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SILS restorative proctocolectomy with ileoanal pouch

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18/07/2010

 Single incision laparoscopic restorative procto-colectomy with ileo-anal pouch anastomosis.

 K Gash, B Vestweber* AR Dixon. 

Depts., Colorectal Surgery Frenchay Hospital, Bristol, UK &

 

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 the definitive procedure in ulcerative colitis. The potential benefits afforded by a single incision laparoscopic (SILS) approach make it appropriate to consider provided that there is no adverse affect on short-term outcome and long-term functionality.

Methods.  Electronic data were prospectively collected from all patients who underwent SILS restorative procto-colectomy (SILS-RPC): June 2009 - June 2010.

Results.  10 consecutive patients (4 male), median BMI 22 (20-28kg/m2) underwent SILS-LRPC over a 1yr period. Two had undergone a previous emergency laparoscopic colectomy. Single port devices (SILSTM Covidien, Hamshire, UK or Olympus Tri-portsTM, Southend UK) were positioned at the site of the existing or proposed temporary ileostomy (2.5cm incisions). The colon and rectum were extracted through the SILS site (8) or transanally following a mucosectomy (2). 20cm J-pouches were construction extra-corporeally and returned via the ileostomy site. Pouch-anal anastomosis was performed intra-corporeally (8) or hand sutured (2) and a diverting loop ileostomy created at the SILS port site. The median operation time was 185 mins (100-381). There were no conversions or additional ports required.  Median time to full diet was 36hrs (4-48hrs) with a median hospital stay of 3 days (2-8 days).  There were no 30-day readmissions.  Complications included: surgical empysema/temperature and a panic attack.  Nine stomas have been closed. All patients have spontaneity of defecation, with a median pouch frequency/24hrs of four, including once at night. All are fully continent and able to defer during the day. One reported a dry ejaculate for 10 weeks.

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

Introduction

Most surgeons are now convinced of the benefits of multiport laparoscopic colorectal surgery, which include shorter postoperative stay, early return of function and reduced complications.  The disadvantages centre on the requirement for 3-5 port sites in the abdominal wall and an additional incision to remove the specimen; all of which causes cutaneous and parietal trauma.

Single Incision Laparoscopic Surgery (SILS) first was introduced in the late 1990’s for appendicectomy and cholecystectomy but due to issues of instrumentation, a difficult learning curve and peer group pressure (surgeons) it did not gain acceptance.  However, over the last three years there has been a remarkable turn-around1,2, particularly in urology3,4.  Remzi performed the first SILS colectomy at the Cleveland clinic in July 20085; a right hemicolectomy undertaken through a 3.5 cm incision. The first case series came out of Australia the following year6; seven resections for cancer using traditional laparoscopic instruments via a single umbilical incision. The average incision length was 3.1 cm, the length of stay was 5.4 days and the average lymph node harvest was 15. Data that falls into line with that reported following traditional laparoscopic colectomy with the added benefit of a smaller scar7.

Spurred on by these early successes, SILS restorative procto-colectomy has been recently reported for both ulcerative colitis8 and FAP9 with the added benefit of a shortened hospital stay.  Some would consider that these two disease processes lend themselves to this particular approach (young patients, benign disease)10-16. However, three or four-port laparoscopic restorative procto-colectomy is technically challenging and time consuming itself12,,16,17 let alone the challenge afforded by SILS.

The aim of this study was to report our up-to-date experience of SILS restorative procto-colectomy (SILS-RPC), highlight the difficulties encountered and the short-term results that can be obtained.

 

 Patients and methods

A prospectively collected, password protected electronic database of all colorectal laparoscopic procedures from both institutions was been used to identify surgical outcomes in 10 consecutive patients who underwent SILS restorative proctectomy ileal pouch anal anastomosis (SILS-LRPC).

