Laparoscopic Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis: A Comparative Observational Study on Long-term Functional Results
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- Fichera, A., Silvestri, M.T., Hurst, R.D. et al. J Gastrointest Surg (2009) 13: 526. doi:10.1007/s11605-008-0755-9
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Long-term results after laparoscopic ileal pouch anal anastomosis (IPAA) have not been thoroughly evaluated. Our study prospectively compares short- and long-term outcomes of laparoscopic and open IPAA.
Between October 2002 and November 2007, 73 laparoscopic and 106 open IPAA patients were enrolled. Patient- and disease-specific characteristics and short- and long-term outcomes were prospectively collected.
There were no differences in demographics, treatment, indication, duration of surgery, and diversion between groups. Laparoscopic patients had faster return of flatus (p = 0.008), faster assumption of a liquid diet (p < 0.001), and less blood loss (p = 0.026). While complications were similar, the incidence of incisional hernias was lower in the laparoscopic group (p = 0.011). Mean follow-up was 24.8 months. Average number of bowel movements was 6.8 ± 2.8/day for laparoscopy and 6.3 ± 1.7 for open (p = 0.058). Overall, 68.4% of patients were fully continent at 1 year, up to 83.7% long term without differences between groups. Other indicators of defecatory function and quality of life remain similar overtime.
Laparoscopic IPAA confers excellent functional results. Most patients are fully continent and have an average of six bowel movements/day. When present, minor incontinence improves over time. Laparoscopy mirrors the results of open IPAA and is a valuable alternative to open surgery.
KeywordsUlcerative colitis Laparoscopic surgery Quality of life Surgical outcomes
Despite significant advances in the medical treatment of ulcerative colitis (UC),1,2 surgery still remains the definitive option for UC patients who fail medical management or are diagnosed with neoplastic degeneration. Restoration of intestinal continuity with an ileal pouch anal anastomosis (IPAA) is uniformly considered the gold standard of modern management of UC patients in need of surgical treatment. A laparoscopic approach to IPAA has been proposed not only in the adult3,4 but also in the pediatric population.5 While long-term function after conventional open IPAA has been extensively analyzed,6,7 the results of laparoscopic IPAA have been reported only as single institution series8 with short follow-up9 or in small prospective randomized trials.10,11
From the limited data available, it is clear, however, that laparoscopic IPAA offers significant advantages over the open conventional procedure in terms of body image and cosmesis.11,12 Although these findings may have been expected, cosmesis and body image are important factors in the acceptance of surgery in this young patient population. The results of postoperative return of bowel function and analgesic requirements after laparoscopic IPAA have been less concordant. Although several authors have reported faster return of bowel function after laparoscopy, often associated with decreased use of narcotic pain medications,9 these findings did not always translate into a shorter hospital stay.10
On the other side of the argument, concerns have been raised regarding the longer duration of surgery often reported even by very experienced laparoscopic colon and rectal surgeons.9,10 Although this finding may in part reflect the learning curve of the surgical team, in studies comparing costs, longer duration of surgery often resulted in higher expenses.10
Though feasibility and safety remain the main issues when proposing a new procedure, especially for a benign condition in a young patient population, efficacy and functional results ought to be analyzed as well. Data on long-term sequelae after laparoscopic IPAA, such as the incidence on incisional hernias and bowel obstruction, have not to our knowledge been published. The same applies to pouch function and quality of life with very few studies reporting adequate follow-up.8,9,11,12
The number and quality of studies available does not allow us to draw any definitive conclusions on this topic to date. Clearly this is a procedure that requires a dedicated surgical team with highly sophisticated skills and expertise. To justify the additional training and expenses, long-term results of this procedure and the tangible benefits for our patients need to be further characterized. Since 2002 when laparoscopic IPAA was first introduced in our practice, we have been prospectively collecting data to answer some of these questions. In light of the need for long-term functional data on this topic, our current study was designed to prospectively analyze short- and long-term outcomes after laparoscopic IPAA in comparison with contemporary open IPAA from the same tertiary practice.
Materials and Methods
Patients and Operative Technique
Consecutive UC patients that were referred for surgery between August 2002 and November 2007 were evaluated for inclusion in this study. The decision to offer a laparoscopic approach was left to the surgeon’s assessment. No formal inclusion or exclusion criteria were defined for this study; the decision to offer laparoscopy was left to the surgeon’s judgment and experience. Although obesity and previous abdominal operations often make laparoscopic colorectal procedures difficult to complete, they were not considered absolute contraindications to laparoscopy in our study. As experience with the laparoscopic approach increased, laparoscopic-assisted IPAA has become the procedure of choice in our practice.
