Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1621_Библиотеки_им_академика_М_И_Перельмана.pdf
285
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_32
S. L. Whitney
Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai,
New York, NY, USA
A. J. Greenstein (
*)
Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai,
New York, NY, USA
Department of Health Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
e-mail: alexander.greenstein@mountsinai.org
32
Role ofMinimally Invasive Surgery
inPouch Surgery
StewartL.Whitney andAlexanderJ.Greenstein
P (Patients)
I
(Intervention)
C
(Comparator)
O (Outcomes)
Ulcerative colitis patients
undergoing ileal pouch-anal
anastomosis
MIS Open Complication rate,
quality of life
Introduction
Ileal pouch-anal anastomosis (IPAA) has undergone a progression of techniques
over the last several decades. It was rst described in 1978 by Sir Alan Parks in the
British Medical Journal [1]. Although other types of pouches have been employed,
such as the S-pouch and W-pouch, the J-pouch remains the most common pouch
technique employed currently [2]. The creation of the pouch is commonly per-
formed in 2 or 3 stages, although single stage creation has been described [3]. These
stages typically include total abdominal colectomy (or subtotal colectomy), fol-
lowed by restorative proctocolectomy with pouch creation with or without a divert-
ing loop ileostomy, and then closure of the diverting loop ileostomy.
Laparoscopic surgery has been shown to be safe and effective in colorectal sur-
gery in general, and ulcerative colitis in particular [4–6]. These minimally invasive
286
approaches were initially used in ulcerative colitis for the total abdominal colec-
tomy portion but are now commonly used during completion proctectomy and
IPAA [7–12]. Our goal is to present and examine the data to support the safety,
efcacy, and benets of laparoscopy in surgery for ulcerative colitis by showing the
comparisons of outcomes, quality of life and other endpoints.
Search Strategy
A comprehensive literature search of the Cochrane Review Database, Medline and
PubMed was performed to identify all publications involving laparoscopy, ileal pouch-
anal anastomosis, minimally invasive between 1980 and 2018. Keywords for search
included: “ileal-pouch anal anastomosis”, “laparoscopy”, “minimally invasive”. Studies
were excluded if a laparoscopic or minimally invasive approach was not employed or
was not mentioned in the study. References of these studies were then reviewed to incor-
porate any other pertinent studies. Outcomes measured and compared were: short-term
morbidity, mortality, intra-operative complications, blood loss, operative time, func-
tional outcomes (number of bowel movements per 24h, night-time frequency, inconti-
nence), quality of life, cosmesis, body image, fertility, incisional hernia rates.
Results
Early studies reporting on laparoscopic or minimally invasive IPAA tended to be
single institution case series and cohort studies discussing their experience and out-
comes. Over time, this led to several randomized trials with more robust data on
long-term and functional outcomes.
Short-Term Outcomes
Short-term outcomes include: operating room time, intraoperative complications,
return of bowel function, time to resumption of diet, length of stay, and postoperative
complications. Operative time was reported by 10 trials and was noted to be signi-
cantly longer for the laparoscopic approach. Median operative time was 133min with
open and 214min (range 149–400) with the laparoscopic approach (p< 0.001). Of
note, several trials found that this gap closed over the years as the surgeons became
more experienced with the laparoscopic technique [13–16]. Seven trials reported reop-
eration rates and there was a no signicant difference between the laparoscopic and
open approaches [14, 16–21]. In the single RCT reported by Maartense, there was 1
intraoperative complication in each group. Major complications were reported as 4/30
(13%) in the laparoscopic group and 5/30 (20%) in the open group (p=0.74) [21].
Length of stay (LOS) is a perceived advantage of the laparoscopic approach, and
thus was a primary endpoint in several studies. Many studies showed a statistically
signicant decrease in LOS when compared to open [22–24], while others showed
no statistical difference [21, 25–27]. The RCT showed no difference between the
S. L. Whitney and A. J. Greenstein
287
groups, with mean LOS at 11days (range 6–28days) in the open group and 10days
in the laparoscopic group (range 5–24days; p=0.76). A Cochrane Review pub-
lished in 2011 [28] found a small, non-signicant decrease in LOS when comparing
laparoscopic to open with mean LOS being 11 and 12days, respectively. Mortality
was reported in nine trials, with eight showing 0 deaths in either group. One trial
had a single death in the open group: however the Cochrane review showed no sig-
nicant difference [13, 28] (Table32.1).
