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World Journal of Surgery

, Volume 42, Issue 11, pp 3746–3754 | Cite as

Case-Matched Comparison of Long-Term Functional and Quality of Life Outcomes Following Laparoscopic Versus Open Ileal Pouch-Anal Anastomosis

  • Olga A. Lavryk
  • Luca Stocchi
  • Jean H. Ashburn
  • Meagan Costedio
  • Emre Gorgun
  • Tracy L. Hull
  • Hermann Kessler
  • Conor P. Delaney
Original Scientific Report

Abstract

Background

Laparoscopic ileal pouch–anal anastomosis (IPAA) is associated with recovery benefits when compared with open IPAA. There is limited data on long-term quality of life and functional outcomes, which this study aimed to assess.

Methods

An IRB-approved, prospectively maintained database was queried to identify patients undergoing laparoscopic IPAA (L), case-matched with open IPAA (O) based on age ± 5 years, gender, body mass index (BMI) ± 5 kg/m2, diagnosis, date of surgery ± 3 years, stapled/handsewn anastomosis, omission of diverting loop ileostomy and length of follow-up ± 3 years. We assessed functional results, dietary, social, work, sexual restrictions and the Cleveland Clinic global quality of life score (CGQoL) at 1, 2, 3, 4, 5 and 10 years postoperatively. Functional outcomes were assessed based on number of stools (day/night) and seepage protection use (day/night). Variables were evaluated with Kaplan–Meier survival curves, uni- and multivariable analyses.

Results

Out of 4595 IPAAs, 529 patients underwent L, of whom 404 patients were well matched 1:1 to an equivalent number of O based on all criteria. Median follow-ups were 2 (0.5–17.8) versus 2.4 (0.5–22.2) years in L versus O, respectively (p = 0.18). L was associated with significantly decreased number of stools at night and less frequent pad usage at 1 year, both during the day and at night. Functional outcomes became similar during further follow-up. L was also associated with improved overall CGQoL, and energy scores at 1 year postoperatively, and decreased social restrictions for 1–2 years. There were no significant differences in quality of health, dietary, work or sexual restrictions. Laparoscopy was not associated with increased risk of pouch failure (p = 0.07) or significantly different causes of pouch failure when compared to O.

Conclusions

Laparoscopic and open IPAA are associated with equivalent long-term functional outcomes, quality of life and pouch survival rates. Laparoscopic technique is associated with temporary benefits lasting 1 or 2 years.

Introduction

Total proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the preferred surgical procedure for patients with mucosal ulcerative colitis (UC), diffuse familial adenomatous polyposis (FAP) and indeterminate colitis [1, 2, 3]. Laparoscopic IPAA (LIPAA) is associated with postoperative morbidity comparable to the open technique, but results in shorter hospitalization, faster postoperative recovery and improved cosmesis [4, 5, 6, 7].

The literature remains sparse on the long-term outcomes of restorative proctocolectomy, with respect to either functional outcomes or quality of life (QoL) [8, 9]. Most series have indicated that defecatory function and quality of life remain similar in laparoscopic and open approach when assessed between 1 and 3 years after IPAA [7, 8, 9, 10], but there is limited data on longer follow-up [10, 11]. It is therefore uncertain if the use of laparoscopic surgery is associated with a difference in functional and QOL results during a longer follow-up, and if the risk of pouch failure, which is cumulative over time, is different to open IPAA (OIPAA) [12, 13, 14].

The aim of the current study is to analyze the long-term outcomes, QoL and functional outcomes of LIPAA in comparison with OIPAA.

Methods

Two Institutional Review Board-approved, prospectively maintained, departmental Ileal Pouch and Laparoscopic colorectal surgery databases were queried to identify all patients who underwent primary LIPAA between 2002 and 2015. Patients who underwent trans-abdominal redo or other revisionary IPAA were excluded. The definition of LIPPA was consistent with previous descriptions by our group [4, 15] and others [9, 16] and included cases where the rectal dissection could be completed under direct vision after either complete laparoscopic mobilization of the colon or initial laparoscopic rectal dissection in the course of completion proctectomy. In such cases, rectal transection was performed using a linear stapler. Hand-assisted and straight laparoscopic procedures (single or multiport) were combined for these analyses. Conversion to open surgery was defined as creation of a conventional midline laparotomy used to perform the operation beyond specimen retrieval. A small midline or Pfannenstiel incision to perform a portion of the rectal dissection and IPAA was not considered a conversion. However, cases of completion proctectomy in which the rectal dissection was completely performed under direct vision were not considered laparoscopic operations. Patients whose operations were started laparoscopically but ultimately required conversion to laparotomy were also considered in the laparoscopic group in an intention-to-treat analysis.

