Does mesorectal preservation protect the ileoanal anastomosis after restorative proctocolectomy?

Long Rectal Cuff and Remnant Mesorectum Are Major Preventable Causes of Ileal Pouch Failure

BACKGROUND

Long rectal cuff (>2 cm) and remnant mesorectum are known causes of pouch dysfunction because of obstructive defecation as well as pelvic sepsis after prolonged obstruction.

OBJECTIVE

The aim of this study was to report the rates and management of patients who underwent redo IPAA because of pouch failure associated with a retained mesorectum and long rectal cuff.

DESIGN

This is a retrospective study.

SETTINGS

The investigation is based on data from a quaternary IBD center.

PATIENTS

Patients undergoing redo IPAA surgery with a long rectal cuff and/or remnant mesorectum between September 2016 and September 2023 were included in the study.

MAIN OUTCOME MEASURES

The main outcomes were functioning pouch rate and functional results.

RESULTS

Of the 245 patients who underwent redo IPAA surgery, 98 patients (40%) had long rectal cuff and/or remnant mesorectum. Redo IPAA in this patient group was successful (92%) at a median follow-up of 28 (18-52) months.

LIMITATIONS

The retrospective nature of the study and inclusion of a single specialized center.

CONCLUSIONS

Long rectal cuff and remnant mesorectum are major causes of pouch failure, which can be successfully managed with redo IPAA surgery. Nearly half of pouch failure patients who had successful redo IPAA surgery initially received unnecessary biologic therapy before coming to our center. See Video Abstract .

MUON RECTAL LARGO Y MESORRECTO REMANENTE SON LAS PRINCIPALES CAUSAS PREVENIBLES DE DISFUNCIN DE LA BOLSA ILEAL

ANTECEDENTES:El muñon rectal largo (>2 cm) y el mesorrecto remanente son causas conocidas de disfunción de la bolsa debido a defecación obstructiva, así como de sepsis pélvica tras obstrucción prolongada.OBJETIVO:El objetivo de este estudio es informar las tasas y el tratamiento de los pacientes que se sometieron a una nueva anastomosis anal con bolsa ileal debido al fracaso de la bolsa asociado a mesorrecto remanente y el muñon rectal largo.DISEÑO:Se trata de un estudio retrospectivo.LUGAR:La investigación se basa en un centro cuaternario de enfermedad inflamatoria intestinal.PACIENTES:Se incluyeron en el estudio los pacientes sometidos a una nueva cirugía de anastomosis anal con bolsa ileal y que tenían muñon rectal largo y/o mesorrecto remanente entre septiembre de 2016 y septiembre de 2023.PRINCIPALES MEDIDAS DE VALORACIÓN:Los principales resultados fueron la tasa de funcionamiento de la bolsa y los resultados funcionales.RESULTADOS:De los 245 pacientes que se sometieron a una nueva cirugía de anastomosis anal con bolsa ileal, 98 (40%) pacientes tenían un muñon rectal largo y/o mesorrecto remanente. La repetición de la anastomosis anal con bolsa ileal en este grupo de pacientes fue exitosa (92%) en una mediana de seguimiento de 28 (18-52) meses.LIMITACIONES:La naturaleza retrospectiva del estudio y la experiencia de un solo centro especializado.CONCLUSIONES:El muñon rectal largo y el mesorrecto remanente son las principales causas de fracaso de la bolsa, que pueden tratarse con éxito mediante una nueva cirugía de anastomosis anal con bolsa ileal. Casi la mitad de los pacientes con fracaso de la bolsa que se sometieron con éxito a una nueva cirugía de anastomosis anal con bolsa ileal recibieron inicialmente un tratamiento biológico innecesario antes de acudir a nuestro centro. (Traducción-Ingrid Melo ).

Long-term outcomes after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

During ileal pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC), rectal dissection can be performed via close rectal dissection (CRD) or in a total mesorectal excision plane (TME). Although CRD should protect autonomic nerve function, this technique may be more challenging than TME. The aim of this study was to compare long-term outcomes of patients undergoing CRD and TME.

