Cost-effectiveness of preventive aspirin use and intensive downstaging polypectomy in patients with familial adenomatous polyposis: A microsimulation modeling study.

OBJECTIVE: Although there is increasing evidence to suggest the cost-effectiveness of aspirin use to prevent colorectal cancer (CRC) in the general population, no study has assessed cost-effectiveness in patients with familial adenomatous polyposis (FAP), who are at high risk of developing CRC. We examined the cost-effectiveness of preventive use of low-dose aspirin in FAP patients who had undergone polypectomy in comparison with current treatment practice. DESIGN: We developed a microsimulation model that simulates a hypothetical cohort of the Japanese population with FAP for 40 years. Three scenarios were created based on three intervention strategies for comparison with no intervention, namely intensive downstaging polypectomy (IDP) of colorectal polyps at least 5.0 mm in diameter, IDP combined with low-dose aspirin, and total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Cost-effective strategies were identified using a willingness-to-pay threshold of USD 50,000 per QALY gained. RESULTS: Compared with no intervention, all strategies resulted in extended QALYs (21.01-21.43 QALYs per individual) and showed considerably reduced colorectal cancer mortality (23.35-53.62 CRC deaths per 1000 individuals). Based on the willingness-to-pay threshold, IDP with low-dose aspirin was more cost-effective than the other strategies, with an incremental cost-effectiveness ratio of $57 compared with no preventive intervention. These findings were confirmed in both one-way sensitivity analyses and probabilistic sensitivity analyses. CONCLUSION: This study suggests that the strategy of low-dose aspirin with IDP may be cost-effective compared with IDP-only or IPAA under the national fee schedule of Japan.

Fluorescence perfusion assessment of vascular ligation during ileal pouch-anal anastomosis.

BACKGROUND: Intraoperative fluorescence angiography (FA) is of potential added value during ileal pouch-anal anastomosis (IPAA), especially after vascular ligation as part of lengthening measures. In this study, time to fluorescent enhancement during FA was evaluated in patients with or without vascular ligation during IPAA. METHODS: This is a retrospective cohort study of all consecutive patients that underwent FA-guided IPAA between August 2018 and December 2019 in our tertiary referral centre. Vascular ligation was defined as disruption of the ileocolic arcade or ligation of interconnecting terminal ileal branches. FA was performed before and after ileoanal anastomotic reconstruction. During FA, time to fluorescent enhancement was recorded at different sites of the pouch. RESULTS: Thirty-eight patients [55.3% male, median age 45 years (IQR 24-51 years)] were included, of whom the majority (89.5%) underwent a modified-2-stage restorative proctocolectomy. Vascular ligation was performed in 15 patients (39.5%), and concerned central ligation of the ileocolic arcade in 3 cases, interconnecting branches in 10, and a combination in 2. For the entire cohort, time between indocyanine green (ICG) injection and first fluorescent signal in the pouch was 20 s (IQR 15-31 s) before and 25 s (IQR 20-36 s) after anal anastomotic reconstruction. Time from ICG injection to the first fluorescent signal at the inlet, anvil and blind loop of the pouch were non-significantly prolonged in patients that received vascular ligation. CONCLUSIONS: Results from this study indicate that time to fluorescence enhancement during FA might be prolonged due to arterial rerouting through the arcade or venous outflow obstruction in case of vascular ligation.

Standardization of ileoanal J-pouch surgery technique: Quality assessment of minimally invasive ileoanal J-pouch surgery videos.

