Clinical efficacy of laparoscopic and open total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis / 中华消化外科杂志

Objective To compare the short-term and long-term outcomes between laparoscopic and open total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC).Methods The retrospective cohort study was conducted.The clinical data of 150 UC patients who underwent total proctocolectomy with IPAA in the Renji Hospital of Shanghai Jiaotong University between January 2003 and December 2016 were collected.Among 150 patients,87 undergoing laparoscopic total proctocolectomy with IPAA and 63 undergoing open total proctocolectomy with IPAA were respectively allocated into the laparoscopy group and open group.Observation indicators:(1) comparisons of intra-and post-operative situations;(2) postoperative complications;(3) follow-up situation.Follow-up using outpatient examination and telephone interview was performed to detect postoperative recovery and complications up to December 2017.Measurement data with normal distribution were represented as x-±s and comparison between groups was analyzed using the t test.Comparison between groups of count data was analyzed using the chi-square test.Results (1) Comparisons of intra-and post-operative situations:operation time,volume of intraoperative blood loss,time of initial intestinal stoma exsufflation and duration of hospital stay were respectively (306±3) minutes,(197± 12) mL,(62.1±1.8) hours,(8.2±0.4) days in the laparoscopy group and (224±4) minutes,(308±24) mL,(75.6±2.0) hours,(10.1±0.6) days in the open group,with statistically significant difference between groups (t =16.23,4.33,5.03,2.61,P＜ 0.05).All patients discharged successfully from hospital.All the 150 patients underwent stoma reversion of ileum at 3-12 months postoperatively,and the average time in the laparoscopy group and open group was respectively (6.0±5.6) months and (6.0±4.6)months,with no statistically significant difference between groups (t =0.01,P＞ 0.05).(2) Postoperative complications:cases with postoperative wound infection,retention of urine and frequency of defecation ＞ 4 times / day were respectively 2,8,21 in the laparoscopy group and 8,15,29 in the open group,with statistically significant differences between groups (x2 =5.25,4.37,0.96,P＜0.05).The cases with postoperative intestinal obstruction,anastomotic leakage,pelvic infection,pouch infection,pouch-related Crohn's disease and hyperplasia of ileal pouch were respectively 3,10,5,23,2,1 in the laparoscopy group and 8,7,4,24,1,0 in the open group,with no statistically significant differences between groups (x2=3.65,0.11,0.01,0.96,0.17,0.82,P＞0.05).Patients with postoperative complications were improved by acid suppression,fasting,anti-infection and fluid infusion.(3) Follow-up situation:150 patients were followed up for 12-60 months,with a median time of 48 months.There was no abnormality of postoperative anastomotic stoma and intestinal mucosa through comparison of colonoscopy results between pre-operation and 5 year postoperatively.During the follow-up,50 patients had shapeless stool and irregular defecation (times ＞ 4 times / day) at 3 years after stoma reversion of small intestine bypass,including 21 in the laparoscopy group and 29 in the open group,with a statistically significant differences between groups (x2 =4.72,P＜0.05).Eleven and 10 patients in the laparoscopy group and open group had shapeless stool and irregular defecation at 5 years postoperatively,but status were improved compared with the preoperative status,with no statistically significant difference between groups (x2=0.32,P ＞ 0.05).Conclusion The security of laparoscopic total proctocolectomy with IPAA for UC is equivalent to that of open total proctocolectomy,with the better short-term and long-term outcomes.

Surgery for ulcerative colitis in the era of biological agents therapy / 中华消化外科杂志

Ulcerative colitis is an inflammatory disease of colon and rectum whose etiology is still unclear.Infliximab is an anti-tumor necrosis factor antibody,which has been approved recently by the United States FDA for the treatment of ulcerative colitis to reduce signs and symptoms,to induce clinical remission and healing of the intestinal mucosa.Total proctocolectomy with pouch-anal anastomosis are the standard operation for ulcerative colitis now.The perioperative infliximab use,operation timing and procedures are the important factors affecting prognosis of patients in the era of infliximab therapy.

