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Prensentation - LAPAROSCOPIC IBD SURGERY Laparoscopic surgery for

VIEWS: 21 PAGES: 12

									LAPAROSCOPIC IBD SURGERY




        Single port laparoscopic ileocecal resection




             Willem Bemelman
        Professor in Minimal InvasiveSsurgery

Department of Surgery, Academic Medical Center,
                  Amsterdam




                                                                  Laparoscopic surgery for inflammatory bowel disease
                                                                                      OUTLINE

                                                              •   Justification for laparoscopy




                                                              •   Developments
                                                                   • Specimen extraction
                                                                   • Single port surgery




                                                                  Laparoscopic surgery for inflammatory bowel disease
                                                                                where do we look for ?

                                                              •   Shortterm results               •   Longterm results

                                                                   •   Operating times                 •   Incisional hernia
                                                                   •   Conversion rates                •   Obstructive small bowel
                                                                   •   Morbidity                           disease
                                                                   •   Hospital stay                   •   Fertility
                                                                   •   Costs                           •   Recurrence of disease
                                                                                                       •   Function
                                                                                                       •   QOL
                                                                                                       •   Body image & cosmesis




                                                       Page
                               Inflammatory bowel disease
                                                                                                         Laparoscopic surgery for Crohn’s disease
                                                                                                                       procedures

    •   Crohn’s disease
                                                                                                     Segmental resection small and large bowel
    •   Ulcerative colitis                                                                             • Mostly ileocolic resections

                                                                                                     Stoma formation

                                                                                                     total (procto)colectomy




           Crohn’s disease: ileocolic resection                                                       Laparoscopic ileocolic resection for Crohn’s
Laparoscopic surgery? 4 systematic reviews & metaanalyses!                                      Randomised multicenter trial. Maartense et al. Ann Surg 2006



                               CV < 10-20%
                                                                                          •   Costs for surgical procedure (median with range):
                                                                                               • Laparoscopy € 1103 (€ 885- 2318)
                                                                                               • Open              € 744 (€ 453- 1083)
                                                                                                   • P < 0.001 (Mann-Whitney U)

                                                                                          •   Total costs (including readmission, reoperation, etc)
                                                                                               • Laparoscopy € 6412 (€ 4195-35569)
                                                           morbidity                           • Open              € 8196 (€ 4964-19018)
                                                                                                   • P = 0.042 (Mann-Whitney U)


   Rosman et al. Surg Endosc 2005
   Tilney et al. Surg Endosc 2006
   Polle et al. Dig Surg 2007
   Tan et al DCR 2007                                   2 days stay




                   Costs of surgery compared to biologicals                                           Laparoscopic ileocolic resection for Crohn’s
                              Eshuis et al. Exp. Rev. Gastroenterol Hepatol 2010                                       Fistulas

                                                                                          •   72 patients with enteric fistulas

                                    biologicals                surgery                    •   90% Crohn’s disease
                                                                                                •   Enterocolic 34%
                                                                                                •   Ilioileal 29%,
                                                                                                •   Enterocutaneous 20%
                                                                                                •   Ileo/colovesical 15%


                                                                                          •   Conversion rate 4.1%

                                                                                          •   Operating time 199 minutes

                                                                                          •   Stay 5.2 days, morbidity 11%


                                                                                          Regan & Salky. Surg Endosc 2004




                                                                                   Page
                     Laparoscopic ileocolic resection for Crohn’s
                                      Fistulas                                                                                      Long term results
                                                                                                                       open versus laparoscopic ileocolic resection


                                                                                 •     Reoperations for recurrent Crohn’s

                                                                                 •     Reoperations for small bowel obstruction and incisional hernia

                                                                                 •     QOL

                                                                                 •     Body image & cosmesis




                                                                                                                               Re-resectionfree survival
                                  Long term results                                                                     laparoscopic vs open ileocolic resection
                     open versus laparoscopic ileocolic resection
                                                                                                                       100                                   p=0.982
                                                                                          number of patients without




                                                                                                                                                                                     laparoscopic operated
                                                                                                                                                                                     group
                                                                                              reresection (%)




