This study reports the performance of dual-port laparoscopic abdominoperineal resection using a multiple port method. Neither patient experienced any perioperative or postoperative complications. In contrast, the rates of complications were reported to be much higher in patients with CD-related RVF who underwent conventional proctectomy, with 35 % experiencing delayed perineal wound healing, 17 % having intra-abdominal sepsis, and 15 % experiencing stomal complications [7]. Another series reported delayed or failed perineal wound healing in almost 50 % of patients [8]. The novel, minimally invasive procedure described here, dual-port laparoscopic abdominoperineal resection using a multiple port, has been found effective in patients with lower rectal cancer [5] and in patients with medically uncontrolled ulcerative colitis [6]. This procedure was completed successfully in all patients, without any intraoperative complications, and all postoperative outcomes were satisfactory.
This report describes our use of this surgical method in two patients with CD-related RVF and rectal stenosis. The abdominal cavity was approached using two small incisions, with a multichannel port placed at the colostomy site through a 25-mm skin incision in the lower quadrant and a 5-mm trocar inserted via the umbilicus for postoperative placement of a drainage tube. Neither patient experienced any intraoperative or postoperative complications. We recently reported that the postoperative neutrophil count was lower after SLIS +1 port laparoscopy-assisted than after conventional laparoscopy-assisted anterior resection for rectal cancer [4]. Furthermore, the former group experienced a significant difference in body temperature on postoperative day 1, indicating a lower degree of inflammation. Our findings suggest that this procedure, involving small incisions and minimal invasiveness, may reduce the risk of complications and benefit not only patients with rectal cancer and ulcerative colitis but also patients with CD-related RVF and rectal stenosis.
CD is the second most common cause of RVF after obstetrical trauma. The incidence of RVF in women with CD is approximately 3–10 %. RVF may cause significant clinical distress and social embarrassment. RVFs are extremely difficult to close medically [9], often leaving surgery as the only option [10]. Medical treatments have included antibiotics, corticosteroids, and immunosuppressants, but these agents are associated with low rates of long-term symptom control and unacceptably high rates of recurrence [11]. Infliximab, a monoclonal antibody to tumor necrosis-α (TNF-α), is a major advance in the treatment of fistulizing CD disease and has completely altered treatment strategies for perianal disease [12]. However, analysis of the results of the ACCENT II (A CD Clinical trial Evaluating infliximab in a New long-term Treatment regimen in patients with fistulizing CD) trial found that 56 % of patients on maintenance therapy with infliximab experienced RVF recurrence [10]. Another study showed that response to infliximab differed among patients with different types of CD fistula [13]. The closure rate after 4 to 6 weeks of treatment was 76 % for all external CD fistulas, but only 14 % for CD-associated RVF [13].
Patients who cannot be managed medically or are resistant or intolerant to infliximab can be managed surgically. Proctectomy was performed initially because of the high recurrence rate of CD-related RVF and difficulties treating rectal stenosis. To date, there have been no prospective, randomized, controlled trials assessing methods for the surgical correction of CD-related RVF [14]. Transvaginal, perineal, and transanal approaches, with or without transabdominal mobilization, can be used for local repair. Fecal diversion remains a problem, but protecting the fistula repair with a diverting stoma was reported to improve healing and reduce recurrence [15]. However, even with a diverting stoma, the cure rate remains less than satisfactory. The rates of recurrence of CD-related RVF have been reported to range from 25 to 50 %, higher than the recurrence rates of other CD fistulas [16–20]. Furthermore, most studies have considered only short-term outcomes. For example, of 12 patients with CD-related RVF who underwent local repairs, 7 (58 %) showed recurrence [16]. Proctectomy is still considered the only radical cure for Crohn’s-related RVF.
Both patients in this report presented with RVF and rectal stenosis, with the latter causing repeat intestinal obstruction. Rectal strictures due to CD are as difficult to treat as RVF. For example, 66 % of patients with perianal CD and rectal strictures required a permanent stoma, with multivariate analysis showing that rectal stricture was independently predictive of the need for a permanent stoma [3].
This report has certain limitations. First, both patients had low degrees of adhesion, allowing conventional laparoscopic surgery. Second, this operation required high operative skill of the entire surgical team. The surgeon and team in this study had experience with over 500 laparoscopic colorectal resection procedures, including reduced port surgery for colorectal diseases including colorectal cancer.