All identified LIPAA cases were 1:1 matched with open IPAA (OIPAA) counterparts based on age (± 5 years), gender, body mass index (BMI) (± 5 kg/m2), diagnosis (UC, indeterminate colitis or FAP), date of surgery (± 3 years), anastomotic technique (stapled vs. handsewn), omission of diverting loop ileostomy and length of follow-up (± 3 years). We analyzed operative details, which included duration of surgery, pouch configuration (S/J) and number of surgical stages to achieve a functioning IPAA (2 or 3 stages).

Definitions

Anti-TNF monoclonal antibody use was defined as the administration of at least one infusion of infliximab (Janssen Biotech, Inc. Horsham, Pennsylvania, USA) within 12 weeks preceding IPAA or of adalimumab (Abbott, Abbott Park, Illinois, USA) or certolizumab pegol (UCB USA, Smyrna, Georgia, USA), which were occasionally used as off-label drugs, within 4 weeks preceding IPAA. Preoperative steroids use was defined as the administration of corticosteroids within 1 month prior to surgery, while immunosuppressive use was defined as azathioprine (AZA) or 6-mercaptopurine (6-MP) administration within 2 months prior to operation.

Two-staged IPAA was defined as an initial total proctocolectomy and IPAA with loop ileostomy, followed by ileostomy closure. Three-staged IPAA was the sequence of initial total abdominal colectomy with end ileostomy, followed by completion proctectomy with IPAA and loop ileostomy, and finally closure of ileostomy. Postoperative morbidity included septic complications (anastomotic leak, pelvic sepsis, fistula), anastomotic stricture, pouchitis, small bowel obstruction/ileus, wound infection (superficial surgical site infection) and pouch failure. Pouch failure was defined as either excision of ileal anal pouch with permanent end ileostomy or indefinite diverting loop ileostomy while leaving the constructed, dysfunctional ileal pouch in situ. Pelvic sepsis included chronic abscess formation, either related to leak or chronic sinus with cavity or fistula, established by clinical, radiologic or operative means. Anastomotic separation was defined as a break in the integrity of the anastomosis, as documented by a combination of clinical, endoscopic, radiologic and operative findings in the perioperative period. Anastomotic stricture was defined as an outlet obstruction, diagnosed with digital examination or in the operating room during an examination under anesthesia. Bowel obstruction was considered as the presence of at least three of the following five symptoms: abdominal pain, nausea, vomiting, abdominal distension, and absence of flatus and/or stool within the previous 24 h, findings indicating obstruction based on plain X-ray or contrast studies, or a diagnosis of intestinal obstruction as confirmed by surgery. As previously described, pouchitis was defined as a complex of symptoms based on clinical or endoscopic and histologic findings, including increased stool frequency, urgency, tenesmus, incontinence, nocturnal seepage, abdominal cramping, pelvic discomfort, fever, dehydration and malnutrition [1, 17].

The main focus of this paper was on long-term functional and quality of life results. Cleveland Clinic Pelvic Pouch Questionnaire (CGQL), a previously described self-administered, structured questionnaire, was used to assess QoL after IPAA. CGQL score includes 3 items: current QOL, current health and current level of energy, each on a scale of 0–10 (0, worst; 10, best) [17]. The scores were added and the final CGQL utility score was obtained by dividing the resulting number by 30 (range 0–1); 0 being the worst, and 1 the best [17]. Work, social life, travel and sexual life restrictions were also evaluated. Patient’s response regarding desire to undergo surgery again if needed and if they would recommend surgery to others were also analyzed. Functional outcomes were assessed based on number of stools (total, day/night), overall incontinence present at all times and seepage protection use (day/night). Both QOL and functional parameters were evaluated at 1, 2, 3, 4, 5 and 10 years postoperatively [17].