METHODS

This single-centre retrospective cohort study included consecutive patients who underwent IPAA surgery for UC between January 2002 and October 2017. Primary outcomes were chronic pouch failure (PF) among patients who underwent CRD and TME and the association between CRD and developing chronic PF. Chronic PF was defined as a pouch-related complication occurring ≥ 3 months after primary IPAA surgery requiring redo pouch surgery, pouch excision or permanent defunctioning ileostomy. Secondary outcomes were risk factors and causes for chronic PF. Pouch function and quality of life were assessed via the Pouch dysfunction score and Cleveland global quality of life score.

RESULTS

Out of 289 patients (155 males, median age 37 years [interquartile range 26.5-45.5 years]), 128 underwent CRD. There was a shorter median postoperative follow-up for CRD patients than for TME patients (3.7 vs 10.9 years, p < 0.01). Chronic PF occurred in 6 (4.7%) CRD patients and 20 (12.4%) TME patients. The failure-free pouch survival rate 3 years after IPAA surgery was comparable among CRD and TME patients (96.1% vs. 93.5%, p = 0.5). CRD was a no predictor for developing chronic PF on univariate analyses (HR 0.7 CI-95 0.3-2.0, p = 0.54). A lower proportion of CRD patients developed chronic PF due to a septic cause (1% vs 6%, p = 0.03).

CONCLUSIONS

Although differences in chronic PF among CRD and TME patients were not observed, a trend toward TME patients developing chronic pelvic sepsis was detected. Surgeons may consider performing CRD during IPAA surgery for UC.

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

Transanal ileal pouch-anal anastomosis for ulcerative colitis: a single-center comparative study

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the procedure of choice in patients with ulcerative colitis (UC) requiring surgery. Advantages of laparoscopic IPAA (lap-IPAA) compared to open surgery have been investigated. However, laparoscopic dissection in the pelvis is still a challenge. A transanal approach provides better access to lower pelvis and avoids multiple staple firings, which could reduce the risk of anastomotic complications. The aim of this study was to compare short-term outcomes of transanal proctectomy with IPAA (ta-IPAA) with conventional lap-IPAA in patients with UC.

METHODS

A single-center retrospective study was conducted on consecutive UC patients, treated at Copenhagen University Hospital, Hvidovre, undergoing either laparoscopic or transanal IPAA in the period between January 2013 and December 2020. Exclusion criteria were Crohn's disease, previous extensive abdominal surgery and impaired sphincter function. Primary outcomes were overall postoperative complications. Secondary outcomes were length of hospital stay and re-admissions. For comparison between ta-IPAA and lap-IPAA, the Mann-Whitney U test was used for continuous variables, and Chi-square and Fisher's exact test for categorical variables.

RESULTS

A total of 65 patients with ta-IPAA (34 males, 31 females, median age 31 years [range 12-66 years]) and 70 patients with lap-IPAA (35 males, 35 females, median age 26 years [range 12-66 years]) were included. There was no difference between ta-IPAA and lap-IPAA regarding age, sex, body mass index or American Society of Anesthesiologists class. The primary colectomy procedure was performed laparoscopically in 95% of the ta-IPPA and 91% of the lap-IPAA patients (p = 0.493). The mean time between total colectomy and IPAA was 15 and 9 weeks for ta-IPAA and lap-IPAA, respectively (p = 0.048). A higher proportion of patients with ta-IPAA were treated with biologics preoperatively (98 vs. 82%; p = 0.002). Patients with ta-IPAA had a significantly higher mean operative time compared to lap-IPAA (277 min vs. 224 min; p = 0.001). There was no difference in the overall postoperative complication rate (ta-IPAA: 23% vs. lap-IPAA: 23%; p = 0.99). Pouch-related complications occurred in 13% of the ta-IPAA patients and 29% of lap-IPPA patients (p = 0.402). There was no difference in the anastomotic leakage rates. Readmission rates were similar in the ta-IPAA and lap-IPAA group (26 vs. 29%; p = 0.85), including IPAA-related readmissions. The mean follow-up time was 24 and 75 months for ta-IPAA and lap-IPAA, respectively (p = 0.001), and the ileostomy closure rate was similar in both groups of patients (p = 0.96).

CONCLUSIONS

The ta-IPAA approach for UC is a safe procedure and offers acceptable short-time outcomes.