Comparison between laparoscopic and open approaches with regards to time to
regular diet were reported by several studies [22, 25, 29–32]. Maartense reported
median time to regular diet at 6days in the laparoscopic group and 7in the open
group (p=0.6) [21]. Two studies showed a signicantly faster return of bowel func-
tion in the laparoscopic group. Fichera reported that the laparoscopic group regained
bowel function one day faster (p<0.001) [33], and Marcello showed median days
to return of bowel function at 2days in the laparoscopic group vs. 4days in the open
group (p=0.03) [22]. However, several other studies have shown no difference in
time to regular diet between the two approaches [25, 30, 32].
Long-Term Outcomes
Long-term outcomes were reported by many studies. Functional outcomes included
defecation frequency, fecal incontinence, and sexual dysfunction. Fecal inconti-
nence was expanded to daytime episodes, nighttime episodes, soiling and urge
incontinence. In these categories of fecal incontinence, no signicant difference was
found between the laparoscopic and open approaches.
Quality of life (QOL) aspects were reported by several studies. Dunker reported a
mean number of defecations during the day at 5.7 (SD 1.3) in the laparoscopic group
and 6.3 (SD 2.0) in the open group (p=nonsignicant) [16]. The RCT reported day-
time frequency at 6.09 (SD2.29) in the laparoscopic and 5.35 (SD 1.82) in the open
group, respectively (p=0.161). Nighttime frequency was reported by these studies
as well. This same study reported a nighttime rate of 1.0 (SD 0.7) in the laparoscopic
group compared to 1.3 (SD 0.7) in the open group (p=non-sig). The RCT reported
nighttime frequency rate at 2.14 (SD 1.91) in the lap group and 1.78 (SD 1.41) in the
open group (p=0.371). Incontinence rates were reported by 4 trials and all found a
no signicant difference between the groups. Each study had different parameters
and denitions, and as such it is difcult to pool results (Table32.2).
It is well-studied that laparoscopic surgery offers signicant advantage with
regards to future development of incisional hernia [34]. This is of particular interest in
our cohort of patients given the need for an extraction site during the colectomy stage
and the IPAA.Many surgeons now use the stoma site as the extraction site for a per-
ceived decrease in incisional hernia due to the lack of need for a larger extraction
incision. Two studies showed a signicantly lower rate of incisional hernias in the
laparoscopic group [29, 33]. Fichera and colleagues showed incisional hernia rates at
0% and 8.8% in the laparoscopic and open groups respectively (p=0.011) [33].
Duff reported on their institutional experience with laparoscopic IPAA, and
reported a 0% incisional hernia rate in their series of 75 patients [29]. Other studies
32 Role ofMinimally Invasive Surgery inPouch Surgery
288
Table 32.1 Studies comparing LOS and complications with laparoscopic and open IPAA
First author year
Patients studied Intervention
Study
design N (lap/open) LOS (range)
30-Day major
complication rate
30-Day
reoperation rate
Maartense
(2004) [21]
Patients with UC or
FAP after IPAA
Laparoscopic or
Open IPAA
RCT 30/30 Lap: 10 (5–31)
Open: 11
(6–28)
p=0.767
Lap: 16.7%
Open: 13.3%
p=0.74
Lap: 10%
Open: 13.3%
p=0.72
Marcello
(2000) [22]
Patients with UC or
FAP after IPAA
Laparoscopic or
