Marker L, Kjær S, Levic-Souzani K, Bulut O
Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark.
Copenhagen IBD-Center, Copenhagen, Denmark.
Tech Coloproctol. 2022 Nov;26(11):875-881. doi: 10.1007/s10151-022-02658-1. Epub 2022 Aug 10.
Ileal pouch-anal anastomosis (IPAA) is the procedure of choice in patients with ulcerative colitis (UC) requiring surgery. Advantages of laparoscopic IPAA (lap-IPAA) compared to open surgery have been investigated. However, laparoscopic dissection in the pelvis is still a challenge. A transanal approach provides better access to lower pelvis and avoids multiple staple firings, which could reduce the risk of anastomotic complications. The aim of this study was to compare short-term outcomes of transanal proctectomy with IPAA (ta-IPAA) with conventional lap-IPAA in patients with UC.
A single-center retrospective study was conducted on consecutive UC patients, treated at Copenhagen University Hospital, Hvidovre, undergoing either laparoscopic or transanal IPAA in the period between January 2013 and December 2020. Exclusion criteria were Crohn's disease, previous extensive abdominal surgery and impaired sphincter function. Primary outcomes were overall postoperative complications. Secondary outcomes were length of hospital stay and re-admissions. For comparison between ta-IPAA and lap-IPAA, the Mann-Whitney U test was used for continuous variables, and Chi-square and Fisher's exact test for categorical variables.
A total of 65 patients with ta-IPAA (34 males, 31 females, median age 31 years [range 12-66 years]) and 70 patients with lap-IPAA (35 males, 35 females, median age 26 years [range 12-66 years]) were included. There was no difference between ta-IPAA and lap-IPAA regarding age, sex, body mass index or American Society of Anesthesiologists class. The primary colectomy procedure was performed laparoscopically in 95% of the ta-IPPA and 91% of the lap-IPAA patients (p = 0.493). The mean time between total colectomy and IPAA was 15 and 9 weeks for ta-IPAA and lap-IPAA, respectively (p = 0.048). A higher proportion of patients with ta-IPAA were treated with biologics preoperatively (98 vs. 82%; p = 0.002). Patients with ta-IPAA had a significantly higher mean operative time compared to lap-IPAA (277 min vs. 224 min; p = 0.001). There was no difference in the overall postoperative complication rate (ta-IPAA: 23% vs. lap-IPAA: 23%; p = 0.99). Pouch-related complications occurred in 13% of the ta-IPAA patients and 29% of lap-IPPA patients (p = 0.402). There was no difference in the anastomotic leakage rates. Readmission rates were similar in the ta-IPAA and lap-IPAA group (26 vs. 29%; p = 0.85), including IPAA-related readmissions. The mean follow-up time was 24 and 75 months for ta-IPAA and lap-IPAA, respectively (p = 0.001), and the ileostomy closure rate was similar in both groups of patients (p = 0.96).
The ta-IPAA approach for UC is a safe procedure and offers acceptable short-time outcomes.
回肠储袋肛管吻合术（IPAA）是需要手术治疗的溃疡性结肠炎（UC）患者的首选术式。腹腔镜IPAA（lap-IPAA）与开放手术相比的优势已得到研究。然而，盆腔内的腹腔镜解剖仍是一项挑战。经肛门入路可更好地进入盆腔下部，避免多次钉合，这可能会降低吻合口并发症的风险。本研究的目的是比较经肛门直肠切除术联合IPAA（ta-IPAA）与传统lap-IPAA治疗UC患者的短期疗效。
对2013年1月至2020年12月期间在哥本哈根大学医院惠勒夫分院接受腹腔镜或经肛门IPAA治疗的连续性UC患者进行单中心回顾性研究。排除标准为克罗恩病、既往广泛腹部手术史和括约肌功能受损。主要结局为术后总体并发症。次要结局为住院时间和再次入院情况。对于ta-IPAA和lap-IPAA之间的比较，连续变量采用曼-惠特尼U检验，分类变量采用卡方检验和费舍尔精确检验。
共纳入65例行ta-IPAA的患者（男性34例，女性31例，中位年龄31岁[范围12 - 66岁]）和70例行lap-IPAA的患者（男性35例，女性35例，中位年龄26岁[范围12 - 66岁]）。ta-IPAA和lap-IPAA在年龄、性别、体重指数或美国麻醉医师协会分级方面无差异。95%的ta-IPPA患者和91%的lap-IPAA患者的初次结肠切除术是通过腹腔镜进行的（p = 0.493）。ta-IPAA和lap-IPAA患者全结肠切除术后至IPAA的平均时间分别为15周和9周（p = 0.048）。ta-IPAA患者术前接受生物制剂治疗的比例更高（98%对82%；p = 0.002）。ta-IPAA患者的平均手术时间显著长于lap-IPAA患者（277分钟对224分钟；p = 0.001）。术后总体并发症发生率无差异（ta-IPAA：23%对lap-IPAA：23%；p = 0.99）。ta-IPAA患者中有13%发生储袋相关并发症，lap-IPPA患者中有29%发生（p = 0.402）。吻合口漏率无差异。ta-IPAA组和lap-IPAA组的再次入院率相似（26%对29%；p = 0.85），包括与IPAA相关的再次入院。ta-IPAA和lap-IPAA患者的平均随访时间分别为24个月和75个月（p = 0.001），两组患者的回肠造口关闭率相似（p = 0.96）。
ta-IPAA治疗UC是一种安全的手术方式，可提供可接受的短期疗效。