Indications and Surgical Technique for Transanal Proctectomy and Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease

Surgical management of inflammatory bowel disease has advanced significantly over the years. One particular focus of its evolution has been to minimize invasiveness. Transanal surgery has given the contemporary surgeon an alternate approach to access the low rectum situated in the confines of the deep pelvis. In benign disease, combining transanal surgery with laparoscopy has allowed for the development of novel techniques to create ileal pouch-anal anastomoses, perform intersphincteric Crohn's proctectomies, manage complications from pelvic surgery, and facilitate redo pelvic surgery. We aim to review the indications for transanal surgery in benign disease, describe an approach to transanal pouch surgery in detail, and discuss the potential benefits, pitfalls, and contentious issues surrounding this approach.

Proctocolectomy and ileal pouch-anal anastomosis for the treatment of collagenous colitis

The role of surgery for collagenous colitis (CC) is unexplored. Either diverting stoma, subtotal colectomy with ileo-rectal anastomosis, and proctocolectomy with ileal pouch-anal anastomosis (IPAA) have been proposed. However, the optimal surgical strategy still needs to be defined. The aim of this short report is to report our experience with two cases of IPAA for CC. Two patients affected by histologically proven CC with watery diarrhea refractory to several lines of medical treatment underwent a laparoscopic proctocolectomy with IPAA at a tertiary referral hospital for the treatment of Inflammatory Bowel Disease in Belgium. A longer rectal cuff was left in place because of the absence of macroscopic inflammation of the rectal mucosa and the consequent negligible risk of cuffitis. No postoperative complications (90 days) occurred. Definitive pathological examination confirmed the diagnosis of CC. At six months, pouchoscopy revealed no signs of inflammation. One year after surgery, mean Öresland and Pouch Functional Score were 10.5 (8-13) and 11.5 (9-14). Functional outcomes after IPAA for CC were barely satisfactory. A high stool frequency not responding to high doses of anti-diarrheals was observed. This has also previously been reported for CC patients receiving a diverting stoma. Proctocolectomy and IPAA for medical refractory CC leads to acceptable short-term gastrointestinal functional outcomes which seems to be particularly affected by high stool frequency. For this reason, pouch surgery might not be the optimal indication for collagenous colitis.

Management of Low Rectal Cancer Complicating Ulcerative Colitis: Proposal of a Treatment Algorithm

Low rectal Carcinoma arising at the background of Ulcerative Colitis poses significant management challenges to the clinicians. The complex decision-making requires discussion at the multidisciplinary team meeting. The published literature is scarce, and there are significant variations in the management of such patients. We reviewed treatment protocols and operative strategies; with the aim of providing a practical framework for the management of low rectal cancer complicating UC. A practical treatment algorithm is proposed.

Increasing experience of modified two-stage transanal ileal pouch-anal anastomosis for therapy refractory ulcerative colitis. What have we learned? A retrospective analysis on 75 consecutive cases at a tertiary referral hospital

AIM

Ileal pouch-anal anastomosis (IPAA) should be delayed to a second stage in patients with ulcerative colitis and prolonged exposure to medical therapy. However, there is still discussion about whether a modified two-stage approach is preferable to a three-stage approach. Recently, a transanal approach has been introduced to overcome the well-known difficulties of laparoscopic pelvic surgery. This paper presents short-term outcomes of transanal IPAA (Ta-IPAA) according to a modified two-stage approach.

METHODS

Data from all patients who underwent a modified two-stage Ta-IPAA for ulcerative colitis refractory to medical therapy were retrieved retrospectively from a prospective database. A comprehensive complication index was used for 90-day postoperative complications. Conversion, duration of surgery, hospital stay and reoperation were considered. A logistic regression model was used to assess risk factors for peri-pouch sepsis.

RESULTS

Seventy-five (68.8%) patients were identified from 109 consecutive IPAAs. Median operation time was 159 min. Conversion rate was 4%. Mean comprehensive complication index was 7. All anastomotic leaks (10.6%) were treated with diverting ileostomy. Additionally, active rescue with transanal drainage and early resuturing of the anastomotic gap was performed in six patients. Ileostomy closure occurred after a median period of 5.4 months. At univariable analysis, factors associated with peri-pouch sepsis were male gender and age at IPAA construction.

