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Case-Matched Comparison of Laparoscopic vs. Open Ileal Pouch-Anal Anastomosis Assessing Small Bowel Obstruction and Incisional Hernia Rates
Cigdem Benlice*, Luca Stocchi, Emre Gorgun, Meagan Costedio, Hermann P. Kessler, Feza H. Remzi
Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
Background: There is scant data on the presumed long-term advantages of laparoscopic ileal pouch-anal anastomosis (IPAA) in reducing rates of small bowel obstruction (SBO) and incisional hernia (IH). This study investigated IH and SBO in contemporary patients treated with laparoscopic vs. open IPAA.
Methods: Patients undergoing laparoscopic IPAA between 2008-2011, queried from a prospectively collected database were case-matched to open IPAA based on age (±5 years), extent of resection (completion proctectomy vs. proctocolectomy), gender and body mass index (±5 kg/m2). Study endpoints including IH clinically detected by a physician, admissions to hospital and surgery for SBO, pouch excision and pouchitis were retrospectively obtained from a prospective database and patient charts as necessary. Laparoscopic abdominal colectomy followed by rectal dissection under direct vision (using lower midline or Pfannenstiel incision) and converted cases were analyzed within the laparoscopic group.
Results: Out of 480 patients treated during the study period, 98 patients with laparoscopic IPAA were matched 1:2 with 196 patients having open IPAA. Mean follow-up (2.8 years vs. 2.6 years, respectively, p=0.27) and anti-adhesion barrier use were similar between the groups. The incidences of IH, SBO requiring hospital admission and surgery, pouch excision and pouchitis were also comparable (Table). A subgroup analysis within the laparoscopic group comparing 28 patients with rectal dissection under direct vision vs. 70 patients with laparoscopic rectal dissection showed statistically similar incidence of IH (7.1% vs. 2.9%, respectively, p=0.35), hospital admission and surgery for SBO (14.3% vs. 10%, p= 0.55 and 7.1% vs. 2.9%, p=0.35, respectively).
Conclusion: Laparoscopic IPAA was not associated with a reduction in the incidence or surgery for SBO and offered only a marginal reduction in the IH rate when compared to open IPAA. The lack of these specific putative advantages of the laparoscopic approach should be discussed with patients when offering laparoscopic IPAA. Table. Comparison of demographics and long-term results between laparoscopic and open IPAA | Laparoscopic (N=98) | Open (N=196) | P value | | Age | 38.2 (13.5) | 38.1 (13.2) | 0.91 | | Female, gender | 38 (38.8%) | 76 (38.8%) | >0.99 | | Extent of resection | | | >0.99 | | Completion proctectomy | 63 (64.3%) | 126 (64.3%) | | | Proctocolectomy | 35 (35.7%) | 70 (35.7%) | | | Conversion | 7 (7.1%) | N/A | | | BMI, kg/m2 | 25.6 (5.8) | 25.6 (4.6) | 0.62 | | Anti-adhesion barrier use | 21 (21.4%) | 32 (16.3%) | 0.28 | | Follow-up, years | 2.8 (1.5) | 2.6 (1.5) | 0.27 | | Incisional hernia | 4 (4.1%) | 20 (10.2%) | 0.08 | | Midline | 1 | 9 | | | Ileostomy site | 2 | 11 | | | Umbilical port site | 1 | 0 | | | Pfannenstiel extraction site | 0 | N/A | | | Hospital admission for SBO | 11 (11.2%) | 22 (11.2%) | >0.99 | | Surgery for SBO | 4 (4.1%) | 13 (6.6%) | 0.38 | | Pouch excision | 5 (5.1%) | 3 (1.5%) | 0.12 | | Pouchitis | 26 (26.5%) | 40 (20.4%) | 0.24 |
Values are reported as mean (SD) or absolute values (%).
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