title: Minimal invasive surgery: NOSE and NOTES in ulcerative colitis.
abstract: BACKGROUND
  In patients with ulcerative colitis (UC), laparoscopic pelvic dissection for IPAA is not always straightforward: often, a hand-assistance incision is used to complete the proctectomy, lengthening operative times. Hybrid NOSE and NOTES are emerging as an alternative approach to conventional laparoscopy. We believe that UC patients could benefit from this new hybrid approach in three ways: by easing the proctectomy as performed down to up, avoiding additional incisions and decreasing surgical times. We present the short-term outcomes of our series.
  
  
  METHODS
  All patients with UC who required IPAA were enrolled in a single-arm prospective study (July 2011 to March 2014). A three-step procedure was performed. The first step: laparoscopic colectomy (with transanal removal of the colon) and temporary ileostomy. The second step: "down-to-up" proctectomy (with transanal removal of the rectum) and IPAA with a covering ileostomy. We combined simultaneously transanal and laparoscopic approach. The third step: ileostomy closure. Functional outcomes were assessed 3 months after third step.
  
  
  RESULTS
  Eighteen patients were enrolled. Two patients are waiting to complete the second stage, and 16 underwent all surgical steps. Twelve have been evaluated with functional scores. For the first step, the mean operative time was 162.2 min (SD 40.5) and 170 min (SD 50.1) for the second one. The median hospital stay was 6 days (IQR 5-14.75) for the first step and 5.5 (IQR 5-9.75) for the second one. No major complications occurred. Twenty-four-hour defecation frequency was 5.5 per day (SD 1.7), 0.5 per night. Seventy-five percentage of patients may retain stools for more than 30 min; the mean value of Oresland score was 4.7 and Wexner score 1.4.
  
  
  CONCLUSIONS
  This is a safe and feasible technique to treat UC patients with good short-term outcomes. Long-term outcomes and controlled trials are needed.
authors: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, Fundació Privada Cellex, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
authors: Marta M
authors: MM
authors: Tasende
authors: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, Fundació Privada Cellex, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
authors: Salvadora
authors: S
authors: Delgado
authors: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, Fundació Privada Cellex, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
authors: Marta
authors: M
authors: Jimenez
authors: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, Fundació Privada Cellex, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
authors: Gabriel Diaz
authors: GD
authors: Del Gobbo
authors: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, Fundació Privada Cellex, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
authors: María
authors: M
authors: Fernández-Hevia
authors: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, Fundació Privada Cellex, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
authors: Borja
authors: B
authors: DeLacy
authors: Department of Anesthesiology, Hospital Clinic, Barcelona, Spain.
authors: Jaume
authors: J
authors: Balust
authors: Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, Fundació Privada Cellex, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain. alacy@clinic.ub.es.
authors: Antonio M
authors: AM
authors: Lacy
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy / Q000379:methods*; D003093:Colitis, Ulcerative / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy / Q000379:methods; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D061646:Operative Time; D011446:Prospective Studies; D012007:Rectum / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Bottom-up rectal dissection; NOSE; NOTES; Ulcerative colitis