Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; School of General Surgery, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy.
J Gastrointest Surg. 2024 Apr;28(4):501-506. doi: 10.1016/j.gassur.2024.01.005. Epub 2024 Jan 23.
Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage.
Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes.
The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays.
Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.
虽然腹腔镜回肠贮袋肛管吻合术（IPAA）已成为直肠结肠切除术后的金标准，但手术技术几乎没有变化。相比之下，围手术期护理发生了重大转变，以加速康复方案（ERP）为代表，类固醇的使用方式发生了改变，并且手术方式转为了三阶段手术。
从我们的前瞻性 IPAA 数据库中提取的数据侧重于前 100 例腹腔镜 IPAA 病例（历史组）和最新的 100 例（现代组），旨在衡量这些演变对术后结果的影响。
历史组 IPAA 中 2 阶段手术（92%的结肠切除术）更多，而现代组中 3 阶段手术（86%的直肠切除术）更多（P<.001）。与现代组相比，历史组的患者在手术时更有可能使用类固醇（分别为 5%和 67%；P<.001）或免疫调节剂（分别为 0%和 31%；P<.001）。与历史组相比，现代组的手术时间更短（分别为 335.5±78.4 和 233.8±81.6 分钟；P<.001），住院时间（LOS）更短（分别为 5.4±3.1 和 4.2±1.6 天；P<.001）。与现代组相比，历史组的 30 天发病率更高（分别为 20%和 33%；P=.04），30 天再入院率更高（分别为 9%和 21%；P=.02）。术前使用类固醇会增加并发症（比值比 [OR]，3.4；P=.01），而三阶段 IPAA 可减少并发症（OR，0.3；P=.03）。ERP 被确定为预测住院时间缩短的因素。
虽然 ERP 有效降低了 IPAA 手术中的 LOS，但并未降低并发症。相反，采用三阶段 IPAA 方法有助于降低发病率，而术前使用类固醇会增加并发症。
