Kucher, Bilianskyi, Kryvoruk, Tkachenko, and Stelmakh: Laparoscopic Proctocolectomy for Ulcerative Colitis and Crohn’s Disease of the Large Intestine: Short-Term and Long-Term Outcomes of 53 Cases



Problem statement and analysis of the recent research

Until about 30 years ago, total proctocolectomy with Brooke ileostomy was the only curable option for patients suffering from ulcerative colitis (UC) and familial adenomatous polyposis. The introduction of the ileal pouch construction and transanal mucosal distal proctectomy after a number of technical refinements made restorative proctocolectomy with the ileal pouch-anal anastomosing surgery of choice for these patients [1].

Chronic panintestinal nature of Crohn’s disease (CD) results in multiple recurrences and several surgeries during the patients’ lifetime. For this reason, a conservative approach to the management of CD of the small intestine with limited indications for segmental resections was popularized during last years and was accepted as a standard of care to avoid short bowel syndrome. However, during the last decade for patients with isolated Crohn’s colitis indications to surgery have been changed from limited resections to radical colectomy. Moreover, if the disease is located distally (the descending colon, the sigmoid colon, the rectum) or involves more than two segments of the colon, total proctocolectomy is indicated [2]. On the other hand, patients with rectal sparing Crohn’s colitis after rectal sparing surgery have retained their rectum in 76% of cases for a long term [3]. This controversy in surgical approaches still exists. In our opinion, the prospective evaluation of long-term outcomes of patients with CD after restorative proctocolectomy in comparison to rectal-sparing restorative colectomy is the subject of further discussion.

Since 1992, the reports of laparoscopic approach to total colectomy started the discussion about its recognizable benefits to patients compared with open laparotomy [4].

The objective of the research was to assess the feasibility, safety and possible benefits of laparoscopic one- and two-stage total proctocolectomy for patients with UC and CD.

Materials and methods of the research

We prospectively maintained our database of 53 patients referred for laparoscopic total proctocolectomy: the preoperative status, operative times, blood loss, intraoperative complications, length of stay, postoperative short- and long-term outcomes, patients’ satisfaction, and lessons learned from our experience. Between 1996 and 2014, our group performed 53 laparoscopic total colectomies. The median age was 43 years (it ranged from 19 to 56 years). There were 24 women and 19 men. The diagnosis of ulcerative colitis was made in 32 patients; Crohn’s colitis was diagnosed in 21 patients.

During the procedure a 4- or 5-port technique was applied. There were used two options to remove the specimen: 1) via small Pfannenstiel incision, in these cases the ileal pouch was constructed extracorporeally using GIA stapler for open surgery; 2) via transanal approach, in these cases the ileal pouch was fashioned laparoscopically using a universal linear stapler Endo GIA-60 (2 cases).

Primary restorative proctocolectomy with transanal distal rectal mucosectomy followed by ileal pouch-anal hand-sewn anastomosis was performed in 5 patients with UC. Total colectomy with low anterior resection of rectum followed by the ileal pouch-rectal double stapling anastomosis was applied in 8 patients with CD. Total proctocolectomy (with primary abdominoperineal resection of the rectum, terminal ileostomy) was performed in 3 patients with CD and multiple perianal fistulas. Total colectomy, low anterior resection of the rectum, and terminal ileostomy (first stage of surgical treatment) was performed in 37 patients with acute colitis requiring urgent surgery: 27 patients suffered from UC, 10 patients suffered from CD. Second-stage restorative surgery was performed in17 patients: 14 patients with UC were managed with laparoscopically assisted J-pouch construction (two of them – totally laparoscopically), transanal mucosal proctectomy, and pouch-anal hand-sewn anastomosis formation; 3 patients with CD were managed with laparoscopically assisted J-pouch construction and pouch-low rectal double stapling anastomosing. The restorative procedure was followed by temporary diverting ileostomy in all patients. Two patients with CD required rectal stamp ablating (perineal approach) due to multiple anal fistula and anal sphincter destruction 2 and 3 years after urgent laparoscopic total colectomy combined with obstructive low anterior resection.

Results

Operative times were long averaging 6.8 hours (ranging from 4 to 11). Blood loss averaged 180 ml (ranging from 100 to 800 ml). The major intraoperative complications occurred in 4 (7.5%) patients. In one patient with UC (the 2nd stage restorative surgery) the urine bladder wall was damaged during the rectal stump dissection from the scar tissues in the pelvis. Laparoscopic suture of the bladder wall was successful. In two other patients the parietal branches of the internal iliac veins were damaged resulting in severe pelvic bleeding. In one urgent case the descending colon wall was ruptured by a holding grasper and the abdominal cavity was contaminated with bowel content. There were 3 (5.7%) conversions to laparotomy caused by bleeding in the pelvis (2 cases), and colonic wall rupture (1 case of UC complicated by toxic megacolon). There were also some minor intraoperative complications which were successfully resolved laparoscopically.

There were no deaths after surgery. The major postoperative complications were observed in 13 (24.5%) patients including pelvic abscess in 4 cases, J-pouch-rectal anastomosis leakage in 1 case, small bowel obstruction in 3 cases, infection of the minilaparotomy wound in 3 cases, diverting ileostoma stenosis in 2 cases.

Bowel function returned in 1.5 day (1-3 days). The length of hospital stay averaged 6.7 days (5-13 days).