Analysis of complications of total proctocolectomy with ileal pouch-anal anastomosis in treatment of ulcerative colitis / 中华消化外科杂志

Objective To analyze the complications of total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) in treatment of severe or refractory ulcerative colitis (UC).Methods The retrospective cross-sectional study was conducted.The clinical data of 67 patients with severe or refractory UC who underwent TPC-IPAA in the Xinhua Hospital Affiliated to Shanghai Jiaotong University from February 2008 to October 2015 were collected.All the patients received open and laparoscopy-assisted TPC-IPAA,and two-stage or three-stage surgery was performed according to the patients' conditions.Observation indicators:(1) treatment and follow-up situations,(2) short-term complications after TPC-IPAA,(3) long-term complications after TPC-IPAA.The follow-up using telephone interview and outpatient examination was performed to detect the quality of postoperative life in patients and occurrence of complications up to July 2016.Measurement data with skewed distribution were described as M (range).The comparison of quality of pre-and post-operative life in patients was done using the paired t test.Results (1) Treatment and follow-up situations:all the 67 patients received successful surgery,including 45 with two-stage surgery and 22 with three-stage surgery.Thirty-seven patients underwent open surgery and 30 underwent laparoscopic surgery.The average frequency of postoperative daily defecation,average scores of quality of pre-and post-operative lifes were 5.6,0.47 and 0.67,respectively,with a statistically significant difference between preoperative indicators and postoperative indicators (t =-4.80,P ＜ 0.05).All the 67 patients were followed up for a median time of 4.6 years (range,1.0-8.4 years).(2) Short-term complications after TPC-IPAA:Of 67 patients,10 had short-term complications (some patients with multiple complications).One patient was complicated with presacral abscess secondary to sinus formation and then was cured by topical incision of sinus under colonoscopy.Five patients were complicated with anastomotic site-related complications of TPCIPAA,and 1 with pouch-anal anastomotic fistula combined with presacral abscess underwent drainage with ileostomy and didn't undergo stoma reversion of ileum.Two patients with fistula at the top of pouch were improved by surgery and repair.Of 2 patients with pouch-vagina fistula,1 underwent resection of pouch stump-vagina fistula and then were cured,and the space between pouch stump and posterior fornix was filled with a free greater omentum flap and temporary ileal bypass was simultaneously conducted.The other patient received twice transanal vaginal fistula repairs with advancement flap,and unclosed fistula was confirmed by angiography,with a clinical symptomatic relief.Eight patients with wound infection received actively dressing change after discharge,and no wound dehiscence was occurred.(3) Long-term complications after TPC-IPAA:28 of 67 patients had long-term complications.Twelve patients with intestinal obstruction underwent conservative treatments of gastrointestinal decompression,anti-inflammatory with corticosteroid and anti-infection with antibiotic,without the occurrence of severe intestinal perforation and prognosis needing surgical intervention,including 9 undergoing open TPC-IPAA and 3 undergoing laparoscopic TPC-IPAA.Thirteen patients with postoperative pouchitis received the conservative treatment of mesalazine.Three patients with failed pouch underwent small intestine permanent colostomy,including 2 with secondary pouch Crohn's disease and 1 with severe pouchitis.Conclusions TPC-IPAA is safe and effective in treatment of UC,with a lower incidence of complications.Anastomotic site-related complication of TPC-IPAA is the main short-term complication.And in the long-term complications,pouchitis is the most,followed it is intestine obstruction.

Early postoperative and long-term oncological outcomes of laparoscopic treatment for patients with familial adenomatous polyposis / 대한외과학회지

