Open Ileal Pouch-anal Anastomosis Research Articles

Development of desmoid tumours after ileorectal anastomosis versus ileal pouch-anal anastomosis in familial adenomatous polyposis

Background & AimsDesmoid tumours (DT) are an important cause of morbidity and mortality in patients with familial adenomatous polyposis (FAP). DT development might be related to the type and approach of colectomy. We aimed to compare DT development after colectomy with ileorectal anastomosis (IRA) and proctocolectomy with ileal pouch-anal anastomosis (IPAA). MethodsWe performed an international historical cohort study in FAP patients who underwent IRA or IPAA between 1961 and 2020. The primary outcome was the incidence of abdominal DT (either mesenteric, retroperitoneal or abdominal wall). Patients with a DT diagnosis before or at colectomy were excluded. Time to DT was considered censored at an eventual secondary proctectomy after IRA. We used multivariable Cox regression modelling to adjust for potential confounders. ResultsWe analysed data from 852 patients: 514 after IRA and 338 after IPAA (median follow-up 21 and 16 years, respectively). DTs were diagnosed in 64 IRA patients (12%) and 66 IPAA patients (20%). The cumulative DT incidence at 5 and 10 years was 7.5% and 9.3% after open IRA and 4.7% and 10.9% after laparoscopic IRA. These estimates were 13.6% and 15.4% after open IPAA and 8.4% and 10.0% after laparoscopic IPAA. The post-operative risk was significantly higher after IPAA (p < 0.01) in multivariable analysis, while approach did not significantly influence the risk. ConclusionsThe risk of developing an abdominal DT was found to be significantly higher after IPAA than after IRA. Postoperative DT risk should be taken into account when choosing between IRA and IPAA in FAP.

P252 Male Genitourinary Dysfunction after Minimally Invasive and Open Ileoanal Pouch

Abstract Background Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for IBD or FAP. As these diseases often manifest during adolescence or early adulthood, treatment effects on genitourinary function (GU), sexual function, and fertility are of paramount importance. However, the difference in male GU function and sexual function after minimally invasive IPAA (MIS-IPAA) compared to open-IPAA are unclear. We conducted an observational survey to compare long-term GU functionality in male patients’ post MIS-IPAA or open-IPAA. Methods All adult male patients who underwent IPAA at a single tertiary hospital between 1983 and 2023 were identified, and demographics and clinical data were obtained from our prospectively maintained pouch registry. Patients were surveyed using validated questionnaires (Table 1). The primary outcome was the composite survey scores. Patients were stratified into MIS-IPAA (laparoscopic, robotic, single-incision surgery) or open-IPAA groups based on the mode of pelvic/rectal dissection. Reoperative IPAA procedures (revisions, redo, and excisions), incomplete surveys, patients with permanent ileostomy, and status post prostatectomy were excluded. Results A total of 1,836 patients were surveyed, and 457 (24.9%) submitted a response. After exclusion criteria, 296 responses were analyzed: 236 (79.7%) open-IPAA and 60 (20.3%) MIS-IPAA. In both groups, most patients had ulcerative colitis (88 vs. 89%). Compared to open-IPAA, MIS-IPAA had a similar age at surgery (40.6 vs. 40.9, p=0.88), younger age at survey (48.2 vs 58.2, p&amp;lt;0.001), and shorter interval between surgery and survey (7.7 vs. 17.4, p&amp;lt;0.001). Male MIS-IPAA patients were able to achieve orgasm more successfully than those with open-IPAA (5 vs. 4, p=0.001). No significant difference was observed between MIS- and open-IPAA in erectile function (SHIM score 22.5 vs 21, p=0.22), IBD-specific male sexual dysfunction (IBD-MSDS, 3 vs. 2, p=0.19), lower urinary tract symptoms (LUTS) (CLLS, 4 vs. 6, p=0.16), or use of therapeutic aids for sexual activity (6 vs. 6, p=0.7). There was no difference in global quality of life (CGQoL, 0.83 vs 0.80, p=0.6). There were no differences between the patients who had difficulty conceiving a child (4 vs. 7, p=0.46) and those who experienced infertility (1 vs. 2, p=0.54). Patients experiencing infertility showed no difference in quality of life between the MIS- and open-IPAA groups (FertiQoL, 84.9 vs 85.9, p=0.64). Conclusion Minimally invasive IPAA had a higher preservation of orgasm ability than did open IPAA. There was no difference in erectile function, LUTS, need for therapeutic aids for sexual function, or fertility between MIS and open approach to pelvic dissection in IPAA.