Operative technique: Single port devices (SILSTM Covidien, Hamshire, UK or Olympus Tri-portsTM, Southend UK) were positioned at the site of the existing or proposed temporary right iliac-fossa ileostomy (2.5cm incisions). The colon and rectum were mobilized12,17 (close mesenteric division) using standard energy devices and straight instruments before being extracted through the SILS site. The fully mobilized gut tube was divided at the level of the pelvic floor (n=8), within the puborectalis sling, utilising an ATG45 (Ethicon Endosurgery, Bracknel, UK) introduced from the RIF and two anterior-posterior firings. In two patients the mobilized procto-colectomy specimen was delivered trans-analy following a rectal mucosectomy.  20cm J-pouches were construction extra-corporeally and returned via the ileostomy site. Pouch-anal anastomoses were performed intra-corporeally (8) or via a hand sutured technique (2).  The pouch was pulled down into the pelvis in the latter two cases using a trans-anal forceps.  Great care is taken to ensure no twisting of the mesentery and a diverting loop ileostomy created at the SILS port site

Operative technique following previous subtotal colectomy: 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: Multimodal analgesia (oral morphine, diclofenac and intravenous paracetamol) augmented by bilateral transversus abdominals plane (TAP) blocks18 was used in eight 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.

 

Results

SILS restorative proctectomy (SILS-RPC) was attempted in 10 patients (4 males) of whom two had undergone a previous emergency laparoscopic colectomy & ileostomy.  The median age was 31 years (range 21-56) with a median BMI 22 (20-28kg/m2). There were no conversions. The median operation time was 185 minutes (range 100-381 minutes). Median time to full diet was 36hrs (4hrs-48hrs) with a median hospital stay of 3 days (2-8). There were no intra-operative complications. Early complications included: surgical emphysema around the ileostomy and temperature (1) and a panic attack. There were no deaths and no patients were readmitted.

Functional outcomes: nine covering ileostomies were closed at between 4 and 6 weeks; all but one are fully continent and 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. The median pouch frequency at six months was four/24 hrs including once at night (range 2-8). There were no cases of new onset impotence or dyspareunia: a 22 year old had a dry ejaculate for 10 weeks.

 

Discussion

Continuous technological innovation and experience encourages surgeons to attempt more complex laparoscopic colorectal interventions with the objective of reducing postoperative pain, allow for earlier mobilization and rapid return of gastrointestinal function, which allows early discharge from hospital, and a return to normal life.  In attempting to improve these outcomes further and improve cosmesis, natural orifice transluminal endoscopic surgery (NOTES), and more recently single incision laparoscopic surgery (SILS) have been advocated. The initial applications of SILS in gastrointestinal surgery were appendicectomy and cholecystectomy1,2. The guiding principle been to operate through a single transumbilical incision, and remove the colonic specimen via the same small incision5,6,8.  Compared to classic 3-4 port laparoscopic colectomy, the potential advantages of the SILS are believed to be reduction in cutaneous and parietal trauma, decreased postoperative pain, improved cosmesis, and shorter recovery, hopefully without additional cost6,8.  That said, only single case reports and small case series of SILS colectomies have been published.

 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 centres have demonstrated the feasibility of carrying out laparoscopic restorative proctocolectomy10-17with immediate complication rates similar to those reported with open surgery but with a shorter overall hospital stay.   A meta-analysis19 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 recovery, morbidity and length of stay data are considerably lower and would suggest that SILS is cost effective.

Dunker’s comparative study10, 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 SILS restorative procto-colectomy has not associated with adverse function in the short term (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.

SILS presents several disadvantages compared to multiport laparoscopic surgery. The handling of straight instruments in parallel with the laparoscope through a small single incision decreases the freedom of motion for the surgeon and complicates the holding of the laparoscope for the assistant. Inside the peritoneal cavity, lack of instrument triangulation increases the complexity of colonic exposure and dissection but it is possible – triangulation is created by using traction against tissue planes.. To improve view and dissection, a 30° laparoscope is considered essential. In our experience, we have found the best results and least technical difficulty with straight instruments. In cases of intraoperative difficulty, SILS always offers the possibility to rapidly convert to multiport laparoscopic surgery, permitting the advantages of laparoscopic surgery to be preserved

We have shown that unselected SILS restorative procto-colectomy with ileo-anal pouch is technically feasible and can be performed without an unduly lengthy operation or morbidity. Recovery and hospital discharge are remarkably quick and endorse our earlier experience8 and by definition would make SILS cost effective. More importantly, it is safe and predictable with good functional outcomes that are comparable to open and conventional laparoscopic techniques.  However, the procedure is difficult and technically demanding and requires lots of concentration.

