Reduced port versus conventional laparoscopic total proctocolectomy and ileal J pouch-anal anastomosis

Single access laparoscopic total colectomy for severe refractory ulcerative colitis

BACKGROUND

Single port laparoscopic surgery allows total colectomy and end ileostomy for medically uncontrolled ulcerative colitis solely via the stoma site incision. While intuitively appealing, there is sparse evidence for its use beyond feasibility.

AIM

To examine the usefulness of single access laparoscopy (SAL) in a general series experience of patients sick with ulcerative colitis.

METHODS

All patients presenting electively, urgently or emergently over a three-year period under a colorectal specialist team were studied. SAL was performed via the stoma site on a near-consecutive basis by one surgical team using a “surgical glove port” allowing group-comparative and case-control analysis with a contemporary cohort undergoing conventional multiport surgery. Standard, straight rigid laparoscopic instrumentation were used without additional resource.

RESULTS

Of 46 consecutive patients requiring surgery, 39 (85%) had their procedure begun laparoscopically. 27 (69%) of these were commenced by single port access with an 89% completion rate thereafter (three were concluded by multi-trocar laparoscopy). SAL proved effective in comparison to multiport access regardless of disease severity providing significantly reduced operative access costs (> 100€case) and postoperative hospital stay (median 5 d vs 7.5 d, P = 0.045) without increasing operative time. It proved especially efficient in those with preoperative albumin > 30 g/dL (n = 20). Its comparative advantages were further confirmed in ten pairs case-matched for gender, body mass index and preoperative albumin. SAL outcomes proved durable in the intermediate term (median follow-up = 20 mo).

CONCLUSION

Single port total colectomy proved useful in planned and acute settings for patients with medically refractory colitis. Assumptions regarding duration and cost should not be barriers to its implementation.

Pouch Volvulus in Patients Having Undergone Restorative Proctocolectomy for Ulcerative Colitis: A Case Series

BACKGROUND

Restorative proctocolectomy with IPAA improves quality of life in patients with medically refractory ulcerative colitis. Although bowel obstruction is common, pouch volvulus is rare and described only in case reports. Diagnosis can be challenging, resulting in delayed care and heightened morbidity.

OBJECTIVE

The purpose of this study was to delineate the symptoms and successful management strategies used in patients with IPAA volvulus that result in pouch salvage.

DESIGN

This study was a case series.

SETTINGS

The study was conducted at a tertiary referral center for ulcerative colitis in Milwaukee, Wisconsin.

PATIENTS

Patients included those with volvulus of the IPAA.

MAIN OUTCOME MEASURES

Over the study period (2010-2015), 6 patients were diagnosed with IPAA volvulus. The primary outcomes were symptom manifestation, diagnostic practices, and treatment of pouch volvulus.

RESULTS

Six patients with ulcerative colitis were identified with pouch volvulus. The majority (n = 4) underwent a laparoscopic pouch creation and had early symptom manifestation after surgery. Complications preceding volvulus included pouch ulceration (n = 5) and pouchitis (n = 4). The most common presenting symptoms of volvulus were abdominal pain (n = 4) and obstipation (n = 4). Multiple imaging modalities were used, but volvulus was most frequently identified by CT scan. Management was primarily operative (n = 5), composed of excision of the pouch (n = 3), pouch-pexy (n = 1), and detorsion with defect closure (n = 1). Both operative and nonoperative treatment with endoscopic detorsion resulted in low morbidity and improved patient symptoms.

LIMITATIONS

This single-institution study is limited by its retrospective design and small number of patients.

CONCLUSIONS

IPAA volvulus is a rare and challenging cause of bowel obstruction in ulcerative colitis. Heralding signs and symptoms, such as pouch ulceration and acute obstipation, should initiate a workup for a twisting pouch. Diagnosis, which is multimodal, must occur early to avert necrosis and allow for preservation of a well-functioning pouch. See Video Abstract at http://links.lww.com/DCR/A561.

Short-term outcomes following reduced-port, single-port, and multi-port laparoscopic surgery for colon cancer: tailored laparoscopic approaches based on tumor size and nodal status

PURPOSE

Surgeons have recently developed more minimally invasive surgical procedures to reduce surgical stress and improve cosmesis. Although single-port laparoscopic colectomy (SPLC) has potential benefits over multi-port laparoscopic colectomy (MPLC), there are concerns about the increased technical difficulties associated with SPLC. Therefore, we attempted reduced-port laparoscopic colectomy (RPLC). The purpose of this study was to evaluate the difference in perioperative outcome following tailored laparoscopic approaches for colon cancer on the basis of tumor characteristics.

