Minimally invasive total Proctocolectomy with Brooke Ileostomy for Ulcerative Colitis

Abstract

In the 21st century, minimally invasive surgery (MIS) for ileal pouchanal anastomosis (IPAA) has emerged as the procedure of choice for the surgical treatment of chronic ulcerative colitis (CUC). However, minimal literature exists regarding MIS total proctocolectomy with permanent Brooke ileostomy (TPC-BI). The aim of this study was to describe the safety and feasibility of MIS TPC-BI for CUC. Using a prospective institutional database, we identified a cohort of CUC patients who underwent MIS TPC-BI from 2000 - 2007. Peri-operative variables and short-term (30-day) outcomes were abstracted. Statistically significant differences between three MIS subgroups were assessed using Kruskal-Wallis and Fisher's exact test for continuous and categorical variables, respectively; p>0.05 were considered not significant. Numbers represent frequency (proportion), or median (range). Over 7 years, 44 patients underwent MIS proctocolectomy with permanent ileostomy for CUC. Median age was 65 years (54 - 73), 24 were male (55%), and the BMI was 26.5 (22.1 - 30.2) kg/m2. Duration of disease was 66 months (24 - 240); 18 (40%) patients had prior abdominal surgery, with a median Charlson score of 3 (0 - 4). The surgical indication was refractory colitis in 36 (82%), and neoplasia in 8 (18%). Factors influencing the non-restorative surgical approach were advanced age in 18 (41%), lifestyle in 13 (30%), medical comorbidities in 11 (25%), fecal incontinence in 10 (23%), oncologic reasons in 3 (6.8%), and obesity in 3 (6.8%); 18 (41%) of patients had >1 factor. MIS approaches included hand-assisted laparoscopic surgery (HALS) in 23 (52%), laparoscopic-assisted (LAP) in 13 (30%); and laparoscopic-incisionless (INC-LESS) with transanal specimen extraction in 8 (18%). Operative variables and outcomes are shown in Table 1. Two LAP cases (4.6%) were converted, and one HALS patient (2.2%) required transfusion after a pelvic bleed. Operative time was 329 (173 - 538) minutes, and length of stay 5 (3 - 10) days. Major post-operative complications (>= Clavien grade 3) occurred in 4 (9%) including stoma revision in 3 (7%), and relaparoscopy for pelvic bleeding in 1 (2.2%). There were no 30 day mortalities. Operative Variables and Outcomes Operative Variables and Outcomes MIS total proctocolectomy with Brooke ileostomy is a safe and feasible option for the surgical treatment of ulcerative colitis. These surgical approaches offer short lengths of stay and low morbidity rates, and should be considered in patients with refractory CUC or neoplasia who choose not to undergo, or who have contraindication to, IPAA.