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Subtotal colectomy in severe ulcerative and Crohn's colitis: what benefit does the laparoscopic approach confer?
David E Messenger1, Dana Mihailovic, Helen M MacRae
11Division of General Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada 2Zane Cohen Clinical Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada 3Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada 4Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 5Department of Surgery, University of Toronto, Toronto, Ontario, Canada 6Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Background:
Comparative outcome data for laparoscopic and open subtotal colectomy in IBD are lacking and often difficult to interpret owing to low case volumes, heterogeneity in case mix, and variation in laparoscopic technique.
Objective:
This study aimed to determine the safety of laparoscopic subtotal colectomy in severe colitis and to determine whether the laparoscopic approach improved short-term outcomes in comparison with the open approach.
Design:
This was a retrospective cohort study using data from a prospectively maintained clinical database.
Setting:
This study was conducted at a single center, Mount Sinai Hospital, Toronto.
Patients:
All patients undergoing subtotal colectomy for either ulcerative or Crohn's colitis between 2000 and 2011 were included.
Intervention:
A standardized operative technique was used for both laparoscopic and open subtotal colectomies. Cases performed by non-laparoscopic surgeons were excluded.
Main Outcome Measures:
Perioperative outcome measures were operative duration, estimated blood loss, total morphine requirement, and length of postoperative stay. Postoperative outcome measures were the rates of minor and major complications.
Results:
Laparoscopic subtotal colectomies were performed in 131 of 290 cases (45.2%). Nine patients required conversion to an open procedure (6.9%). The uptake of laparoscopic subtotal colectomy increased from 10.2% in 2000/2001 to 71.7% in 2010/2011. Regression analysis with propensity-score adjustment for operative approach revealed that the operative duration was 25.5 minutes longer in laparoscopic cases (95% CI 12.3-38.6; p < 0.001), but that patients experienced fewer minor complications (OR 0.47; 95% CI 0.23-0.96; p = 0.04) and required less morphine (adjusted difference, -72.8 mg; 95% CI 4.9-141; p = 0.04).
Limitations:
The inherent selection bias of this retrospective cohort study may not be accounted for by multivariate analysis with propensity-score adjustment.
Conclusions:
Laparoscopic subtotal colectomy is safe and may reduce the rate of minor postoperative complications. The increase in operative duration reflects the technical demands associated with this procedure (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A160).
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