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10 yr experience of laparoscopic ileoanal pouch surgery

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06/06/2010

 Laparoscopic restorative procto-colectomy: a 10-year experience of an evolving technique

 

AC Goede, Angela Reeves* AR Dixon.  

Dept., Colorectal Surgery and Stoma care*  Frenchay Hospital, North Bristol NHS Trust, BS16 1LT

 

Corespondence: Mr Tony Dixon.

Anthony.Dixon@nbt.nhs.uk 

 

 

Keywords. Ileal pouch-anal anastomosis, Laparoscopic restorative procto-colectomy, SILS, Single port surgery

 

 

 

Introduction. Restorative procto-colectomy with ileoanal pouch is accepted as the definitive procedure in ulcerative colitis. The potential benefits afforded by a minimal invasive approach make it appropriate to consider provided that there is no adverse affect on functionality.

Methods.  Electronic data were prospectively collected from all patients who underwent laparoscopic restorative procto-colectomy (LRPC) from October 1999 to April 2010.

Results.  72 patients (40 male), median BMI 24 (19-48kg/m2) underwent LRPC over 10yrs: three had cancer. 42 had undergone a previous colectomy (laparoscopic in 38). 40 underwent W-pouch construction via a Pfannenstiel incision whilst 32 were J-pouches constructed and returned via the ileostomy site;7 were single port procedures. The median operation time was 210 mins (75-330). There were five conversions (7%), one of which resulted in an immediate pouch failure.  Median time to full diet was 36hrs (4-168hrs) with a median hospital stay of 7 days (2-64).  There were 7 readmissions (10%).  Complications included: immediate (3%), early  (22%) and long-term (11%). The incidence of failure (excision or indefinite diversion) was 2.7%.  67 stomas have been closed. All patients have spontaneity of defecation, with a median pouch frequency/24hrs of four, including once at night.  90% are fully continent and 98% able to defer during the day. None admit to new onset impotency, or dyspareunia.

Conclusion.  Laparoscopic restorative procto-colectomy is safe with good functional outcomes when performed by an experienced laparoscopic surgeon.

Introduction

Large, long-term randomized controlled trials of laparoscopic surgery for colorectal cancer (MRC CLASICC1, COST2 and Barcelona3 trials) have all concluded that it is not only safe, but it is associated with better short-term outcomes and without any compromise to long-term cancer survival.  NICE recommends4 that NHS trusts give patients the option of laparoscopic resection as an alternative to open surgery provided that appropriately trained surgeons perform it.

Restorative procto-colectomy can also be performed laparoscopically and some would say that ulcerative colitis lends itself to this particular approach (young patients, benign disease)5 -13. However, when carried out in this situation, laparoscopic surgery is both technically challenging and time consuming; findings that will no doubt add to the ongoing debate regarding precisely how and where pouch surgery should be conducted. The aim of this study was to report our up-to-date experience of laparoscopic assisted and “total” laparoscopic restorative procto-colectomy (LRPC) and highlight the difficulties encountered And the functional results that can be obtained.

 

 Patients and methods

A prospectively collected, password protected electronic database of all colorectal laparoscopic procedures performed between October 1999 and April 2010 has been used to identify surgical outcomes in 72 consecutive patients who have undergone laparoscopic restorative proctectomy – ileal pouch anal anastomosis (LRPC).  This has been cross-referenced with the same units stoma nurses database, which contains additional data on functionality.

Operative technique: Our initial 3-port technique utilizing rectal mobilization within the TME plane, close division of the colonic mesentery with omental preservation has already been described9. A 6cm Pfannenstiel incision was utilized in the first 40 patients to allow closure of the gut-tube 1cm above the dentate line, transection and retrieval of the rectum followed by construction of a 12cm W-pouch. The pouch-anal anastomosis was then constructed under direct vision using a double staple technique. A suitable portion of ileum was chosen for the diverting loop ileostomy and drawn through the enlarged 12mm right iliac fossa (RIF) port-site.

The remaining 32 patients underwent total laparoscopic mobilization with the specimen delivered (divided rectum end first) through the suitably dilated 12mm port placed at the site of the chosen ileostomy.  The gut tube was again divided at the level of the pelvic floor but this time using an ATG45 (Ethicon Endosurgery, Bracknell, UK) introduced from the RIF using two anterior-posterior firings.  The secret in performing this division is in fully dissecting and defining the “gut tube” at the pelvic floor. A 20cm J-pouch was created and returned for the pouch anal anastomosis to be carried out under direct laparoscopic vision taking great care to ensure no twisting of the mesentery.  The last 5 cases were carried out using a single port approach (SILS) positioned at the proposed ileostomy site14.