                                                                                                                                                                                     open operated group

                                                                                                                        80
                                                                                                                                                                                    22% at 8 years
Reoperations Crohn’s
recurrence
                                                                                                                        60
                                                                                                                             0    12      24   36       48   60      72   84   96
                                                                                                                                       re-resectionfree survival in months


                                                                                                                             27    27     25   24       24      22   20   14   11                            Stop smoking
                                                                                                                                  laparoscopic operated group

                                                                                                                             44   43      40    38      38      36   34   32   21


                                                                                                                                  open operated group


                                                                                                                             71   70      65    62      62      58   54   46   32

                                                                                                                                  total
    Stocchi et al. Surgery 2008
                                                                                                                             number of patients at risk
                                                                                                                                                                                                             Eshuis et al. DCR 2008




                             Re-resectionfree survival
                      laparoscopic vs open ileocolic resection
                                                                                                                                    Long term results
                                                                                                                       open versus laparoscopic ileocolic resection


                                                                                                     Mean FU 7 years



                                            7 vs 12% at 7 years




                                                                                                                                                                                                                      0.06


                                                                             †χ2 test of Fisher’s exact test

                                                                           Eshuis et al. unpublished




                                                                    Page
                                                                                                                                                          Trial profile longterm results RCT: QOL
                                      Long term results
                         open versus laparoscopic ileocolic resection




Other abdominal
reoperations




       Stocchi et al. Surgery 2008
                                                                                                                              Eshuis et al. Submitted




                                     longterm results RCT: QOL-SF-36

                                                                          P-value < 0.005 is accepted as significant
                                                        la p g r o u p
       100
                                                        ope n gro up
        90

        80                                                                                                                                                               ”LOOKS”
        70

        60
S re
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        50

        40

        30

        20

        10

         0
                                             ng




                                               in


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Eshuis et al. Submitted




                                         Body image and Cosmesis                                                                                        Incision less/single port access surgery
                                            Ileocolic resection                                                                                                                    POTENTIAL FOR
                                                                                                                                                                                  REDUCED TRAUMA
                                                                                                                                                                                       HIGH




                                                                                                                                                                                                                                NOTES™

                                P=0.02        P<0.000                                                                                                                                              INCISIONLESS   SINGLE PORT
                                                                                                                                                                                                     SURGERY         ACCESS
                                                                                                                                                                                      MICRO
                                                                                                                                                                                  LAPAROSCOPIC
                                                                                                                                                                                    SURGERY
                                                                                                                               COMPLEXITY




                                                                                                                                                                                                                                         COMPLEXITY
                                                                                                                                  LOW




                                                                                                                                                                                                                                            HIGH




                                                                                                                                                                                  LAPAROSCOPIC
                                                                                                                                                                                    SURGERY




                                                                                                                                                                  HAND-ASSISTED
                                                                                                                                                                  LAPAROSCOPIC
                                                                                                                                                                    SURGERY



                                                                                                                                                 OPEN
                                                                                                                                                SURGERY

                                                                                                                                                                                       LOW
                                                                                                                                                                                   POTENTIAL FOR
                 Min – max     5 – 20         3 - 24                                                                                                                              REDUCED TRAUMA




             Dunker et al. Surg Endosc 1998
             Eshuis et al. BJS 2010




                                                                                                                       Page
                                              Transcolonic




                                           Single Port Access
                                           ileocolic resection



•   Time consuming

•   More infectious complications

•   Future application with
    improved anastomotic
    techniques




                                           Single Port Access
                                           ileocolic resection




                                    Page
 Single Port Access
 ileocolic resection
                              Laparoscopic resection after primary ileocolic resection?