PURPOSE: We evaluated the short- and long-term outcomes of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (TPC/IPAA) for treatment of familial adenomatous polyposis (FAP). Also, we assessed the oncologic outcomes in FAP patients with coexisting malignancy. METHODS: From August 1999 to September 2010, 43 FAP patients with or without coexisting malignancy underwent TPC/IPAA by a laparoscopic-assisted or hand-assisted laparoscopic surgery. RESULTS: The median age was 33 years (range, 18 to 58 years) at the time of operation. IPAA was performed by a hand-sewn method in 21 patients (48.8%). The median operative time was 300 minutes (range, 135 to 610 minutes), which reached a plateau after 22 operations. Early postoperative complications within 30 days occurred in 7 patients (16.3%) and long-term morbidity occurred in 15 patients (34.9%) including 6 (14.0%) with desmoid tumors and 3 (7.0%) who required operative treatment. Twenty-two patients (51.2%) were diagnosed with coexisting colorectal malignancy. The median follow-up was 58.5 months (range, 7.9 to 97.8 months). There was only 1 case of local recurrence in the pelvic cavity. No cases of adenocarcinoma at the residual rectal mucosa developed. 5-year disease-free survival rate for 22 patients who had coexisting malignancy was 86.5% and 5-year overall survival rate was 92.6%. Three patients died from pulmonary or hepatic metastasis. CONCLUSION: Laparoscopic TPC/IPAA in patients with FAP is feasible and offers favorable postoperative outcomes. It also delivered acceptable oncological outcomes in patients with coexisting malignancy. Therefore, laparoscopic TPC/IPAA may be a favorable treatment option for FAP.

Synchronous Multiple Colorectal Cancer Occurring in Polyposis

The frequencies of multiple synchronous carcinomas of the colon and the rectum have been reported to range from 2.1 to 6.3%. Currently, the frequency is higher in colorectal cancer patients, and the diagnosis is better due to the many diagnostic tools that have been developed. There are a few reported cases of five cancers in a patient at the same time. We report here on the case of five synchronous cancers arising from the colon and the rectum in a patient without a familial history of colon cancer or of genetic predisposing factor. The patient was a 62-yr-old woman who presented with frequently loose stool for six months and intermittent abdominal pain for two months. Colonoscopic examination revealed two adenocarcinomas, one each at the sigmoid colon and the rectum; the cancer in the sigmoid colon was obstructed at nearly 40 cm above the anal verge. Computed tomographic colonoscopy revealed many other polyps and masses in the colon and a metastatic mass at segment 8 in the liver. A total proctocolectomy and ileostomy were performed. Histologic evaluation revealed the five lesions to be adenocarcinomas invading the pericolic fat; 1 out of 30 lymph nodes was invaded by the cancer cells.

Clinical Analysis for 30 Cases of Total or Subtotal Abdominal Colectomy and Total Proctocolectomy

PURPOSE: A total or a subtotal abdominal colectomy and a total proctocolectomy are performed occasionally for the surgical treatment of familial adenomatous polyposis, multiple colorectal cancers, ulcerative colitis, acute lower GI bleeding, and malignancy other than colorectal cancer. We studied 30 cases of patients who received either a total or a subtotal abdominal colectomy and a total proctocolectomy in one of the three hospitals affiliated with the Catholic University between January 1990 and December 2001. Our goal was to determine whether the total or subtotal abdominal colectomy and the total proctocolectomy are difficult and complicated procedures by comparing the mortality, the morbidity, the survival rate, and the complications to previously considered and reported results. METHODS: Thirty patients treated with either total or subtotal abdominal colectomy and with a total proctocolectomy from January 1990 to December 2001 were chosen for this study. Their gender, age, underlying diseases, family history, hospital days, symptoms, changes in defecation habits following the procedure, complications, mortality, survival rate, and relationship to malignancy were evaluated. RESULTS: Of the patients who received either total or subtotal abdominal colectomy and a total proctocolectomy, the average age was 44.6 years, the gender ratio was 1:1, and the underlying diseases were familial adenomatous polyposis (FAP) (43%), ulcerative colitis (UC) (20%), multiple colorectal cancers (17%), stomach cancer (7%), and Crohn's disease (3%). Diarrhea and rectal bleeding were the most common clinical symptoms, and abdominal pain and intestinal obstruction were frequently observed. A total proctocolectomy (TPC) with permanent ileostomy was the most frequently performed procedure (47%), and a TPC with ileoanal anastomosis was done in 10% of the cases. A total abdominal colectomy (TAC) with ileorectal anastomosis was applied in 23% of the cases, and subtotal abdominal colectomy (sTAC) with ileosigmoidal anastomosis was done in 20% of the cases. The operative mortality rate was 3% as one patient among thirty died. Postoperative complications developed in 33% of the patients. FAP and UC patients without cancer (45%) survived for over 4 or 5 years, but FAP and UC patients with cancer, especially an adenocarcinoma, survived for only 2.5 years. CONCLUSIONS: A total or subtotal abdominal colectomy (TAC or sTAC) and a total proctocolectomy (TPC) are appropriate procedures with low mortality, low morbidity, and a low complication rate for several kinds of diseases. A TPC with ileorectal anastomosis is the procedure of choice for sparing the rectum in FAP and UC patients without coexisting cancer and without mutation of the APC gene after codon 1250, but a TPC with ileoanal anastomosis is recommended if there is a mutation of the APC gene after codon 1250. A TPC with ileostomy is the preferred method for FAP and UC patients with coexisting cancer.

