Surgery
Minimally Invasive Rectal Procedures for Ulcerative Colitis, Rectal Prolapse, and Rectal Cancer
Elizabeth C Wick, MD and Jonathan Efron, MD, FACS, FASCRS Division of Colorectal Surgery, Johns Hopkins Hospital, Baltimore
Abstract
Laparoscopic and robotic techniques are increasingly being used for rectal resections. Initially these techniques were used primarily for benign diseases such as rectal prolapse and inflammatory bowel disease, but with the recent appreciation that laparoscopic and open operations for colon cancer have equivalent oncologic results there has been an increasing interest in applying minimally invasive techniques to rectal cancer. This article outlines short- and long-term outcomes of laparoscopic rectal prolapse and ileal pouch procedures as well as early results of a series of laparoscopic proctectomy for rectal cancer. The next few years will be particularly seminal for the role of the laparoscopy in proctectomy for rectal cancer because we can anticipate results from the American College of Surgeons Oncology Group (ACOSOG) trial comparing the two techniques and, if they are found to be equivalent, the technique may enjoy more widespread appeal.
Keywords Robotic, laparoscopic, proctectomy, rectal cancer, ulcerative colitis, rectal prolapse
Disclosure: The authors have no conflicts of interest to declare. Received: November 25, 2009 Accepted: October 2, 2010 Citation: US Gastroenterology & Hepatology Review, 2010;6:85–9 Correspondence: Jonathan Efron, MD, FACS, FASCRS, Chief Ravitch Division of GI Surgery, Johns Hopkins University, Division of Colorectal Surgery, Department of Surgery, Blalock 658, 600 North Wolfe Street, Baltimore MD 21287. E:
ewick1@jhmi.edu or
jefron1@jhmi.edu
Over the last two decades, there has been an explosion in the application of minimally invasive techniques for abdominal procedures. Initially, laparoscopy was embraced for benign colon pathology (diverticular disease, inflammatory bowel disease, constipation, etc.) but with the completion of large prospective trials demonstrating equivalent oncologic outcomes with laparoscopic and open colectomy for colon cancer, there has been a rapid increase in the annual number of laparoscopic colon procedures. Over the years, a combination of technical innovations and surgeon experience has led to improved surgical outcomes and decreased operating room times for minimally invasive colectomies. Minimally invasive colorectal surgery is associated with less post-operative pain, reduced narcotic requirement, and shorter hospital stays. Patients who undergo minimally invasive colectomies and have their post-operative care standardized with ‘fast-track’ protocols have an average hospital stay of three days.1
Laparoscopic proctectomy is more
technically challenging than laparoscopic colectomy. The Conventional Versus Laparoscopic-assisted Surgery in Patients with Colorectal Cancer (CLASICC) included both colon and rectal resections. Only proficient laparoscopic surgeons were allowed to participate in the study—prior to participation each surgeon had to have completed at least 20 laparoscopic colorectal resections. In this trial, the conversion rate for proctectomy was significantly higher than colectomy (34% compared with 25%). Common reasons for conversion were tumor fixation and concern about the distal margin.2
Thus, currently there is clearly a role for minimally invasive colectomy and with the embracement of laparoscopic © TOUCH BRIEFINGS 2010
colectomy and the more advanced instruments and optics available, there has been keen interest in applying minimally invasive (laparoscopic and robotic) techniques to rectal procedures for both benign and malignant disease.
Applications for Minimally Invasive Proctectomy Ileal Pouch Anal Anastomosis for Ulcerative Colitis and Familial Polyposis (see Table 1) Laparoscopic proctectomy and/or rectal mobilization has been initially embraced for benign diseases (ileal pouch anal anastomosis [IPAA] for ulcerative colitis and familial polyposis and rectopexy ± resection for rectal prolapse). Currently, IPAA is the most common operation performed for patients with ulcerative colitis and familial polyposis. Over the past 10 years there has been an increased interest in completing this procedure with a minimally invasive approach. Short- term studies have demonstrated that the procedure is feasible and associated with shorter hospital stay and shorter post-operative stay, albeit at the expense of longer operative times.3
Recently, longer-term
studies have confirmed that the complication rate and functional outcomes are equivalent in the open and laparoscopic groups. In a case-control study of 33 patients undergoing IPAA (lap or open), with a median follow up of 13 months, 30-day complication rate and quality of life as measured by a validated survey were equivalent. These findings have subsequently been confirmed by other groups.4,5 Currently there are ongoing studies to define more specific advantages
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