Open IPAA
P, NR 20/20 Lap: 7 (4–14)
Open: 8 (6–17)
p=0.02
Lap: 4 (20%)
Open: 5 (25%)
p=NS
Not reported
El-Gazzaz
(2009) [23]
Patients with UC or
FAP after IPAA
Laparoscopic or
Open IPAA
P, NR 119/238 Lap: 5 (4–7)
Open: 6 (5–8)
p=0.001
Lap: 23.1%
Open: 21.5%
p=0.760
Not reported
Fajardo (2010)
[25]
Patients with UC or
FAP after IPAA
Laparoscopic or
Open IPAA
R, NR 55/69 Lap: 8.4 (3–32)
Open: 7/8
(3–31)
p=0.55
Lap: 50.1%
Open: 59.4%
p=0.34
Lap: 21.8%
Open: 20.3%
p=NS
Polle (2008)
[26]
Patients with UC or
FAP after IPAA
Laparoscopic or
Open IPAA
P, NR 65/30 (Total lap: 35,
Hand-assist: 30)
Total lap: 9
(5–39)
Hand-Assist:
10 (5–31)
Open: 11
(6–28)
p=0.13
Total lap: 20%
Hand-assist: 16.7%
Open: 13.3%
p=0.745
Total lap: 20%
Hand-assist:
10%
Open: 13.3%
p=0.70
White (2014)
[24]
Patients with UC or
FAP after IPAA
Laparoscopic or
Open IPAA
P, NR 76/131 Lap: 6 (4–8)
Open: 8 (7–12)
P<0.001
Lap: 16%
Open: 11.5%
p=NS
Lap: 13.2%
Open: 7.6%
p=NS
R retrospective, P prospective, NR non-randomized, RCT randomized control trial, NS non-signicant
S. L. Whitney and A. J. Greenstein
289
Table 32.2 Studies comparing functional outcomes between laparoscopic and open IPAA
First author
year
Patients studied Intervention
Study
design
N (lap/
open)
Daytime bowel movement
frequency (mean and SD/
range)
Nighttime bowel
movement frequency
Incontinence
Dunker
(2001) [16]
Patients with UC
or FAP after IPAA
Laparoscopic or
open IPAA
R, NR 15/17 Lap: 5.7 (1.3)
Open: 6.3 (2.0)
p=NS
Lap: 1.0 (0.7)
Open: 1.3 (0.7)
p=NS
Lap: 0
Open: 1 (<1/
week)
p=NS
Maartense
(2004) [21]
Patients with UC
or FAP after IPAA
Laparoscopic or
open IPAA
RCT 22/23 Lap: 6.09 (2.29)
Open: 5.35 (1.82)
p=0.161
Lap: 2.14 (1.91)
Open: 1.78 (1.41)
p=0.371
Not applicable
Larson (2005)
[17]
Patients with UC
or FAP after IPAA
Laparoscopic or
open IPAA
P, NR 33/33 Lap: 7 (3–14)
Open: 6 (3–12)
p=0.23
Lap: 1 (1–5)
Open: 2 (1–4)
p=0.86
Lap daytime:
70%
Open
daytime:70%
p=0.96
Lap nighttime:
52%
Open nighttime:
45%
p=0.16
Otani (2001)
[15]
Patients with UC
or FAP after IPAA
Laparoscopic or
open IPAA
NR 10/18 Lap: 8 (2.3)
Open: 11 (1.0)
p=NS
(reported as 24h)
Not applicable Not applicable
R retrospective, P prospective, NR non-randomized, RCT randomized control trial, NS non-signicant
32 Role ofMinimally Invasive Surgery inPouch Surgery
290
have shown there is no difference, however. Benlice and colleagues showed no dif-
ference in incisional hernia rates between the groups, with the open group having an
incidence of 8.4 while the laparoscopic group had a rate of 5.8% (p=0.4) [35].
Fewer adhesions after laparoscopic intraabdominal surgeries has long been an argu-
ment for laparoscopy. Indar reported their ndings after performing a laparoscopic
evaluation of pelvic adhesions during the closure of the loop ileostomy following pre-
vious laparoscopic IPAA. 68% had no adhesions to the anterior abdominal wall, with
the remaining 32% had mild, avascular lmy adhesions to the anterior abdominal wall
[36]. No patients were found to have dense adhesions. Adnexal adhesions were also
quantied using a standardized method and 15 of 21 (71%) female patients were found
to have no adnexal adhesions, 5 of 21 (24%) had lmy adhesions enclosing less than
one-third of one adnexa and 1 of 21 (5%) had lmy adhesions enclosing one-third to
two-thirds of one adnexa. No patients had adhesions involving both adnexae.