P449 Minimally invasive IPAA in UC: Preliminary results from a referral center

Abstract Background Minimally invasive approaches in performing restaurative total proctocolectomy in Ulcerative Colitis(UC) have been increasingly adopted. In particular, the robotic approach could be used with more benefits in proctectomy with ileal pouch anal anastomosis (IPAA). In fact, the robotic device seems to potentially overcome all the limitations found in laparoscopic and conventional open surgery. The aim of our study was to compare and evaluate early and late functional postoperative outcomes and complications after IPAA, performed with open, laparoscopic and robotic techniques in UC patients. Methods At our institution, 397 UC patients who underwent restorative proctocolectomy with IPAA during the period 1986-2022, consecutively treated either with open surgery, laparoscopic or robotic techniques were enrolled. The incidence of early (&amp;lt;30 days) and late (&amp;gt;30 days) postoperative complications (intestinal occlusion, haematoma/wound infection, anastomotic dehiscence), hospital stay and an assessment about continence, autonomic nerve damage, incidence of pouchitis and cuffitis was evaluated. Results About the 397 patients, 344 underwent conventional open IPAA, 31 laparoscopically and 22 robotically. Comparable early and late postoperative surgical complications were recorded among the different techniques [early and late complications respectively 24/53 (45,2%) and 146/344(42,4%)] in minimally invasive and open groups. Minimally invasive surgery showed a better outcome regarding wound infections [0/53 (0%)], anastomotic dehiscence and reduced length of stay but open surgery demonstrated a better result on early and late intestinal occlusion [8/53 (15%)vs 22/344 (6,39%)] and anastomotic stenosis [5/53 (9,43%) vs 15/344 (4,36%)]. Lastly, the rate of cuffitis was higher in open surgery than in the minimally invasive group [(3/53 (5,66%) vs 46/344(13,37%)] and within these, robotic approach seems to show better results compared to laparoscopy. Conclusion UC patients undergoing IPAA could benefit from a minimally invasive surgical approach. Our experience confirms that robotics seems to be related to hopeful outcomes both in the short and long term period, even if more studies are needed to refine the promising results.

Laparoscopic ileal pouch-anal anastomosis reduces the risk of surgical site infections: An ACS-NSQIP study

Previous literature related to postoperative outcomes after laparoscopic vs. open ileal pouch-anal anastomosis (IPAA) is primarily based on small numbers of patients from single institutions. The aim of this study is to evaluate these outcomes in a large number of patients using propensity score matching (PSM). The ACS-NSQIP Program data files (2016-2019) were reviewed to identify patients who underwent an IPAA creation. The impact of surgical approach on operative and postoperative outcomes were evaluated. 1:1 propensity score matching (PSM) on all patient characteristics was used to obtain matched groups. Fisher's Exact/Chi-Squared tests were used to compare outcomes between groups. A Bonferroni correction was applied to the outcomes, with a p-value of 0.0031 representing statistical significance. 1802 patients were identified, with 1001 patients in the laparoscopic group and 801 patients in the open group. PSM yielded 702 patients in each matched group. Median operative time was longer for laparoscopic IPAA (278vs218.5 minutes, p<0.001). Laparoscopic IPAA patients were less likely to develop superficial and deep SSIs (3.0% vs 6.6% p=0.003). There were no differences in in-hospital mortality (0.4% vs 0.0%, p=0.3), anastomotic leak (4.0% vs 3.3%, p=1.0), organ-space SSI (6.7% vs 6.0, p=1.0), or reoperation (5.7% vs 4.0%, p=0.2) between groups. Length of stay was lower after laparoscopic IPAA (5.0 vs 6.0 days, p=0.004). There were no differences between groups in other postoperative complications. These data suggest that when matched for other confounding variables, laparoscopic IPAA is associated with reduced length of stay and superficial/deep SSIs when compared to open IPAA. Other surgical complications, including in-hospital mortality and anastomotic leak, are similar. Given the recovery benefit of the laparoscopic approach and the reduced SSI, laparoscopy should be the method of choice for the majority of patients undergoing IPAA.