CONCLUSIONS

A modified two-stage Ta-IPAA is safe and feasible. Standardization and reproducibility of the technique are reflected in few conversions and intra-operative complications. Finally, morbidity and anastomotic leak do not differ from those reported in previous Ta-IPAA series with a variable proportion of multistage procedures.

Transanal Ileal Pouch-Anal Anastomosis for Ulcerative Colitis has Comparable Long-Term Functional Outcomes to Transabdominal Approach: A Multicentre Comparative Study

BACKGROUND

The transanal approach to ileal pouch-anal anastomosis [Ta-IPAA] provides better access to the lower pelvis with lower short-term morbidity in ulcerative colitis [UC]. The aim of this study was to assess the long-term functional outcomes after Ta-IPAA vs transabdominal IPAA [Abd-IPAA] in UC.

METHODS

A multicentre cohort analysis was performed between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. CGQL [Cleveland global quality of life] score at 12 months with a functioning pouch was considered the primary end point.

RESULTS

A total of 374 patients [100 Ta-IPAA vs 274 Abd-IPAA] were included. Ta-IPAA demonstrated a comparable overall quality of life [CGQL score] to Abd-IPAA [0.75 ± 0.11 vs 0.71 ± 0.14; respectively, p = 0.1]. Quality of life [7.71 ± 1.17 vs 7.30 ± 1.46; p = 0.04] and energy-level items [7.16 ± 1.52 vs 6.66 ± 1.68; p = 0.03] were significantly better after Ta-IPAA, while the quality of health item was comparable [7.68 ± 1.26 vs 7.64 ± 1.44; p = 0.96]. Analysis excluding anastomotic leaks did not change the overall CGQL scores. Stool frequencies [>10/24 h: 22% vs 21%; p = 1.0] and the rate of a single episode of major incontinence during the following 12-month period [27% vs 26%; p = 0.89] were similar. The differences in 30-day morbidity rates [33% vs 41%; p = 0.2] and anastomotic leak rates were not significant [6% vs 13%; p = 0.09].

CONCLUSIONS

This study provides evidence of comparable long-term functional outcome and quality of life after Ta-IPAA and Abd-IPAA for UC.

Comparison of posterior rectal dissection techniques during rectosigmoid colon resection as part of cytoreductive surgery in patients with epithelial ovarian cancer: Close rectal dissection versus total mesorectal excision

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes of close rectal dissection (CRD) compared with those of total mesorectal excision (TME) as the posterior rectal dissection procedure during rectosigmoid colectomy performed as part of cytoreductive surgery in patients with epithelial ovarian cancer.

METHODS

We retrospectively reviewed the medical records of 163 patients who underwent posterior rectal dissection for rectosigmoid resection, including low anterior resection or subtotal colectomy, as part of ovarian cancer surgery from 2006 to 2018. The TME technique was mainly performed by colorectal surgeons, and the CRD technique preserving the mesorectal tissue was performed by an experienced gynecologic oncology surgeon. The patients were divided into the TME group and the CRD group, and their clinical outcomes were analyzed.

RESULTS

A total of 163 patients with ovarian cancer underwent rectosigmoid colon resection. Among the patients, 87 (53.4%) underwent CRD and 76 (46.6%) underwent TME as the posterior rectal dissection technique. The disease severity according to FIGO stage (p = .390) and the residual disease status (p = .412) were not statistically different between the 2 groups. However, the postoperative incidences of anastomotic leakage (p = .045) and prolonged ileus (>7 days, p = .055) were higher in the TME group. The pelvic recurrence rate and progression-free survival did not differ between the 2 groups (p = .663 and .790, respectively).

CONCLUSIONS

Considering the perioperative outcomes, CRD may be an alternative technique for rectal dissection in ovarian cancer with less perioperative morbidity and equivalent oncologic outcomes.

Close rectal dissection in benign diseases of the rectum: A review

PURPOSE

Total mesorectal excision (TME) is the gold standard resectional strategy for rectal cancer to minimize loco-regional recurrence and optimize oncological outcomes. This plane is described by many as 'bloodless' but it does contain important pelvic neural plexuses and dissection may be close to the ureters and major vascular structures, particularly in inflammatory conditions of the distal colon and rectum. In such benign diseases a more conservative excision, so-called close rectal dissection, has been advocated to minimize damage to these structures.

