Laparoscopic Surgery for Ulcerative Colitis
Laparoscopic emergency and elective surgery for Ulcerative Colitis
Lucy Fowkes, K Krishna, A Menon, GL Greenslade*, AR Dixon,
Dept Colorectal Surgery and Anaesthesia*
Frenchay Hospital, North Bristol NHS Trust, BS16 6UT
Correspondence to Mr AR Dixon
E.Mail – Anthony.Dixon@nbt.nhs.uk
Objective. Analyse surgical outcomes of fulminate & medically resistant ulcerative colitis (UC) carried out laparoscopicaly.
Methods. A prospective database identified 69 consecutive patients who underwent surgery for UC under the senior author over a 5 yr period to April 2006.
Results. 32 patients (18 male), median BMI 26 underwent laparoscopic sub-total colectomy (LSTC): 22 acute emergencies, 10 refractory to medical therapy and unfit for restorative proctocolectomy. All were receiving IV steroids; azathioprine (7), cyclosporin (5). The median operation time was 135mins (65-280). There was one conversion. 29 have subsequently undergone completion proctectomy and W-pouch formation (24 were performed laparoscopically - LCP); widespread adhesions precluded this in 5. 26 underwent restorative laparoscopic proctocolectomy (LRP) - one conversion. 20 underwent W-pouch reconstruction via a Pfannenstiel incision. Six J-pouches were constructed and returned via the ileostomy site. Three underwent a laparoscopic pan-proctocolectomy (LPPC); 1 conversion. Eight patients underwent open STC.
The median time to normal diet was 48 hrs (1 – 7 days) for LSTC/LCP and 36 hrs (1-5 days) LRP. There were 2 major complications following LRP, 2 following LSTC, 1 following LCP, 1 following LPPC and 5 following open surgery. Median hospital stay was 8 days (6-72) LSTC, 7 days (6-9) LCP and 5 days (3-45) LRP. There were six 30-day readmissions following laparoscopic surgery (DVT, reactive depression, ileostomy hold up (2), abdominal pain, high output ileostomy).
Conclusion. Laparoscopic subtotal and restorative proctocolectomies in fulminate and medically resistant ulcerative colitis are feasible, safe and largely predictable operations that allow for early hospital discharge. Laparoscopic colectomy facilitates subsequent proctectomy and pouch construction.
Key words: laparoscopic colectomy, laparoscopic restorative proctocolectomy, ulcerative colitis – fulminate disease/medically resistant
Laparoscopic colectomy is an exciting adjunct to traditional surgery. It is however, one of the more difficult operations with a relatively steep learning curve. Few would dispute that laparoscopy has not only revolutionised fundoplication, bile duct exploration and splenectomy but has also made the morbidity associated with traditional surgery very evident. Numerous1-4 large randomised, meta-analysis and case-controlled studies comparing laparoscopic and open colonic surgery have demonstrated significant reductions in ileus, pain, length of stay and earlier return to domestic activities in favour of the laparoscopic approach. In addition, there is some evidence5 that direct costs may fall as a result. The most obvious patient benefit is preservation of their abdominal wall and superior cosmesis. For surgeons, laparoscopy offers a greatly magnified view.
The complexity and risks of a surgical intervention in ulcerative colitis are at their greatest in fulminate disease refractory to systemic immunosuppresion. Not only are these patients at high risk for developing complications, the inflammatory process produces friable, oedematous tissue. Subtotal colectomy is used to control the inflammatory process and allow full restoration of immunological and nutritional status prior to undertaking the more complex restorative procedure. Whilst laparoscopic restorative proctocolectomy with ileoanal pouch (LRP) or laparoscopic sub-total colectomy (LSTC) followed by a laparoscopic completion proctectomy and restorative ileoanal pouch (LCP) are very appealing to this group of patients who are generally young and in whom we would hope to obtain the benefits of decreased disability and better body image, the role of laparoscopy in this setting is poorly defined and highly controversial. We report our up to date experience of using this approach to our management of ulcerative colitis.
Patients and methods
A prospectively collected, institution approved and password protected electronic database of all colorectal laparoscopic procedures performed between April 2001 and May 2006 was used to identify surgical outcome in 69 consecutive patients who underwent 85 laparoscopic interventions for ulcerative colitis. All had been made aware that the laparoscopic approach was both new and controversial: each gave informed consent. Eight open sub-total colectomies were undertaken during the same period; suspected perforation, out of hours surgery (2), equipment unavailability (2), liver transplant for primary sclerosing cholangitis, BMI>45 and toxic megacolon.
All patients were placed in the dorsi-lithotomy position using Allen stirrups, arms extended by their side and minimal hip flexion. All received single dose gentamicin (4mg/kg) and metronidazole prophylaxis. The surgeon and camera-operator stand on the side opposite to the site of dissection. Monitors are placed on either 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 lateral suprapubic ports on each side.
