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Modified-Pfannenstiel Open Approach as an Alternative to Laparoscopic Restorative Proctocolectomy: Comparison of Outcomes and Quality of Life - A Matched Study
Leonardo C. Duraes*, Destiny A. Schroeder, David Dietz
Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH

Background:
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical approach for ulcerative colitis, profuse familial adenomatous polyposis, indeterminate colitis, and selected cases of Crohn's disease. Laparoscopic approach to IPAA has better short-term outcomes and cosmesis while open surgery has shorter operative times. We hypothesized that an open approach via a modified-Pfannestiel incision would combine the advantages of both techniques. The aim of this study was to compare open restorative total proctocolectomy surgery with IPAA using Pfannenstiel incision versus laparoscopic approach.
Methods:
A single institution database was queried to identify patients submitted to total proctocolectomy with IPAA from 1998 until 2014. Patients submitted to open total proctocolectomy with IPAA using modified-Pfannenstiel incision (P) were compared to patients who underwent the surgery by laparoscopy (L). Short and long term outcomes were evaluated, and quality of life questionnaires were assessed. Then, the patients were matched 1:1 by diagnosis, gender, age (+/- 5 years) and BMI (+/- 5 Kg/m2). Short and long-term outcomes, and quality of life were assessed.
Results:
Out of 1275 patients, 119 underwent L, and 33 underwent P. P patients were younger, female, had less BMI, and lower ASA classification compared to L. Surgical time was lower in P, and no difference was observed in length of hospital stay (LOS). Also, no difference was observed in post-operative complications, pouch failure, and quality of life (table 1). When patients were matched, P still had shorter surgical time, and no difference was observed in LOS, complications, pouch failure or quality of life (table 2). In long-term follow-up, of all patients, pouchitis symptoms occurred more frequently in P (mean follow up 7.3 years), and seepage was more frequently observed in L (mean follow-up 4.2 years). These differences were not observed in matched patients.
Conclusion:
Open Pfannenstiel approach provides equivalent short-term and long-term outcomes, and similar quality of life compared to laparoscopic total proctocolectomy with IPAA, but with shorter operative time. It may be an efficient option in selected thin female patients.
Table 1 - Patient characteristics and outcomes by surgery type
 Laparoscopy
(n=119)
Pfannenstiel
(n=33)
p value
Age (mean/SD)37.0 (15.0)29.3 (10.8)0.006
Female Gender53 (44.5)32 (97.0)<0.001
BMI (mean/SD)24.7 (5.0)20.3 (3.0)<0.001
ASA Classification  0.005
ASA 15 (4.2)3 (27.3) 
ASA 294 (79.7)8 (72.7) 
ASA 319 (16.1)- 
Diagnosis  0.009
MUC87 (73.1)21 (63.6) 
FAP22 (18.5)4 (12.1) 
Indeterminate8 (6.7)8 (24.2) 
Crohn's2 (1.7)  
Overall Postoperative Complications91 (76.5)25 (75.8)0.93
Anastomotic Separation10 (8.4)5 (15.2)0.25
Abdomino-Pelvic Sepsis14 (11.8)2 (6.1)0.34
Wound Infection12 (10.1)2 (6.1)0.48
Pouch Failure2 (1.7)-0.45
Length of Hospital Stay (mean/SD)8.1 (5.8)7.3 (3.8)0.44
Surgical Time (min - mean/SD)295.9 (79.4)175.1 (32.9)<0.001
Quality of Life (mean/SD)7.9 (1.9)8.4 (1.4)0.25
Quality of Heath (mean/SD)7.9 (1.9)8.2 (1.3)0.43
Level of Energy (mean/SD)7.3 (2.1)7.3 (1.8)0.87
Dietary Restriction40 (44.0)10 (32.3)0.25
Social Restriction16 (17.6)5 (17.2)0.97
Work Restriction21 (23.1)4 (13.3)0.25
Sexual Restriction17 (18.9)5 (16.1)0.73
Pouchitis Symptoms18 (24.7)16 (51.6)0.007
Seepage Protection20 (28.2)2 (7.1)0.023
Surgery Satisfaction (mean/SD)8.4 (1.8)8.1 (2.1)0.52

Data are reported as number (%), unless otherwise specified.
Table 2 - Patient characteristics and outcomes by surgery type - patients matched by diagnosis, gender, age (+/- 5 years) and BMI (+/- 5 Kg/m2)
 Laparoscopy
(n=21)
Pfannenstiel
(n=21)
p value
Age (mean/SD)31.4 (11.4)31.1 (12.0)0.93
Female Gender20 (95.2)20 (95.2)1
BMI (mean/SD)22.4 (2.9)20.4 (3.0)0.032
ASA Classification  0.041
ASA 1-7 (33.3) 
ASA 218 (85.7)14 (66.7) 
ASA 33 (14.3)- 
Diagnosis  1
MUC18 (85.7)18 (85.7) 
FAP3 (14.3)3 (14.3) 
Overall Postoperative Complication16 (76.2)15 (71.4)0.73
Anastomotic Separation2 (9.6)2 (9.6)1
Abdomino-Pelvic Sepsis2 (9.6)1 (4.8)0.55
Wound Infection1 (4.8)1 (4.8)1
Pouch Failure1 (4.8)-0.31
Length of Hospital Stay (mean/SD)6.3 (2.4)8.1 (4.2)0.095
Surgical Time (min, mean/SD)284.1 (50.5)179.2 (39.1)<0.001
Quality of Life (mean/SD)7.8 (2.1)8.1 (1.6)0.67
Quality of Heath (mean/SD)7.9 (2.2)8.1 (1.5)0.79
Level of Energy (mean/SD)7.1 (2.1)7.3 (1.9)0.82
Dietary Restriction9 (50.0)6 (30.0)0.21
Social Restriction3 (15.8)4 (22.2)0.69
Work Restriction5 (26.3)2 (10.5)0.40
Sexual Restriction5 (26.3)4 (20.0)0.72
Pouchitis Symptoms3 (21.4)7 (35.0) 0.39
Seepage Protection3 (20.0)2 (11.8)0.65
Surgery Satisfaction (mean/SD)8.7 (2.0)8.0 (2.1)0.28

Data are reported as number (%), unless otherwise specified.


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