Sexual function was reported by three trials. Each trial had different denitions
for sexual function, and none of these studies found a signicant different between
the groups [16, 17, 21]. Cosmesis was reported by two studies using the same cos-
mesis scale, showing higher scores in the laparoscopic group compared to the open
group [16, 21]. The RCT performed by Maartense found a superior score on the
cosmesis scale from 14.7 to 18.5in the laparoscopic group (p=0.01) [21]. Dunker
found a similar difference with mean score of 16in the open group and 19.8in the
laparoscopic group (p=0.03) [16].
Fertility is an important discussion with female patients undergoing IPAA, as
these patients have a higher risk of infertility postoperatively. It has been well shown
that open IPAA carries a high risk of infertility [37]. Bartels found that those patients
who underwent laparoscopic IPAA had signicantly lower infertility rates when
compared to the open group, which was hypothesized to be secondary to decreased
adnexal adhesions in the laparoscopic cohort [38]. This study used a questionnaire
sent to female patients who had previously undergone IPAA. 50 patients reported
they had attempted to conceive; 23 (46%) had undergone open and 27 (54%) had
undergone laparoscopic IPAA.Their analysis showed a higher pregnancy rate in the
laparoscopic IPAA group when compared to the open (p=0.03). Three metaanalyses
showed infertility rates in the open group at 48%, 43%, and 63%, respectively [39–
41]. Beyer-Berjot found that that 73% of female patients after laparoscopic IPAA
who attempted to conceive were able to, with a global infertility rate of 27%, which
is much lower than the reported rates for the open groups [42] (Table32.3).
Table 32.3 Studies evaluating fertility rates after Laparoscopic IPAA
First author
year
Patients studied Intervention
Study
design
N (lap/
open)
Spontaneous
pregnancy rate
Bartels
(2012) [38]
Patients who
underwent
laparoscopic IPAA
Laparoscopic
IPAA
R, NR 27/23 Lap: 19 (70%)
Open: 9 (39%)
p=0.023
Beyer-
Berjot
(2013) [42]
Patients who
underwent
laparoscopic IPAA
Laparoscopic
IPAA
R, NR 63
(only
Lap)
73%
R retrospective, P prospective, NR non-randomized, RCT randomized control trial, NS
non-signicant
S. L. Whitney and A. J. Greenstein
291
Personal View
Over the last 10–15years, laparoscopy has become the primary surgical approach
for IPAA.Our experience mirrors that seen in the studies; laparoscopic IPAA has
similar functional outcomes when compared to open, can have shorter length of
stays, with relatively low rates of conversion to open surgery. Our laparoscopic
technique has evolved over the years, beginning with frequent use of hand-assist
laparoscopic surgery (HALS) via a Pfannensteil incision. This technique was often
employed when the colectomy and IPAA were performed in a single stage. The
colon was mobilized laparoscopically and extracted, and the construction of the
pouch and IPAA were performed via the hand-assist port.
Now, given the widespread use of biologics in our patients and the high percent-
age of patients that come for their initial operation after admission through the
emergency room, we often create the IPAA in three stages, and perform this purely
laparoscopically. We typically use a double staple technique unless there is rectal
dysplasia or severe proctitis which would push us more towards mucosal stripping
and a handsewn ileoanal anastomosis. Our preferred extraction site for the colon
during the subtotal colectomy portion of the procedure is the ostomy site itself, but
if the colon is too fatty and/or bulky, a small Pfannenstiel incision can be used.
There is typically a 3 month wait between the rst and second stages and then a
2–3month wait between the second and third stages. There is routine use of divert-
ing ileostomy during creation of the pouch and we have moved away from plain lm
enema studies towards CT pouchogram as the best strategy for evaluating the pouch
prior to closure. Using standard 5mm laparoscopic ports, we have had good results.
Our patients are generally discharged on postoperative day 3 following the rst and
second stages with no change appreciated in either functional outcomes or leak rate.
We have found that we can obtain better visualization and thus a lower dissection in
the pelvis with the laparoscopic technique when compared to open, and that subse-
quent cuff lengths can be signicantly reduced. Endo GIA (Medtronic) is our stapler of
choice and by using the shorter length staple loads (i.e. 45 and 30mm) and deploying
them through a 12mm suprapubic port, it is easier to achieve a more ush staple line.
