Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care

Abstract

Aim Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes. Method Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed. Results In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three‐staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90‐day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06). Conclusion IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

Technical Issues and Early Outcomes of Restorative Proctocolectomy for Familial Adenomatous Polyposis and Ulcerative Colitis: The Largest Romanian Single-Team Experience

“…The estimated blood loss in the present series is comparable with data reported in high volume centers worldwide (20).…”

“…The present series of RPC has some particularities compared with the Western ones. Thus, in the present series, the most common indication for RPC was FAP (70.1% of patients), while in the Western series, UC represents the main indication (68 -93%) (16)(17)(18)(19)(20). This difference can be explained at least in part by the lower incidence of UC in Romania, compared with the Western countries (21,22).…”

“…A diverting ileostomy is widely recommended for patients with RPC because it may reduce the ileo-anal leakage rate (4,8,20). In the present series, a diverting ileostomy was performed in 92.2% of the patients.…”

“…In the present series, a J pouch was performed 93.5% of the patients. An S pouch is used mainly when there is a problem getting a J pouch to reach the anus for anastomosis (20), as it was the case in the present series.…”

“…The J-shape pouch is the most frequently performed pouch because it is simple and associated with excellent long-term functional outcomes (8,20,27). No differences between the different pouch designs were observed regarding the small-bowel obstruction, anastomotic leakage, and pelvic sepsis and wound infection rates (27,28).…”