A prospective analysis of the postoperative and long-term functional outcomes of a novel technique to perform rectal transection during laparoscopic restorative proctectomy and ileal pouch-anal anastomosis.

Laparoscopic ileal pouch-anal anastomosis (IPAA) technique is not standardized. An irregular division of the rectum could result in poor functional outcomes and residual diseased mucosa. The aim of the study was to develop a new technique for performing the rectal transection via a laparoscopic approach, and to compare the outcomes of this technique with those of the open surgery IPAA. This prospective study included all patients who underwent restorative proctectomy (following a previous subtotal colectomy) for ulcerative colitis in October 2017-November 2020. Rectal division was performed using a 30 mm open linear stapler which was applied laparoscopically across the distal rectum. Postoperative and functional outcomes, length of anal stump and completeness of mucosal removal were compared. Only the patients who had their ileostomy reversed by 31 December 2020 and, therefore, a minimum follow-up of 6months from the ileostomy closure, were included in the analysis of the functional outcomes and quality of life. There were 207 patients (161 laparoscopic, 46 open). Median age was 43 (18-77) years and 85 patients (41.1%) were male. Major complications (9.3 vs. 8.7%, p = 0.89) including anastomotic leaks (3.7 vs 4.4%, p = 0.84) were similar after laparoscopic and open IPAA. Patients reported a comparable number of bowel movements during the day (6 vs. 7, p = 0.21) and at night (2 vs. 2, p = 0.66), and a similar rate of episodes of incontinence during the previous 6months (3.7 vs. 4.3%, p = 0.75). The mean Cleveland Global Quality of Life score was also similar (0.79 vs. 0.74, p = 0.35). Our technique is safe and reproducible, and replicates the results of the open IPAA, while maintaining the advantages of minimally invasive surgery and avoiding any kind of anal manipulation which could result in poor long-term functional outcomes.

A Single-Center Comparative Study of Open Transabdominal and Laparoscopic Transanal Ileal Pouch-Anal Anastomosis with Total Mesorectal Excision. Has the Bar Been Raised?

BackgroundMost ulcerative colitis (UC) patients requiring surgery undergo transabdominal ileal pouch-anal anastomosis (IPAA) performed minimally invasively or open. Although one multicenter study demonstrated acceptably low morbidity after transanal pouch, our initial single-center experience with transanal IPAA (ta-IPAA) was associated with an unacceptably high rate of anastomotic leak. The aim of this study was to compare the short-term outcomes of ta-IPAA and transabdominal IPAA with growing experience of transanal proctectomy and determine whether one approach offered any advantage or benefit over the other. MethodsSingle-center series of consecutive ulcerative colitis patients underwent 3-stage IPAA, either ta-IPAA or transabdominal IPAA at a tertiary referral center. The primary outcome measure was overall complications until immediately prior to stoma closure. Secondary outcomes included postoperative clinical measures. ResultsThe study group consisted of 113 patients, which included 37 (33%) patients undergoing transabdominal or open IPAA and 76 (67%) patients undergoing ta-IPAA. The overall complication rate was numerically higher in the ta-IPAA group (56%) compared to the transabdominal group (38%) (p = 0.07) as was the incidence of anastomotic leak in the ta-IPAA group (12 vs. 5%) (p = 0.17). Mean length of hospital stay was significantly higher in the transanal IPAA group (p = 0.04). Operating time, opioid use and pain scores were similar between groups. ConclusionTransanal IPAA has a higher incidence of overall complications and anastomotic leak compared to transabdominal IPAA. Postoperative length of stay is significantly higher in patients undergoing ta-IPAA. Operating room time, opiate use and pain scores are comparable between the two surgical approaches. Transanal IPAA appears to offer little advantage over transabdominal IPAA.