METHODS

A review of the literature was conducted to document the evolution of this procedure. Contemporary literature was interrogated to ascertain how this approach is adopted in minimally invasive surgery. Post-operative outcomes are compared to those from TME surgery.

RESULTS

From early descriptions in 1956, this procedure has been adapted for use in laparoscopic surgery. It may be particularly useful in trans-anal mesorectal surgery. Reported benefits include reduced nerve injury and pelvic sepsis. However, this must be balanced against risks of mesorectal bleeding, rectal injury, and ongoing inflammation from the retained mesorectum.

CONCLUSION

Rectal surgery in inflammatory conditions is technically challenging. Close rectal dissection is an alternate approach available to colorectal surgeons in these cases to minimize pelvic morbidity and optimize postoperative outcomes.

[How does the ileoanal pouch keep its promises? : Functioning of the ileoanal pouch after restorative proctocolectomy]

Restorative proctocolectomy with an ileoanal pouch anastomosis (IAPA) is the surgical therapy of choice for patients with refractory ulcerative colitis and/or associated (pre)neoplastic lesions. It is predominantly performed laparoscopically. Reconstruction with a J‑pouch is the most frequently applied variant due to the ideal combination of technical simplicity and good long-term results. In the present review, potential postoperative pouch complications, their risk factors, diagnostics and surgical management, as well as mid-term and long-term quality of life after pouch construction are differentially presented based on the current literature.

[The technique of restorative proctocolectomy with ileal J‑pouch : Standards and controversies]

BACKGROUND

Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC).

OBJECTIVES

This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC.

RESULTS

RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J‑pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated.

CONCLUSION

The evidence in regard to controversial points remains limited.

Variables associated with loss of ileoanal pouches constructed in childhood

AIMS

To quantify the incidence of loss of an ileoanal pouch in children and to identify variables associated this event.

METHODS

Logistic regression of possible explanatory variables: age, sex, indication for procto-colectomy, pre-operative continence status, use of immunosuppressive drugs, open or laparoscopic surgery, number of stages, anastomotic leak, operative complication excluding anastomotic leak, performance of revisional surgery, albumin concentration and platelet count at time of surgery, rank order in series. Univariate logistic regression was used to identify significant variables which were then assessed in a multivariate model and construction of Kaplan-Meier graphs.

RESULTS

103 children, 56 girls, underwent ileoanal pouch at median age 14years (SD 3.7). Indications and mean age were: ulcerative colitis (n=71, 14years), polyposis syndromes (n=13, 15years), chronic idiopathic constipation (n=9, 11years), Hirschsprung's disease (n=4, 1year), Crohn's disease (n=2, 16years), and fibrosing colonopathy (n=2, 11years). 13 patients had their pouch excised or permanently diverted. Three patients had successful revisional pouch surgery. Only pre-operative fecal incontinence and anastomotic leak were significantly associated with pouch excision/diversion, however on multivariate analysis, only fecal incontinence remained significant, odds ratio 21 (95%CI 1.8-235, p=0.01). Pouch survival was significantly worse where there was fecal incontinence pre-operatively, p<0.0001 or an anastomotic leak, p<0.001.

CONCLUSIONS

13% of children subjected to restorative procto-colectomy ultimately receive a permanent ileostomy. Fecal incontinence prior to surgery is a relative contra-indication. Anastomotic leak increases the probability of later pouch excision.

LEVEL OF EVIDENCE

IV.

Transanal total mesorectal excision for restorative coloproctectomy in an obese high-risk patient with colitis-associated carcinoma

Transanal total mesorectal excision (TaTME) offers great potential for the treatment of malign and benign diseases. However, laparoscopic-assisted TaTME in ulcerative colitis has not been described in more than a handful of patients. We present a 47-year-old highly comorbid female patient with an ulcerative colitis-associated carcinoma of the ascending colon and steroid- refractory pancolitis. A two-stage restorative coloproctectomy including right-sided complete mesocolic excision was conducted. The second step consisted of a successful nerve-sparing TaTME and a handsewn ileal pouch-anal anastomosis. TaTME may extend the possible treatment options in inflammatory bowel disease, especially for high-risk patients.