Another notable advantage is the signicant decrease in adhesions in the
laparoscopically- created IPAAs. We have found that re-operations in patients who
underwent open IPAA had have had signicantly worse intra-abdominal and pelvic
adhesions when compared to the laparoscopic group, especially for those patients
who underwent the pure laparoscopic approach without hand-assist.
We have found the laparoscopic approach to be safe with good functional out-
comes, quicker return of bowel function and shorter length of stay. Our technique
has evolved over the years with a signicant learning curve required prior to reduc-
tion of operative times and complications.
References
1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. BMJ.
1978;ii:85–8.
32 Role ofMinimally Invasive Surgery inPouch Surgery
292
2. Cohen Z, McLeod RS, Stephen W, Stern HS, O’Connor B, Reznick R.Continuing evolution
of the pelvic pouch procedure. Ann Surg. 1992;216:506–111.
3. Ky AJ, Sonoda T, Milsom JW.One-stage laparoscopic restorative proctocolectomy: an alterna-
tive to the conventional approach? Dis Colon Rectum. 2002;45:207–10.
4. Bohm B, Schwenk W.Results of prospective randomized trials of laparoscopic versus conven-
tional resection for colorectal cancer [abstract]. Int J Color Dis. 1998;13:179.
5. Stage JG, Schulze S, Moiler P, etal. Prospective randomized study of laparoscopic versus open
colonic resection for adenocarcinoma. Br J Surg. 1997;84:391–6.
6. Milsom JW, Bohm B, Hammerhofer KA, Fazio V, Steiger E, Elson P.A prospective, random-
ized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery:
a preliminary report. J Am Coil Surg. 1998;187:46–54.
7. Wexner SD, Johansen OB, Nogueras JJ, Jagelman DG.Laparoscopic total abdominal colec-
tomy: a prospective trial. Dis Colon Rectum. 1992;35:651–5.
8. Reissman P, Salky BA, Pfeifer J, Edye M, Jagelman DG, Wexner SD.Laparoscopic surgery in
the management of inammatory bowel disease. Am J Surg. 1996;171:47–51.
9. Sardinha TC, Wexner SD.Laparoscopy for inammatory bowel disease: pros and cons. World
J Surg. 1998;22:370–4.
10. Lui CD, RolandeIli R, Ashley SW, Evans B, Shin M, McFadden DW.Laparoscopic surgery for
inammatory bowel disease. Am Surg. 1995;61:1054–6.
11. Hildebrandt U, Lindemann W, Kreissler-Hagg D, Feifei G, Ecker KW. Laparoscopically-
assisted proctocolectomy with ileoanal pouch in ulcerative colitis. Zentralbl Chir.
1998;123:403–5.
12. Milsom JW, Ludwig KA, Church JM, Garcia Ruiz A.Laparoscopic total abdominal colec-
tomy with ileorectal anastomosis for familial adenomatous polyposis. Dis Colon Rectum.
1997;40:675–8.
13. Araki Y, Ishibashi N, Ogata Y, Shirouzo K, Isomoto H. The usefulness of restorative
laparoscopic- assisted total colectomy for ulcerative colitis. Kurume Med J. 2001;48(2):99–103.
14. Berdah SV, Barthet M, Emungania O, Orsoni P, Alliot P, Grimaud JC, Brunet C. Two
stage video-assisted restorative proctocolectomy. Early experience of 12 cases. Ann Chir.
2004;129(6–7):332–6.
15. Otani Y, Nakamura T, Kanazawa H, Aihara N, Kokuba Y, Ihara A, Kakita A. Article in
Japanese [Laparoscopy–assisted ileal pouch anal canal anastomosis for ulcerative colitis]. Jpn
J Gastroenterol Surg. 2001;34(4):351–6.
16. Dunker MS, Bemelman WA, Slors JFM, van Duijvendijk P, Gouma DJ.Functional outcome,
quality of life, body image, and cosmesis in patients after laparoscopic assisted and conventional
restorative proctocolectomy—A comparative study. Dis Colon Rectum. 2001;44(12):1800–7.