BACKGROUND: Ileal pouch anal anastomosis is a complex procedure associated with significant morbidity, with several complications after ileal pouch anal anastomosis surgery leading to pouch failure. The aim of the study is to evaluate the heterogeneity surrounding the technique of ileoanal J-pouch surgery by assessing the safety and quality of published online peer-reviewed surgical videos. METHODS: Ileal pouch anal anastomosis videos published on peer-reviewed surgical journals and video channels were edited and anonymized to demonstrate specific steps of the surgical procedure: mobilization and division of the rectum, formation of the ileoanal J-pouch reservoir, anastomosis, and lengthening techniques. The anonymized videos were presented to a group of reviewers with expertise in ileal pouch anal anastomosis blinded to the names and affiliations of the surgeons performing the procedure. Primary outcome was the rate of interobserver variability in the assessment of specific technical steps of the ileal pouch anal anastomosis surgery procedure. Secondary outcome was the appropriateness of the use of surgical videos review as an assessment tool for ileal pouch anal anastomosis surgery, measured as rate of reviewers being unable to answer for poor video quality. RESULTS: In total, 29 video fragments were distributed, and 13 assessors completed a 60-item survey, organized in 7 major domains. The survey completion rate was 93.4%. Out of a total 729 answers, in 23 (3.2%) the reviewers indicated they were unable to comment due to poor video image, and in 48 (6.5%) were unable to comment due to the particular step not being shown in the procedure. The proportion of assessors rating rectal mobilization technically appropriate ranged from 30.7% to 92.3% and from 7.7% to 69.2% for safety. The level of rectal division was considered appropriate in 0 to 53.8% of the videos, whereas the stapling technique used for rectal division was appropriate in 0 to 70% of the videos. CONCLUSION: Our study assessed published peer-reviewed videos on ileal pouch anal anastomosis surgery and reported heterogeneity in the safety of the demonstrated techniques. Blind assessment of published peer-reviewed ileal pouch anal anastomosis videos reported a high rate of unsafe or inappropriate technique for rectal mobilization and transection in the reviewed videos, with fair interobserver agreement among reviewers. There is a need for consensus on what is considered safe and appropriate in ileal pouch anal anastomosis surgery. Peer review of ileal pouch anal anastomosis surgery videos could facilitate training and accreditation in this complex procedure.

Use of Biological Medications Does Not Increase Postoperative Complications Among Patients With Ulcerative Colitis Undergoing Colectomy: A Retrospective Cohort Analysis of Privately Insured Patients.

BACKGROUND: Existing studies on the effects of biological medications on surgical complications among patients with ulcerative colitis have mixed results. Because biologicals may hinder response to infections and wound healing, preoperative exposure may increase postoperative complications. OBJECTIVE: The purpose of this study was to evaluate associations between biological exposure within 6 months preceding colectomy or proctocolectomy and postoperative complications among patients with ulcerative colitis. DESIGN: This was a retrospective cohort study with multivariate regression analysis after coarsened exact matching. SETTINGS: A large commercial insurance claims database (2003-2016) was used. PATIENTS: A total of 1794 patients with ulcerative colitis underwent total abdominal colectomy with end ileostomy, total proctocolectomy with end ileostomy, or total proctocolectomy with IPAA. Twenty-two percent were exposed to biologicals in the 6 months preceding surgery. MAIN OUTCOMES MEASURES: Healthcare use (length of stay, unplanned reoperation/procedure, emergency department visit, or readmission) and complications (infectious, hernia or wound disruption, thromboembolic, or cardiopulmonary) within 30 postoperative days were measured. RESULTS: Exposure to biological medications was associated with shorter surgical hospitalization (7 vs 8 d; p <0.001) but otherwise was not associated with differences in healthcare use or postoperative complications. PATIENTS: who underwent total proctocolectomy with IPAA had higher odds of infectious complications compared with those who underwent total abdominal colectomy with end ileostomy (adjusted OR = 2.2 (95% CI, 1.5-3.0); p < 0.001) but had lower odds of cardiopulmonary complications (adjusted OR = 0.4 (95% CI, 0.3-0.6); p < 0.001). LIMITATIONS: Analysis of private insurance database claims data may not represent uninsured or government-insured patients and may be limited by coding accuracy. Matched cohorts differed in age and Charlson Comorbidity Index, which could be influential even after multivariate adjustments. CONCLUSIONS: Biological exposure among patients with ulcerative colitis is not associated with higher odds of postoperative complications or healthcare resource use. These data, in combination with clinical judgment and patient preferences, may aid in complex decision-making regarding operative timing, operation type, and perioperative medication management. See Video Abstract at http://links.lww.com/DCR/B370. EL USO DE MEDICAMENTOS BIOLÓGICOS NO AUMENTA LAS COMPLICACIONES POSTOPERATORIAS ENTRE PACIENTES CON COLITIS ULCERATIVA SOMETIDOS A UNA COLECTOMÍA: UN ANÁLISIS DE COHORTE RETROSPECTIVO DE PACIENTES CON SEGURO PRIVADO: Estudios existentes sobre los efectos de medicamentos biológicos, en complicaciones quirúrgicas, en pacientes con colitis ulcerativa, presentan resultados mixtos. Debido a que los productos biológicos pueden retrasar la respuesta a las infecciones y curación de heridas, su exposición preoperatoria pueden aumentar las complicaciones postoperatorias.Evaluar las asociaciones entre la exposición biológica dentro de los seis meses anteriores a la colectomía o proctocolectomía y las complicaciones postoperatorias entre los pacientes con colitis ulcerativa.Estudio de cohorte retrospectivo con análisis de regresión multivariante después de una coincidencia exacta aproximada.Una gran base de datos de reclamaciones de seguros comerciales (2003-2016).Un total de 1.794 pacientes con colitis ulcerativa, se sometieron a colectomía abdominal total con ileostomía terminal, proctocolectomía total con ileostomía terminal o proctocolectomía total con anastomosis anal y bolsa ileal. 22% estuvieron expuestos a productos biológicos, seis meses antes de la cirugía.Utilización de la atención médica (duración de la estadía, reoperación o procedimiento no planificado, visita al servicio de urgencias o reingreso) y complicaciones (infecciosas, hernias o dehiscencias de heridas, tromboembólicas o cardiopulmonares) dentro de los 30 días postoperatorios.La exposición a medicamentos biológicos se asoció con una hospitalización quirúrgica más corta (7 frente a 8 días, p <0,001), pero por lo demás, no se asoció con diferencias en la utilización de la atención médica o complicaciones postoperatorias. Los pacientes que se sometieron a proctocolectomía total con anastomosis anal y bolsa ileal, tuvieron mayores probabilidades de complicaciones infecciosas, en comparación con aquellos que se sometieron a colectomía abdominal total con ileostomía final (aOR 2.2, IC 95% [1.5-3.0], p <0.001) pero tuvieron menores probabilidades de complicaciones cardiopulmonares (aOR 0.4, IC 95% [0.3-0.6], p <0.001).El análisis de los datos de reclamaciones, de la base de datos de los seguros privados, puede no representar a pacientes no asegurados o asegurados por el gobierno, y puede estar limitado por la precisión de la codificación. Las cohortes emparejadas diferían en la edad y el índice de comorbilidad de Charlson, lo que podría influir incluso después de ajustes multivariados.La exposición biológica entre los pacientes con colitis ulcerativa, no se asocia con mayores probabilidades de complicaciones postoperatorias, o a la utilización de recursos sanitarios. Estos datos, en combinación con el juicio clínico y las preferencias del paciente, pueden ayudar en la toma de decisiones complejas con respecto al momento quirúrgico, el tipo de operación y el manejo de la medicación perioperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B370. (Traducción-Dr Fidel Ruiz Healy).

