Laparoscopic Subtotal-Colectomy for fulminate Ulcerative Colitis
Laparoscopic subtotal-colectomy for fulminate ulcerative colitis
F Court, RHR Soulsby, KLR Cross, 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
Objective. The aim of this study was to analyse the outcome of subtotal colectomy for fulminate ulcerative colitis carried out by laparoscopic surgery.
Methods. A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and October 2004 has been used to identify surgical outcomes in 28 consecutive patients who have undergone laparoscopic subtotal colectomy (LSTC) and Brooke ileostomy.
Results. Twenty-eight patients (18 male), median BMI 26 have undergone LSTC over a three and a half year period: 18 were emergencies for acute severe colitis, 10 refractory to long term medical therapy and unfit for a restorative proctocolectomy. All were receiving high dose steroids; azathioprine (7), cyclosporin (2). The median operation time was 165 minutes; time has not decreased with experience. There were no deaths. Patient controlled analgesia continued for a median of 48 hrs. The median time to normal diet was 48 hrs and median hospital stay 8 days. Twenty have since undergone proctectomy and restorative ileal-anal pouch (16 performed laparoscopicaly); dense adhesions precluded a laparoscopic approach in 4. All are satisfied with outcome and superior cosmesis.
Conclusion. LSTC in fulminate and medically resistant ulcerative colitis is a feasible, safe and predictive operation that allows for early hospital discharge. It also appears to facilitate subsequent pelvic pouch construction. We are encouraged to continue to offer our patients the option of a laparoscopic resection. Colonic perforation, however small is now considered a relative contraindication.
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 here 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. In addition to patient benefits, laparoscopic techniques also offer the advantages to the surgeon eg the greatly magnified view.
The complexity and risks of a surgical intervention in ulcerative colitis are at there greatest in fulminate disease refractory to full systemic immunosuppresion. Not only are these patients at high risk for complications, but the inflammatory process often produces friable tissue and adhesions. Subtotal colectomy is used to control the disease process and allow restoration of immunological and nutritional status prior to undertaking a restorative procedure. Whilst LSTC is very appealing to this group of patients who are generally young and we would hope would obtain the potential benefits of decreased disability and better body image accrued from a more cosmetic incision, the role of laparoscopy in this setting is poorly defined and controversial.
Having moved to routine laparoscopic appendicectomy5 and TEP hernia repair6 we offer laparoscopic colorectal surgery to all but a highly selected group of individuals. We report our up to date experience of LSTC.
Patients and methods
A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and October 2004 has been used to identify surgical outcomes in 28 consecutive patients who have undergone laparoscopic STC. All were made aware that the laproscopic approach was new and controversial; each gave informed consent. Eight open resections were performed during the same period; suspect perforation, out of hours surgery (2), equipment unavailability (2), liver transplant for primary sclerosing cholangitis, BMI >40 and megacolon.
All elective patients had their colon cleansed with Fleet Phospho-soda (De Witt) to facilitate removal of the colon through the ileostomy site. “Emergency” patients were similarly prepared if an abdominal x-ray showed evidence of heavy faecal loading. 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. A 12-mm port is placed in the umbilical tube using an open approach. A 10mm 300 laparoscope is used throughout. Additional threaded disposable ports were placed under vision; 12mm at the site of the proposed ileostomy (as lateral as possible), 5mm port approximately 12cm below. The exact site was dependent on the patients body habitus.
With the patient in reverse Trendelenburg and rotated to the right, dissection begins in the left lower quadrant. The colon is retracted using atraumatic DeBakey-type forceps and the bowel mobilised using the Harmonic Scalpel (Ethicon Endosurgery). The mesentery is divided close to the bowel wall (about 2cms) and the dissection carried out medial to lateral. It is important to fully mobilise the splenic flexure from Gerota’s fascia. The patient is rotated to the left and approaching from the left and or between the abducted patient legs, the ascending colon is mobilised starting with the caecum, appendix and terminal ileum. The preserved greater omentum is retracted over the surface of the liver to allow easier mobilisation of the transverse colon; appropriate application of traction and countertraction and the maximal use of gravity facilitates this dissection. The omentum and transverse mesocolon in the majority is approached from the patient’s right. The patient is then placed in steep Trendelenburg and the distal sigmoid divided using the ATW45 – green cartridge (Ethicon Endosurgery). The divided colon is grasped and carefully delivered through the newly prepared ileostomy site (where the 12 mm port had been). The small bowel is divided and the ileostomy constructed. A drain is placed into the pelvis via the 5mm port. The umbilical port site is closed and the wounds infiltrated with local anaesthetic. In no case did intra-operative clinical judgement dictate it necessary to bring out the distal stump as a mucus fistula. The rectum was drained with a 22F urinary catheter.
Patients were allowed fluids as tolerated. Patients were mobilised the following morning and offered a light diet. Analgesia was provided by intra-operative fentanyl, diclofenac and paracetamol followed post-operatively by patient controlled analgesia (morphine). Discharge was determined by the stoma nurses assessment of competency at ileostomy management.