                              Eshuis et al:
                              All patients with prior laparoscopic approach could be treated
                                 laparoscopically as well (9 patients)




                                                                          No need of conversion after
                                                                          prior laparoscopy (15 pts)



                                                           BJS 2006




                                  Laparoscopic surgery for ulcerative colitis

                              Emergency colectomy                           feasible & safe
                                • Fowkes et al. Colorectal Dis 2008
                                • Marcello et al. DCR 2001
                                • Dunker et al. Surg Endosc 2000




      Results                                              Results

ACUTE COLECTOMY                              COMPLETION PROCTECTOMY
  Operative data                                   Operative data




                       Page
                                                                                                 Laparoscopic colectomy
                                        Adhesions                                                 transrectal extraction



    •   Open abdominal surgery: >90%

    •   Cause of 75% of small bowel obstruction cases
    •   Secundary infertility

    •   Possible reduction in adhesion formation following laparoscopic
        vs. open colectomy




Indar Surg Endosc 2009, Dowson BJS 2008




                                                                                            Laparoscopic colectomy
         Laparoscopic colectomy trans stoma site extraction
                                                                                    trans stoma site/transrectale extraction




                                                                                                                     Transstoma site extraction
                                                                                                                               (slow transit obstipation)




                                                                                                                    Transrectal extraction
                                                                                                                            (emergency colectomy)




                                     Total colectomy                                                    Total colectomy
                                         Patients                                                           Results

                                                     N=9
                                                                                                                      N=9
              M:F                                    5:4
                                                                                 Operating time (minutes)*            219     (197-235)
              Age (years)                            28.4   (19-40)
              BMI*                                   22.3   (18-24)              Length specimen                      93      (76-116)

              Disease:                                                           Minor complications                  1
              - Refractory Colitis                   6                            - Stoma dysfunction                 -1
              - Crohns disease                       2
              - Slow transit                         1                           Major complicatiions                 -

              Diseases in years*                     4.5    (1.5-6.9)            Postoperative stay (days)*           7       (5-9)
              Procedures                                                         Readmissions                         -
              - Colectomy & ileorectal anastomosis   1
              - Colectomy & ileostomy                8


                *mediaan (iqr)                                                   *median (iqr)




                                                                          Page
            Laparoscopic surgery for ulcerative colitis
                            pouch
Restorative proctocolectomy + pouch
• systematic review and metaanalysis (Tilney et al. 2007)
• Cochrane (Ali et al. 2009)




                                                                      Int J Colorect Dis 2007




                                                                                     “function, QOL & outcome”




  Cochrane Library Issue 1 2009




                                                                                                Quality of life

                              Functional outcome at one year




  Surg Endosc 2007




                                                               Page
                                   Laparoscopic vs open restorative proctocolectomy                                                                                                                                                                                                                                                     Laparoscopic vs open restorative proctocolectomy
                                                 SF-36 questionnaire                                                                                                                                                                                                                                                                                  SF-36 questionnaire

       Physical Functioning scale:                                                                                                                 Role Physical scale:                                                                                                                              Vitality scale:                                                                                                     Social Functioning scale:

                                                                        100                                                                                                                              100                                                                                                                                 90                                                                                                                          120
                                   Mean +- 2 SE PHYSICAL FUNCTIONING




                                                                                                                                                                                                                                                                                                                                             80




                                                                                                                                                                                                                                                                                                                                                                                                                                      Mean +- 2 SE SOCIAL FUNCTIONING
                                                                                                                                                                                                         80                                                                                                                                                                                                                                                              100
                                                                            80
                                                                                                                                                                                                                                                                                                                                             70
                                                                                                                                                    Mean +- 2 SE ROLE PHYSICAL

                                                                                                                                                                                                         60                                                                                                                                                                                                                                                               80
                                                                                                                                                                                                                                                                                                                                             60
                                                                            60




                                                                                                                                                                                                                                                                                                          Mean +- 2 SE VITALITY
                                                                                                                                                                                                         40                                                                                                                                  50                                                                                                                           60

                                                                            40
                                                                                                                                                                                                                                                                                                                                             40
                                                                                                                                                                                                         20                                                                                                                                                                                                                                                               40

                                                                                                                                                                                                                                                                                                                                             30
                                                                            20                                                  Laparatomy                                                                                                                        Laparatomy                                                                                                                          Laparatomy                                                                                                        Laparatomy
                                                                                                                                                                                                          0                                                                                                                                                                                                                                                               20
                                                                                                                                                                                                                                                                                                                                             20

