Stéphane Berdah

In Brief Objective: To assess with a single-blinded, multicenter, randomized trial, the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation (MBP). Background: The collective evidence from literature strongly suggests that MBP, before elective colonic surgery, is of no benefit in terms of postoperative morbidity. Very few data and no randomized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP. Methods: From October 2007 to January 2009, patients scheduled for elective rectal cancer sphincter-saving resection were randomized to receive preoperative MBP (ie, retrograde enema and oral laxatives) or not. Primary endpoint was the overall 30-day morbidity rate. Secondary endpoints included mortality rate, anastomotic leakage rate, major morbidity rate (Dindo III or more), degree of discomfort for the patient, and hospital stay. Results: A total of 178 patients (103 men), including 89 in both groups (no-MBP and MBP groups), were included in the study. The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group, 44% versus 27%, P = 0.018, and 34% versus 16%, P = 0.005, respectively. Regarding both anastomotic leakage and major morbidity rates, there was no significant difference between no-MBP and MBP group: 19% versus 10% (P = 0.09) and 18% versus 11% (P = 0.69), respectively. Moderate or severe discomfort was reported by 40% of prepared patients. Mortality rate (1.1% vs 3.4%) and mean hospital stay (16 vs 14 days) did not differ significantly between both groups. Conclusions: This first randomized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate. Thus, it suggests continuing to perform MBP before elective rectal resection for cancer. This study is registered with clinicaltrials.gov, number NCT00554892. Collective evidence from literature strongly demonstrated that elective colonic surgery without mechanical bowel preparation (MBP) was safe without compromising postoperative morbidity. By contrast, this first randomized study on rectal cancer suggests that rectal cancer surgery without MBP increased both overall and infectious morbidity rates.

OBJECTIVE: To assess the infertility rate after laparoscopic ileal pouch-anal anastomosis (IPAA). BACKGROUND: Total proctocolectomy with IPAA is known to be associated with postoperative infertility in open surgery, which may be caused by pelvic adhesions affecting the fallopian tubes. However, fertility after laparoscopic IPAA has never been assessed. METHODS: All patients who underwent a total laparoscopic IPAA between 2000 and 2011 and were aged 45 years or less at the time of operation and 18 years or more at the time of data collection were included. The patients answered a fertility questionnaire by telephone. All demographic and perioperative data were prospectively collected. The results were compared with those of controls undergoing laparoscopic appendectomy. RESULTS: Sixty-three patients were included. The mean age at the time of surgery was 31 ± 9 years (range 14-44). IPAA was performed for ulcerative colitis in 73% of the cases and familial adenomatous polyposis in 17%. The mean follow-up after IPAA was 68 ± 33 months (range 6-136). Fifty-six patients answered the questionnaire (89%). Half of them already had a child before IPAA. Fifteen patients attempted pregnancy after IPAA, of which 11 (73%) were able to conceive, resulting in 10 ongoing pregnancies and 1 miscarriage. The global infertility rate was 27%. There was no difference in fertility over time compared with the 14 controls who attempted pregnancy during the same period (90% vs 86% at 36 months, P = 0.397). CONCLUSIONS: The infertility rate appears to be lower after laparoscopic IPAA than after open surgery.

BACKGROUND: Restorative proctocolectomy with ileo pouch anal anastomosis (IPAA) is the main surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). With the advancements of minimal-invasive surgery this demanding operation is increasingly being performed laparoscopically. Therefore, the presumed benefits of the laparoscopic approach need to be systematically evaluated. OBJECTIVES: To compare the beneficial and harmful effects of laparoscopic versus open IPAA for patients with UC and FAP. SEARCH STRATEGY: We searched The Cochrane IBD/FBD Group Specialized Trial Register (April 2007), The Cochrane Library (Issue 1, 2007), MEDLINE (1990 to April 2007), EMBASE (1990 to April 2007), ISI Web of Knowledge (1990 to April 2007) and the web casts of the American Society of Colon and Rectal Surgeons (ASCRS) (up to 2006) for all trials comparing open versus laparoscopic IPAA. SELECTION CRITERIA: All trials in patients with UC or FAP comparing any kind of laparoscopic IPAA versus open IPAA. No language limitations were applied. DATA COLLECTION AND ANALYSIS: Two authors independently performed selection of trials and data extraction. The methodological quality of all included trials was evaluated to assess bias risk. Analysis of RCTs and non-RCTs was performed separately. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. MAIN RESULTS: Eleven trials included 607 patients of whom 253 (41%) in the laparoscopic IPAA group. Only one of the included trials was a randomised controlled trial. There were no significant differences in mortality or complications between the two groups. Reoperation and readmission rates were not significantly different. Operative time was significantly longer in the laparoscopic group both in the RCT and meta-analysis of non-RCTs (weighted mean difference (WMD) 91 minutes; 95% Confidence Interval (CI) 53 to 130). There were no significant differences between the two groups regarding postoperative recovery parameters. Total incision length was significantly shorter in the laparoscopic group, while two trials evaluating cosmesis found significantly higher cosmesis scores in the laparoscopic group. Other long-term outcomes were poorly reported. AUTHORS' CONCLUSIONS: The laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable. Large high-quality trials focusing on differences regarding specific postoperative complications, cosmesis, quality of life and costs are needed.