Sanne A. L. Bartels

Significantly Increased Pregnancy Rates After Laparoscopic Restorative Proctocolectomy A Cross-Sectional Study

Objective:To assess the impact of a laparoscopic approach on female fecundity in ileoanal pouch surgery. Background:Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is associated with tubal factor infertility in female patients. Different studies showed less adhesion formation after laparoscopic colectomy. The relation between laparoscopic pouch surgery and fertility, however, has not been studied so far. Methods:This cross-sectional study was carried out in 3 university hospitals in the Netherlands and in Belgium. Female patients older than 18 years that had IPAA under the age of 41 were eligible for inclusion (n = 179). We sent them a questionnaire addressing medical and fertility history. The primary endpoint was time to first spontaneous pregnancy after IPAA. This study has been registered with ISRCTN.org (ISRCTN85421386). Results:Of 179 eligible patients, 160 (89%) returned the questionnaire. After IPAA, 50 (31%) patients attempted to conceive. Of these, 23 (46%) had undergone open and 27 (54%) had undergone laparoscopic IPAA. Patient characteristics were similar in both groups. Indications for surgery were ulcerative colitis (UC) in 37 patients, familial adenomatous polyposis (FAP) in 12 patients, and colonic ischemia in 1 patient. A Kaplan-Meier survival function was plotted for time to first spontaneous pregnancy and showed a higher pregnancy rate after laparoscopic IPAA (log-rank, P = 0.023). Similarly, subsequent survival analysis for all patients with UC showed an increased pregnancy rate for the laparoscopic group (log-rank, P = 0.033). Conclusions:Pregnancy rates are significantly higher after laparoscopic IPAA. This makes the laparoscopic approach the method of choice in young women.

Which fast track elements predict early recovery after colon cancer surgery

Aim  It is questioned whether all separate fast track elements are essential for enhanced postoperative recovery. We aimed to determine which baseline characteristics and which fast track elements are independent predictors of faster postoperative recovery in patients undergoing resection for colon cancer.

Systematic review and meta-analysis of laparoscopic versus open colectomy with end ileostomy for non-toxic colitis.

This review compared short‐term outcomes after laparoscopic versus open subtotal colectomy for acute, colitis medically refractory.

Small bowel obstruction, incisional hernia and survival after laparoscopic and open colonic resection (LAFA study).

Short‐term advantages to laparoscopic surgery are well described. This study compared medium‐ to long‐term outcomes of a randomized clinical trial comparing laparoscopic and open colonic resection for cancer.

Early, minimally invasive closure of anastomotic leaks: a new concept

Chronic pelvic sepsis after ileoanal or coloanal anastomosis precludes ileostomy closure and, even if closure is ultimately possible, function of the neorectum is badly affected. Early closure of the anastomotic leak might prevent chronic pelvic sepsis and its adverse sequelae. In our experience of early closure in a consecutive group of six patients with a leaking low anastomosis (five with ileoanal pouch anastomosis and one after a low anterior resection), we were able to achieve anastomotic closure in five by means of initial endosponge therapy followed either by early suture (four patients) or endoscopic clip repair (one patient). Early minimally invasive closure of low anastomotic leaks is therefore possible provided that the para‐anastomotic cavity is drained well prior to closure and the anastomosis is defunctioned.

Short-term morbidity and quality of life from a randomized clinical trial of close rectal dissection and total mesorectal excision in ileal pouch–anal anastomosis

Posterior rectal dissection during ileal pouch–anal anastomosis (IPAA) can be performed in the total mesorectal excision (TME) or close rectal dissection (CRD) plane. The aim of this study was to compare morbidity and quality of life (QoL) in patients having TME or CRD during proctectomy followed by IPAA for benign disease.

The effect of colonoscopic tattooing on lymph node retrieval and sentinel lymph node mapping.

BACKGROUND In colorectal cancer (CRC), colonoscopic tattooing is performed to mark the tumor site before laparoscopic surgery. OBJECTIVE To determine whether colonoscopic tattooing can be used to refine staging accuracy by increasing the lymph node (LN) yield per specimen and to determine its accuracy as a sentinel LN procedure. DESIGN Retrospective, case-control study. All LNs were microscopically examined for the presence of carbon particles. SETTING A university hospital and a teaching hospital. PATIENTS A consecutive series of 95 tattooed patients who had surgery for CRC between 2005 and 2009. A series of 210 non-tattooed patients who had surgery in the same time period served as controls. MAIN OUTCOME MEASUREMENTS Total number of LNs retrieved, detection rate, and sensitivity of tattooing as a sentinel node procedure. RESULTS A higher LN yield was observed in patients with preoperative tattooing, median (interquartile range) 15 (10-20) versus 12 (9-16), (P = .014). In multivariable analysis, the presence of carbon-containing LNs was an independent predictive factor for a higher LN yield (P = .002). The detection rate was 71%, with a median of 5 carbon-containing LNs per specimen. If preoperative tattooing was used for sentinel node mapping, the overall accuracy of predicting LN status was 94%. In the 24 N1 cases, there were 4 false-negative procedures (sensitivity 83%). LIMITATIONS Retrospective series. CONCLUSION After tattooing of CRC, the LN yield was higher than in a control group, and it could be used as a sentinel node procedure with acceptable accuracy rates. Because LN yield and sentinel node mapping are associated with improved diagnostic accuracy of LN involvement, preoperative tattooing can refine staging.

Prolonged preoperative hospital stay is a risk factor for complications after emergency colectomy for severe colitis

Risk factors for postoperative complications in patients undergoing emergency colectomy for severe colitis in inflammatory bowel disease have hardly been studied. Therefore, this study aimed to define predictors of a complicated postoperative course in these patients.

External validation of a prognostic model of preoperative risk factors of failure of restorative proctocolectomy

The Cleveland Clinic has proposed a prognostic model of preoperative risk factors for failure of restorative proctocolectomy (RPC) with ileal pouch–anal anastomosis. The model incorporates four predictive variables: completion proctectomy, handsewn anastomosis, diabetes mellitus and Crohns disease. The aim of the present study was to perform an external validation of this model in a new cohort of patients who had RPC.

Reply to Letter: "Laparoscopy Within Fast-Track or Within Enhanced Recovery After Surgery?"

Reply: W e appreciate the interest of Dr Slim for our paper.1 The author suggests that there is a difference between the “fast track” and the “enhanced recovery” concepts; we, however, see this as merely a question of semantics. In many papers, including a recent paper by Kehlet and Slim, these terms are used interchangeably.2,3 Moreover, the author states that length of stay should no longer be considered as a main endpoint. This is an interesting discussion indeed, but we still consider the length of stay to be an adequate reflection of clinical recovery. This is supported by the work of van Bree et al and by the work of Veenhof et al in a subset of patients enrolled in the LAFA study. Van Bree et al demonstrated that laparoscopic surgery and fast-track care were both significant independent predictors of a faster recovery of colonic transit. Laparoscopy and fast-track care were both associated with improved clinical recovery, shorter time to tolerance of first food, and first bowel movement.4 Veenhof et al showed that the immune function of human leukocyte antigen–DR stayed highest in the group randomized to laparoscopic resection and fast-track care. Also, interleukin-6 and C-reactive protein levels were highest in the patients who had open surgery with standard care.5 Both authors subsequently demonstrated that their findings could be attributed to the type of surgery, not to the type of af-