METHODS

The prospectively collected data of 170 patients who underwent only minimally invasive colectomy for colon cancer from July 2010 to June 2013 were reviewed. The MPLC, SPLC, and RPLC groups comprised 92 (54.1 %), 40 (23.5 %), and 38 (22.4 %) patients, respectively.

RESULTS

The number of harvested lymph nodes was significantly higher in the RPLC group than in the MPLC and SPLC groups (29.9 ± 21.5, 21.9 ± 12.1, and 24.2 ± 13.8, respectively; p = 0.027). The mean operating time was significantly different among the MPLC, SPLC, and RPLC groups (243.5 ± 59.0, 207.2 ± 49.6, and 216.2 ± 53.7 min, respectively; p = 0.001). The time to first flatus was also significantly different among the MPLC, SPLC, and RPLC groups (3.1 ± 1.2, 3.6 ± 1.3, and 3.4 ± 1.1 days, respectively; p = 0.039). No significant differences in the other short-term surgical outcomes were observed among the three groups.

CONCLUSIONS

SPLC and RPLC according to tailored laparoscopic approaches for colon cancer appear to be beneficial in terms of operative time and lymph node retrieval, and may be considered as surgical options in laparoscopic colectomy for colon cancer patients with favorable tumor characteristics.

Minimal access laparoscopic surgery for treatment of ulcerative colitis and familial adenomatous polyposis coli in children and adolescents

BACKGROUND

Laparoscopic restorative proctocolectomy is standard surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis coli (FAP). Scar burden can be minimized by reducing the number of laparoscopic ports. The aim of this study is to review the authors' experience with reduced-port laparoscopy in this setting and to compare it with conventional laparoscopy using multiple ports.

MATERIALS AND METHODS

Charts of pediatric patients undergoing colectomy for UC or FAP between 2009 and 2012 were retrospectively reviewed. Patients who had the operation performed through one or two multichannel ports were assigned to the minimal access (MA) study group. Patients who had four or five single-channel ports with or without an additional small laparotomy were assigned to the LAP group.

RESULTS

Twenty-two patients were identified. Ages at first operation were 2-18 years (median, 13.5 years). There were no conversions to laparotomy and no mortality. Mean operative times for the MA and LAP groups, respectively, were 250 and 284 minutes for abdominal colectomy with end ileostomy (P=.15), 198 and 301 minutes for completion proctectomy with diverting loop ileostomy (DLI) (P=.26), and 455 and 414 minutes for proctocolectomy with ileal pouch-anal anastomosis and DLI (P=.72). A major complication requiring laparotomy occurred in 1 patient (9%) in the MA group and in 2 patients (18%) in the LAP group.

CONCLUSIONS

Minimal access laparoscopic surgery for UC and FAP is safe and feasible. A slightly larger incision at the ostomy site facilitates extraction of the specimen and extracorporeal construction of a J-pouch. Operative times and hospital stay are comparable to those with multiport laparoscopy.

Single-port laparoscopic colorectal resections in obese patients are as safe and effective as conventional laparoscopy

BACKGROUND

Obese patients pose additional operative technical difficulties, and it is unclear if the outcomes of single-port colorectal surgery are equivalent to those of conventional laparoscopy in such patients. The aim of this study was to compare perioperative variables and short-term outcomes of single-port versus conventional laparoscopy in obese patients undergoing colorectal surgery.

PATIENTS AND METHODS

Obese patients (BMI ≥ 30 kg/m(2)) undergoing single-port laparoscopic colorectal resections between March 2009 and September 2012 were case matched 1:1 with obese counterparts undergoing conventional (multi-port) laparoscopic surgery based on diagnosis and operation type.

RESULTS

Thirty-seven patients who underwent single-port surgery were matched with 37 conventional laparoscopic counterparts. Male gender predominated in the single-port group (26 vs 15, p = 0.02). The number of patients with a history of previous abdominal operations (17 vs 13, p = 0.48) and ASA score (3 vs 2, p = 0.6) were similar between the groups. No differences were observed with respect to conversion rate (2 vs 5, p = 0.43), operative time (146 vs 150 min, p = 0.48), estimated blood loss (159 vs 183 ml, p = 0.99), time to first flatus (3 vs 3 days, p = 0.91), time to first bowel movement (3 vs 4 days, p = 0.62), length of hospital stay (7 vs 6 days, p = 0.37), or reoperation (2 vs 1, p > 0.99), and readmission rates (2 vs 2, p > 0.99). There were no deaths.

CONCLUSION

For obese patients undergoing colorectal resections, single-port laparoscopy appears to be as safe and effective as conventional laparoscopy.