A long-term follow-up after open ileal J pouch volvulus repair in a FAP patient - A case report.

IntroductionMost patients with familial adenomatous polyposis (FAP) undergo proctocolectomy with ileal pouch–anal anastomosis (IPAA). Pouch volvulus is one of the very rare complication of open IPAA surgery that can mimic small bowel obstruction secondary to adhesion. High index of suspicion and proper investigation is required.Presentation of caseThe patient is a 44-year-old female with FAP who is currently on the mend after a 2-stage total proctocolectomy with ileal pouch–anal anastomosis. Presented eight years after indexed surgery with pouch volvulus, successfully treated with bowel resection without pouchopexy.DiscussionThe surgery of choice for most patients with FAP is IPAA. Pouch volvulus is a rare complication of laparoscopic IPAA surgery and extremely rare after open surgery which can be treated surgically in various ways. But it can be catastrophic if not treated in timely manner. This case report presents a FAP patient with pouch volvulus after open IPAA treated with bowel resection and obliteration of space between the pouch mesentery and the sacral space without standard pouchopexy.ConclusionVolvulus is a rare side effect of an IPAA. Managing the initial procedure successfully is critical in order to avoid recurrence and consequences. The goal of this study is to identify symptoms and a successful management strategy for pouch volvulus.

Does laparoscopic ileal pouch-anal anastomosis reduce infertility compared with open approach?

BackgroundThe aim of this study was to assess the association of the mode of surgery on female fertility after restorative proctocolectomy with ileal pouch-anal anastomosis. MethodsAll female patients aged 18 to 44 years who underwent restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis, familial adenomatous polyposis, or Crohn’s disease at the Cleveland Clinic Ohio or the Cleveland Clinic Florida from 1983 to 2012 were sent a standardized fertility questionnaire. Infertility was defined as lack of pregnancy after 1 year of unprotected sexual intercourse. Patients who had attempted to conceive after restorative proctocolectomy with ileal pouch-anal anastomosis were compared based on the surgical approach: laparoscopic ileal pouch-anal anastomosis versus open ileal pouch-anal anastomosis. ResultsA total of 890 female patients were surveyed, of which 519 (58.3%) responded. Of these, 161 (31%) had attempted pregnancy after surgery: 18 (12%) had laparoscopic ileal pouch-anal anastomosis and 143 (88%) had open ileal pouch-anal anastomosis. There were no significant differences regarding demographics between groups. There was no difference in reported infertility rates (61.1% vs 65%, respectively, P = 0.69) between the laparoscopic ileal pouch-anal anastomosis and open ileal pouch-anal anastomosis groups. The median time to pregnancy (3.5 months vs 9 months, respectively, log-rank P = 0.01) was reduced in patients who underwent laparoscopic ileal pouch-anal anastomosis compared with those who underwent open ileal pouch-anal anastomosis. ConclusionPostoperative infertility rates were higher after ileal pouch-anal anastomosis regardless of mode of surgery. However, laparoscopy was associated with a significantly reduced time to conceive compared with the open approach.

Comparison of Short-Term Outcomes after Laparoscopic and Open Ileal Pouch Anal Anastomosis for Colonic Polyposis

Comparison of Short-Term Outcomes after Laparoscopic and Open Ileal Pouch Anal Anastomosis for Colonic Polyposis

Minimally invasive surgery and stoma-related complications after restorative proctocolectomy for ulcerative colitis. A two-centre comparison with open approach

BackgroundAlthough the creation of a stoma reduces the risk of septic pouch complications following ileal pouch-anal anastomosis (IPAA), the stoma itself and its reversal can give rise to substantial morbidity during the two- or three-stage concept. Aim of study is to compare stoma-related complications in Ulcerative Colitis patients undergoing laparoscopic versus open IPAA. MethodsWe collected data on 250 IPAA patients from two Italian Centres between 2005 and 2015. We compared perioperative and postoperative events in 150 open vs 100 laparoscopic IPAA. We performed a case-matched analysis based on baseline differences among groups to compare the rate of mechanical complications. ResultsThere were no significant differences between open and laparoscopic IPAA in overall stoma complications (complications during ileostomy: 11.3% vs 12%,p = 0.8; early complications: 10% vs 8%,p = 0.5; late complications: 12.6% vs 6%,p = 0.08). The case-matched analysis found a slightly reduced incidence of obstructive complications at any stage with laparoscopy. ConclusionsOverall stoma related complications do not seem to be reduced by minimally-invasive approach itself, but patients might experience less mechanical problems with laparoscopy without conversion.