Ileorectal Anastomosis Versus IPAA for the Surgical Treatment of Ulcerative Colitis: A Markov Decision Analysis.

BACKGROUND: Ileorectal anastomosis in patients with ulcerative colitis results in decreased postoperative morbidity and better functional outcome but leads to increased risk for rectal cancer compared with IPAA. OBJECTIVE: This study aims to compare ileorectal anastomosis with IPAA in ulcerative colitis by using a decision model. DESIGN: A Markov simulation model was designed to simulate clinical events of ileorectal anastomosis and IPAA over a time horizon of 40 years with time cycles of 1 year. All probabilities and utilities were derived from observational studies, identified after a systematic literature search using MEDLINE. Primary outcomes were life-years and quality-adjusted life-years. Deterministic and probabilistic sensitivity analyses were performed. SETTINGS: A decision model using Markov simulation was designed. PATIENTS: The base case was a 35-year-old patient with ulcerative colitis and a relatively preserved rectum. MAIN OUTCOMES MEASURES: The primary outcome measures were (quality-adjusted) life-years. RESULTS: The model resulted in lower life-years (36.22 vs 37.02) and higher quality-adjusted life-years (33.42 vs 31.57) for ileorectal anastomosis. This was confirmed after probabilistic sensitivity analysis. The model was sensitive to the utility of ileorectal anastomosis, IPAA, and end-ileostomy. A higher proportion of patients with ileorectal anastomosis will develop rectal cancer (7.6% vs 3.2%) and 43.5% of all patients with ileorectal anastomosis will end with an ileostomy as opposed to 23.0% of all patients with IPAA. LIMITATIONS: The study was limited by characteristics inherent to modeling studies, including assumptions necessary to build the model, data input based on best available but often limited evidence, and unavoidable extra- and interpolation of data. CONCLUSIONS: Ileorectal anastomosis was the preferred treatment option when quality-adjusted life-years were the outcome, with higher life-years for IPAA. This model highlights that both surgical strategies are useful in patients who have ulcerative colitis with a relatively spared rectum. See Video Abstract at http://links.lww.com/DCR/B249. ANASTOMOSIS ILEORRECTAL VERSUS ANASTOMOSIS ANAL CON RESERVORIO ILEAL EN EL TRATAMIENTO QUIRÚRGICO DE LA COLITIS ULCEROSA: ANÁLISIS DE DECISIÓN DE MARKOV: Las anastomosis ileorrectales en pacientes con colitis ulcerosa se encuentran asociadas con la disminución de la morbilidad postoperatoria y un mejor resultado funcional, pero conducen a un mayor riesgo de cáncer de recto cuando se las compara con casos de confección de un reservorio íleo-anal.Comparar las anastomosis ileorrectales con la anastomosis de un reservorio íleo-anal en casos de colitis ulcerosa, utilizando un modelo de procesos de decisión.Se diseñó un modelo de proceso de Markov para simular eventos clínicos en casos de anastomosis ileorrectales y anastomosis de reservorios íleo-anales en un horizonte temporal de 40 años comprendiendo ciclos temporales de 1 año. Todas las probabilidades y utilidades se derivaron de estudios observacionales, identificados después de una búsqueda sistemática de literatura usando MEDLINE. Los resultados primarios fueron años de vida y los años ajustados a la calidad de vida. Se realizaron los análisis de sensibilidad determinada y de probabilística.Se diseñó un modelo de decisión utilizando el proceso de simulación de Markov.El caso base fue el de un paciente de 35 años con colitis ulcerosa y con un recto relativamente sano.El resultado principal fué la medida de los años de vida (con ajuste en la calidad de vida).El modelo resultó en menos años de vida (36.22 frente a 37.02) y años de vida de menor calidad (33.42 frente a 31.57) para los casos de anastomosis ileorrectales. Esto se confirmó después del análisis de sensibilidad probabilística. El modelo era sensible a la utilidad de la anastomosis ileorrectal, la anastomosis del reservorio íleo-anal y la ileostomía terminal. Una mayor proporción de pacientes con anastomosis ileorectales desarrollarán cáncer de recto (7,6% frente a 3,2%) y el 43,5% de todos los pacientes con anastomosis ileorrectales terminarán con una ileostomía en comparación con el 23,0% de todos los pacientes con un reservorio íleo-anal.El analisis estuvo limitado por las características inherentes a los estudios de modelado, incluidas las suposiciones necesarias para construir el modelo, la entrada de datos basada en la mejor evidencia disponible pero a menudo limitada y la extrapolación e interpolación inevitable de datos.Las anastomosis ileorrectales fueron la opción de tratamiento preferida cuando el resultado fue ajustado en años con calidad de vida, con años de vida más larga para la anastomosis de reservorios íleo-anales. Este modelo destaca que ambas estrategias quirúrgicas son útiles en pacientes con colitis ulcerosa con rectos relativamente sanos. Consulte Video Resumen en http://links.lww.com/DCR/B249.

Is diverting loop ileostomy necessary for completion proctectomy with ileal pouch-anal anastomosis? A multicenter randomized trial of the GETAID Chirurgie group (IDEAL trial): rationale and design (NCT03872271).

BACKGROUND: There is no quality evidence of the benefit of defunctioning ileostomy (DI) in ileal pouch-anal anastomoses (IPAAs) performed for inflammatory bowel disease (IBD), but most surgical teams currently resort to DI. In the case of a staged procedure with subtotal colectomy first, completion proctectomy with IPAA is performed for healthy patients, namely, after nutritional support, inflammation reduction and immunosuppressive agent weaning. Therefore, the aim of this trial is to assess the need for systematic DI after completion proctectomy and IPAA for IBD. METHODS/DESIGN: This is a multicenter randomized open trial comparing completion proctectomy and IPAA without (experimental) or with (control) DI in patients presenting with ulcerative colitis or indeterminate colitis. Crohn's disease patients will not be included. The design is a superiority trial. The main objective is to compare the 6-month global postoperative morbidity, encompassing both surgical and medical complications, between the two groups. The morbidity of DI closure will be included, as appropriate. The sample size calculation is based on the hypothesis that the overall 6-month morbidity rate is 30% in the case of no stoma creation (i.e., experimental group) vs. 55% otherwise (control group). With the alpha risk and power are fixed to 0.05 and 0.80, respectively, and considering a dropout rate of 10%, the objective is set to 194 patients. The secondary objectives are to compare both strategies in terms of morbi-mortality at 6 months and functional results as well as quality of life at 12 months, namely, the 6-month major morbidity and unplanned reoperation rates, 6-month anastomotic leakage rate, 6-month mortality, length of hospital stay, 6-month unplanned readmission rate, quality of life assessed 3 and 12 months from continuity restoration (i.e., either IPAA or stoma closure), functional results assessed 3 and 12 months from continuity restoration, 12-month pouch results, 12-month cost-utility analysis, and 12-month global morbidity. DISCUSSION: The IDEAL trial is a nationwide multicenter study that will help choose the optimal strategy between DI and no ileostomy in completion proctectomy with IPAA for IBD. TRIAL REGISTRATION: ClinicalTrial.gov: NCT03872271, date of registration March 13th, 2019.

