Page 61 - World Journal of Laparoscopic Surgery

Evolution of Surgical Management for Ulcerative Colitis
The randomizer was used to avoid any selection bias in choosing following 95 patients undergoing IPAA, McKevitt et al. reported a
the articles for review on the authors’ part. shift in the trend for IPAA, from an open surgical approach toward
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a minimal access approach over a period of 20 years (1998–2017).
Inclusion Criteria This they attributed to potentially fewer complications as well as
• Patients ≥18 years of age. improved cosmesis and functional results with the latter. 6
• Articles on surgical management of UC. A retrospective review by Fajardo et al. which compared the
• Articles published in the last 6 months of 2010 and 2020. outcomes of 55 patients undergoing laparoscopic IPAA and 69
undergoing open IPAA between April 1999 and July 2008, showed
Exclusion Criteria that the laparoscopic approach of IPAA was comparable to the
• Surgical management of UC in the pediatric population. open approach in terms of postoperative mortality and morbidity.
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• Articles regarding surgical management of any other One of their significant findings was the duration of the closure of
gastrointestinal conditions except UC. ileostomy which occurred on an average of 24.1 days sooner in
the laparoscopic group compared to the open group, irrespective
dIscussIon/revIew of patient characteristics and occurrence of postoperative
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Ulcerative colitis is an autoimmune disease belonging to the complications. This resulted in shorter discharge time and also
group of IBD. First described in 1859, UC is defined by mucosal helps explain the shorter length of stay (LOS) as reported by
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inflammation initiating in the rectum and extending proximally to multiple trials in the past. Laparoscopic IPAA was also associated
involve the colon in a continuous fashion. The diagnosis is usually with longer average operating times of 79.2 minutes compared to
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a combination of the clinical and histopathological evidence of a conventional open procedure (266.7 minutes vs 187.5 minutes).
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the same. It presents with a constellation of symptoms, the most However, the study showed no significant difference between
common being bloody diarrhea. The long-standing disease can the two groups in terms of estimated blood loss, return to bowel
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lead to dysplasia and colorectal cancer, which are some of its function, readmission rates, and total complications. Some of its
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most serious complications, if left untreated. Until the mid-1950s, limitations are its retrospective nature which could contribute
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when corticosteroids were first used to treat UC, the condition to selection bias in patients. The last decade has also seen the
had a withering prognosis with >50% mortality rate among development of newer techniques such as Robot-assisted and
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patients. However, steroids are also associated with side effects hybrid IPAA, which seem very promising. As reported by Hota et al.,
like osteoporosis, osteonecrosis, weight gain, insulin resistance, based on a survey conducted on 2129 UC patients who underwent
increased risk of infections, etc. With the advancement of medical robotic, laparoscopic, or open IPAA, 30-day postoperative
science, the treatment options for UC and IBD, in general, have outcomes were better for minimally invasive techniques in terms
broadened, where the current trends include initial management of postoperative ileus, wound infections, and anastomotic leaks,
with medical therapies and switching over to surgical management but the multivariate analysis of their data shows no statistically
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in refractory cases. The review aimed to understand how surgery significant difference in LOS among the three groups. The minimal
has evolved in the last decade compared to the previous decade access approach also provided advantages in other aspects of
in terms of surgical procedures, patient outcomes, quality of 30-day postoperative surgical outcomes and shorter postoperative
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life, and complications. In our review, we found that the surgical LOS, respectively. Lim et al., in their institutional experience
procedure used for the management of UC has largely remained study, where they reported outcomes and impact of surgical
the same in the last decade, with the procedure of choice being evolution over a period of 26 years (1990–2016), also reported a
restorative proctocolectomy with ileal pouch-anal anastomosis shift toward minimal access technique (laparoscopic) in the last
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(RP-IPAA). Restorative proctocolectomy with ileal pouch-anal decade, with an increase in stapled IPAA (vs Hand-sewn IPAA) and
anastomosis involves removal of the colon and rectum and modified 2-stage procedure (vs a 3 stage procedure) compared
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establishing continuity, most commonly using a J-pouch, which is to the previous decade. Their findings also show a decline in the
created using a loop of the small intestine. It is usually performed defunctioning ileostomy rate in the last decade compared to the
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as a staged procedure over two or three operative occasions. previous decade. Over time, the use of J-pouch configuration (vs
It best helps eliminate the need for a permanent stoma in these a W-pouch configuration) gained more importance, which was
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patients, which is associated with a better overall quality of life. supported by their randomized trial findings comparing functional
Since Parks and Nicholls described it for the first time in 1978, the outcomes between the 2 configurations showing better outcomes
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technique has undergone several technical modifications. In a with J-pouch compared to W-pouch. They found their results to
study by Ikeuchi et al., where 1000 patients undergoing IPAA were be consistent with a surgical evolution study conducted by the
followed over a period of 24 years for short-term and long-term Leuven group, who in their study also reported decreased rates
outcomes, they demonstrated that ileal pouch-anal anastomosis of anastomotic leak and small bowel obstruction with surgical
(IPAA) had low rates of mortality and morbidity with pouch success evolution. 9,10 Lim et al., however, also reported an increase in
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rates to be 97% and 92% after 10 and 20 years, respectively. With the number of patients undergoing acute surgery, despite an
increased availability and accessibility to laparoscopic and robotic increase in the use of immunomodulatory therapies over time, the
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equipment, we have seen a shift in trend from open RP-IPAA to reason behind this was not clear. A multivariate analysis of their
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minimal access RP-IPAA. This change in approach from open to complications revealed that a BMI of 18.1 or more before surgery
minimal access has shown improved overall outcomes in patients, was associated with a decreased rate of anastomotic leak, while
along with fewer associated complications, while using the same, steroid use before colectomy was a risk factor that was not further
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although technically more challenging surgical procedure. There elaborated on. In terms of complications, Lim et al., also reported
is some literature suggesting a laparoscopic approach being used an increase in pouchitis rates which was seen in patients with a
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to perform RP-IPAA in the previous decade as well. In a study more aggressive preoperative disease, evidenced by the increased
World Journal of Laparoscopic Surgery, Volume 15 Issue 3 (September–December 2022) 247