MANOS proctocolectomy and ileo pouch anal anastomosis for ulcerative colitis

Marta M Tasende Presedo, MD, Salvadora Delgado, MD, Gabriel G Diaz Del Gobbo, MD, Maria Fernandez, MD, Jaume Balust, MD, Dulce Momblan, MD, Raquel Bravo, MD, Antonio M de Lacy, PhD, MD. Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Centro Esther Koplowitz, University of Barcelona.

Background: Laparoscopy is widely accepted for the treatment of Ulcerative Colitis (UC). It represents a safe and feasible technique. However, there are technical difficulties for rectal dissection that need to be solved. Evolution of technology brings Trans rectal MANOS as an emerging alternative. This approach offers another advantages: avoid abdominal incisions and the issue of injury a healthy organ, because the enterotomy is performed through the future resected organ. We present the short-term outcomes of our series.

Material and Methods: All patients with UC who required IPAA, were selected and enrolled in a single arm, prospective study of minilaparoscopy-assisted natural orifice surgery (MANOS). Pre and postoperative clinical status and follow up data were obtained for 11 patients from July 2011 to July 2013. A three-step procedure was performed: colectomy (with transanal removal of the colon) and temporary ileostomy in the first step; proctectomy and pouch with a loop ileostomy in the second step (The terminal ileum extracted thought the ileostomy wound and the J-pouch is confectioned). We combined a transrectal multiport device and laparoscopy dissection for all cases. For stapled anastomoses, we performed a double purse-string, using a prolapse-hemorrhoid 33 mm circular stapler. Finally, the third step is the ileostomy closure, restoring the normal bowel transit. Functional outcome was assessed following Oresland Score.

Results: 11 patients, 63,6% (n=7) male, 36,4% (n=4) female. Mean age 36,6 (SD 15). BMI 22,7 kg/m2 (SD 5,8). All procedures were performed in a hybrid manner without conversion. Operative time at first surgical procedure was 158 min (SD 41). No intra or post op complication, hospital stay 10 days (SD 8,6). For second surgical procedure, mean operative time 182 min (SD 62). 0% conversion rate. Stapled anastomosis in 10 cases (90,9%), handsewed 1 patient (9,1%). Complications: 3 cases (27,3%) of pouch bleeding increased ileostomy output 2 patients (18,2%), 1 case (9,1%) postoperative ileus. Oral intake started at 1,5 days (SD 0,7) after surgery. Medium EVA score 1, pain was adequately controlled with oral analgesia at 4 days (SD 0,5). Time to regular diet was 4,3 days (SD 1,9). Hospital stay was 7,7 days (SD 3). No leaks, re operation or readmission. The median follow up after closure of ileostomy was 14,3 month (SD 0,6); at this time, 24h defecation frequency was 5,6 per day (SD 1,8), 0,5 per night. 63,6% (n=7) may retain stools for more than 30min, 18,2% (n=2) more than 10min, Oresland Score 5 (SD 3,7). There was no incontinence, bowel obstruction, ileitis, bladder or sexual dysfunction. Pouchitis with associated fistula 9,1 %(n=1).

Conclusions: The initial experience with MANOS proves that is a safe and feasible technique to treat UC patients. Early clinical and functional results are good. MANOS provides a significative advantage to avoid abdominal incisions and all their related problems, better cosmetic, low post operative pain and a fast recovery. Still long term outcomes and controlled trials are needed.

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