Operative technique following previous subtotal colectomy: Pneumoperitoneum was established using a Verres needle inserted in the left upper quadrant. This was replaced with a 5mm optical port and 5mm 300 laparoscope. The latter was used to survey a site for potential further ports or in deciding to go for an immediate mobilization of the ileostomy (12mm port placed within a purse string once the stoma was mobilized with additional 12mm umbilical and 5mm inferior RIF ports i.e., the same as had been used for the previous colectomy)15. Single port (SILS) restorative proctectomy (Olympus Tri port, Southend, UK) was used successfully in two cases via the RIF after first mobilizing the end stoma.

Postoperative care: Analgesia was delivered via a PCA in 34 patients with oral morphine, diclofenac and intravenous paracetamol in the remaining 38; the latter was augmented by bilateral transversus abdominals plane (TAP) blocks16 in 23 cases. Patients were allowed fluids as tolerated, mobilized the following morning and offered a light diet. Discharge was determined by the stoma nurse’s assessment of competency at management of the new loop ileostomy.  Catheters were removed after two days.

Functional assessment: All patients were asked about pouch function (stool frequency per 24hrs and at night, ability to defer, faecal incontinence, antidiarrhoeal medication and protective pad use) as well as problems with micturition and sexual function (potency, ejaculation, dyspareunia, faecal leakage during intercourse) three months post ileostomy closure and annually thereafter.  Incontinence was reported as never, occasional (< twice/week), and frequent or frank faecal incontinence.  Complications were divided into early and long-term.  Pouchitis was defined by the presence of fever, abdominal colic, bloody diarrhea and appropriate histology changes.  Failure was defined as the need for pouch excision or for a defunctioning ileostomy for more than a year with the pouch in situ.

 

 

Results

Laparoscopic restorative proctectomy (LRPC) was attempted in 72 patients (40 males) of whom 42 (58%) had undergone a previous colectomy & ileostomy (laparoscopic in 38).  The median age was 39 years (range 16-80) with a median BMI 24 (19-48kg/m2). Three had a synchronous cancer (Duke’s A, C and C) with a median nodal yield of 30; all were Ro resections.  One cancer had not been diagnosed pre-operatively. 40 underwent hand sewn W-pouch construction via Pfannenstiel incisions whilst the most recent 32 patients had J-pouches constructed and returned via the ileostomy site. Seven underwent a SILS procedure (included two procto-sigmoidectomies and ileo-anal pouch).

There were five early conversions (7%) due to widespread, four-quadrant adhesions; only one conversion followed an “open” colectomy. The median operation time was 210 minutes (range 75-330 minutes).  Post-operative analgesia was provided by PCA in 34 patients for a median of 36hrs (range 24hrs - 7 days); 80% of PCAs were discontinued by 48hrs.  Median time to full diet was 36hrs (4hrs-7days) with a median hospital stay of 7 days (2-64). The median stay for the “incision less” patients was 5 days, falling to 4 days for the SILS cases (3-7).  

Immediate intra-operative complications: There were two intra-operative complications.  A case of immediate pouch failure from acute onset ischaemia following construction of the pouch-anal anastomosis and followed an early conversion (previous open colectomy).  The second mishap occurred in spouting the wrong end of a loop ileostomy. 

 

Early complications included: gastric ileus (9), high-output ileostomy (2), chest infection (2), ileostomy bridge perforation/pressure necrosis and resultant wound sepsis, PE, coagulopathy, anastomotic bleed & leak.  There were no complications following the seven SILS cases. Two patients required a blood transfusion (coagulopathy and anastomotic bleed). The latter occurred on the first post-operative evening; laparotomy and evacuation of a haematoma followed four days later. The same patient then developed a below knee DVT.  

The wrongly spouted ileostomy was closed after a normal contrast study on day 9 (patient developed a pouch-anal leak 5 days later and the pouch was re-defunctioned). The loop ileostomy perforation occurred in a male with a BMI of 32 and followed an ileus/chest infection. The stoma was reversed and the wound debrided only for the closure to then leak. There was an additional Pfannenstiel wound breakdown following a superficial infection.  There were no deaths.

