Ulcerative colitis (UC) is an inflammatory disorder limited to the colon, with rectal involvement in >95% of patients [1]. The annual incidence of UC is reported at 10–12 cases per 100,000 population, with bimodal age distribution. UC peaks in patients aged 15–25 years and again in those 55–65 years of age [2]. The pathogenesis of UC has yet to be well defined. Proposed mechanisms range from autoimmune and immune-mediated phenomena to genetic or environmental predisposition [3–5].

The natural course of UC varies. While some patients remain relatively asymptomatic, others present with disease manifestations requiring operative intervention [6, 7]. Operative indications include failure of immunosuppressive therapy, toxic megacolon, colonic perforation, evidence of carcinoma or dysplasia, and systemic complications from immunosuppressants [8, 9]. When operative intervention is warranted for disease refractory to immunosuppressive therapy, colectomy with subsequent completion proctectomy is curative.

Operative intervention depends upon surgical indication and surgeon preference. Initial interventions range from temporizing measures such as subtotal colectomy (STC) with end ileostomy to one-stage restorative procedures. In the setting of fulminant or severe colitis, STC is recommended. While several prospective studies have demonstrated laparoscopic STC to be a safe alternative to laparotomy in patients with IBD, few have assessed its utility in the urgent or emergent setting [10–13]. The purpose of this study is to establish the safety and efficacy of laparoscopic STC in UC patients with medically refractory disease requiring urgent or emergent operative intervention.

Patients and methods

Following approval by The Mount Sinai Medical School Institutional Review Board, a retrospective chart review was performed of 90 consecutive patients with medically refractory UC undergoing subtotal colectomy with end ileostomy from January 1, 2002 to December 31, 2007. Patients were identified from an administrative database by cross-matching ICD-9 diagnosis codes for ulcerative colitis (556.0–556.9) with ICD-9 (45.8) and CPT-4 (44150–44160 and 44210–44212) surgical procedure codes for open and laparoscopic subtotal or total abdominal colectomy. Diagnosis of ulcerative colitis was confirmed by patient history and pathologic specimen report.

All operations were performed at The Mount Sinai Medical Center. Laparoscopic procedures were performed by four dedicated laparoscopic surgeons who specialize in inflammatory bowel disease (IBD). All laparoscopic procedures were performed by medial to lateral approach. Specimen extraction was either via the newly created stoma site or by a small Pfannenstiel incision. No hand ports were used (Fig. 1). Open subtotal colectomy was performed by two surgeons, both with dedicated IBD practices and mean 25-year experience. For laparotomy, dissection was carried out lateral to medial and incision size was minimized. Minors, patients with Crohn’s disease or indeterminate colitis, patients with toxic megacolon, and patients undergoing subtotal colectomy for colonic dysplasia or neoplasm were excluded from the study.

Fig. 1
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Specimen extraction via the newly created stoma site

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Preoperative patient demographics, medical and social history, operative indication, and operative record were reviewed. Indications for emergent STC included: failed intensive medical therapy while hospitalized or fulminant colitis. Urgent procedures were performed for failure of outpatient immunomodulatory therapy. Hospital course, length of stay (LOS), and postoperative morbidity and mortality were recorded. Major morbidity was defined as a life-threatening complication, readmission or reoperation within 30 days of surgery. Patient outcome at a mean of 36 months assessing restoration of gastrointestinal continuity was assessed. Univariate analysis was conducted by unpaired Student t-test with two-tailed distribution for quantitative variables and chi-square test for categorical variables. P values of less than 0.05 for associations were considered to indicate statistical significance. Prism 4.0 statistical software (April 2003, San Diego, CA) was used for all analyses.

Preoperative bowel preparation, use of ureteral stents, closed suction drains, and method of operation were at the discretion of the individual surgeon. Patients met discharge requirements when they were afebrile for greater than 24 h, tolerated oral diet, had ileostomy function, and achieved adequate pain control on oral pain medication.

Results

Since 2002, 90 patients underwent STC for UC refractory to medical therapy. Sixty-one (66%) patients underwent laparotomy and 29 (34%) underwent laparoscopic procedures. On assessment of patient populations, no difference in age, gender, comorbidity, preoperative American Society of Anesthesiologists (ASA) score, use of preoperative corticosteroids or acuity of presentation was demonstrated (Table 1).

Table 1 Demographics and medical history of patients with medically refractory UC undergoing open versus laparoscopic STC
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Intraoperative assessment demonstrated that patients undergoing uncomplicated laparoscopic STC had decreased intraoperative blood loss (130.4 ± 38.4 vs. 201.4 ± 43.2 ml, p < 0.05) and longer operative times (216.4 ± 20.2 vs. 169.9 ± 14.4 min, p < 0.01) versus open STC. Two (7%) patients in the laparoscopic group required open conversion secondary to adhesions. No difference in intraoperative complications was demonstrated. One patient in the open STC group had intraoperative complication of splenic injury requiring splenectomy (Table 2).