The indications for a stapled versus hand-sewn IPAA in our practice have been previously described13 and were applied to both the open and the laparoscopic group. Briefly, hand-sewn IPAA with a transanal mucosectomy starting at the dentate line was recommended to patients whose colonoscopic biopsy showed evidence of dysplasia, irrespective of location and severity. Stapled IPAA was recommended only after the presence of dysplasia had been ruled out by multiple endoscopic biopsies.13
Although a hand-assisted approach is a valuable alternative to laparoscopic-assisted surgery, it has not been offered to any of our patients in this series.
Postoperative management did not follow a formal care path, but patients from both groups were treated similarly. Diet was advanced as bowel function resumed, with clears given upon passage of flatus and solids given after patients had a bowel movement. Pain was controlled with parenteral narcotics through patient-controlled analgesia, which was weaned as patient pain could be controlled with oral medications. Early postoperative mobilization was implemented equally for both groups, and patients were discharged once they were tolerating solid food, having bowel movements, and not requiring intravenous narcotics.
Patients’ demographics, disease-specific characteristics, intraoperative variables, short-term perioperative results, and long-term postoperative outcomes were analyzed. The study was approved by the Institutional Review Board of the Division of Biologic Sciences of the University of Chicago.
Questionnaires and Data Analysis
Patients completed a previously validated two-part questionnaire at 3, 6, 9, 12, 18, and 24 months after the procedure and yearly thereafter.7 Part I evaluated bowel habits and functional parameters as well as quality of life and adjustment to the new lifestyle following the operation. Part II consisted of a week-long diary of daily frequency, timing, and consistency of bowel movements, in addition to the timing and severity of any fecal incontinence episodes.
These surveys were followed by clinic visits in which the answers were evaluated, and diet and medications reviewed. Suggestions were made to improve functional results, but the surveys were not changed. The diary results for each patient were averaged over the 7-day period and expressed as mean number of daily bowel movements, daytime and nighttime bowel movements, and percentage of bowel movements that were solid, pasty, or liquid. Additional follow-up data, including long-term complications and need for additional surgery, were collected at the clinic visits.
The results were initially analyzed comparing the open and the laparoscopic groups, along with subgroup analyses when indicated, based on body mass index (BMI) and anastomotic technique (hand-sewn versus stapled) within and between the two groups.
Statistical analysis was performed using SPSS 14.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were analyzed using independent samples t tests, and categorical variables were analyzed with the Pearson χ2 test. The Fisher Exact Test was used for categorical variables when there were fewer than five observations in a particular group. For questionnaire measures with more than two categories, the responses were dichotomized prior to analysis. A p value of less than 0.05 was considered to indicate statistical significance.
Gender (% male)
Body mass index
Indication (failure of medical Tx)
Previous abdominal colectomy
There were no significant differences in age, gender distribution, BMI, indication for surgery, percentage of patients that had undergone previous abdominal colectomy, and the use of a temporary diverting ileostomy between the groups. More patients in the laparoscopic group received a stapled IPAA (79.5% versus 56.9%, p = 0.002). The mean follow-up was 24.8 months (range = 3–60 months) and there was no difference in the length of follow-up between the two groups.