Readmissions:  seven patients were readmitted (10%): high-output ileostomy (2), reactive depression, anterior anastomotic leak (drained at EUA), bolus obstruction at the junction of the abdominal wall and ileostomy (2), one of which developed an external iliac DVT and finally a patient requiring reassurance/immediate discharge home.

Functional outcomes: 67 covering ileostomies were closed at between 1 and 6 months; all but two patients are fully continent at one year and 98% are able to defer during the day.  One a 67 year old women (not sexually active) reports occasional minor daily soiling and the need to wear a pad as well as occasional nocturnal incontinence (an offer to defunction the pouch has been repeatedly declined). The median pouch frequency at one year was four/24 hrs including once at night (range 2-8) with 28 (41%) reporting using anti-diarrheal medication.  There have been no cases of histological proven pouchitis; one patient reported having received two courses of metronidazole prescribed by her GP.  There were no cases of new onset impotence in the 40 male patients: a 22 year old had a dry ejaculate for 10 weeks.  Two patients have had elective cesarean sections.

Long-term complications and pouch failure occurred in 8 patients (11%): incisional hernia following ileostomy closure (3), anastomotic stricture requiring dilatation (3) and a small bowel volvulus at 11 months around the pouch (no intra-abdominal adhesions) which lead to mesenteric ischaemia and death. The second “pouch failure” occurred in the patient with the perforated loop ileostomy; a second leak occurred after bowel continuity was restored for a second time.  There have been no re-admissions with small bowel obstruction since ileostomy closure and no patient has developed a fistula.

Late onset ODS type symptoms were reported by three patients (two female, one of whom had undergone an elective section seven years earlier) at one and six and seven years.  Both responded to a period of intense biofeedback therapy following banding and excision of the prolapsed anterior wall of the pouch in two case.

 

 

Discussion

Continuous technological innovation and experience encourages surgeons to attempt more complex laparoscopic colorectal interventions. The objectives remain the same: reduced postoperative pain, early mobilisation, reduced rates of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital and 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 traditionalists have been and remain deeply skeptical about its application to inflammatory bowel disease.

That said, several specialist centres have shown the feasibility of carrying out laparoscopic restorative proctocolectomy5-13with immediate complication rates similar to those reported with open surgery but with a shorter overall hospital stay.   A meta-analysis17 of nine studies (329 patients) compared open and laparoscopic RPC; 168 (51.1%) underwent laparoscopic resection. Operative time was significantly longer (86mins) in the laparoscopic group (p<0.001) and throughout the subgroup analysis, but this finding was associated with significant heterogeneity. Operative blood loss was lower (84mls) in the laparoscopic group. There was no significant difference in post-operative complications. Although they reported a median length of stay approaching 13 days for LRPC, a statistically significant reduction in length of hospital stay was observed for LRPC in high-quality studies and those studies reporting on more than 30 patients by 1.1 days (p=0.02 in both subgroups) and studies published in or since 2001 by 3.0 days (p=0.004) but not overall. The authors concluded that any potential advantage of a laparoscopic ileal pouch surgery remains to be established.  Our length of stay data are considerably lower, yet similar to those recently reported by the Leeds group13 whose median length of stay was 6 (3-26) days.

This series represents our total experience of LRPC and describes our move from using a traditional11-13,,15,17 Pfannenstiel incision to remove the specimen, transect the gut tube and create a hand sewn W-pouch followed by a postoperative PCA (median stay 7 days)9, through to “incision less” total laparoscopic resection with removal of the specimen through the chosen ileostomy site and construction of a J-pouch (median stay 5 days)11 to our current position of offering single-port LRPC (median stay 4 days)14.  This move has coincided with our move to “accelerated recovery” using TAP blocks to avoid the unwanted effects of parenteral opiates that delay recovery and discharge16.