Statistical analysis

Analyses were performed using R version 2.15.1 (www.r-project.org). Categorical variables were compared using the Fisher’s exact (when any group contains < 10 data points) or χ2 test, while quantitative and ordinal variables were compared using the Wilcoxon Rank sum test. A p value < 0.05 was considered statistically significant. Associations between pouch failure and study variables were assessed using univariable Cox regression models, which yielded log rank test p values for categorical variables and Wald p values for quantitative variables. The model was constructed using the following variables: age, gender, BMI, ASA classification, prior medications used, prior anal pathology (history of anal fistula, fissure, stricture, abscess), diagnosis (UC, indeterminate colitis, FAP), conversion, pouch design and anastomotic technique. Hazard ratios and 95% confidence intervals were also produced using the Cox models, and Kaplan–Meier curves were used to display pouch failure percentages across the follow-up period. Associations between postoperative morbidity and study variables were assessed using logistic regression, from which odds ratio estimates and 95% confidence intervals were produced. The multivariable models were built using stepwise selection of variables based on Akaike’s information criterion (AIC), which is a measure of the model’s predictive ability for pouch failure.

Results

Out of a total of 4595 IPAAs, 529 patients underwent LIPAA from 2002 to 2016. After 1:1 matching based on all criteria, there were 404 patients in each group (Table 1). Median follow-ups were 2.0 (0.5–17.8) versus 2.4 (0.5–22.2) years in LIPAA versus OIPAA, respectively (p = 0.18). In particular, there were 266 (66%) in LIPAA and OIPAA with follow-up longer than 3 years, and 196 (49%) patients in each group with follow-up longer than 5 years, respectively. Demographic characteristics are reported in Table 2.
Table 1

Laparoscopic versus open IPAA matching criteria

Variable

Lap IPAA n = 404

Open IPAA n = 404

p value

Median (range) age at surgery, years

35 (13–78)

35 (13.3–70)

0.87

Male gender

224 (55.4)

224 (55.4)

0.99

BMI, median, range, kg/m2

25.3 (15.1–43.2)

25.3 (16.5–46)

0.19

ASA score

  

0.07

 1,2

300 (74.3)

275 (68.2)

 

 3,4

104 (25.7)

129 (31.8)

 

Final pathology

  

1.00

 Ulcerative colitis

352 (87.1)

352 (87.1)

 

 Familial adenomatous polyposis

17 (4.2)

17 (4.2)

 

 Indeterminate colitis

35 (8.7)

35 (8.7)

 

Pouch configuration

  

0.45

 J-Pouch

400 (99.5)

397 (99)

 

 S-Pouch

2 (0.50)

5 (1)

 

Anastomotic technique

  

0.99

 Stapled

398 (98.5)

398 (98.5)

 

 Handsewn

6 (1.5)

6 (1.5)

 

Mean follow-up, years

3.4 ± 3.7

3.8 ± 3.1

0.18

BMI body mass index, ASA American Society of Anesthesiologists, FAP familial adenomatous polyposis

Table 2

Demographics, disease-related and treatment-related variables

Variable

Lap IPAA

n = 404

Open IPAA

n = 404

p value

Pre-op albumin, mG/dL

4.3 (2.4–5.1)

4.3 (2–5.3)

0.19

Pre-op hemoglobin, mG/dL

12.7 (11.3–17.4)

12.7 (11.5–16.8)

0.77

Biologic medication use

209 (52)

180 (45)

0.07

5-ASA medication use

102 (27)

81 (22)

0.12

Steroid medication use

94 (23)

94 (23)

0.99

Operation type

  

0.002

Completion proctectomy

229 (57)

283 (70)

 

Total proctocolectomy

175 (43)

121 (30)

 

Duration of surgery, hours

4.3 (1.2–9.6)

2.8 (1.2–7.8)