Table 2 Intraoperative course of patients with medically refractory UC undergoing open versus laparoscopic STC
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Perioperative outcome in patients without complications demonstrated decreased hospital LOS for patients undergoing laparoscopic versus open surgery (4.53 ± 0.74 vs. 6 ± 1.32 days, p < 0.001). In the presence of postoperative complication, LOS was equivalent regardless of operative approach. No mortalities occurred in either group. Seven wound infections and five wound dehiscences occurred in patients who underwent open STC. No wound complications occurred in the laparoscopic group. A trend toward increased postoperative ileus was demonstrated in patients undergoing laparoscopic surgery as compared with open approach (17% vs. 10%, p = not significant, NS). No difference in overall morbidity, 30-day reoperation or readmission was demonstrated by operative approach (Table 3).

Table 3 Postoperative length of stay, morbidity, and mortality of patients with medically refractory UC undergoing open versus laparoscopic STC
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Follow-up at a mean of 36 months demonstrated that the percentage of patients who underwent a restorative procedure was equivalent. Of patients undergoing laparoscopic STC, 19 (66%) underwent restorative procedures, 4 (14%) underwent abdominoperineal resection (APR), and 6 (20%) remained with ileostomy. Of patients who underwent open STC, 46 (75%) underwent restorative procedures, 4 (7%) underwent APR, and 11 remained with ileostomy (18%). Patients with postoperative complications, major or minor, were less likely to undergo restorative procedure, regardless of operative approach. Restoration of gastrointestinal continuity in patients who underwent laparoscopic STC without and with postoperative complications was 81% vs. 54% (p < 0.05) and for open STC without and with complications was 100% vs. 57% (p < 0.01).

Discussion

Initially met with hesitation, laparoscopic surgery has gradually gained acceptance for the treatment of patients with IBD. Many studies demonstrate the laparoscopic approach to be preferable to laparotomy, particularly for patients with Crohn’s disease undergoing primary ileocolic resections [14–18]. The utility of laparoscopy for urgent or emergent operative intervention in patients with UC requiring STC is under investigation. Literature remains limited, with most studies including patients with Crohn’s or indeterminate colitis, as well as a mix of laparoscopic and hand-assisted approaches [19]. Cima et al. published one of the largest available series on patients with severe colitis secondary to IBD who required emergent versus semi-emergent STC. Although this descriptive study did not compare the laparoscopic group with a control group, it did demonstrate laparoscopic STC to be a safe procedure in this patient population, with resultant shorter hospital stays [20].

Our study focused solely on patients with biopsy-proven UC who required urgent or emergent STC for disease refractory to medical therapy. Patients were well matched by demographic, comorbidity, acuity of presentation, preoperative ASA score, and use of preoperative corticosteroid or immunodmodulatory therapy. Assessment of operative course demonstrated that patients who underwent laparoscopic versus open STC experienced increased operative times but decreased intraoperative blood loss. One intraoperative complication of splenic injury requiring splenectomy occurred in the open STC group. While not statistically significant, available literature does support decreased iatrogenic splenic injury with laparoscopic versus open colectomy [21].

Postoperatively, patients who underwent laparoscopic STC had significantly shorter hospital stays and negligible wound complications as compared with counterparts who underwent laparotomy. Wound complications have long been associated with increased LOS and direct cost of hospitalization [22]. Laparoscopy has been demonstrated by many studies to decrease the postoperative wound complication rate [23]. A prospective study by Poon et al. demonstrated a 50% decrease in surgical-site infections in patients who underwent laparoscopic versus open colorectal resection [24]. This study also demonstrated open colorectal resection as an independent risk factor for development of surgical-site infection with an odds ratio of 2.36 and 95% confidence interval of 1.1–5.3 [24]. In our study, use of laparoscopy decreased surgical-site infections from 13% to 0% (p < 0.05) and wound dehiscence from 9% to 0% (p = 0.13). Lack of significance for the latter value is likely representative of a type II error secondary to sample size.

Assessment by operative approach demonstrated no difference in overall morbidity rate for laparoscopic and open STC (34% and 28%, respectively), and both were comparable to morbidity rates reported in the literature [13–20]. Mean follow-up of 36 months demonstrated equivalent time to and percentage of patients who underwent restorative ileal pouch-anal anastomosis (IPAA) with or without diverting loop ileostomy.

Other potential benefits of the laparoscopic versus open approach are decreased development of incisional hernias as well as reduced adhesion formation following abdominal surgery [25]. Decreased intra-abdominal adhesion formation may ultimately reduce incidence of small bowel obstruction and potentially facilitate ease of future IPAA construction. Further investigation and prospective studies are needed to truly assess the impact of laparoscopy on adhesion formation following STC.

Laparoscopic STC confers the benefits of improved cosmesis, reduced intraoperative blood loss, negligible wound complications, and shorter hospital stay for uncomplicated procedures. Urgent or emergent laparoscopic STC is a safe and technically feasible approach to the patient with UC refractory to medical therapy. The utility of laparoscopy in patients with toxic megacolon, however, should be further investigated and at this time is not recommended or routinely performed by the authors.