Laparoscopically assisted colectomy and ileoanal pouch procedure with and without protective ileostomy.
BACKGROUND
Apart from an obviously better cosmetic situation, there is controversy on the actual benefit of laparoscopic and laparoscopically assisted techniques in restorative proctocolectomy. The need for a protective ileostomy remains unclear.


METHODS
Fifty-nine consecutive patients with ulcerative colitis and familial polyposis were included in this prospective cohort study. The colon was mobilized laparoscopically with a four-trocar technique, facilitating vascular dissection, rectal resection, and ileoanal pouch construction to be done through a Pfannenstiel incision. A protective ileostomy was constructed only in patients where the operation was difficult or where the anastomosis was under tension. Intra- and postoperative data were recorded; statistical analyses were performed by exact logistic regression.


RESULTS
Laparoscopic mobilisation was successful in 54 patients (91.2%). Two patients had to be primarily converted because of exceeding the set time limit; 3 other patients had to have an additional median laparotomy. These 5 patients all had an increased body mass index (BMI), which was a statistically significant risk factor for failure of the laparoscopic technique. 18.6% of patients developed major complications (n = 11). Nine patients required secondary ileostomies; all of them either were under high dose immunosuppressants (n = 5) or had an increased BMI (average 28.42 kg/m2). Failure of the laparoscopic technique was associated with major complications.


CONCLUSIONS
Laparoscopically assisted restorative proctocolectomy is technically feasible; an increased BMI is a relevant risk factor for failure. The minimally invasive approach probably does not reduce the need for a protective ileostomy in selected patients. The selection criteria for the addition or omission of a protective ileostomy in minimally invasive restorative proctocolectomy remain to be clearly defined.
Kienle
P
P
Surgical Department, University of Heidelberg, INF 110, 69120 Heidelberg, Germany. Peter_Kienle@med.uni-heidelberg.de
Weitz
J
J
Benner
A
A
Herfarth
C
C
Schmidt
J
J
D011125:Adenomatous Polyposis Coli / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D015331:Cohort Studies; D003082:Colectomy / Q000379:methods* / Q000706:statistics & numerical data; D003093:Colitis, Ulcerative / Q000601:surgery; D005260:Female; D006801:Humans; D007081:Ileostomy / Q000379:methods* / Q000706:statistics & numerical data; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D007813:Laparotomy / Q000379:methods / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications; D011183:Postoperative Complications / Q000209:etiology; D016737:Proctocolectomy, Restorative / Q000379:methods* / Q000706:statistics & numerical data; D011446:Prospective Studies; D012307:Risk Factors; D017211:Treatment Failure