<0.001

Completion proctectomy

  <2005

4.5 ± 0.8

2.7 ± 0.6

0.007

  2005–2010

4.4 ± 1.4

3.2 ± 1.1

0.001

  2011–2015

4.6 ± 1.4

2.9 ± 0.8

0.001

Total proctocolectomy

  <2005

5.4 ± 1.4

2.6 ± 0.7

0.001

  2005–2010

4.5 ± 1.2

3.0 ± 0.8

0.001

  2011–2015

4.6 ± 1.2

3.0 ± 0.9

0.001

 Mean (± SD) length of hospital stay, days

6.3 ± 4.0

7.3 ± 4.3

<0.001

 Mean (± SD) estimated blood loss, mls

217 ± 187

258 ± 205

<0.001

LIPAA was associated with both a significantly longer duration of surgery and a shorter length of hospital stay. There was no difference in postoperative complications rates between the groups. In particular, anastomotic separation and pelvic sepsis were similar between the groups (Table 3). Rates of postoperative ileus and small bowel obstruction were also comparable. A logistic regression analysis identified male gender, development of clinical Crohn’s disease of the ileal pouch, 3-staged versus 2-staged approach, increased intraoperative blood loss, history of preoperative anal fistulas or fistulas developing as postoperative complication, anastomotic leak and pelvic sepsis as significantly associated with an increased probability of pouch failure. The laparoscopic approach was not significantly associated with pouch failure when assessed with univariate logistic regression analysis (p = 0.07). A stepwise Cox regression model identified pouch-related fistula as the only independent factor associated with the risk of long-term ileal pouch failure (Table 4).
Table 3

Comparative postoperative complications and pouch survival

Complication

Open IPAA n = 404

Laparoscopic IPAA n = 404

p value

Anastomotic separation

27 (6.8)

25 (6.7)

0.96

Pelvic sepsis

33 (8.2)

44 (10.9)

0.19

Fistula

18 (4.9)

25 (6.7)

0.30

Anastomotic stricture

27 (7.3)

29 (7.7)

0.84

Hemorrhage

12 (3.3)

6 (1.6)

0.15

Wound infection

36 (9.7)

33 (8.8)

0.66

Small bowel obstruction/ileus

68 (17.3)

84 (21)

0.21

Pouchitis

129 (32)

125 (31)

0.84

Functioning pouches at latest follow-up*

396 (98)

391 (96)

0.29

Cumulative pouch survival**

  

0.12

 1-year

99.4 (96.1–100)

98.2 (94.6–99.4)

 

 3-year

98.1 (94.4–99.4)

96 (91.2–98)

 

 5-year

98.1 (94.4–99.4)

94.1 (89–97)

 

 10-year

96.1 (88.1–99)

94.1 (89- 97)

 

*Chi-squared test

**Kaplan Meier analysis

Table 4

Stepwise cox regression model for ileal pouch failure

Parameter

Hazard ratio (95% CI)

Wald p value

Parameter estimate (SE)

Likelihood ratio p value

Laparoscopy

2.789 (0.745–10.433)

0.13

1.0255 (0.6732)

0.10

Fistula

7.711 (2.325–25.568)

0.001

2.0426 (0.6116)

0.004

Male gender

7.500 (0.962–58.480)

0.055

2.0148 (1.0479)

0.012

Completion proctectomy versus total proctocolectomy

0.313 (0.085–1.159)

0.08

− 1.1611 (0.6677)

0.06

Cumulative pouch survivals at 5-year and 10-year follow-up were comparable. LIPAA and OIPAA also had statistically similar causes of pouch failure (p = 0.22). Specific causes of pouch failure included pelvic sepsis (4 patients in LIPAA vs. 2 patients in OIPAA), pouch dysfunction (4 patients in LIPAA vs. 2 patients in OIPAA), pouch fistula (3 patients in LIPAA vs. none in OIPAA), chronic refractory pouchitis (1 patient in each group). All pouch failure patients had a J configuration.

LIPAA patients more commonly replied to the questionnaire at 1-year follow-up (n = 170, 42% vs. n = 139, 34% after OIPAA, p = 0.02), while the proportion of replying patients became similar between the 2 groups at subsequent follow-ups (at 2, 3, 4, 5 and 10 years postoperatively, p = ns) and at the time of the most recent follow-up (LIPAA n = 366, 91% vs. OIPAA n = 352, 87%, p = 0.11).