Dispelling misconceptions in the management of familial adenomatous polyposis.

Patients with familial adenomatous polyposis require surgical intervention at some point in their lives. The diagnosis is often apparent from their phenotype and family history, however, this is not always the case. Many factors can influence the surgical strategy although the polyposis burden and distribution remain the main consideration. While prophylactic removal of the rectum and colon is often required, sparing the rectum at the index surgery is safe in select patients. This article aims to dispel misconceptions in the diagnosis and treatment of patients with familial adenomatous polyposis.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

Outcomes and cost of diverted versus undiverted restorative proctocolectomy.

BACKGROUND: Some observational studies suggest that diversion during restorative proctocolectomy mitigates the risk of anastomotic complications. However, diversion has its own costs and complications. The aim of this study was to compare the cost and outcomes of diverted to undiverted restorative proctocolectomy. METHODS: This study took advantage of a natural experiment within one surgical department to understand the clinical and financial implications of diversion during restorative proctocolectomy. For the last 10 years, two surgeons routinely diverted all patients undergoing restorative proctocolectomy, and two other surgeons routinely did not. The medical records of 288 consecutive restorative proctocolectomy patients were reviewed. Minimum follow-up time was 1 year, with an average of 4.7 years. Complications rates and costs of care were collected. RESULTS: There were no significant differences between rates of anastomotic leak, fistula, or hernias in diverted versus undiverted patients. The odds of having stricture (odds ratio (OR) = 17.08, P < 0.001) and small bowel obstruction (OR = 5.05, P = 0.02) were both significantly higher in diverted patients. The average cost per patient was $43,000 more in the routinely diverted patients. CONCLUSION: Undiverted restorative proctocolectomy may be the highest value procedure with the most favorable outcomes at the lowest cost.

The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: A review of current evidence.

Up to 35% of patients with ulcerative colitis will require surgery during the course of their disease. Nowadays, a total colectomy with ileal pouch-anal anastomosis is the preferred procedure, which can be performed open or via laparoscopic approach. Since the early '90s, minimally invasive techniques have gained popularity, but the extend of restorative procedures in these patients has restricted the use of laparoscopic approaches mainly to elective procedures in specialised centres. This review discusses the benefits and disadvantages of laparoscopic surgery when compared to open surgery. It presents the current evidence on short-term and long-term post-operative results, functional outcome, fecundity, and costs, for both elective and emergency indications. In addition, the value of new techniques (including single port surgery) and alternative laparoscopic approaches (e.g. ileo-rectal anastomosis, Kock-pouch and appendectomy) will be discussed.

Multidetector-row computed tomography enterographic assessment of the ileal-anal pouch: descriptive radiologic analysis with endoscopic and pathologic correlation.