Length of procedure (min)
Blood loss (ml)
First flatus (POD)
First bowel movement (POD)
Liquid diet (POD)
Solid diet (POD)
Total amount of MSO4 equivalent (mg)
Duration of parenteral narcotic (days)
Hospital stay (days)
SBO before ileostomy closure
Surgery for SBO
Anastomotic septic complications
Stricture requiring mechanical dilation
Surgery for incisional hernia
Frequency and Consistency of Bowel Movements
Frequency and Consistency of Bowel Movements
Number of bowel movements/day
Daytime bowel movements
Nighttime bowel movements
Formed bowel movements
Pasty bowel movements
Liquid bowel movements
Fully continent—entire follow-up
Fully continent—1 year
Fully continent—>1 year
Minor leakage—entire follow-up
Minor leakage—1 year
Minor leakage—>1 year
Major leakage—entire follow-up
Major leakage—1 year
Major leakage—>1 year
Wear pad during day
Wear pad during night
Frequent perianal rash
Frequent rectal itching
Frequently able to delay BM
Frequently able to distinguish flatus from stool
Use medications to control BM
Alter diet to control BM
Change eating times to control BM
Quality of Life
Quality of Life
QOL (better or much better)
QOL compared to the ileostomy (better or much better)
Satisfaction (excellent or good)
Adjustment (excellent or good)
We have very meticulously collected data on pouch function and outcomes in our UC patients for over two decades,7,14,16, 17, 18, 19 for a better understanding of the correct indications for this life-changing operation and to better educate our patients. When laparoscopic IPAA was introduced in our practice in 2002, we designed this study to expand our knowledge and analysis to this new surgical approach. At the beginning of our experience, very limited data on laparoscopic IPAA were available and relatively little has been written on this topic since then.3,4,8, 9, 10, 11, 12,20,21
Our study offers a detailed analysis of the results of the last 5 years of laparoscopic pouch surgery for UC in a tertiary referral practice compared with the results of the contemporary open pouch surgery group. Overall, the two groups had very similar patient characteristics despite the lack of randomization. Even though the laparoscopic group includes the early phases of our learning curve, perioperative results are quite comparable between the two groups. The longer duration of laparoscopic surgery noted by many authors9,21 was not present in our series, despite similar BMI and incidence of previous colectomy between groups. The higher number of hand-sewn anastomoses in the open group may appear to have affected this result, but even when hand-sewn patients are eliminated from both groups for analysis, the operative times remain similar.
In the perioperative period, we observed a faster return of bowel function, represented by passage of flatus and assumption of a liquid diet, in the laparoscopic group, as has been previously described.4,9 However, these findings did not translate into a shorter hospital stay despite similar percentages of patients with a diverting stoma and similar incidence of postoperative complications between the two groups. Other authors have found the same discrepancy10 between return of bowel function and hospital stay.
The incidence of incisional hernia after laparotomy has been reported to be as high as 20% after a 10-year period.22 More recent studies have reported an incidence after colorectal surgery of between 12.9% and 14.7% with a follow-up up to approximately 5 years.23,24 Both studies have also reported a significant lower incidence of incisional hernias after laparoscopic colorectal resections.23,24 Based on anecdotal experience, we believe the incidence of incisional hernias to be significantly higher than reported after open surgery in the inflammatory bowel disease population with increased risk associated with malnutrition, long-term steroid use, chronic illness, and obesity that is not an uncommon finding even in inflammatory bowel disease patients. In our study, we found 8.8% of the open group with incisional hernias, with a follow-up of 24.8 months. We are expecting the incidence of incisional hernias in these patients to increase with the length of follow-up. With these concerns in mind, we have planned our laparoscopic approach to include a Pfannenstiel incision for both the extraction site and for pouch construction and anastomosis. A classic Pfannenstiel incision is a true muscle sparing incision that causes minimal weakening of the abdominal wall, thus in part explaining the fact that we have not seen any incisional hernias in the laparoscopic IPAA patients, even in those that have required an ileostomy closure. We will continue to follow these patients.
Another advantage of the Pfannenstiel incision is the ability to transect the rectum under direct vision using an open stapling device, thus avoiding multiple applications often needed with an endoscopic stapler with the resulting overlapping staple lines. Furthermore, through the Pfannenstiel, we are able to truly construct the pouch in the same way as we have described for the open approach14 and to complete the anastomosis under direct vision. By keeping the pouch construction and anastomosis consistent between the two groups, we have been able to duplicate the results previously published in our large open series.7 The difference noted in consistency of bowel movements and pad usage in favor of our laparoscopic IPAA group is difficult to explain and we will continue to investigate it during further follow-up.
One of the major limitations of the study is the lack of randomization. Additionally, as we have become increasingly comfortable with laparoscopic IPAA since adopting it in 2002, we have offered this approach to more patients, so we were not able to maintain formal inclusion or exclusion criteria for laparoscopy over the course of this study. These methodological drawbacks, however, did not result in significant differences between the characteristics of the two groups, so we believe the results we obtained are valid and valuable. Although some patients in our study did have as much as 5 years of follow-up, the average follow-up for all patients was only slightly over 2 years. While we will continue to follow these patients, we have reason to believe from our previous study7 that functional results after a 12- to 18-month adjustment period generally remain stable over the years to come, so the results from this study are likely to reflect the outcomes that would be found over an even more extended follow-up period.
Our study, like others currently available in the literature, supports the use of laparoscopy in UC patients in need of an IPAA. Laparoscopic IPAA provides comparable results to the traditional open approach, offers some short-term and very promising long-term benefits, and confers excellent functional outcomes.