With respect to functional outcomes, 24-h stool frequency was significantly lower in LIPAA at 1-year and 2-year follow-ups. However, the 2 groups became comparable at 3 years of follow-up and onwards. The number of stools during daytime was comparable starting at the 1-year postoperative assessment, unlike nighttime stools, which were significantly less frequent after LIPAA both at 1 and at 2 years postoperatively, but became comparable starting at 3 years following surgery. Fecal incontinence rates were comparable. (Table 5).
Table 5

Evolution of functional results during follow-up

Variable

Open IPAA n = 404

Laparoscopic IPAA n = 404

p value

Seepage protection during the day

 1 y, n = 210

22 (22.4)

13 (11.4)

0.04

 2 y, n = 168

20 (24.1)

14 (16.5)

0.22

 3 y, n = 191

26 (27.7)

22 (22.7)

0.43

 4 y, n = 154

16 (22.2)

12 (14.6)

0.23

 5 y, n = 184

17 (19.3)

12 (12.5)

0.21

 10 y, n = 63

5 (22.7)

7 (17.1)

0.74

 Latest follow-up, n = 375

32 (18.0)

36 (18.3)

0.94

Seepage protection during the night

 1 y, n = 212

35 (32.4)

25 (20.8)

0.04

 2 y, n = 161

25 (30.9)

11 (13.8)

0.011

 3 y, n = 191

26 (27.7)

22 (22.7)

0.43

 4 y, n n = 159

21 (28.4)

19 (23.5)

0.48

 5 y, n = 184

20 (22.5)

18 (18.9)

0.56

 10 y, n = 61

6 (28.6)

5 (12.5)

0.16

 Latest follow-up, n = 375

43 (23.9)

45 (23.1)

0.85

Number of stools per day

 1 y, n = 212

5.7 ± 2.3

5.3 ± 2.1

0.08

 2 y, n = 196

6.7 ± 7.1

5.3 ± 2.1

0.13

 3 y, n = 224

6.1 ± 3.4

5.4 ± 2.2

0.27

 4 y, n n = 177

5.7 ± 2.6

5.5 ± 2.2

0.67

 5 y, n = 213

5.8 ± 2.7

5.4 ± 2.1

0.45

 10 y, n = 81

6.0 ± 3.3

5.2 ± 2.0

0.37

 Latest follow-up, n = 468

6.1 ± 5.2

5.3 ± 2.2

0.07

Number of stools per night

 1 y, n = 212

2.5 ± 1.7

2.0 ± 1.4

0.006

 2 y, n = 182

2.7 ± 2.2

2.1 ± 1.5

0.009

 3 y, n = 208

2.6 ± 2.1

2.2 ± 1.7

0.06

 4 y, n = 159

2.7 ± 1.8

2.3 ± 1.6

0.06

 5 y, n = 195

2.5 ± 1.7

2.1 ± 1.4

0.09

 10 y, n = 81

1.8 ± 0.9

2.2 ± 1.3

0.21

 Latest follow-up, n = 443

2.5 ± 1.6

2.3 ± 1.4

0.18

Total number of stools

 1 y, n = 212

8.5 ± 3.1

7.1 ± 2.7

0.002

 2 y, n = 195

8.6 ± 5.0

7.2 ± 2.8

0.03

 3 y, n = 223

8.5 ± 5.0

7.5 ± 3.2

0.22

 4 y, n = 177

8.1 ± 4.0

7.6 ± 3.2

0.38

 5 y, n = 213

8.0 ± 3.6

7.3 ± 2.7

0.22

 10 y, n = 80

8.4 ± 5.9

7.2 ± 2.4

0.67

 Latest follow-up, n = 498

7.1 ± 4.6

6.4 ± 3.2

0.14

Incontinence (present at all times)

 1 y, n = 190

1 (1.1)

2 (2.4)

0.35

 2 y, n = 146

0

1 (1.6)

0.41

 3 y, n = 170

0

4 (5.7)

0.13

 4 y, n = 129

0

1 (1.9)

0.45

 5 y, n = 150

1 (1.1)

2 (3.3)

0.89

 10 y, n = 39

3 (11.1)

0

0.17

 Latest follow-up, n = 362

9 (4.8)

13 (7.5)

0.78

Use of pads during daytime was significantly lower in LIPAA versus OIPAA at 1 year postoperatively, while nighttime seepage protection usage was not statistically different. At 2-year follow-up seepage protection use at night was significantly decreased in LIPAA (11 vs. 25%.; p = 0.01), unlike during daytime (17 vs. 24%), p = 0.22). At 3 years rates of pad usage became similar between the groups at either day or nighttime, which was also the case during subsequent follow-up. No functional deterioration was observed over time in either groups when assessing either stool frequency or seepage protection use.

