Laparoscopic proctectomy & restorative ileoanal pouch for Ulcerative Colitis
Laparoscopic proctectomy and restorative ileoanal pouch for ulcerative colitis
S Slawik, RHR Soulsby, AR Dixon
Dept Colorectal Surgery, North Bristol NHS Trust, Frenchay Hospital, Bristol BS16 1LE. UK
Correspondence to Mr Dixon. E Mail; Anthony.Dixon@nbt.nhs.uk.
Key words: Laparoscopic colorectal surgery, Ulcerative colitis, ileoanal pouch.
Objective. The aim of this study was to analyse the outcome of restorative proctectomy for ulcerative colitis carried out by laparoscopic surgery.
Methods. A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and April 2005 has been used to identify surgical outcomes in 24 consecutive patients who have undergone laparoscopic restorative proctectomy and ileoanal pouch (LRP) construction for ulcerative colitis.
Results. Twenty-four patients (14 male), median BMI 25 have undergone an attempted LRP over a four year period; all had previously undergone a laparoscopic subtotal colectomy for fulminate ulcerative colitis. Dense adhesions precluded a laparoscopic approach in five (20%) male patients. The median operation time of the 19 successful LRPs was 165 minutes. There were no deaths. The median time to normal diet was 36 hrs and median hospital stay 7 days. All 19 have had their temporary stoma closed. One developed fulminate ileostomy related intra-abdominal sepsis requiring a laparostomy. Following a period of home parenteral nutrition, he underwent a successful second attempt at closure of his laparostomy/small bowel fistula. 18 reversals are satisfied with outcome and cosmesis. The remaining patient has good pouch function in spite of being out of bowel continuity for 18 months.
Conclusion. LRP following previous laparoscopic sub-total colectomy (STC) is a feasible, safe and predictive operation that allows for early hospital discharge and excellent cosmesis. Laparoscopic STC caused very few adhesions in the majority 80% and appeared to facilitate restorative surgery.
Laparoscopic colectomy is an exciting adjunct to traditional operative modalities for colonic surgery. It is however, one of the more difficult operations to perform with a relatively steep learning curve. Compared to other interventions, the uptake and development of laparoscopic colorectal surgery has been very poor, particularly in the UK. Laparoscopic intervention has revolutionised fundoplication, bile duct exploration and splenectomy making the morbidity associated with traditional methods more evident. Inherent reduction in wound size with laparoscopic surgery has led to more rapid recovery with decreased pain and morbidity. Studies comparing laparoscopic and open colonic surgery demonstrate significant reductions in ileus1, pain, length of stay, return to domestic activities2 and improved cosmesis3. The most obvious benefit to the patient is the preservation of their abdominal wall. Laparoscopy also offers advantages to the surgeon eg., a greatly magnified view.
Restorative proctocolectomy (LRP) can be performed using minimally invasive techniques, the technical feasibility having been described in several series from specialised centres4-9. Many colitics however, are not in a position to undergo immediate restorative surgery presenting with either fulminate disease or disease (sepsis and poor nutrition) and treatment related morbidity arising out of their immunosupression. Reports on laparoscopic surgical treatment of inflammatory bowel disease are few and far between and with small patient populations. Having performed 28 laparoscopic subtotal colectomiesm (LSTC) for fulminate ulcerative colitis it seemed logical to then examine the efficacy of employing a minimally invasive approach in undertaking subsequent restorative procectomy.
Patients and methods
A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and June 2005 has been used to identify surgical outcomes in 48 consecutive patients who have undergone laparoscopic restorative proctectomy (LRP). 19 successful LRPs had followed a previous LSTC. All were made aware that the laproscopic approach was new and controversial; each gave informed consent.
Patients were placed in the dorso-lithotomy position using Allen stirrups, arms extended by their side and minimal hip flexion. All received single dose gentamicin (4mg/kg) and metronidazole. The surgeon and camera-operator stand on the side opposite to the site of dissection. Monitors are placed on each side. The operation starts with open mobilisation of the ileostomy; the bowel closed with a suture. A purse string suture is inserted taking peritoneum and anterior rectus sheath then tied around a 12-mm port. The latter is used for insufflation, the pneumoperitoneum being restricted to 14mmHg. A 300 laparoscope is used throughout. Additional threaded disposable ports are placed under vision; 12mm through the umbilicus, a 5mm port approximately 10-12cm below the ‘ileostomy port’. Exact sites are dependent on the patients body habitus.
The operation begins with a small bowel adhesiolysis (using sharp scissor dissection and DeBakey-type forceps for bowel retraction), particular attention is placed on fully mobilising the ileocolic vascular bundel up to the base of the superior mesenteric artery. With the patient in reverse Trendelenburg and rotated to the right the small bowel is placed in the upper abdomen. Rectal dissection then begins with a medial to lateral approach of the superior rectal vessels and then continued in the mesorectal plane down to the upper anal canal. Dissection is conducted predominantly with ultrasonic shears. The superior rectal vessels were ligated using Hem-o-Lock clips (Pilling Weck, High Wycombe, UK).
