Transanal minimally invasive proctectomy (TaMIP) in patients with inflammatory bowel diseases (IBD) within the TaTME international database

Abstract

BACKGROUND : The necessity of proctectomy in IBD often represents refractory disease, with severe active/chronic inflammation, frequently in the context of immunosuppression. Minimally invasive techniques are currently being used as an option in the often challenging operations required. We aim to assess the feasibility and short-term outcomes of a transanal minimally invasive approach to proctectomy (TaMIP) in patients undergoing surgery for IBD within the TaTME registry. METHODS: The TaTME registry (secure online database), was interrogated from 2014 to 2017 for benign conditions. Data were collected across 11 international centres submitted for IBD patients. Patients with ulcerative colitis (UC) received proctectomy with or without Ta-IPAA, and patients with Crohn’s disease (CD) received TaMIP, with or without total mesorectal excision (TME), for perianal CD (pCD).RESULTS: In total, 174 patients with a median BMI of 25.6 ± 4.7 kg/m2 were entered into the database. The majority of patients (77%; 134 of 174) had UC and 79.9% (111 of 174) had a simultaneous laparoscopic or single-incision laparoscopic (SILS) approach to the abdomen. Active IBD featured in 63.8% (111 of 174) which was more prominent in the CD patients (80% vs. 59%, p = 0.015) and 19% (33 of 174) were on steroids at the time of surgery. The median total operative time was 249 ± 113 min (abdominal phase 206 ± 112 and perineal phase 133 ± 60 min). An incorrect plane was the most common problem encountered intra-operatively (10.3%; 18 of 174) followed by bleeding (9.2%; 16 of 174). There was an inadvertent rectal perforation rate of 5.6% (6 of 107). Over a fifth of abdominal procedures were converted (21.6%; 30 of 139) compared with 17 (9.8%) in the perineal phase. There were more perineal conversions in CD patients (20% vs. 6.7%, p = 0.028). A purse-string was used in 51.1% (81 of 174) at a median height of 3.8 ± 2 cm. Most anastomoses were created using a stapler (85.1%; 57 of 67) at median distance of 2.9 ± 1.5 cm from the anal verge. The median length of postoperative stay was 9 ± 6.5 days, which was longer in the UC patients (9 ± 7 days vs. 6 ± 5 days, p = 0.0079). There were no mortalities. Forty-four patients (25.3%) had a complication and seven (15.9%) of these (i.e. 4% of total cohort) had a grade III Clavien-Dindo complication (re-operation). Data on late morbidity (>1 month) were available in 92 patients and 15 of these patients (16.3%) had a wound breakdown. Two of these had a VAC dressing and three had re-operations. There was a trend towards more wound sinuses in CD (19% vs. 4.8%, p = 0.062). CONCLUSIONS:Our results demonstrate that the application of a transanal minimally invasive approach to proctectomy is a feasible option in IBD patients with a relatively low complication rate.