                                                                            0                                                   HA-laparoscopic                                                          -20                                                      HA-Laparoscopic                                                            10                                                       HA-Laparoscopic                                                      0                                            HA-Laparoscopic
                                                                                   pre           2 w ks       3 mnd                                                                                              pre        2 w ks        3 mnths                                                                                                            pre         2 w ks       3 mnths                                                                                    pre        2 w ks       3 mnths
                                                                                         1 w eek      4 w kn           1 year                                                                                          1 w eek     4 w ks       1 year                                                                                                             1 w eek    4 w ks        1 year                                                                                     1 w eek     4 w ks      1 year


                                                                                 time                                                                                                                          time                                                                                                                                        time                                                                                                                time




Polle et al. Surg Endosc 2007                                                                                                                                                                                                                                                                     Polle et al. Surg Endosc 2007




                                   Laparoscopic vs open restorative proctocolectomy                                                                                                                                                                                                                                                     Laparoscopic vs open restorative proctocolectomy
                                                 SF-36 questionnaire                                                                                                                                                                                                                                                                                  SF-36 questionnaire

   Bodily pain scale:                                                                                                                              General Health Perceptions scale:                                                                                                                 Role Emotional scale:                                                                                               Mental Health scale:
                                                                                                                                                                Mean +- 2 SE GENERAL HEALTH PERCEPTION




                                                     120                                                                                                                                                  90                                                                                                                                 120                                                                                                                         100

                                                                                                                                                                                                                                                                                                                                                                                                                                                                          90
                                                     100                                                                                                                                                  80                                                                                                                                 100
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          80
                                                                                                                                                                                                                                                                                                          Mean +- 2 SE ROLE EMOTIONAL




                                                                                                                                                                                                                                                                                                                                                                                                                                      Mean +- 2 SE MENTAL HEALTH
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          70
                                                                       80                                                                                                                                 70                                                                                                                                      80
        Mean +- 2 SE BODILY PAIN




                                                                                                                                                                                                                                                                                                                                                                                                                                                                          60

                                                                       60                                                                                                                                 60                                                                                                                                      60                                                                                                                      50

                                                                                                                                                                                                                                                                                                                                                                                                                                                                          40
                                                                       40                                                                                                                                 50                                                                                                                                      40
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          30

                                                                                                                                 Laparatomy                                                                                                                              Laparatomy                                                                                                                   Laparatomy                                                          20                                            Laparatomy
                                                                       20                                                                                                                                 40                                                                                                                                      20
                                                                                                                                                                                                                                                                                                                                                                                                                                                                          10

                                                                        0                                                        HA-Laparascopic                                                          30                                                             HA-Laparoscopic                                                               0                                              HA-Laparoscopic                                                      0                                            HA-Laparoscopy
                                                                                 pre         2 w ks          3 mnths                                                                                              pre            2 w ks       3 mnths                                                                                                        pre         2 w ks        3 mnths                                                                                   pre         2 w ks      3 mnths
                                                                                       1 w eek       4 w ks            1 year                                                                                            1 w eek       4 w ks            1 year                                                                                                    1 w eek        4 w ks    1 year                                                                                     1 w eek       4 w ks    1 year


                                                                            time                                                                                                                               time                                                                                                                                        time                                                                                                                time




Polle et al. Surg Endosc 2007                                                                                                                                                                                                                                                                     Polle et al. Surg Endosc 2007




                                                                                                 Results of GIQLI questionnaire                                                                                                                                                                   Body image and Cosmesis in female patients according to
                                                                                                                                                                                                                                                                                                                   surgical approach

              Total score GIQLI:                                                                                                                                                                                                                                                                                                                           20,00                                                                                25,00
                                                                                                                                                                                                                                                                                                                                                                                                                   ORP                                                                                                          ORP
                                                                        120                                                                                                                                                                                                                                                                                                                                        LRP                                                                                                          LRP
                                                                                                                                                                                                                                                                                                                                                           18,00
                                                                                                                                                                                                                                                                                                                                                                                                                                                20,00
                                                                                                                                                                                                                                                                                                                                        Body Image scale




                                                                                                                                                                                                                                                                                                                                                                                                                         Cosmesis scale




                                                                        110
                                                                                                                                                                                                                                                                                                                                                           16,00
                                                                                                                                                                                                                                                                                                                                                                                                                                                    15,00
                                                                        100
                                                                                                                                                                                                                                                                                                                                                           14,00
                                                                                                                                                                                                                                                                                                                                                                                                                                                    10,00
                                                                            90
                                   Total score GIQLI