The Clinical Results of a Total Proctocolectomy with an Ileal Pouch-Anal Anastomosis: 12 Cases

PURPOSE: A restorative proctocolectomy has been accepted as the operation of choice for ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to assess the postoperative complications and functional outcomes following a total proctocolectomy with a J ileal pouch-anal anastomosis. METHODS: The medical records of 12 patients who had undergone a total proctocolectomy, with a J ileal pouch-anal anastomosis, between January 1997 and June 2002, were retrospectively reviewed according to sex, age, underlying disease and postoperative complications. We evaluated the functional outcomes using medical record reviews and patients and telephone interviews. RESULTS: Total proctocolectomy, with a J ileal pouch-anal anastomosis, were done for ulcerative colitis (n=2) and familial adenomatous polyposis (n=10). A diverting ileostomy was performed in 8 patients. Postoperative complications occurred in 7 patients (58%), intestinal obstructions in 4 and complications related with anastomosis in 3, i.e. J ileal pouch leakage (n=2) and ileal pouch-vaginal fistula (n=1). Re-operations, due to postoperative complications, were performed in 4 patients, i.e. small bowel segmental resection (n=1), adhesiolysis (n=1), diverting ileostomy (n=1) and ileal pouch resection & reconstruction (n=1). The daily median defecation frequencies were 7.7 (range 4~20) a month after the operation, 5.4 (3~12) at 2~3 months, 4.5 (3~7) at 6 months and 4.1 (3~5) at 12 months, following the operation. Two patients had gas incontinence, 1 had fluid incontinence, 4 had night soiling and 3 needed pads, but these incontinences, the need for anti-diarrhea medication and the use of pads, all improved within 6 months of the operation. Fluid incontinence and the use of pads improved within 3 months of the operation, gas incontinence and night soiling improved within 6 months of the operation. The mean length of follow-up was 30.6 months. CONCLUSIONS: The postoperative complication rate was 58%. Thirty-three percent of patients had fecal incontinence, but all these improved within 6 months. The long- term functional outcomes, after a total proctocolectomy with J ileal pouch-anal anastomosis, were satisfactory, and the postoperative complications acceptable. The postoperative complication rates were no different between the protective diverting ileostomy and non-ileostomy .

Ileostomia continente com preservação da papila íleo-cecal

The authors report three cases of patients submitted to definitive continent ileostomy and three cases of temporary continent ileostomy. Five of them had inflammatory bowel disease and one had familial adenomatous polyposis associated to lower rectal cancer. It was used the continent ileostomy technique, keeping the ileocecal sphincter and a small border of cecal wall. The ileal flow in the first week of post operative does not overflow 430 ml per day. They conclude that the continent ileostomy is useful procedure in selected cases when we need to keep an efficient control of the intestinal effluent.

Seis doentes foram submetidos a ileostomia continente com preservação da papila íleo-cecal, como tempo cirúrgico complementar à proctocolectomia e à colectomia totais, para tratamento de doença inflamatória intestinal e polipose adenomatosa familiar, associada a pólipo degenerado no reto inferior. A técnica utilizada de ileostomia continente preserva a papila íleo-cecal e uma pequena borda circular de parede cecal exteriorizados na parede abdominal. O débito ileal, na primeira semana pós-operatória, não ultrapassou 430 ml/dia, não houve complicações do procedimento e o aspecto estético ficou excelente. Conclui-se que a ileostomia continente com preservação da papila íleo-cecal, definitiva ou temporária, é um procedimento cirúrgico eficiente, em casos selecionados, quando se deseja manter um controle eficaz do efluente intestinal.