Enteral nutrition combined with glutamine promotes recovery after ileal pouch-anal anastomosis in rats.

AIMTo assess the effect of enteral nutrition (EN) supplemented with glutamine on recovery after ileal pouch-anal anastomosis (IPAA) in rats, to provide an experimental basis for nutritional support in patients with ulcerative colitis (UC) after IPAA.METHODSMale Sprague-Dawley (SD) rats were randomly divided into three groups (n = 8) after IPAA operation using a microsurgical technique. From the third postoperative day, rats in the control group, EN group, and immune nutrition (IN) group were fed standard rat chow, short peptide EN, and short peptide EN combined with glutamine ad libitum, respectively. The rats’ general condition was observed throughout the study. Serum levels of total protein (TP), albumin (ALB), prealbumin (PA), and transferrin (TF) were detected on the 30th postoperative day, using an automatic biochemical analyzer. The ileal pouch mucosa was stained with hematoxylin and eosin (HE), and occludin protein levels were detected by immunohistochemistry.RESULTSThe body weight of rats in the EN group (359.20 ± 10.06 g) was significantly higher than that in the control group (344.00 ± 9.66 g) (P < 0.05) and lower than that in the IN group (373.60 ± 9.86 g) (P < 0.05) on the 30th postoperative day. The levels of serum TP, ALB, PA, and TF in the EN group were significantly higher than those in the control group (P < 0.01 for all) and lower than those in the IN group (P < 0.05 for all). Histopathological score (EN: 0.80 ± 0.37; IN: 0.60 ± 0.40; control group: 2.29 ± 0.18) and expression level of occludin protein (EN: 0.182 ± 0.054; IN: 0.188 ± 0.048; control group: 0.127 ± 0.032) were significantly lower in the control group compared with the EN and IN groups (P < 0.05 for all), but there were no significant differences between the latter two groups (P > 0.05 for all).CONCLUSIONEN combined with glutamine may effectively improve nutritional status after IPAA. Our results suggest a benefit of glutamine supplementation in EN for UC patients undergoing IPAA, although human studies are required to confirm this finding.

Characteristics of learning curve in minimally invasive ileal pouch-anal anastomosis in a single institution.

Previous work from our institution has characterized the learning curve for open ileal pouch-anal anastomosis (IPAA). The purpose of the present study was to assess the learning curve of minimally invasive IPAA. Perioperative outcomes of 372 minimally invasive IPAA by 20 surgeons (10 high-volume vs. 10 low-volume surgeons) during 2002-2013, included in a prospectively maintained database, were assessed. Predicted outcome models were constructed using perioperative variables selected by stepwise logistic regression, using Akaike's information criterion. Cumulative sums (CUSUM) of differences between observed and predicted outcomes were graphed over time to identify possible improvement patterns. Institutional pelvic sepsis and other pouch morbidity rates (hemorrhage, anastomotic separation, pouch failure, fistula) significantly decreased (18.2 vs. 7.0%, CUSUM peak after 143 cases, p=0.001; 18.4 vs. 5.3%, CUSUM peak after 239 cases, respectively, p<0.001). Institutional total proctocolectomy mean operative times significantly decreased (307min vs. 253min, CUSUM peak after 84 cases, p<0.001), unlike completion proctectomy (p=0.093) or conversion rates (10 vs. 5.4%, p=0.235). Similar learning curves were identified among high-volume surgeons but not among low-volume surgeons. Learning curves were identified in the two busiest individual surgeons for pelvic sepsis (peaks at 47 and 9 cases, p=0.045 and p=0.002) and in one surgeon for operative times (CUSUM peak after 16 and 13 cases for both total proctocolectomy and completion proctectomy (p<0.001 and p=0.006) but not for other pouch complications (peak at 49 and 41 cases, p=0.199 and p=0.094). Pouch complications, particularly pelvic sepsis, are the most consistent and relevant learning curve end points in laparoscopic IPAA.