17. Larson DW, Cima RR, Dozois EJ, Davies M, Piotrowicz K, Barnes SA, Wolff B, Pemberton
J.Safety, feasibility, and short-term outcomes of laparoscopic illeal-pouch- anal anastomo-
sis—A single institutional case-matched experience. Ann Surg. 2006;243(5):667–72.
18. Schmitt SL, Cohen SM, Wexner SD, Nogueras JJ, Jagelman DG. Does laparoscopic-
assisted ileal pouch anal anastomosis reduce the length of hospitalization? Int J Color Dis.
1994;9(3):134–7.
19. Brown SR, Eu KW, Seow-Choen F.Consecutive series of laparoscopic-assisted vs. minilapa-
rotomy restorative proctocolectomies. Dis Colon Rectum. 2001;44(3):397–400.
20. Hashimoto A, Funayama Y, Naito H, Fukushima K, Shibata C, Naitoh T, Shibuya K, Koyama
K, Takahashi K, Ogawa H, Satoh S, Ueno T, Kitayama T, Matsuno S, Sasaki I.Laparascope-
assisted versus conventional restorative proctocolectomy with rectal mucosectomy. Surg
Today. 2001;31(3):210–4.
21. Maartense S, Dunker MS, Slors JF, Cuesta MA, Gouma DJ, van Deventer SJ, van Bodegraven
AA, Bemelman WA. Hand-assisted laparoscopic versus open restorative proctocolectomy
with ileal pouch anal anastomosis: a randomized trial. Ann Surg. 2004;240(6):984–91.
22. Marcello PW, Milsom JW, Wong SK, Hammerhofer KA, Goormastic M, Church JM, Fazio
VW.Laparoscopic restorative proctocolectomy: case-matched comparative study with open
restorative proctocolectomy. Dis Colon Rectum. 2000;43(5):604–8.
S. L. Whitney and A. J. Greenstein
293
23. El-Gazzaz GS, Kiran RP, Remzi FH, Hull TL, Geisler DP.Outcomes for case-matched laparo-
scopically assisted versus open restorative proctocolectomy. Br J Surg. 2009;96(5):522–6.
24. White I, Jenkins JT, Coomber R, Clark SK, Phillips RKS, Kennedy RH.Outcomes of laparo-
scopic and open restorative proctocolectomy. Br J Surg. 2014;101(9):1160–5.
25. Fajardo AD, Dharmarajan S, George V, Hunt SR, Birnbaum EH, Fleshman JW, Mutch
MG.Laparoscopic versus open 2-stage ileal pouch: Laparoscopic approach allows for faster
restoration of intestinal continuity. J Am Coll Surg. 2010;211(3):377–83.
26. Polle SW, Van Berge Henegouwen MI, Slors JFM, Cuesta MA, Gouma DJ, Bemelman
WA.Total laparoscopic restorative proctocolectomy: Are there advantages compared with the
open and hand-assisted approaches? Dis Colon Rectum. 2008;51(5):541–8.
27. Rivadeneira DE, Marcello PW, Roberts PL, Rusin LC, Murray JJ, Coller JA, Schoetz
DJ.Benets of hand-assisted laparoscopic restorative proctocolectomy: A comparative study.
Dis Colon Rectum. 2004;47(9):1371–6.
28. Ali UA, Keus F, Heikens JT, Bemelman WA, Berdah SV, Gooszen HG, Van Laarhoven
CJHM.Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis
and familial adenomatous polyposis. Cochrane Database Syst Rev. 2009;(1):CD006267.
29. Duff SE, Sagar PM, Rao M, Macafee D, El-Khoury T.Laparoscopic restorative proctocolec-
tomy: Safety and critical level of the ileal pouch anal anastomosis. Color Dis. 2012;14(7):883–6.
30. Gill TS, Karantana A, Rees J, Pandey S, Dixon AR. Laparoscopic proctocolectomy with
restorative ileal-anal pouch. Color Dis. 2004;6(6):458–61.
31. Polle SW, Dunker MS, Slors JFM, Sprangers MA, Cuesta MA, Gouma DJ, Bemelman
WA. Body image, cosmesis, quality of life, and functional outcome of hand-assisted laparo-
scopic versus open restorative proctocolectomy: long-term results of a randomized trial. Surg
Endosc. 2007;21(8):1301–7.