OBJECTIVE: To describe the multidetector-row computed tomography enterographic (MD-CTE) features of the ileal-anal pouch after ileal pouch anal anastomosis (IPAA) surgery and correlate them with pouch endoscopy and histopathologic findings. METHODS: All MD-CTE examinations performed on patients who underwent IPAA from July 1, 2005 to December 1, 2010 (n = 35; 16 [45.7%] men; mean age, 37.7 years; age range, 22-72 years) were retrospectively evaluated in consensus by 2 radiologists. All studies were evaluated for the presence of multiple imaging features. Two radiographic scores were then calculated: a total radiographic score and a radiographic active inflammation score. In patients who underwent MD-CTE, pouch endoscopy, and biopsy within 30 days (n = 13), both scores were correlated with findings on pouch endoscopy and histopathology. RESULTS: Of the 35 patients, 33 (94%) had at least one MD-CTE finding of active or chronic pouch inflammation and 27 patients (77%) had at least one MD-CTE finding of active pouch inflammation. Of the 13 patients who underwent endoscopy and biopsy, the total radiographic score demonstrated a strong positive correlation with endoscopic score (r = 0.81; P = 0.001) and a moderate positive correlation with histopathologic score (r = 0.56; P = 0.047). The radiographic active inflammation score demonstrated a strong positive correlation with endoscopic score (r = 0.83; P = 0.0004), but only a weak nonsignificant positive correlation with histopathologic score (r = 0.492, P = 0.087). CONCLUSIONS: In patients who had IPAA surgery, findings on MD-CTE correlate positively with findings on pouch endoscopy and histopathology and are sensitive measures for pouch inflammation with high positive predictive value. Thus, MD-CTE can be a useful noninvasive test in the early evaluation of symptomatic patients.

[Laparoscopic surgery for inflammatory bowel disease; an update]. / Laparoscopische chirurgie voor inflammatoire darmziekten: een update.

OBJECTIVE: To carry out a review of the literature for the short- and long-term effects of various laparoscopic operations in the inflammatory bowel diseases ulcerative colitis and Crohn's disease and to compare these operations with open surgical procedures. DESIGN: Review of the literature. METHOD: PubMed (Medline), Embase and Cochrane databases were searched for randomised clinical trials and meta-analyses on this topic, published between January 1991 and August 2008. If no level A1, A2 or A2B studies were found, we searched for the best available evidence. RESULTS: For Crohn's disease, there was level A2 evidence that, in comparison with open surgery, in experienced hands laparoscopic ileocaecal resection enhanced recovery and led to a shorter hospital stay and lower costs. Following laparoscopic surgery, subjective body image and cosmetic appearance scores were higher, when compared in the long term. In patients with ulcerative colitis, the expected benefits of laparoscopic proctocolectomy have not yet been demonstrated in a randomised study. Although there was a trend towards a reduced hospital stay (1.6 days) when laparoscopy proctocolectomy was performed, the operating time was 1.5 h longer than in conventional surgery. Body image and cosmetic appearance scores were also higher here when compared in the long term. CONCLUSION: Laparoscopic ileocaecal resection is preferable in Crohn's disease, provided that it is performed in a centre with sufficient expertise in laparoscopic surgery. In patients with ulcerative colitis, laparoscopic proctocolectomy with construction of an ileoanal pouch is indicated in young active patients who are concerned for their appearance. Given its complexity, this operation should be performed only in specialist centres.

Laparoscopic restorative proctocolectomy with ileal S-pouch.

PURPOSE: Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. METHODS: One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. RESULTS: The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). CONCLUSION: Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.

Laparoscopic proctectomy for rectal adenocarcinoma.

During the past 15 years, there has been increasing enthusiasm for the use of laparoscopic techniques in the operative treatment of patients suffering from colorectal disease. Laparoscopic colectomy has been demonstrated to be safe for patients suffering from adenocarcinoma of the intraperitoneal colon. Attention is now being focused on the treatment of patients with rectal adenocarcinoma using laparoscopic methods. Prospective data analysis will be crucial in determining whether laparoscopic proctectomy provides equivalent results to open procedures.

Surgery insight: minimally invasive surgery for IBD.

The most frequently described laparoscopic operations for the management of patients with IBD are restorative proctocolectomy for ulcerative colitis and ileocolic resection for Crohn's disease. For patients with Crohn's disease, there is level 1b evidence that, in experienced hands, laparoscopic ileocolic resection enhances recovery and leads to a shorter hospital stay compared with conventional ileocolic resection. The demonstrated advantages of laparoscopic ileocolic resection with regard to cost and cosmesis, and the acceptable long-term results achieved (which are at least comparable to those achieved by conventional ileocolic resection) favor the use of laparoscopic ileocolic resection over conventional ileocolic resection in patients with ileocolic Crohn's disease. For patients with ulcerative colitis, the expected advantages of laparoscopic restorative proctocolectomy over conventional restorative proctocolectomy have yet to be clearly shown. Although there is a trend towards a reduced hospital stay (of only 1.6 days) when laparoscopic restorative proctocolectomy is performed, operating times are disproportionably prolonged. The most important argument for offering patients with IBD the chance to undergo a laparoscopic procedure, rather than conventional open surgery, is (particularly for women) the long-term superior cosmesis and body image it confers.