Laparoscopic subtotal colectomy with end ileostomy (LSTC) was performed in 28 patients; 18 males. The median age was 42 years (range 23-83), median weight 76 kg (median BMI 26 (range 19-35). 18 had severe disease and were performed as “emergencies” on elective lists; 10 had failed long term medical management and were considered too unfit for a restorative proctocolectomy. All were on high dose steroids (18 intravenous) at the time of surgery; azathioprine (7) and cyclosporin (2). The median operation time was 165 minutes (range 115-280 minutes).
There was one “conversion”; a small midline incision to deliver a colon which had a small localised perforation (unsuspected preoperatively and once identified laparoscopically repaired) and allow a more generous peritoneal lavage. Unfortunately this patient went on to develop small sub-phrenic and hepatic collections that required a re-laparotomy; the wound was left to heal as a laparostomy. She was discharged home after 72 days.
Operative time has not decreased with increasing experience and appears not to relate to patient sex, BMI or severity of disease. Post-operative analgesia was provided by PCA for a median of 48hrs (range 24hrs - 4 days); PCAs were discontinued after 48hrs in 76%. The median dose of morphine administered was 48mgs (22 – 259mgs). The median time to resumption of light diet was 48 hrs (range 24hrs - 7 days).
There were no other intra-operative complications, inadvertent colotomies or post-operative deaths. Twenty patients (69%) had an uncomplicated recovery. Two emergency patients required brief 24hr nasogastric decompression for delayed gastric emptying. Two experienced high output ileostomy flux, one of who was readmitted with acute pre-renal failure. Three patients experienced temporary small bowel hold up where their ileostomy passed through their abdominal wall. Wound (stoma) infection was seen in three patients; one followed a small leak of faecal material from the stapled off end of the colon delivered caecum first. Other complications included atrial fibrillation (2) and chest infection (1). Four patients received a blood transfusion, three for correction of pre-operative anaemia. The median hospital stay was 8 days (range 6-72).
Twenty patients have since undergone a completion proctectomy and restorative ileo-anal pouch. In 16 cases the proctectomy was performed laparoscopically and the pouch constructed utilising a small pfannensteil incision. Dense adhesions precluded this minimal access approach in the remaining four patients. All 17 patients who have had their covering ileostomy closed are fully continent of flatus and stool, are able to suppress urgency and have a median pouch frequency of 4/24 hrs (3-7). None admit to having developed problems with potency, orgasm sensation, ejaculation, micturition or dysparunia. All 17 patients are highly satisfied with the outcome of their operation and the cosmetic results.
Continuous technological innovation has encouraged surgeons to attempt more complex laparoscopic colorectal interventions. The objectives of the laparoscopic approach 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. Not only are these patients at high risk for complications (sepsis and poor healing) arising out of their immunosupression, but their inflammatory process also produces its own problems. Specifically, the mesentery can be very friable and vascular with obliteration of the normal retroperitoneal planes. Whilst open inflammatory bowel disease surgery can be demanding in itself, with increasing surgical skills, refinement of techniques and improvements in instrumentation, we believe that a laparoscopic approach to the management of ulcerative colitis has now become a logical and viable extension.
Reports of laparoscopic surgery to treat inflammatory bowel disease are few and far between, with small patient populations. Most have centred on Crohn’s disease. Reports on laparoscopically-assisted subtotal or total colectomy for ulcerative colitis, in contrast are quite limited7,8. Marcello’s case control study of 40 patients7 reported that LTC was associated with an earlier recovery of bowel function (2 versus 8 days; p<0.03) and shorter length of 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” results8 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%. A similar level of morbidity (30%) was reported in an earlier report of 30 colectomies9.
Peters was the first to look at the feasibility of laparoscopic total proctocolectomy10 in two patients with ulcerative colitis. An early comparison11 of the efficacy of laparoscopic compared to the traditional open approach demonstrated no advantages in terms of length of ileus or hospital stay; laparoscopy was associated with higher levels of morbidity (68% v 35%). We have recently reported on our experience of laparoscopic proctocolectomy with restorative ileoanal pouch12. The median times for surgery was 260 minutes, full diet 48hrs, hospital stay 7 days.
No randomised studies on the efficacy of laparoscopic sub-total colectomy have so far been published. However, there are very few randomised trials, even for common operations that compare open and laparoscopic techniques and even fewer that demonstrate an advantage one way or another. However, the majority of surgeons and even fewer patients would dispute that laparoscopy has become the standard approach for cholecystectomy and fundoplication, laparoscopic surgery having made the morbidity associated with traditional methods more evident. We would hope that most surgeons would agree that abdominal wall preservation is a definitive and undisputed advantage over open laparotomy!
Whilst our patients were delighted with the cosmetic results of their surgery, a recent small comparative study13 in restorative proctocolectomy just failed to demonstrate a significantly higher body image score compared with that obtained following conventional surgery; cosmetic scores however, were significantly higher in the laparoscopic group. This study showed no difference in functional outcome and quality of life scores between the two treatment modalities.
A final consideration is cost benefit. Simple ways to save money are through a quicker postoperative recovery, fewer complications, earlier 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 to repair 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 anaesthesia 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 show that laparoscopic sub-total colectomy with end ileostomy in fulminate ulcerative colitis is technically feasible and can be performed with out an unduly lengthy operation. More importantly, it is also 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. In light of our experiences we would voice a note of caution in continuing with LSTC when a perforation is discovered.
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