A 6cm Pfannenstiel incision is made to allow closure of the gut tube 1cm above the dentate line using the TX30G (Ethicon Endosurgery), transection and retrieval of the rectum. The small bowel is delivered through the wound and a 12cm W pouch constructed using continuous 3/0 Monocryl (Ethicon), without application of retractors. The anvil of a 29mm CDH (Ethicon Endosurgery) is secured in the anterior wall of the pouch with interrupted sutures. The pouch anal anastomosis is constructed under direct vision using a double staple technique. A suitable portion of ileum is chosen for the diverting loop ileostomy and drawn through the old ileostomy site. A pelvic drain is brought out of the inferior 5mm port site. The peritoneal cavity is irrigated with saline/savlon. The wound is then closed and infiltrated with 0.25% Bupivicane.
Patients were allowed fluids as tolerated, mobilised the following morning and offered a light diet. Analgesia was provided by intra-operative fentanyl, diclofenac and latterly paracetamol followed post-operatively by patient controlled analgesia (morphine). Discharge was determined by the stoma nurse’s assessment of competency at management of the new loop ileostomy.
Laparoscopic restorative proctectomy (LRP) was attempted in 24 patients (14 males). Their median age was 40 years (range 23-83), median weight 75 kg and median BMI 25 (range 21-33). There were five early conversions (20%) to a full midline laparotomy. The reason in each case was widespread four quadrant dense fibrotic adhesions; each case proved to be a technical challenge. The median operation time of the completed LRPs was 165 minutes (range 125-245 minutes). Adhesions in these 19 patients were minimal and confined to the ‘free edge’ of the small bowel mesentry. The retained greater omentum was freely mobile in each case.
Post-operative analgesia was provided by PCA for a median of 36hrs (range 24hrs - 7 days); 80% PCAs were discontinued by 48hrs. The median time to resumption of light diet was 48 hrs (range 24hrs - 7 days). There were no other intra-operative complications or post-operative deaths. One patient bled from the pouch anal anastomosis on the first post-operative evening. He underwent a laparotomy and evacuation of a haematoma four days later; the pouch was unaffected. The patient made a full recovery and was discharged home on day nine. He unfortunately then went on to develop a below knee DVT. One patient experienced temporary mechanical hold up at the ileostomy/abdominal wall and one a minor wound infection. There were no problems of gastric emptying. Sixteen patients (84%) had an uncomplicated recovery. The median hospital stay was 7 days (range 6-9).
19 patients have had their ileostomy closed, all are fully continent of flatus and stool, able to suppress urgency and have a median pouch frequency of 4/24 hrs (3-8). None admit to having developed problems with potency, orgasm sensation, ejaculation, micturition, vaginal dryness or dysparunia. 18 patients are highly satisfied with the outcome of their operation and the cosmetic result.
Continuous technological innovation has encouraged surgeons to attempt more complex laparoscopic colorectal interventions. The objectives are reduced postoperative pain, early mobilisation, reduced rates of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital, return to normal life, avoidance of incisional hernias and long-term improvements in cosmesis. Although laparoscopic intestinal surgery has been employed in a variety of settings, many surgeons have been sceptical about its application with inflammatory bowel disease.
Several centres have shown the feasibility of laparoscopic restorative proctocolectomy4-9. Reports on laparoscopically-assisted subtotal or total colectomy for ulcerative colitis are more limited5,10. Marcello’s case control study of 40 patients5 reported that LTC was associated with faster resolution of ileus (2 versus 8 days; p<0.03) and shorter stay (7 versus 8 days); p<0.02. Morbidity was similar and operative time was significantly longer (330 versus 230 minutes; p<0.001); there were no differences in rates of complications. Bell et al., reported “favourable” results10 for LSTC in a series of 18 patients with fulminate ulcerative colitis. Whilst length of stay was shorter than a group of 6 patients undergoing open surgery, postoperative complications occurred in 33%. Similar results have been reported by others11,12.
Others13 have shown that following laparoscopically assisted emergency colectomy for ulcerative colitis, restorative proctectomy can be safely performed through a Pfannenstiel incision. In their case matched study, the median operative time in 17 cases was 186 minutes, 28 mins longer than via a midline. Median hospital stay in the Pfannenstiel group was 10 days (versus 12); complications were similar. There are however, two important potential concerns with this approach. Pfannenstiel incisions do not offer good exposure for a small bowel adhesiolysis, mobilisation of the ileocolic vessels or rectal mobilisation within the mesorectal plane, particularly anteriorly or deep within the pelvis. They do provide good access for stapling the gut tube.