The impact of mesenteric tension on pouch outcome and quality of life in patients undergoing restorative proctocolectomy.

The study aimed to establish a method for the measurement of mesenteric tension after ileal pouch-anal anastomosis (IPAA) and to evaluate the impact of tension on clinical outcome and quality of life. All consecutive patients undergoing an open IPAA from July 2008 to October 2009 were prospectively enrolled. After the creation of the anastomosis, mesenteric tension was estimated by the surgeon in the operating room on a 10-point scale (1, least tension; 10, most tension). The association was analysed between mesenteric tension defined as low (1-2), medium (3-7) and high (8-10) and postoperative complications and quality of life (Cleveland Clinic Global Scale). A mesenteric tension score was obtained in 134 patients (71 men, 53.0%). Median age was 38.5 (29.3-47.0) years. Fifty-six patients (41.8%) had a low, 59 (44.0%) a medium and 19 (14.2%) a high degree of mesenteric tension. Patients with a high mesenteric tension had a shorter anal transitional zone, a longer distance from the upper border of the symphysis pubis to the apex of the small bowel loop designated for the ileoanal anastomosis, a thinner abdominal wall at the stoma site and a longer distance from the pouch to the ileostomy. The proportion of patients with high mesenteric tension was less after stapled anastomosis. On long-term follow-up, patients with high mesenteric tension were more likely to suffer from anastomotic stricture and pouch failure. Pouch function was not influenced by mesenteric tension. High mesenteric tension after IPAA is adversely associated with postoperative complications and pouch survival.

Ileal pouch anal anastomosis in pediatric familial adenomatous polyposis: A 24-year review of operative technique and patient outcomes

BackgroundTotal proctocolectomy with ileal pouch anal anastomosis (IPAA) is the operative procedure of choice for familial adenomatous polyposis (FAP) patients. We review 24years of operative experience and outcomes in pediatric patients with FAP. MethodsPatients with FAP, age<20years, presenting to a single institution between 1987 and 2011 were included. Operative technique and outcomes were reviewed retrospectively. Primary outcomes included postoperative complications (30days), long-term bowel function, and polyp recurrence at the anal anastomosis. Results95 patients with FAP underwent IPAA. Mean age at IPAA was 15.5years with a mean follow-up of 7.6years. 29 patients underwent 1-stage IPAA, 65 patients had a two-stage IPAA, and 1 patient underwent a 3-stage procedure. 67 patients had an open procedure, 25 underwent a laparoscopic approach, and more recently 3 patients underwent single incision laparoscopic IPAA. Patients with 1-stage IPAA demonstrate better long term bowel control vs. 2-stage IPAA patients (10.7% vs. 36.0% occasional incontinence, p=0.018). However, 1-stage IPAA patients suffered increased short-term complications, such as anastomotic leak (17.2% vs. 0%, p=0.002) and reoperation (20.7% vs. 4.6%, p=0.02) compared to 2-stage IPAA. Anal anastomosis polyp recurrence occurred in 22.7% of 1-stage patients and 10.0% of 2-stage patients. Short-term complications, polyp recurrence, or long-term continence were equivalent between open and laparoscopic cases. ConclusionSingle-stage IPAA in children with FAP is associated with better bowel control but increased anastomotic leak, reoperative rate, and polyp recurrence. In experienced hands, laparoscopic IPAA is equivocal to open IPAA.