32. Goede AC, Reeves A, Dixon AR.Laparoscopic restorative proctocolectomy: a 10-year experi-
ence of an evolving technique. Color Dis. 2011;13(10):1153–7.
33. Fichera A, Silvestri MT, Hurst RD, Rubin MA, Michelassi F.Laparoscopic restorative procto-
colectomy with ileal pouch anal anastomosis: a comparative observational study on long-term
functional results. J Gastrointest Surg. 2009;13(3):526–32.
34. Taylor GW, Jayne DG, Brown SR, et al. Adhesions and incisional hernias following
laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. Br J Surg.
2010;97:70–8.
35. Benlice C, Stocchi L, Costedio M, Gorgun E, Hull T, Kessler H, Remzi FH.Laparoscopic
IPAA is not associated with decreased rates of incisional hernia and small-bowel obstruc-
tion when compared with open technique: Long-term follow-up of a case-matched study. Dis
Colon Rectum. 2015;58(3):314–20.
36. Indar AA, Efron JE, Young-Fadok TM.Laparoscopic ileal pouch-anal anastomosis reduces
abdominal and pelvic adhesions. Surg Endosc Other Interv Tech. 2009;23(1):174–7.
37. Oresland T, Palmblad S, Ellstrom M, et al. Gynaecological and sexual function related to
anatomical changes in the female pelvis after restorative proctocolectomy. Int J Color Dis.
1994;9:77–81.
38. Bartels SAL, D’Hoore A, Cuesta MA, Bensdorp AJ, Lucas C, Bemelman WA.Signicantly
increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional
study. Ann Surg. 2012;256(6):1045–8.
39. Waljee A, Waljee J, Morris AM, Higgins PD. Threefold increased risk of infertility: a
meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis. Gut.
2006;55:1575–80.
40. Cornish J, Tan E, Singh B, et al. Female infertility following restorative proctocolectomy.
Color Dis. 2011;10:e339–44.
41. Rajaratnam SG, Eglinton TW, Hider P, etal. Impact oleal pouch-anal anasto- mosis on female
fertility: meta-analysis and systematic review. Int J Color Dis. 2011;11:1365–74.
42. Beyer-Berjot L, Maggiori L, Birnbaum D, Lefevre JH, Berdah S, Panis Y.A total laparoscopic
approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study. Ann
Surg. 2013;258(2):275–82.
32 Role ofMinimally Invasive Surgery inPouch Surgery
295
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_33
R. D. Hurst (*)
Department of Surgery, University of Chicago Pritzker School of Medicine,
Chicago, IL, USA
e-mail: rhurst@surgery.bsd.uchicago.edu
33
How Many Stages Should WeUse
inPouch Surgery?
RogerD.Hurst
Introduction
For the last three decades restorative proctocolectomy with J-pouch ileoanal anasto-
mosis has been the primary treatment for ulcerative colitis patients who require sur-
gery. While most patients requiring surgery for ulcerative colitis are young and are at
baseline in good health, many are at least temporarily debilitated from either severity
of disease, infection, malnutrition, obesity or side effects of immunosuppressant
medications. These factors greatly increase the risk for poor surgical outcomes, both
in the short and long term. Even when conditions are optimized, the ileoanal anasto-
mosis is known to be a high-risk anastomosis with frequent leaks and pelvic sepsis.
Leak rates for the procedure are reported to be between 5% and 14% [1].
The high risk for anastomotic dehiscence was recognized early in the develop-
ment of the procedure and strategies have been implemented in the hopes of dimin-
ishing the risks and consequences of poor anastomotic healing. For these reasons,
performing the operation in multiple stages was the initial standard approach.
However, the absolute need for staging has been questioned, with many advocating
for a strategy of omitting the approach of multiple stages in selected cases and oth-
ers omitting staging in almost all cases [2–4]. This chapter will review current avail-
able evidence to support the need for staging of operations in ulcerative colitis.
The ileoanal procedure can be performed in either a single stage, two-step, or
three-step approach [5, 6]. The decision points for the number of stages selected
center around two separate issues (Tables 33.1 and 33.2).