 

 

References

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8.    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].

9.    Geisler DP, Condon ET, Remzi FH. Single incision laparoscopic total procto-colectomy with ileopouch anal anastomosis. Colorectal Dis., {Epub ahead of print].

10.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.

11.Ky AJ, Sonoda TM, Milsom JW. One-stage laparoscopic restorative proctocolectomy: an alternative to the conventional approach? Dis Colon Rectum 2002; 45: 207-211.

12.TS Gill, A Karantana, J Rees, S Pandey, AR Dixon Laparoscopic proctocolectomy with retorative ileal-anal pouch.. Colorectal Disease 2004; 6: 458-461.

13.Larson DW, Dozois EJ, Piotrowicz K, Cima RR, Wolff BG, Young Fadok TM.  Laparoscopic assisted vs open ileal pouch anal anastomosis: functional outcomes in a case matched series. Dis Colon Rectum 2005; 48: 1845-50.

14.Kienle P, Z’graggen K, Schmidt J, Benner A, Weitz J, Buchler MW. Laparoscopic restorativeproctocolectomy. Br.J.Surg 2005; 92: 88-93..

15.Larson DW, Cima RR, Dozois EJ, Davies M, Piotrowicz K, Barnes SA et al. Safety, feasibility and short-term outcomes of laparoscopic ileal pouch anal anastomosis: a single institutional case-matched experience. Ann Surg 2006; 243: 667-70.

16.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.

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18.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;

19.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

20.  Dalton SJ, Ghosh A, Greenslade GL, Dixon AR. Laparoscopic colorectal surgery – why would you not want to have it and more importantly, not be trained in it? A consecutive series of 500 elective resections with anastomosis. Colorectal Dis. 2009 Nov 2. [Epub ahead of print].  

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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.

3.              Lacey AM, Garcia-Valdecasas JC, Delgado S et al., Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer; a randomized trial.  Lancet 2002; 359: 2224-2229.

4.              National Institute for Health and Clinical Excellence (NICE).  Laparoscopic surgery for colorectal cancer.  London (UK): National Institute for `health and Clinical Excellence (NICE); 2006 Aug. (Technology appraisal guidance; No. 105). http://www.nice.org.uk/nicemedia/pdf/TA105guidance.pdf

5.             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.

6.             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.

7.             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.

8.             Ky AJ, Sonoda TM, Milsom JW. One-stage laparoscopic restorative proctocolectomy: an alternative to the conventional approach? Dis Colon Rectum 2002; 45: 207-211.

9.             TS Gill, A Karantana, J Rees, S Pandey, AR Dixon Laparoscopic proctocolectomy with retorative ileal-anal pouch.. Colorectal Disease 2004; 6: 458-461.

10.         Larson DW, Dozois EJ, Piotrowicz K, Cima RR, Wolff BG, Young Fadok TM.  Laparoscopic assisted vs open ileal pouch anal anastomosis: functional outcomes in a case matched series. Dis Colon Rectum 2005; 48: 1845-50.

11.         Kienle P, Z’graggen K, Schmidt J, Benner A, Weitz J, Buchler MW. Laparoscopic restorativeproctocolectomy. Br.J.Surg 2005; 92: 88-93..

12.         Larson DW, Cima RR, Dozois EJ, Davies M, Piotrowicz K, Barnes SA et al. Safety, feasibility and short-term outcomes of laparoscopic ileal pouch anal anastomosis: a single institutional case-matched experience. Ann Surg 2006; 243: 667-70.

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].

15.         Fowkes L, Krishna K, Menom A, Greenslade GL, Dixon AR. Laparoscopic emergency and elective surgery for ulcerative colitis. Colorectal Dis 2008; 10: 373-8.

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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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 <