Sexual Function and Body Image are Similar after Laparoscopy‐Assisted and Open Ileal Pouch–Anal Anastomosis

Ileal pouch-anal anastomosis (IPAA) is performed in patients with ulcerative colitis and familial adenomatous polyposis where the majority of patients are sexually active. Laparoscopic surgery is becoming the preferred technique for most colorectal interventions, and we examined postoperative sexual function and body image compared to those after open surgery IPAA. Patients treated with IPAA in the period from October 2008 to March 2012 were included. Evaluation of sexual function, body image, and quality of life was performed using the Female Sexual Function Index (FSFI), the International Index of Erectile Function (IIEF), the Body Image Questionnaire (BIQ), and the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). We included 72 patients (38 laparoscopy-assisted and 34 open). Response rate was 74 %. There were no differences in demographics, functional outcome, quality of life (SIBDQ score: 53 vs. 53), or time of follow-up (637 vs. 803 days). All women and men showed scores above the cutoff line of normal sexual function. There was no significant difference in sexual function between the laparoscopic and open groups. We found no differences in BIQ between open and laparoscopic IPAA; however, there was a tendency toward lower postoperative self-esteem among women compared to men (p = 0.07). We also found a tendency toward a better body image among laparoscopy-treated women compared to open-treated women (p = 0.07). Although there might be a tendency toward better body image among laparoscopy-treated women, the two surgical techniques seem equal with respect to postoperative sexual function.

Adhesions after laparoscopic and open ileal pouch–anal anastomosis surgery for ulcerative colitis

Emerging evidence suggests that a laparoscopic approach to colorectal procedures generates fewer adhesions. Even though laparoscopic ileal pouch-anal anastomosis (IPAA) is a lengthy procedure, the prospect of fewer adhesions may justify this approach. The aim of this study was to assess abdominal and adnexal adhesion formation following laparoscopic versus open IPAA in patients with ulcerative colitis. A diagnostic laparoscopy was performed at time of ileostomy closure. All abdominal quadrants and the pelvis were video recorded systematically and graded offline. The incisional adhesion score (IAS; range 0-6) and total abdominal adhesion score (TAS; range 0-10) were calculated, based on the grade and extent of adhesions. Adnexal adhesions were classified by the American Fertility Society (AFS) adhesion score. A total of 43 patients consented to participate, of whom 40 could be included in the study (laparoscopic 28, open 12). Median age was 38 (range 20-61) years. There was no difference in age, sex, body mass index, American Society of Anesthesiologists grade and time to ileostomy closure between groups. The IAS was significantly lower after laparoscopic IPAA than following an open procedure: median (range) 0 (0-5) versus 4 (2-6) respectively (P = 0·004). The TAS was also significantly lower in the laparoscopic group: 2 (0-6) versus 8 (2-10) (P = 0·002). Applying the AFS score, women undergoing laparoscopic IPAA had a significantly lower mean(s.d.) prognostic classification score than those in the open group: 5·2(3·7) versus 20·0(5·6) (P = 0·023). Laparoscopic IPAA was associated with significantly fewer incisional, abdominal and adnexal adhesions in comparison with open IPAA.

Laparoscopic Versus Open 2-Stage Ileal Pouch: Laparoscopic Approach Allows for Faster Restoration of Intestinal Continuity

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for patients with ulcerative colitis and familial adenomatous. This study examined the impact of the surgical approach (laparoscopic versus open) to IPAA on short-term outcomes and time to ileostomy closure in 2-stage restorative proctocolectomies. A retrospective review was performed on a prospectively maintained database at Washington University School of Medicine for patients undergoing elective 2-stage restorative proctocolectomy and IPAA from April of 1999 through July of 2008. Outcomes for patients were analyzed according to laparoscopic versus open technique. A total of 124 patients (55 laparoscopy, 69 open) were included in this study. Laparoscopic IPAA took, on average, 79.2 minutes longer to complete than open IPAA (p < 0.0001) and required significantly more intravenous fluid administration (p = 0.0004). There was no significant difference between laparoscopic and open IPAA with respect to estimated blood loss, blood transfusions, postoperative narcotic usage, return of bowel function, length of stay, and hospital readmission rates. Total complications were not statistically significant between the 2 groups. Patients in the laparoscopic IPAA group underwent ileostomy closure an average of 24.1 days sooner than patients in the open group (p = 0.045). Multivariate analysis revealed that surgical approach (p = 0.018) and length of stay (p = 0.004) were associated with faster time to closure of loop ileostomy. Laparoscopic IPAA is safe, with postoperative morbidity comparable with open IPAA. Laparoscopic IPAA can lead to faster recovery and result in faster progression to restoration of intestinal continuity in patients undergoing 2-stage restorative proctocolectomy.