                                                                                                                                                                                                                                                                                                                                                           12,00

                                                                            80                                                  Laparatomy
                                                                                                                                                                                                                                                                                                                                                                                                                                                                        5,00
                                                                                                                                                                                                                                                                                                                                                           10,00                   P = 0.029 ‡                                                                                                   P = 0.006 ‡
                                                                            70                                                  HA-Laparoscopic
                                                                                   pre             4 w ks             1 year                                                                                                                                                                                                                                8,00                                                                                                        0,00
                                                                                          2 w ks            3 mnths

                                                                                                                                                                                                                                                                                                                                                                         >1 year post-operatively                                                                                      >1 year post-operatively
                                                                                 time




                                                                                                                                                                                                                                                                                                  Polle et al. Surg Endosc 2007
                                                                                                                                                                                                                                                                                                                                                                                                     open                                                                         laparoscopic




                                                                                                                                                                                                                                                                                           Page
         Body image and Cosmesis in male patients according to
                                                                                                                                                                                                               Cosmesis & body image
                          surgical approach
                                                                                                                                                                                                                  level V evidence!

                                        20                                                                25
                                                                                   ORP                              89                     ORP
                                                                                   LRP                                                     LRP
                                        19
                     Body Image scale




                                                                                                          20
                                                                                         Cosmesis scale

                                        18


                                        17                                                                15


                                        16

                                                          P = NS ‡                                        10           P = NS ‡
                                        15


                                        14                                                                5

                                                 >1 year post-operatively                                      >1 year post-operatively

                                                                                                                                                                                             Laparoscopic restorative proctocolectomy
       Polle et al. Surg Endosc 2007
                                                                       open                                      laparoscopic




                                         Sexuality after lap pouches                                                                                                                                            Pouch and sexuality

                                                                                                                                                                   Increased dyspareunia                                                8 -> 25%

                                                                                                                                                                              •   Cause?
                                                                                                                                                                                   • Nerve damage
                                                                                                                                                                                   • Pelvic adhesions
                                                                                                                                                                                   • Fear of
                                                                                                                                                                                       • feacal leakage during intercourse
                                                                                                                                                                                       • Damage of the pouch anal anastomosis


                                                                                                                                                                       Tiainen Sc J Gastroenterol 1999
                                                                                                                                                                       Moody Dig 1993
                                                                                                                                                                       Hueting Int J Col Dis
                                                                                                                                                                       Berndtsson Sc J Gastroenterol 2004
                                                                                                                                                                       Cornish DCR 2007




                                                                            PLEXLAB study *
                                                                                                                                                                                                  Vaginal doppler plethysmography

      Aim:                                                                                                                                                               •   Similar subjective arousal, but lower vaginal flow after
                                                                                                                                                                             more extensive vaginal denervation
      Assessing whether sexual dysfunction
      after restorative proctocolectomy                                                                                                                                                                                     Vaginal plethysmography
      with IPAA is caused by surgical damage
      of the autonomic nerves
                                                                                                                       Plexus
                                                                                                                       Hypogastricus
                                                                                                                       Inferior
                                                                                                                                          Plexus Sacralis




                                                                                                                                                                                Objective measurement of the integrity of the autonomic nerves!
*M.S.Vlug , P.J. van Koperen , S.W. Polle , E. Laan , R.H.W. van Lunsen , J.F.M. Slors , W.A. Bemelman
          1                                  1        1        2               2           1                       1
                                                                                                                                                                    CP Maas et al. Br J Obst Gyn 2004
1. Department of Surgery, 2. Department of Department of Sexology and Psychosomatic Obstetrics and Gynaecology,
                                                                                                                                                                    Pieterse QD et al. Int J Gyn Cancer 2008
Academic Medical Centre, University of Amsterdam, the Netherlands




                                                                                                                                                            Page
                              Patients & methods                                                                                       Methods

                                                                                                                          Questionnaires pre –and post op
Timing:
   - Preoperatively and > 9 months after surgery                                                   Subjective measurement with validated questionnaires