LIPAA was also associated with improved overall CGQoL and energy scores at 1 year postoperatively (Table 6). Quality of health and QoL scores at 1 year after surgery were both numerically higher in LIPAA, however, without reaching statistical significance. QoL parameters were otherwise comparable.
Table 6

Evolution of quality of life parameters during follow-up

Variable

Open IPAA n = 404

Laparoscopic IPAA n = 404

p value

Overall CGQOL

 1 y, n = 309

0.7 ± 0.2

0.8 ± 0.2

0.01

 2 y, n = 232

0.8 ± 0.2

0.8 ± 0.1

0.44

 3 y, n = 262

0.8 ± 0.2

0.8 ± 0.2

0.94

 4 y, n = 217

0.8 ± 0.2

0.8 ± 0.2

0.91

 5 y, n = 255

0.8 ± 0.2

0.8 ± 0.2

0.99

 10 y, n = 106

0.72 ± 0.2

0.8 ± 0.2

0.87

 Latest follow-up, n = 718

0.7 ± 0.2

0.7 ± 0.2

0.51

Quality of health

 1 y, n = 312

7.5 ± 2.0

8.0 ± 1.7

0.06

 2 y, n = 234

8.0 ± 2.0

8.1 ± 1.5

0.36

 3 y, n = 263

7.9 ± 1.8

8.0 ± 1.8

0.92

 4 y, n = 217

7.8 ± 1.9

7.7 ± 2.0

0.89

 5 y, n = 255

7.8 ± 2.0

7.6 ± 2.0

0.50

 10 y, n = 106

7.3 ± 2.4

7.7 ± 1.7

0.73

 Latest follow-up, n = 721

7.4 ± 2.1

7.6 ± 1.7

0.47

Energy level, n = 756

 1 y, n = 311

6.9 ± 2.1

7.4 ± 2.0

0.02

 2 y, n = 234

7.2 ± 2.2

7.6 ± 1.9

0.19

 3 y, n = 265

7.2 ± 2.1

7.3 ± 2.0

0.64

 4 y, n = 217

7.1 ± 2.1

7.2 ± 2.1

0.79

 5 y, n = 255

7.0 ± 2.1

7.2 ± 2.1

0.46

 10 y, n = 106

6.7 ± 2.5

7.0 ± 2.0

0.51

 Latest follow-up

6.8 ± 2.0

7.0 ± 2.0

0.38

Quality of life, n = 756

 1 y, n = 313

7.5 ± 2.0

7.9 ± 1.8

0.06

 2 y, n = 235

7.9 ± 2.1

8.2 ± 1.4

0.65

 3 y, n = 264

8.1 ± 1.9

7.9 ± 1.9

0.30

 4 y, n = 217

8.0 ± 1.8

7.9 ± 2.0

0.93

 5 y, n = 255

7.9 ± 1.7

8.0 ± 1.8

0.83

 10 y, n = 106

7.6 ± 2.6

7.9 ± 1.6

0.73

 Latest follow-up, n = 723

7.5 ± 2.1

7.6 ± 1.8

0.91

Dietary restriction

 1 y, n = 313

61 (43.6)

74 (42.8)

0.62

 2 y, n = 234

44 (40.0)

41 (33.1)

0.27

 3 y, n = 265

46 (35.4)

42 (31.1)

0.46

 4 y, n = 216

28 (28.3)

36 (30.8)

0.69

 5 y, n = 255

34 (29.1)

50 (36.2)

0.23

 10 y, n = 105

17 (38.6)

18 (29.5)

0.33

 Latest follow-up, n = 723

156 (43.9)

160 (43.5)

0.90

Social restrictions

 1 y, n = 312

31 (22.3)

24 (13.9)

0.05

 2 y, n = 232

23 (21.3)

16 (12.9)

0.09

 3 y, n = 265

30 (23.1)

19 (14.1)

0.06

 4 y, n = 216

19 (19.2)

17 (14.5)

0.36

 5 y, n = 254

21 (18.1)

21 (15.2)

0.54

 10 y, n = 105

10 (22.7)

10 (16.4)

