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Does Intramesorectal Proctectomy Affect Overall Complication Rates Compared to Standard Total Mesorectal Excision in Patients With Ulcerative Colitis?
Caitlin W. Hicks*1,2, Richard a. Hodin1, Lieba R. Savitt1, Liliana Bordeianou1
1Department of Surgery, Massachusetts General Hospital, Boston, MA; 2Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
Purpose: In patients with ulcerative colitis (UC), intramesorectal proctectomy involves close dissection along the rectal wall with concomitant rectal eversion (IMP/RE). In contrast, standard total mesorectal excision (TME) involves close dissection along the pelvic wall with an intraabdominal stapled rectal transection above the levator muscles. Our goal was to compare surgical outcomes among UC patients following IMP versus TME (Figure).
Methods: All patients undergoing IPAA surgery for active UC at a tertiary referral hospital over a 10.5-year period (09/2000-04/2011) were included in analysis. Univariate analysis (T-tests and chi square tests) and step-wise fit regression modeling were used to compare complications rates among patients undergoing IMP vs. TME procedures.
Results: Of 201 patients identified for inclusion in the study, 119 (59%) underwent IMP/RE. Age, race, gender, smoking status, disease comorbidity, steroid or other immunomodulator use, surgical urgency, severity of disease on pathology, and surgical staging were similar between groups (p=ns). IMP/RE patients underwent fewer laparoscopic procedures (2% vs. 37%, p<0.0001) based on surgeon preference. On univariate analysis, IMP/RE patients had fewer total perioperative complications (0.9±0.1 vs. 1.4±0.1, p=0.02), but no differences in abdominal sepsis, post-operative length-of stay, or hospital readmissions (p=ns). However, in a step-wise regression model accounting for age, co-morbidities, disease severity, pre-operative medications, operative technique, and follow-up time (mean 5.5±0.2 years), both anastamotic leak rate [OR -0.56 (95% CI 0.33, 0.99); p=0.04] and overall post-operative combined pouch-related and infectious complications were lower in the IMP/RE group (2.0±0.2 vs. 2.6±0.2, p=0.03).
Conclusions: IMP/RE appears to be associated with fewer overall post-operative complications than TME in patients with UC. This may be a reflection of smaller free space within the pelvis and/or the ability to invert the rectal stump staple line during concomitant rectal eversion. However, further studies on functional and long-term outcomes are needed.
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