With the patient in reverse Trendelenburg and rotated to the right, dissection begins in the left lower quadrant. The colon is retracted using fenestrated Johan forceps (Karl Storz) and the bowel mobilised using the Harmonic Scalpel (Ethicon EndoSurgery). The mesentery is divided close to the bowel wall (about 2cms). The patient is rotated to the left and approaching from the left and or between the legs, the ascending colon is mobilised starting with the caecum and terminal ileum. The preserved greater omentum is retracted over the liver to allow mobilisation of the transverse colon; appropriate application of traction and counter traction and the maximal use of gravity facilitates this dissection. The majority of the transverse dissection is approached from the patient's right.
For patients undergoing restorative proctocolectomy, start with a nerve sparring proctectomy. In women, it is generally possible to close the gut tube 1cm above the dentate line using an ATG45 (Ethicon EndoSurgery) linear stapler. Using counter pressure on the perineum it is possible to almost angle and close the ATG45 (Ethicon EndoSurgery) at 90o. The pressure has to be released to allow the stapler to re-align at 45 degrees and so allow the firing mechanism to be activated. The distal sigmoid is divided in sub-total colectomy cases with the ATG45 (Ethicon EndoSurgery).
The divided rectum (restorative proctectomy cases) or colon (sub-total colectomy cases) is grasped and slowly delivered through a newly prepared and dilated ileostomy site (where the 12 mm port had been). The small bowel is divided and the ileostomy or J-pouch constructed (6 patients). Otherwise a 6-8cm Pfannenstiel incision was utilised to close the gut tube using a TX30G (Ethicon EndoSurgery), deliver the specimen and construct a 12cm w-pouch. Panproctocolectomy specimens are delivered through the pelvic floor (intersphincteric dissection) after division of the ileum.
In laparoscopic proctectomy and ileoanal pouch cases, the operation starts with open mobilisation of the ileostomy and closure of the bowel. A purse string suture taking peritoneum and anterior rectus sheath is tied around a 12-mm port. The latter is used for insufflation. Surgery begins with scissor adhesiolysis, particular attention been placed on mobilisation of the ileocolic vascular bundle up to the base of the superior mesenteric artery. With the patient in reverse Trendelenburg and rotated to the right the small bowel is moved to the upper abdomen. Rectal dissection begins with a medial to lateral approach to the superior rectal vessels and then continued in the mesorectal plane to the pelvic floor.
A drain is placed into the pelvis via a 5mm port. The umbilical port is closed and the wounds infiltrated with local anaesthetic. In no case did intra-operative clinical judgment dictate it necessary to bring out the distal rectal stump as a mucus fistula. The rectum was drained in STC patients with a 22F urinary catheter. Patients were allowed fluids as tolerated, 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 morphine. Discharge was determined by the stoma nurses assessment of patient competency at ileostomy management. A diverting loop ileostomy was used for all reconstructive cases.
Laparoscopic subtotal colectomy with end ileostomy (LSTC) was performed in 32 patients: 18 males. The median age was 42 years (range 23-83), median weight 76 kg (median BMI 26 (range 19-35). 22 had severe disease and were performed as emergencies; 10 had failed long term medical management and were considered too unfit for a restorative proctocolectomy. All were receiving high dose steroids at the time of surgery; azathioprine (7) and cyclosporin (2). The median operation time was 135 minutes (range 65-280 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 developed small subphrenic and hepatic collections that required a re-laparotomy; the wound was left to heal as a laparostomy. She was discharged home on day 72. A successful open restorative proctectomy and W-pouch was performed 14 months later.
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 28mgs (8 - 259mgs). The median time to resumption of diet was 48 hrs (24hrs-7 days).
Twenty patients (63%) had an uncomplicated recovery. Two emergency patients required brief 24hr nasogastric decompression for delayed gastric emptying. Two experienced high output ileostomy flux; one 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 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 7 days (range 5-72).
Laparoscopic completion proctectomy (LCP) and ileo-anal pouch formation was performed in 26 patients (14 males). There were five early conversions (20%) to a full midline laparotomy. The reason, in each case was widespread four quadrant fibrotic adhesions; each proved to be a technical challenge and required scalpel dissection. The median operation time for the completed LCPs was 145 minutes (range 105-245 minutes). Adhesion formation in these 21 patients was minimal and confined to the `free edge' of the small bowel mesentry. The retained greater omentum was freely mobile in all cases. A W-pouch was constructed utilising a Pfannenstiel incision. Post-operative analgesia was provided by PCA for a median of 36hrs (range 24hrs - 7 days). The median time to resumption of diet was 48 hrs (range 24hrs-7 days).