0.42

 Latest follow-up, n = 723

92 (26.0)

80 (21.7)

0.17

Work restrictions

 1 y, n = 312

34 (24.3)

29 (16.9)

0.11

 2 y, n = 233

24 (22.0)

13 (10.5)

0.02

 3 y, n = 265

27 (20.8)

18 (13.3)

0.11

 4 y, n = 214

17 (17.2)

18 (15.7)

0.76

 5 y, n = 254

19 (16.4)

26 (18.8)

0.61

 10 y, n = 104

11 (25.6)

12 (19.7)

0.48

 Latest follow-up, n = 724

110 (31.0)

95 (25.7)

0.12

Sexual restrictions

 1 y, n = 312

31 (22.1)

27 (15.7)

0.15

 2 y, n = 232

24 (22.0)

22 (17.9)

0.43

 3 y, n = 264

28 (21.7)

27 (20.0)

0.73

 4 y, n = 216

19 (19.2)

22 (18.8)

0.94

 5 y, n = 254

25 (21.6)

24 (17.4)

0.40

 10 y, n = 103

14 (33.3)

12 (19.7)

0.12

 Latest follow-up, n = 724

88 (24.8)

75 (20.3)

0.15

Would undergo surgery again

 1 y, n = 206

84 (89.4)

98 (87.5)

0.68

 2 y, n = 167

81 (95.3)

77 (93.9)

0.74

 3 y  n = 190

87 (91.6)

85 (87.6)

0.37

 4 y, n = 157

72 (93.5)

72 (90.0)

0.43

 5 y, n = 184

87 (94.6)

85 (92.4)

0.55

 10 y, n = 65

23 (95.8)

40 (97.6)

1.00

 Latest follow-up, n = 372

158 (90.3)

172 (87.3)

0.37

Would recommend surgery

 1 y, n = 207

89 (93.7)

108 (96.4)

0.52

 2 y, n = 165

80 (95.2)

79 (97.5)

0.68

 3 y, n = 190

87 (93.5)

93 (95.9)

0.53

 4 y, n = 155

72 (96.0)

77 (96.2)

1.00

 5 y, n = 181

86 (95.6)

89 (97.8)

0.44

 10 y, n = 65

23 (95.8)

40 (97.6)

1.00

 Latest follow-up, n = 368

159 (92.4)

185 (94.4)

0.45

Discussion

This study reports the largest series to date on long-term outcomes following LIPAA, case-matched with OIPAA, with the longest postoperative follow-up period extending to 10 years. Our data confirm LIPAA as an acceptable approach without any difference in cumulative pouch survival when compared with OIPAA at any time period. Functional outcomes were temporarily improved after LIPAA during the first and second postoperative year, but subsequently became comparable. Similarly, LIPAA was associated with improvements in QoL, also lasting for one or 2 years after surgery, after which QoL metrics were comparable.

A meticulous matching was performed to minimize the effect of confounding variables on the outcomes of interest, by selecting relevant patient-related, disease and treatment-related variables. With respect to anastomotic technique, the vast majority of patients underwent stapled anastomosis, consistent with the technical evolution of IPAA. We paid particular attention to include as a matching criterion the duration of postoperative follow-up, considering that our goal was to compare pouch longevity, long-term complications, functional results and QoL outcomes over time. The assessment of the perioperative outcomes not surprisingly confirmed that laparoscopic surgery is associated with a reduction in length of hospital stay by about a day, which offsets the longer duration of surgery. With respect to other significant variables, the use of medications and laboratory values was otherwise comparable between the 2 groups, which strengthens the validity of our comparative results. Immediate complications were also comparable and the multivariate analysis assessing independent factors associated with pouch failure did not identify laparoscopy as a factor independently associated with pouch failure. This corroborates the feasibility of laparoscopic surgery as an acceptable standard of care, which has at least stood the test of time several years after its introduction into clinical practice. The evolution over time of both functional results and quality of life outcomes is somewhat more difficult to explain, in particular with respect to the temporary advantages associated with laparoscopic surgery which leveled off over time. Presented differences in stools frequency were noted during 1st and 2nd year postoperatively. At 3 years after surgery daytime and nighttime stool frequency, seepage protection usage was comparable between the groups. A decreased number of individuals returning the questionnaire over time might have affected these results and remains a definitive limitation of our findings.