Early and late surgical outcomes of ileal pouch-anal anastomosis within a defined population in Sweden

OBJECTIVE

Ileal pouch-anal anastomosis (IPAA), has become the procedure of choice in patients requiring reconstructive surgery for ulcerative colitis or familial adenomatous polyposis. The aim of this population-based study was to present data prospectively registered and retrospectively evaluated on the short-term and the long-term results of 124 consecutive IPAA performed chronologically by three surgeons in a single referral centre.

MATERIALS AND METHODS

All patients who underwent IPAA from 1993 to 2012 were included. Early and late morbidity and mortality were evaluated.

RESULTS

Early complications were observed in 25 patients. There was one death from cardiac failure, high output stoma occurred in six patients and wound infection occurred in four patients. Complications were associated with higher BMI (P=0.032). Four patients had to be reoperated. Peroperative bleeding was reduced when using an ultrasonically activated scalpel for the perimuscular dissection (P<0.00001). Clavien-Dindo grade III-V affected five patients. Only one patient developed anastomotic leak and septic complications.Late complications occurred in 61 patients. There was no procedure-related mortality. Pouchitis was the most common complication (n=37). Primary sclerosing cholangitis and age younger than 40 years were associated significantly with a three- and two-fold increased risk of pouchitis, respectively. Small bowel obstruction was the second most common complication (n=16), more common in women (P=0.031). The pouch failure rate was low: 2.4%. Clavien-Dindo grade III-V affected 13 patients.

CONCLUSION

In the hands of experienced high-volume surgeons, IPAA is a safe procedure associated with a relatively low early morbidity as well as an acceptable late morbidity.

Short-term morbidity and quality of life from a randomized clinical trial of close rectal dissection and total mesorectal excision in ileal pouch–anal anastomosis

Background

Posterior rectal dissection during ileal pouch–anal anastomosis (IPAA) can be performed in the total mesorectal excision (TME) or close rectal dissection (CRD) plane. The aim of this study was to compare morbidity and quality of life (QoL) in patients having TME or CRD during proctectomy followed by IPAA for benign disease.

Methods

In this randomized clinical trial, patients undergoing IPAA were allocated to TME or CRD. Thirty-day morbidity was determined and QoL assessed using Short Form 36, GIQLI (GastroIntestinal Quality of Life Index) and COREFO (COloREctal Functional Outcome) questionnaires. The primary outcome (pouch compliance) of the trial is to be reported separately.

Results

Fifty-nine patients were included, 28 in the CRD and 31 in the TME group. Baseline data were similar, except for more previous abdominal surgery in the TME group. Operating time was longer for patients having CRD (195 min versus 166 min for TME; P = 0·008). More patients in the TME group had a primary defunctioning ileostomy (7 of 31 versus 1 of 28 for CRD; P = 0·055). Severe complications occurred more frequently in the TME group (10 of 31 versus 2 of 28 for CRD). QoL was better in the CRD group for several subscales of the questionnaires measured at 1, 3 and 6 months after surgery. At 12 months, QoL was similar in the two groups for all subscales.

Conclusion

CRD led to a lower severe complication rate and better short-term QoL than wide TME.

Surgical treatment of ulcerative colitis: Ileorectal vs ileal pouch-anal anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the current gold standard in the surgical treatment of ulcerative colitis (UC) refractory to medical management. A procedure of significant magnitude carries its own risks including anastomotic failure, pelvic sepsis and a low rate of neoplastic degeneration overtime. Recent studies have shown that total colectomy with ileorectal anastomosis (IRA) has been associated with good long-term functional results in a selected group of UC patients amenable to undergo a strict surveillance for the relatively high risk of cancer in the rectum. This manuscript will review and compare the most recent literature on IRA and IPAA as it pertains to postoperative morbidity and mortality, failure rates, functional outcomes and cancer risk.

