[Therapy of refractory proctocolitis and Crohn's disease. Incisionless laparoscopic proctocolectomy with a Brooke ileostomy].
BACKGROUND
Laparoscopic colorectal surgery is nowadays also widely used in surgery of inflammatory bowel disease. With the correct indications laparoscopic surgery is an attractive cosmetic alternative for the predominantly juvenile patients. Refractory fistulizing Crohn's proctocolitis is a very severe disease with a maximal limitation on the quality of life. Proctocolectomy with a Brooke ileostomy represents a very effective option for these patients. The laparoscopic technique can at least spare the patients a salvage laparotomy incision. We report about our preliminary experiences


METHODS
A total of 8 patients (mean age 25 years, range 19 Background 31 years, female:male ratio 5:3) were operated on. The mean preoperative time course of the disease was 28 months (range 12 Background 156 months). All patients had received long-term prednisolone therapy of >15mg, 2 patients received azathioprine medication, 2 underwent anti TNF-alpha therapy and 6 received 5-aminosalicylic acid (5-ASA). The mean preoperative BMI was 19 (range 15 Background 21). All patients suffered from Crohn's pancolitis with anorectal fistulas. Laparoscopic proctocolectomy was performed using 4 trocars place in a semicircular fashion. The resected tissue was salvaged transanally and the Brooke ileostomy was drained via the right lateral trocar. The terminal exit of the rectum occurred transanally with preservation of the pelvic floor and the anal sphincter and the anal fistulas were separated. The small pelvis was filled by a transanally fixed omentum.


RESULTS
The median time for surgery was 236.5 mins (range 220-330 mins). A complication of postoperative paralysis of the bowel occurred in two patients and 4 patients could be discharged problem-free according to the fast-track concept. Cosmetic results were excellent in all cases. Perianal and perirectal manifestations healed completely after a median of 4 weeks.


CONCLUSIONS
Incisionless proctocolectomy represents a good and realizable alternative to open surgery. The main advantages are excellent cosmetic results and a better preservation of the external integrity of the abdomen.
Kroesen
A J
AJ
Chirurgische Klinik I: Allgemein-, Gefäss- und Thoraxchirurgie, Charite-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany. a.kroesen@khporz.de
Gröne
J
J
Buhr
H J
HJ
Ritz
J P
JP
D000328:Adult; D016063:Blood Loss, Surgical / Q000517:prevention & control; D003082:Colectomy / Q000379:methods*; D003424:Crohn Disease / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D012003:Rectal Fistula / Q000601:surgery; D012007:Rectum / Q000601:surgery*; D055815:Young Adult