Having moved to routine LSTC for fulminate colitics unfit for concurrent restorative proctocolectomy14, the logical approach was to explore the feasibility of a minimal access approach to subsequent adhesiolysis and restorative proctocolectomy. The overall complication rate in this study is within the lower range of values reported for conventional open approaches15. The most obvious advantage of the minimally invasive compared to the conventional approach is undoubtedly the cosmetic result.
A final consideration is cost. Simple ways to save money are through having a quicker postoperative recovery, fewer complications, early discharge, return to work and containment of equipment costs. Although we have not undertaken a comparison with open colectomy, we believe that we are well on the way to achieving these goals and that they and the improved cosmesis, zero incisional hernias are well worth the slightly longer operation time and the cost of the harmonic scalpel (Ethicon Endosurgery). The latter cost is counterbalanced by a shorter induction/extubation time, absence of an epidural and no routine high dependency requirement. Our Trust’s accountants have recently conducted an independent exercise in costing laparoscopic anterior resection and right hemicolectomy. A substantially favourable comparison to open surgery has led them to continue to support our laparoscopic programme.
We have shown that laparoscopic sub-total colectomy with end ileostomy in fulminate ulcerative colitis followed at a later date by a laparoscopic assisted restorative proctectomy is technically feasible and can be performed without an unduly lengthy operation. More importantly, it is safe and predictable. We are encouraged to continue to offer our patients what some UK surgeons might consider controversial surgery. We do not however support triumph for technology over sound common sense. It is however, less invasive than open operation and preserves the abdominal wall.
1. Chen HH, Wener SD, Iroatulum AJ et al., Laparoscopic colectomy compares favourably with colectomy by laparotomy for reduction of postoperative ileus. Dis Colon Rectum 2000; 43:61-5.
2. Chen HH, Wexner SD, Weiss EG. Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared to laparotomy. Surg Endosc., 1998; 12: 1397-400.
3. Stag JG, Schulze S, Moller P et al., Prospective randomized study for laparoscopic versus open colonic resection for adenocarcinoma. Am.J.Surg., 1997; 84: 391-6.
4. Thiabault C, Poulin EC. Total laparoscopic proctocolectomy and laparoscopically assisted proctocolectomy for inflammatory bowel disease: operative technique and preliminary report.
Surg.Laparosc.Endosc., 1995; 5: 472-476.
5. Marcello PW, Milsom JW, Wong SK, Brady K, Goormastic M, Fazio VM. Laparoscopic restorative proctocolectomy: a case-matched comparative study with open restorative proctocolectomy. Dis.Colon Rectum 2000; 43: 604-8.
6. Dunker MS, Bemelman WA, Slores JFM, van Duijvendijk, Gouma DJ. Functional outcome, quality of life, body image and cosmesis in patients after laparoscopic assisted and conventional restorative proctocolectomy. Dis Colon Rectum 2002; 44: 1800-1807.
7. Ky AJ, Sonoda TM, Milsom JW. One-stage laparoscopic restorative proctocolectomy: an alternative to the conventional approach? Dis Colon Rectum 2002; 45: 207-211.
8. Laparoscopic proctocolectomy with retorative ileal-anal pouch. TS Gill, A Karantana, J Rees, S Pandey, AR Dixon. Colorectal Disease 6; 6: 458-461.
9. Kienle P, Z’graggen K, Schmidt J, Benner A, Weitz J, Buchler MW. Laparoscopic restorativeproctocolectomy. Br.J.Surg 2005; 92: 88-93..
10. Bell RL, Seymour NE. Laparoscopic treatment of fulminant ulcerative colitis. Surg Endosc., 2002; 16: 1778-82.
11. Reissman P, Salky BA, Pfeifer J, Edye M, Jagelman DG, Wexner SD. Laparoscopic surgery in the management of inflammatory bowel disease. Am J Surg 1996; 171: 47-51.
12. Dunker MS, Bemelman WA, Slors JF, van Hogezand RA, Ringers J, Gouma DJ. Laparoscopic-assisted vs open colectomy for severe acute colitis in patients with inflammatory bowel disease (IBD): a retrospective review in 42 patients.
Surg Endosc 2000; 14: 10; 911-914.
13. Maartense S, Dunker MS, Slors JFM, Gouma DJ, Bemelman WA. Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: a case-matched study. Colorectal Disease 2004 ; 6: 254-7
14. Court F, Soulsby RH, KTC Cross, AR Dixon. Laparoscpic subtotal colectomy for fulmiant ulcerative colitis. Colorectal Disease 2005 (In submission).
15. Nichols RJ, Gatzen C. Complications of pouch surgery. In Recent Advances in Coloproctology. Beynon J, Carr ND (eds). Springer: London, 1999; 1-29.