On the first evening one pouch anal anatomises bled. A haematoma was evacuated on day 4; the pouch was unaffected. The patient was discharge on day nine and later readmitted with a below knee DVT. A further patient experienced temporary mechanical hold up at the ileostomy and one a wound infection. There were no problems with gastric emptying. 26 patients (90%) had an uncomplicated recovery. The median hospital stay was 7 days (range 6-9). All 26 patients have since had their ileostomy closed; all are fully continent of flatus and stool and are able to suppress faecal urgency. On direct questioning, none admit to having developed problems with potency, orgasm sensation, ejaculation, micturition, vaginal dryness or dyspareunia.
26 underwent a two stage restorative laparoscopic proctocolectomy with covering ileostomy (LRP); 20 W-pouches constructed via a small Pfannensteil and 6 J-pouches via the ileostomy port site. Their median age was 33 years (range 16-76), median weight 67 kg median BMI 24 (range 18-35). There was one conversion (time constraint). The median operation time was 190 minutes (range 140-330 minutes). Post-operative analgesia was provided by PCA for a median of 24hrs (0-4days). The median time to resumption of diet was 36 hrs (1-5 days). 22 patients had an uncomplicated recovery. Complications comprised intra-operative coagulopathy (1), wound infection (3), superficial dehiscence (1). The median hospital stay was 5 days (range 3-45). There were six 30-day readmissions: reactive depression/anorexia requiring psychiatric treatment, ileostomy hold up (2), abdominal pain (1), DVT and a muco-cutaneous stomal fistula.
Eight patients underwent open sub-total colectomy; suspected perforation, out of hours surgery (2), equipment unavailability (2), liver transplant for primary sclerosing cholangitis, BMI>45 and toxic megacolon. Five suffered major complications; peritonitis, coagulopathy, near fatal liver haemorrhage, emergency proctectomy, enteric cutaneous fistula, PE (1), prolonged ileus, spontaneous small bowel perforation, late incisional hernia (1), acute renal failure from high output ileostomy, small bowel obstruction (1) renal failure, high output stoma, jejunostomy, ambulatory total parenteral nutrition. (1). A final patient developed a pouch vaginal fistula at 11 months.
Of the three patients who underwent laparoscopic panproctocolectomy, the converted case (BMI 39) was complicated an ischaemic ileostomy which required a second laparotomy. At a later date the stoma was re-sited and two incisional hernias repaired.
Continuous technological innovation encourages surgeons to attempt more complex interventions. The objectives of a laparoscopic approach are reduced levels of pain, wound infection, transfusion requirements, a rapid return of gastrointestinal function allowing early mobilisation hospital discharge and return to normal life. Long-term goals include the avoidance of incisional hernias, adhesions and superior cosmesis. Although laparoscopic surgery has been employed in a variety of colorectal settings, many surgeons remain sceptical about its application in inflammatory bowel disease. Not only are these patients in themselves at high risk for developing complications (e.g., sepsis and poor healing) arising out of their immunosuppression, but their inflammatory process also produces its own problems. Specifically, the mesentery tends to be vascular, laden with lymph nodes and very friable with further obliteration of the normal retroperitoneal planes. Whilst open inflammatory bowel disease surgery can be demanding in itself, with increasing 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.
Several centres have shown the feasibility of laparoscopic restorative proctocolectomy6-9. There is little comparative data on restorative proctocolectomy performed via the conventional open or minimally invasive approach. Reports on laparoscopically assisted subtotal (LSTC) or total colectomy for ulcerative colitis are more limited. Patient populations are small and most have centred on Crohn's disease. Marcello's case control study6 of 40 patients reported that LSTC was associated with an earlier recovery of bowel function (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 complications. Bell et al., reported "favourable" results10 for LSTC in 18 patients with fulminate ulcerative colitis. Whilst length of stay was shorter than that seen in a group of 6 patients undergoing open surgery, postoperative complications occurred in 33%. Similar levels of morbidity (30%) were reported in an earlier series of 30 colectomies11.
An early comparison12 of the efficacy of laparoscopic restorative proctocolectomy (LRP) compared to the more traditional open approach demonstrated no advantages in length of ileus or hospital stay; laparoscopy was also associated with higher levels of morbidity (68% versus 35%). In their 2005 report of 50 LRP, Kienle et al9 reported a conversion rate of 8%, median operation time of 320mins, length of stay 12 days; 30% of patients had complications! We have reported13 our early experience of laparoscopic proctocolectomy with restorative ileoanal pouch; the median time for surgery was 260 minutes, resumption of full diet 48hrs with a hospital stay of 7 days.