In a Select Group of Patients Meeting Strict Clinical Criteria and Undergoing Ileal Pouch-Anal Anastomosis, the Omission of a Diverting Ileostomy Offers Cost Savings to the Hospital

Ileal pouch-anal anastomosis is the standard care for the majority of patients with ulcerative colitis or familial adenomatous polyposis requiring surgery. The aim of this study is to determine whether the omission of an ileostomy in patients undergoing ileal pouch surgery offers cost savings to the hospital. Patients who underwent open ileal pouch-anal anastomosis between 2000 and 2007 were identified. They were grouped according to the absence or presence of an ileostomy at the time of their surgery. Direct costs were calculated from the hospital's accounting database. Costs analyzed included those from the index surgery, ileostomy closure, and 6-month complications. Cost data were available for 835 patients undergoing ileal pouch-anal anastomosis. Seven hundred fifteen (86%) had a diverting ileostomy, and the ileostomy was omitted in 120 (14%). Patients without an ileostomy had a longer length of stay (8.7 vs 6.0 days; P < .001) and a 15% greater cost (P < .001) at the time of index surgery than did those with an ileostomy. There was no significant difference between the 2 groups in costs related to complications. The total costs, including ileal pouch-anal anastomosis, ileostomy closure, and complications, were 25% greater in the ileostomy group than in the group who had the ileostomy omitted at the index surgery ($9176 (+/- 6559) vs $11,451 (+/- 8791); P < .001). The above data shows that in a select group of patients meeting well-defined clinical criteria, the omission of a diverting ileostomy will provide significant cost savings for the hospital.

The benefits of a laparoscopic approach in ileal pouch anal anastomosis formation: a single institutional retrospective case-matched experience

A laparoscopic approach to ileoanal pouch formation is novel. By using prospectively gathered data, laparoscopic and open restorative proctocolectomy procedures in mucosal ulcerative colitis (UC) and familial adenomatous polyposis (FAP) patients were compared using a case-matched design. Ten consecutive patients have had laparoscopic ileal pouch anal anastomosis (IPAA) since April 2005. Their intraoperative findings, immediate and early postoperative outcomes are compared with ten non-selected patients who had an open IPAA pre April 2005. Laparoscopic IPAA group had a shorter time to ileostomy function, a reduced mean time to regular diet and a mean shorter hospital stay. Their overall opioid analgesia requirements were 50% that of the open group. There were no re-operations or readmissions in either group. Mean operative time was longer for the laparoscopic group. Patients undergoing laparoscopic IPAA can expect faster postoperative gastrointestinal recovery, reduced blood loss, reduced opioid requirements and improved cosmesis.

Outcomes for case-matched laparoscopically assisted versus open restorative proctocolectomy

The aim of this study was to compare safety, early and late outcomes, quality of life and functional results of laparoscopically assisted versus open ileal pouch-anal anastomosis (IPAA). Patients who had laparoscopically assisted IPAA between 1992 and 2007 were identified from a database and retrospectively matched for age, sex, body mass index (BMI) and operation date to patients who had open IPAA at a ratio of 1:2. Intraoperative, postoperative and long-term functional outcomes were compared. Quality of life was determined by the Cleveland Global Quality of Life scale at 1 and 5 years. A total of 119 patients (59 men, 60 women; mean(s.d) age 35.5(14.2) years, BMI 24.7(5.0) kg/m(2)) had laparoscopically assisted IPAA, with conversion in nine patients (7.6 per cent); these were compared with 238 patients who had open IPAA. The 30-day and long-term results were similar, as well as quality of life at 1 and 5 years, except that patients in the laparoscopic group had shorter median time to stoma action (2 versus 3 days; P = 0.001) and marginally shorter hospital stay. Median operating times were longer in the laparoscopic group (272 versus 163 min; P = 0.040). Laparoscopically assisted IPAA had similar outcomes to open IPAA, but with some short-term advantages.