The choice of incision to complete the dissection and to deliver the specimen remains a focus of debate.  In much of North America, Australasia17 and Europe11 a small peri-umbilical incision with direct extracorporeal ligation of the mesocolic vessels is popular. It remains our choice for specimen delivery when performing resectional cancer surgery, where it is our belief that in combination with TAP blocks, pain control is improved and recovery faster16,19. The fulcrum effect of using a linear laparoscopic stapler through a port, the limitation in the angulations of currently available staplers and the need for multiple firings are frequently quoted as being limiting factors in allowing laparoscopic low rectal transection13,20,21.  Pfannenstiel incisions have been used to overcome these perceived problems13.  An alternative approach adopted by others is to use a supra-pubic port, hand-port22 or incision.  We have learnt through experience19 that it is possible in all but the largest of tumours and narrowest of android pelvises to transect and staple the gut tube low down at the level of the pelvic floor using an ATG45 (Ethicon Endosurgery, Bracknell, UK) introduced from the right iliac fossa using two anterior-posterior firings.  The secret is in dissecting/defining the “gut tube” and pelvic floor (optimized by using a 300 laparoscope) and more importantly utilize the fulcrum effect of the port by placing the stapler with a fully pronated forearm, flexed wrist and an internally rotated, abducted shoulder.  The linear cutter will flex and close at 900 if the tip is pressed against a fixed structure i.e., pelvic side wall/sacrum, a fist placed against the perineum; once the pressure is released it will “return” to 450 and allow firing.  A Spackman uterine retractor22 not only helps with the dissection, but also once completed, keeps the vagina under tension and away from pouch anal anastomosis.

Although our 32% morbidity (early and late onset complications plus readmissions) is on the high side, and is probably a reflection of the complexity of the surgery (the comparable figure18 for segmental resection in our unit is 22%), it is vey similar to that reported by others11,12,22,25.   The DVT/PE occurred in a patient who went on to be diagnosed as factor VLeiden deficiency. Dense impenetrable adhesions necessitated early conversion in 7%, a rate similar to that reported by Kienle et al11 in their 50 patients.  Surprisingly four of the five conversions followed an initial laparoscopic colectomy.  The Leeds group recently reported a 0% conversion rate in 36 patients13.  51 of our (70%) patients had an uncomplicated recovery.

One of the problems with open ileal pouch surgery is the high rate (23%) of adhesive small-bowel obstruction (SBO); the cumulative risk of SBO in 1,178 patients has been calculated at 8.7% at 30 days, 18% at 1 year, 27% at 5 years and 31% at 10 years26.  In their case note review27 of 276 patients followed for a median of 6.3 years, the Oxford Group reported a readmission rate of 28% with 10% requiring re-operation (43% within one year). The laparoscopic sub-set required less adhesiolysis at second-stage surgery (0% vs. 36%, p < 0.0001) and had fewer small bowel obstructive episodes within the first year (0% vs. 14%, p < 0.0001) than open patients.  This benefit was translated into a potential financial saving of $1,832 per pouch constructed. LRPC with its reduced risk of adhesions may have an important role in maintaining fertility; 71% of 34 female study patients were found to have no adnexal adhesions at laparoscopy prior to ileostomy closure and no patient had adhesions affecting both adenaxea)28. The one late fatality in our present series and only case of small bowel obstruction followed a small bowel mesenteric volvulus; the complete absence of any adhesions, including the free edge of the mesentery of the afferent limb of the pouch probably had a major role in its development.

Dunker’s comparative study7, in which a midline wound was used for specimen extraction and pouch construction, 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. The Mayo group29 examined a larger subset; 125 of 289 patients (43% responders) were questioned one year after operation to evaluate sexual function, body image, and quality of life. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between responders and those who did not. There were no differences in results between laparoscopic and open patients using the three survey instruments. Whilst orgasmic function scores were significantly lower in men who underwent LRPC compared with open procedures, overall, sexual function scores were equal to, or better than normal values for men but were lower in women. Interestingly, overall body image and quality of life scores were above the means published for the United States.

Although it is important to know that morbidity following LRPC is low, it is perhaps more reassuring that the adoption of laparoscopic restorative procto-colectomy has not associated with adverse function (24hr and nocturnal frequency as well as incontinence) and impaired quality of life. After all it is this endpoint that matters to the patient in the long-term. It is contentious whether or not laparoscopic rectal surgery itself is associated with a higher incidence of bladder and sexual function compared with open surgery; 41% of CLASICC1 patients reported a severe change in sexual function, compared to 26% in the open group (not significant). The groups however were poorly matched and there were more TMEs in the laparoscopic group. The Brisbane group30 report a more appropriate 6% sexual dysfunction in 101 male patients; this falls to 2% when the effect of radiotherapy is excluded.  Whilst the pelvic dissection is technically challenging, particularly when mobilizing a fibrosed defunctioned rectal stump in a male with a narrowed pelvis, the magnification does afford a superior view of the autonomic nerves, particularly behind the seminal vesicles and a 300scope allows one to “look around corners”. The main problem with laparoscopic TME is that it is very easy to tent the hypogastric nerves by retracting in a cranial/lateral direction, particularly so on the left hand side, and if the operator is unaware of this difference from open surgery then it is very easy to enter the presacral plane and damage or worse still divide the nerves.  This effect is reduced if you do not employ an assistant to hold and retract the recto-sigmoid cranially to the left hand-side.   