There are no randomised studies on laparoscopic sub-total colectomy. However, there are very few large randomised trials, even for common operations that compare open and laparoscopic techniques and even fewer that demonstrate an advantage one way or another. We would suggest that the majority of surgeons and even fewer patients would dispute the fact that laparoscopy has become the standard approach for cholecystectomy and fundoplication, laparoscopic surgery having made the morbidity associated with traditional surgical methods very evident. Hopefully, most surgeons would agree that abdominal wall preservation and the improved cosmetic result in this predominantly young group of patients is a definitive and undisputed advantage!
Whilst our patients were all delighted with the cosmetic results of their individual surgery, a recent comparative study14 in restorative proctocolectomy 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 small study showed no difference in functional outcome and quality of life scores between the two contrasting approaches to treatment.
We have shown 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, predictable and leads to an earlier discharge and postoperative recovery. By definition it also prevents late incisional hernia development. Our experience would suggest to us that bowel preparation is important in allowing an easier and safer removal of the colon through the ileostomy site. If there were any colonic perforation, however small, we would now advocate immediate open conversion, as laparoscopic peritoneal lavage is insufficient.
This approach allows us to offer our patients at a later date the option of a safe laparoscopic small bowel adhesiolysis and restorative proctectomy. Other groups have also shown that following laparoscopically assisted emergency colectomy, restorative proctectomy can be safely performed through a Pfannenstiel incision. In their case matched study15 of 17 patients, the median operative time was 186 minutes, 28mins longer than via a midline laparotomy. The median hospital stay in the Pfannenstiel group was 10 days (versus 12); complications were similar. We have two concerns with this approach. Pfannenstiel incisions, unless very large, do not offer good exposure for a small bowel adhesiolysis, mobilisation of the ileocolic and superior mesenteric vessels necessary for an ileo-anal pouch or rectal mobilisation within the mesorectal plane, particularly anteriorly or deep within the pelvis. They do provide good access for stapling the gut tube. When Buchler’s group9 moved over to a total laparoscopic dissection with specimen retrieval/pouch construction via a small umbilical incision they reported a significantly reduced blood loss and consequent lack of requirement for a perioperative blood transfusion. We believe that the magnification afforded by the laparoscope allows a better an identification of the anatomical plane when performing total mesorectal excision. Laparoscopic surgeons may well be more meticulous about haemostasis as any bleeding or staining of tissue planes impairs vision through light absorption.
Pfannenstiel incisions it must be remembered are not without complication; reduced sensation in the overlying skin, chronic pain, impaired cosmesis and a risk of long term hernia development. Now that we have become more expert at laparoscopic division of the gut tube at the level of the pelvic floor, we have abandoned our long held view that a W is superior to a J pouch and should be performed at all costs, and where possible utilise the proposed ileostomy site to deliver the terminal ileum and create a J pouch and so negate the need for a Pfannenstiel incision. The overall complication rate in the present study is within the range of values previously reported for conventional surgery and reflects the risk of surgical morbidity in these patients17.
A final consideration is cost. Simple ways to save money are through having a quicker postoperative recovery, fewer complications, early discharge and return to work along with containment of equipment costs. Ultimately, laparoscopic colon and rectal surgery may reduce direct and total hospital costs at more experienced centres5,18. Although we have not as yet completed a comparison with open colectomy, we do believe that we are well on the way to achieving these goals and that coupled with the improved cosmesis, zero incisional hernia rate to date, the benefits are well worth the slightly longer operation time and the cost of both the harmonic scalpel (Ethicon EndoSurgery) and disposable ports. The latter cost is more than counterbalanced by a shorter induction/extubation time, avoidance of epidural anaesthesia and improved theatre throughput. Minimal access surgery as practiced in our unit also avoids the routine requirement for either over night recovery or high dependency nursing. In our experience these patients are also usually self-caring within 36hrs of surgery. 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.
However, early discharge from the hospital following laparoscopic colon and rectal operations has generated concern that patients may develop complications whilst at home that may result in increased rates of complication, unplanned readmissions and poorer outcomes19. These complications and readmissions could have a significant impact on the patient’s morbidity and risk of mortality in addition to increasing overall costs. These concerns may be unfounded given that the 30-day unplanned readmission rate for the 85 laparoscopic interventions in this series was 7.5%; most large series of laparoscopic colorectal procedures have a rate of around 10%1,20. The most common reason for readmission was bowel obstruction and ileus. What is perhaps surprising is the low rate of readmission given that inflammatory bowel disease and steroid administration have both been shown on univariate and multivariate analysis to predict readmission21.
The most obvious advantage of the minimally invasive compared to an open approach is the improved overall cosmetic result in what is predominantly a young group of patients. Recovery is faster and the hospital stay is shorter. On the other hand, significant increases in length of surgery have to be anticipated, as is a steeper and longer learning curve. Like many things in surgery, prospective randomised studies are needed before what can only be described as complex technical procedures, be considered the best option for the surgical management of this disease.
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