Long-term outcomes: in 1 patient with CD ileal pouch-perineal fistula occurred (patient refused further surgical treatment and possible diverting ileostomy closure); in 2 patients with CD after urgent colectomy the disease progression in the rectal stump was very prompt causing perianal fistulas and anal sphincter damage, as a result, both patients were subjected to rectal stump ablation, using perineal approach; in 3 out of 4 patients with postoperative pelvic abscess formation the presacral sinus tract to the rectal stump occurred, all 3 patients were successfully treated during the 2nd-stage restorative procedure – transanal (combining with laparoscopic approach) mucosal rectal stump removing and J-pouch-anal anastomosing. Pouchitis occurred in 4 (13.3%) patients, and in one of these patients the pouch was removed and Brooke ileostomy was applied. In 2 patients with CD the recurrence of the disease in the rectal stump occurred 4 and 6 months after urgent colectomy with low anterior resection of the rectum. Both of them are still requiring constant conservative treatment.

The functional results of restorative surgery were evaluated in 29 patients. Bowel movements 12 months after ileostomy closure averaged 6 times in a 24 hour period (4-11movements). Complete continence was observed in 19 (65.6%) patients, the ability to postpone the pouch emptying for at least 30 min was observed in 23 (79.3%) patients.

Discussion

Under elective conditions, proctocolectomy with the ileal pouch anal anastomosis is the surgery of choice for treatment of patients with UC. Surgical technique has evolved significantly during the last decade. Mucosal proctectomy and J-pouch-anal anastomosing via transanal suturing can be performed with a low rate of complication, good anal sphincter function and resulting in a good quality of life for a long time. It is still debating whether diverting ileostomy is needed. In our group we applied diverting ileostomy in all cases except one. In this one case we observed pouch-anal anastomosis leakage, which after healing process caused fibrotic change in the intestine wall very close to the internal anal sphincter, and finally resulting in low continence. As anal continence has a great value for functional outcomes at all, we consider temporary diversion of the small bowel passage as an important tool for prevention of healing complications. On the other hand, in 2 out of 29 patients who underwent pouch-anal anastomosing followed by diverting ileostomy we observed small bowel obstruction because the intestinal loop dropped to the pelvic cavity via the “stoma window”. Thus, at the moment the indications for intestine diversion need further investigation.

In group of patients with Crohn’s colitis we applied the double-stapling technique of J-pouch-rectal anastomosing, which retains a small (up to 1-1.5 cm long) rectal stump above the dentate line. This technique is easier compared to mucosectomy, however, it can be applied only in case of healthy inferior wall of the rectum. We do not advocate this technique for using in patients with UC to avoid the possible complications due to retained diseased mucosa. However, the indications to each method of surgery and criteria for selection of patients with both UC and CD are still discussed in literature.

We performed 37 laparoscopic colectomies with low anterior resection and terminal ileostomy as a salvage procedure. The indications for such obstructive colectomy included complications of the disease (fulminant colitis, toxic megacolon, colonic strictures), status of patient (anemia, immune suppression, steroid-resistance, diabetes, body mass deficiency), the unclear difference in diagnosis of UC and Crohn’s colitis. We retained a very short (6-7 cm) rectal stump. The reason was that such a short stump is equally suitable for every further surgery. Further options of surgical treatment depended on the status of the rectal stump mucosa, presence or absence of presacral sinus, perianal fistulas, anal sphincrer function as well as patients’ status in general. There were 4 treatment options for this group of patients:

  1. Transanal mucosectomy of the short rectal stump and laparoscopically assisted ileal pouch construction with pouch-anal suturing anastomosing - for those cases where the diagnosis of UC was confirmed and rectal stump inflammation did not damage the anal sphincter.

  2. Rectal stump ablation (removal of the rectal stump together with anal sphincter) using only the perineal approach - for those cases where anal incontinence was combined with the progression of rectal stump inflammation, anal fistulas formation, fibrotic deformation of the anal canal.

  3. Laparoscopically assisted ileal pouch construction with double stapling anastomosis between the ileal pouch and short rectal stump - for cases with confirmed diagnosis of CD and “healthy” rectal stump.

  4. to continue conservative treatment of patients with UC who developed mild rectal stump inflammation and refused restorative surgery and patients with CD who developed the recurrence of the disease.

The advantages of laparoscopic approach were: significantly less intraoperative blood loss, less time for postoperative return of bowel function, less length of inpatient treatment, more rapid patients’ recovery, less adhesion formation in the abdominal cavity. The latter was proved by the 2-nd stage procedures. The abdominal cavity was almost free of adhesions; there was a free axis of the pelvis during the 2-nd stage laparoscopy.

Conclusions

Laparoscopic proctocolectomy with extracorporeal ileal pouch construction, transanal mucosectomy, and pouch-anal anastomosis are considered as surgery of choice for UC. The pouch-rectal double-stapling anastomosing is feasible for CD in individual cases. Laparoscopic total colectomy with law anterior resection is recommended as a salvage procedure.

Total laparoscopic proctocolectomy with intracorporeal ileal pouch construction and natural orifice specimen extraction may be the next step in clinical trials.

References

1 

CP Delaney, VW Fazio, FH Remzi, J Hammel, JM Church, TL Hull, et al. Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg. 2003;238:221-228. doi:10.1097/01.sla.0000080825.95166.26

2 

P Martel, PO Betton, D Gallot, et al. Crohn's colitis: experience with segmental resections; results in a series of 84 patients. J Am Coll Surg. 2002;194:448-453. doi:10.1016/S1072-7515(02)01122-5

3 

O Bernell, A Lapidus, G Hellers. Recurrence after colectomy in Crohn's colitis. Dis Colon Rectum. 2001;44:647-654. doi:10.1007/BF02234559

4 

SD Wexner, OB Johansen, JJ Nogueras, DG Jagelman. Laparoscopic total abdominal colectomy: a prospective trial. Dis Colon Rectum. 1992;35:651-655. doi:10.1007/BF02053755



Copyright (c) 2017 M D Kucher, L S Bilianskyi, M I Kryvoruk, F H Tkachenko, A I Stelmakh

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