We have shown that laparoscopic restorative procto-colectomy with ileo-anal pouch is technically feasible and can be performed without an unduly lengthy operation or morbidity. More importantly, it is safe and predictable with good functional outcomes that are comparable to open techniques.  However, the procedure is difficult and technically demanding and requires lots of concentration. No one should embark on LRPC unless they are adept at laparoscopic TME and ultra-low rectal transection.

 

Acknowledgement

We acknowledge the following who have made substantial contributions to the conduction of this work: Gareth Greenslade (Anaesthetist), Fiona Bradden (Data Base) and the following Laparoscopic Fellows - T Singh Gill, S Pandey, Fiona Court, A Hollowood, Ruth Soulsby, Simone Slawik, Katie Cross, N Kenefick, A Mennon, M Cartmell, L Titu, SM Phillips, K Riyad, K Krishna, S Rai, W Chambers and N Zafar

 

 

References

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2.              The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer.  N Engl J Med 2004; 350:2050-9.

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13.           McAllister I, Sagar PM, Brayshaw I, Gonsalves S, Williams GL. Laparoscopic restorative proctocolectomy with and without previous subtotal colectomy.  Colorectal Dis. 2009; 11: 296-301.

14.           Chambers W, Bicsak M, Lamparelli M, Dixon AR. Single-incision laparoscopic surgery (SILS) in complex colorectal surgery: a technique offering potential and not just cosmesis. Colorectal Dis 2010 [Epub ahead of print].

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16.           Zafar N, Davies R, Greenslade GL, Dixon AR.  The evolution of analgesia in an “Accelerated” recovery programme for resectional laparoscopic colorectal surgery with anastomosis.  Colorectal Dis. 2010;

17.           Rickard MJ, Young CJ, Bissett IP, Stitz R, Soloman MJ. Research committee of the Colorectal Surgical Society of Australasia. Ileal pouch-anal anastomosis: the Australasian experience. Colorectal Dis. 2007; 9: 139-45.

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20.           Bergamaschi R, Essani R.  Laparoscopic resection for rectal cancer: are we there yet.  Colorectal Disease 2009; 11: 1-2

21.           Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N.  Relationship between multiple numbers of staple firings during rectal division and anastomotic leakage after laparoscopic rectal resection.  Int J Colorectal Dis 2008; 23: 70.

22.           Maartense S, Dunker MS, Slors JF, Cuesta MA, Gouma DJ, van Deventer SJ et al. Hand assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomosis: a randomized trial. Ann Surg 2004; 240: 984-91.

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24.           Ouaissi M, Alves A, Bouhnik Y, Valleur P, Panis Y. Three step ileal pouch anal anastomosis under total laparoscopic approach for acute severe colitis complicating inflammatory bowel disease. J Am Coll Surg 2006; 202: 637-42.

25.           Maartense S, Dunker MS, Slors JFM, Gouma DJ, Bemelman WA. Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: a case-matched study. Colorectal Dis 2004 ; 6: 254-7.

26.           MacLean AR, Cohen Z, MacRae HM, O’Connor BI, Mukraj D, Kennedy ED, Parkes R, McLeod RS.  Risk of small bowel obstruction after ileal pouch-anal anastomosis.  Ann Surg 2002; 235: 200-6.

27.           Sileri P, Sthory R, McVeigh E, Child T, Cunningham C, Mortenson NJ, Lindsey I.  Adhesions are common and costly after open pouch surgery.  J Gastrointest Surg 2008; 12 : 1239-45.

28.           Indar AA, Efron JE, Young-Fadok TM. Laparoscopic ileal pouch-anal anastomosis reduces abdominal and pelvic flor adhesions. Surg Endosc 2009; 23: 174-7.

29.           Larson DW, Davies MM, Dozois EJ, Cima RR, Piotrowicz K, Anderson K, Barnes SA, Harmsen WS, Young-Fadok TM, Wolf BG, Pemberton JH. Sexual function, body image, and quality of life after laparoscopic and open ileal pouch-anal anastomosis. Dis Colon Rectum 2008; 51: 392-6.

30.           Jones OM, Stevenson ARL, Stitz RW, Lumley JW. Preservation of sexual and bladder function after laparoscopic rectal surgery. Colorectal Dis 2008; 11: 489-495.

 


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