When compared to previous experiences in the assessment of similar metrics based on all operations performed, the overall outcomes reported in our previous series more closely reflected the outcomes in our current LIPAA group presented at comparable postoperative intervals. One technical difference between LIPAA and OIPAA is the transection of the anorectal ring, which is performed with a linear instrument resulting in a transverse staple line in the course of OIPAA as opposed to a laparoscopic stapler in most cases of LIPAA, which simultaneously performs bowel transection and most commonly results in an anteroposterior staple line. This technical difference in the conduct of the operation was not associated with any difference in perioperative complications between the groups and it is therefore unclear how it could be related to temporarily different functional and QoL outcomes.

Baek et al. evaluated the long-term functional outcomes of LIPAA as compared to open IPAA with a median follow-up of 8 years in 149 patients and showed comparable function with slightly lower daytime and nighttime stool frequency no difference in use of medication to control stools, perianal skin irritation, voiding difficulty, sexual problems and occupational change between groups. The authors attributed the slightly improved function outcomes after LIPAA to a more prevalent use of the stapled technique than in the open counterparts. In our study, the groups were intentionally matched for anastomotic technique and functional outcomes were assessed at different time points [18].

While our study supports offering LIPAA to patients due to accelerated postoperative recovery and temporary functional and quality of life benefits, it is certainly not definitive in terms of the exact extent of benefits associated with the laparoscopic technique. The incidence of postoperative small bowel obstruction was similar, corroborating a previous evaluation of our own institutional experience, which did not indicate any significant reduction in the risk of small bowel obstruction associated with LIPAA, despite previous evidence indicating reduction in the adhesion formation when using laparoscopic technique [19, 20]. Our data also did not address another possible advantage attributed to LIPAA, namely greater preservation of fecundity rates, as reported by others [19].

Our study presents inevitable limitations related to its retrospective design, only partially attenuated by the matching design. First of all, we considered a long time period, during which it is conceivable that the evolution in both surgical techniques and in the experience of the operators might have disproportionally altered the characteristics of the study groups, considering the more recent introduction of LIPAA into clinical practice when compared with OIPAA and the evidence of a learning curve both in OIPAA and LIPAA [20]. However, LIPAA was shown to be equivalent in this analysis and it could be argued that once LIPAA becomes more established among different operators, its results might even improve. In addition, we included several slightly different surgical approaches in the laparoscopic surgery group, consistent with previous publications from both our institution and others [21, 22], which included cases where the rectal dissection could be carried out, in part or completely, under direct vision after complete laparoscopic mobilization of the abdominal colon, which could also include transection at the level of the anorectal ring using a conventional linear stapler and Pfannenstiel incision, rather than laparoscopic instruments. This led to a somewhat heterogeneous study group, but is consistent with an inherent ambiguity in the definition of laparoscopic IPAA, which permeates the literature [5, 13, 19]. Furthermore, different proportions of our patient population were treated with 2 versus 3-staged procedures according to the technique performed. At the onset of our study we had no evidence that this could be associated with a different risk of pouch failure based on previous evidence (1) while the multivariate analysis suggested no significant association between 2-staged IPAA and increased risk of pouch failure in our patient population. In addition, the study design implies that the data collected are based on the actual proportion of patients who returned their questionnaire, which inevitably was less than 100% and decreased over time, thus predisposing to bias.

In conclusion, LIPAA is associated with similar perioperative complications and long-term complications when compared with OIPAA for patients with UC, IC and FAP, but is associated with postoperative recovery advantages and temporary advantages in functional results and quality of life parameters during the first 2 postoperative years. After this time period, laparoscopy is comparable to the same operation performed using open technique. LIPAA can therefore be offered to most patients with ulcerative colitis.

Notes

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

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Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Olga A. Lavryk
    • 1
  • Luca Stocchi
    • 1
  • Jean H. Ashburn
    • 1
  • Meagan Costedio
    • 1
  • Emre Gorgun
    • 1
  • Tracy L. Hull
    • 1
  • Hermann Kessler
    • 1
  • Conor P. Delaney
    • 1
  1. 1.Department of Colorectal Surgery, Digestive Disease and Surgery InstituteCleveland ClinicClevelandUSA

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