The ileo neo-rectal anastomosis in patients with familial adenomatous polyposis: a prospective case series with long-term follow up

AIM

In patients with familial adenomatous polyposis (FAP), removal of the colonic mucosa is essential to reduce the lifetime risk of developing cancer). For this purpose, ileo-pouch anal anastomosis (IPAA) has been the gold standard, but morbidity related to the dissection of the pelvis remains substantial. In an attempt to reduce the procedure-related complications of pelvic dissection, ileoneo-rectal anastomosis (INRA) has been developed. In this case series of FAP patients, the long-term functional results, morbidity and quality of life (QoL) of the INRA procedure were evaluated and compared with its early outcome.

METHOD

Long-term follow up of a consecutive group of eight FAP patients with an INRA procedure (between 1998 and 2005) was undertaken. Data on functional results, complications, manometry and endoscopy were recorded prospectively.

RESULTS

Eight patients with FAP underwent the INRA procedure. The median number of defaecations over 24 h was five. No pelvic sepsis or bladder dysfunction occurred. One patient, in whom concomitant Crohn's disease was diagnosed in retrospect, was converted to IPAA. In the INRA patients, no sexual dysfunction occurred. Endoscopic examination showed normal mucosa without any evidence of polyp formation.

CONCLUSION

Restorative surgery by means of the INRA procedure yields good functional results in FAP patients, without any pelvic dissection-related morbidity or regrowth of polyps in the neo-rectum.

Robotic-assisted proctectomy for inflammatory bowel disease: a case-matched comparison of laparoscopic and robotic technique

BACKGROUND

The objective of this study was to compare short-term outcomes of robotic and laparoscopic proctectomy in patients with inflammatory bowel disease (IBD).

METHODS

This is an IRB-approved case-matched review. Seventeen robotic proctectomies (RP), 10 with ileal pouch anal anastomosis (IPAA) and 7 completion (CP), were matched to laparoscopic proctectomies (LP). Short-term and functional outcomes were compared between LP and RP.

RESULTS

In CP cohort, operative times were longer in the RP group (351 RP vs 238 LP min, p = 0.03), mean robotic time 90 min. Estimated blood loss (EBL) was similar between RP-CP and LP-CP groups (p = 0.18). Return of bowel function (RBF) was slower in RP-CP group (3.0 vs 1.7 days, p = 0.04), and length of stay (LOS) was longer (6.4 vs 4.1 days, p = 0.02). In the IPAA group, there were no differences between operative times (p = 0.14), robotic time 86 min; EBL (p = 0.15), and postoperative complications. Return of bowel function (3.6 vs 2.6 days, p = 0.3) and LOS (8.5 vs 6.1 days, p = 0.17) were similar between RP and LP. Bowel and sexual function were equivalent between LP and RP-IPAA groups.

CONCLUSIONS

Robotic proctectomy is a safe and effective technique for patients with IBD. It is comparable to LP with regard to perioperative outcomes, complications, and short-term functional results.

Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

OBJECTIVE

The objective of this study is to provide a comprehensive update of the outcome of the ileo-pouch anal anastomosis (IPAA).

DATA SOURCES

An extensive search in PubMed, EMBASE, and The Cochrane Library was conducted.

STUDY SELECTION AND DATA EXTRACTION

All studies published after 2000 reporting on complications or functional outcome after a primary open IPAA procedure for UC or FAP were selected. Study characteristics, functional outcome, and complications were extracted.

DATA SYNTHESIS

A review with similar methodology conducted 10 years earlier was used to evaluate developments in outcome over time. Pooled estimates were compared using a random-effects logistic meta-analyzing technique. Analyses focusing on the effect of time of study conductance, centralization, and variation in surgical techniques were performed.

RESULTS

Fifty-three studies including 14,966 patients were included. Pooled rates of pouch failure and pelvic sepsis were 4.3% (95% CI, 3.5-6.3) and 7.5% (95% CI 6.1-9.1), respectively. Compared to studies published before 2000, a reduction of 2.5% was observed in the pouch failure rate (p = 0.0038). Analysis on the effect of the time of study conductance confirmed a decline in pouch failure. Functional outcome remained stable over time, with a 24-h defecation frequency of 5.9 (95% CI, 5.0-6.9). Technical surgery aspects did not have an important effect on outcome.

CONCLUSION

This review provides up to date outcome estimates of the IPAA procedure that can be useful as reference values for practice and research. It is also shows a reduction in pouch failure over time.