Surgery:                                                                                             - Personal & Sexual History Questionnaire (PSHQ)
   - proctectomy according to TME posteriorly, anteriorly close rectal                               - Maudsley Marital Questionnaire (MMQ)
                                                                                                     - Female/Male Sexual Function Index (F/M-SFI)
Inclusion criteria:                                                                                  - Short Personal Experience Questionnaire (SPEQ (vrouwen))
   - Patients with FAP or CU planned for a proctocolectomy with IPAA                                 - International Index of Erectile Function (IIEF (mannen))
                                                                                                     - Female / Male Sexual Distress Scale (F/M- SDS)
Exclusion criteria:
                                                                                                     - Subjective Sexual Arousal Questionnaire (SSAQ)
   - < 18 years
                                                                                                     - Beck Depression Inventory (BDI)
   - Previous laparotomy
   - DM
                                                                                                     - Body Image Questionnaire (BIQ)
   - Depression                                                                                      - Short Form 36 health survey questionnaire (SF-36)
   - Sexual abuse
   - Use of medication that can interfere with sexual response




                                       Methods                                                                                       Measurement

                                                                                             Sexual laboratorium “”the wet lab “                       Vaginal plethysmography

Objective measurement of sexual arousal pre- and postoperatively
assessed by:
  - Vaginal plethysmography
               - measuring genital blood flow
  - Barlow registration
               - measuring circumferential penile increase
                                                                                                                                                      Barlow Registration           Elasticity
                                                                                                                                                                                       strip
During:
  - Erotic video fragments                                                                                                                             Flexibel
                                                                                                                                                          steal
  - In combination with vibrotactile stimulation




                                                                                                                                   Results                                   The doctor said it
                                                                                                                                                                            would be better after
                                                                                                                                                                              the operation…..
                                Included patients
                                     profile

  •   Informed consent obtained                                   13 patients (65%)            -   Subjective measurement:

                                                                                                     - Significant increase in quality of life after one year
  •   Withdrawal after pre-op measurement                               2                            - Sexual function was comparable before and after surgery
       • Did not like the vibrotactile stimulation (1)
       • Girl friend did not like it (1)
                                                                                               -   Objective measurement:

  •   Pregnant                                                          2                            - Vaginal blood flow during sexual stimulation was equal compared to
                                                                                                     pre-operatively values (p=0.58)

  •   Preliminary results                                         3 men, 6 women                     - No decrease in erectile function after surgery (p=0.84)




                                                                                      Page
         Laparoscopic ileal pouch–anal anastomosis reduces                                               Laparoscopic ileal pouch–anal anastomosis reduces
                  abdominal and pelvic adhesions                                                                  abdominal and pelvic adhesions
               Adrian A. Indar Æ Jonathan E. Efron Æ Tonia M. Young-Fadok. Surg Endosc 2009                   Adrian A. Indar Æ Jonathan E. Efron Æ Tonia M. Young-Fadok. Surg Endosc 2009


                                                                                                          •   Abdominal wall (n=34)
    •   Adhesion assesment at loop ileostomy closure (American Fertility                                       •   No adhesions              68%
        Society adhesion score)                                                                                •   Rest                      filmy, no dense adhesions
         • Abdominal wall
         • Pelvic organs                                                                                       •   No adhesions open         10% - 33% (+/- seprafilm)



                                                                                                          •   Pelvic organs (n=21)
                                                                                                               •   No adhesions              71%
                                                                                                               •   Rest                      filmy at only one adnex




                            Fecundity/fertility                                                          Laparoscopic surgery for inflammatory bowel disease
              pregnancy rate open (n=12) vs lap pouch (n=16)                                                               in conclusion

                                                                                                     •   Enough evidence
                                                                                                          • Short term: at least as good, likely better (stay/MB)
                                     * normal
                                                              ns                                          • Long term: superior body image, similar function & QOL

                                                                                                     •   Growing evidence
                                                                                                          • Less incisional hernia
                                                                                                          • Less small bowel obstruction
                                                                                                          • Less complicated reoperation/completion proctectomy
                                                                                                          • Less pelvic adhesions & superior fertility
Bartels et al. unpublished




                                                                                              Page

								
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