Minimal invasive surgery: NOSE and NOTES in ulcerative colitis

In patients with ulcerative colitis (UC), laparoscopic pelvic dissection for IPAA is not always straightforward: often, a hand-assistance incision is used to complete the proctectomy, lengthening operative times. Hybrid NOSE and NOTES are emerging as an alternative approach to conventional laparoscopy. We believe that UC patients could benefit from this new hybrid approach in three ways: by easing the proctectomy as performed down to up, avoiding additional incisions and decreasing surgical times. We present the short-term outcomes of our series.

All patients with UC who required IPAA were enrolled in a single-arm prospective study (July 2011 to March 2014). A three-step procedure was performed. The first step: laparoscopic colectomy (with transanal removal of the colon) and temporary ileostomy. The second step: "down-to-up" proctectomy (with transanal removal of the rectum) and IPAA with a covering ileostomy. We combined simultaneously transanal and laparoscopic approach. The third step: ileostomy closure. Functional outcomes were assessed 3 months after third step.

Eighteen patients were enrolled. Two patients are waiting to complete the second stage, and 16 underwent all surgical steps. Twelve have been evaluated with functional scores. For the first step, the mean operative time was 162.2 min (SD 40.5) and 170 min (SD 50.1) for the second one. The median hospital stay was 6 days (IQR 5-14.75) for the first step and 5.5 (IQR 5-9.75) for the second one. No major complications occurred. Twenty-four-hour defecation frequency was 5.5 per day (SD 1.7), 0.5 per night. Seventy-five percentage of patients may retain stools for more than 30 min; the mean value of Oresland score was 4.7 and Wexner score 1.4.

This is a safe and feasible technique to treat UC patients with good short-term outcomes. Long-term outcomes and controlled trials are needed.