years before 1981). A smaller proportion of patients underwent operation for cancer prophylaxis during 1981 through 1986 (19%), however, than before 1981 (28%).

CONCLUSION

Referral patterns for surgical treatment of patients with ulcerative colitis have changed in recent years--patients are being referred for operation sooner, before complications develop that necessitate emergent procedures. Although the changed referral pattern may be due to the availability of IPAA, other factors may also have a role.

Quest for continence: surgery for ulcerative colitis and familial adenomatous polyposis

In the past decade pelvic pouch procedure (restorative proctocolectomy) has become the surgical treatment of choice for ulcerative colitis and most cases of familial adenomatous polyposis. It is an operation that eradicates disease yet restores gastrointestinal continuity and maintains continence.

Colonic pouch after low anterior resection of the distal third of the rectum

Very low anterior resection with construction of colo-anal anastomosis for carcinoma of the distal third of the rectum may result in an increased bowel frequency and urgency. These latter problems have been correlated directly with the decreased capacity and compliance of the neo-rectum. Clinical trials have shown a significant advantage of the colonic pouch-anal anastomosis over conventional colo-anal anastomosis in decreasing post-operative bowel frequency and urgency as the former increases neo-rectal capacity. Recent innovations in pouch design and construction with the ingenious use of mechanical stapling devices will enable the widespread use of the colonic pouch to benefit more patients who require very low anterior resection for carcinoma of the distal third of the rectum.