MRI assessment of the bony pelvis may help predict resectability of rectal cancer.

OBJECTIVE: The outcome after surgical treatment of rectal cancer may be influenced by the technical difficulty of the operation, which is thought to be affected by pelvic size. The aim of this study was to examine the association between bony pelvic dimensions and CRM involvement. PATIENTS AND METHODS: All patients with primary rectal cancer between December 1999 and January 2002 were studied. Staging was performed by pelvic MRI. Nine pelvic dimensions were measured from the MR images on a workstation. Pathology reports were obtained for all patients and the mesorectal specimen was examined. Technical difficulty was assessed by circumferential resection margin (CRM) involvement. RESULTS: Of 126 patients with primary rectal cancer, 88 had staging MRI and rectal excision; there were significant differences between the sexes in all 9 pelvic dimensions (P < 0.05). In females, the interspinous diameter was significantly shorter in patients with CRM involvement compared with patients with a negative CRM. In female patients predicted to have a negative CRM, the anteroposterior diameter of the inlet, the anteroposterior diameter of the midplane and the transverse diameter of the midplane (interspinous distance) were significantly shorter in patients who actually had a positive CRM compared with those in whom the CRM was negative. In male patients, there was no correlation between pelvic dimensions and CRM status. CONCLUSIONS: In certain patients with rectal cancer, CRM positivity may be predicted from pre-operative MRI pelvic measurements. This may influence the choice of adjuvant therapy.

Hand-assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomosis: a randomized trial.

OBJECTIVE: The aim of the study was to evaluate postoperative recovery after hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis in a randomized controlled trial. METHODS: Sixty patients were randomized for hand-assisted laparoscopic (n = 30) or open surgery (n = 30). Primary outcome parameter was postoperative recovery in the 3 months after surgery, measured by quality of life questionnaires (SF-36 and GIQLI). Secondary parameters were postoperative morphine requirement and surgical parameters, viz. operating time, morbidity, hospital stay, and costs. RESULTS: There was no difference between the 2 procedures in quality of life assessment in the 3 months after surgery. There was a significant decline in quality of life on all scales of the SF-36 (P < 0.001) and total GIQLI score (P < 0.001) in the first 2 weeks in both groups (no significant difference between the groups). Quality of life returned to baseline levels after 4 weeks. Operating times were longer in the laparoscopic group compared with the open group (210 and 133 minutes, respectively; P < 0.001). No significant differences were found in morphine requirement. Neither morbidity nor postoperative hospital stay differed between the laparoscopic and open group (20% versus 17%, in 10 versus 11 days, respectively). Median overall costs were 16.728 for the hand-assisted laparoscopic procedure and 13.406 for the open procedure (P = 0.095). CONCLUSIONS: Recovery measured using quality of life questionnaires is comparable for hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis. The laparoscopic approach is as safe, but more costly than the open procedure.

Transverse coloplasty pouch after total mesorectal excision: functional assessment of evacuation.

PURPOSE: Colon pouch reconstruction after total mesorectal excision is functionally superior to straight colorectal/ anal anastomosis. In the long-term, stool evacuation difficulties could jeopardize the functional benefit. The transverse coloplasty pouch presents an alternative to the standard J-pouch. This study was designed to analyze functional outcome and defecography findings after total mesorectal excision and transverse coloplasty pouch reconstruction. METHODS: Thirty consecutive patients with cancer of the middle and lower third of the rectum underwent a total mesorectal excision and were examined in a prospective study. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Patients were examined within eight months by means of defecography, manometry, pouch volumetry, and a standardized continence questionnaire. RESULTS: Total mesorectal excision with transverse coloplasty pouch anastomosis was performed successfully in all patients. Symptomatic anastomotic leakage was observed in 2 of 30 patients and the radiologic leak rate was 4 of 30. All patients evacuated the pouch completely; none needed enemas or suppositories to facilitate defecation. Twenty-five of 27 patients had a maximum of three bowel movements per day, and all patients were continent for solid stools. Patients with abnormal findings on defecography proved more likely to have anal dysfunction. CONCLUSIONS: Transverse coloplasty pouch reconstruction after total mesorectal excision leads to good functional results and is not associated with stool evacuation problems. Urgency and incontinence correlate rather with impaired pelvic floor movement than with pouch size or anal sphincter tonus.