Transanal minimal invasive proctectomy (TaMIP) for perineal Crohn’s disease; a multi-centre prospective cohort study

Abstract

BACKGROUND: Transanal minimally invasive proctectomy (TaMIP) has some advantages particularly in relation to access to the deep pelvis. Key challenges faced with the TaMIP approach for proctectomy in Crohn’s disease are the diseased pelvis and inflamed, bulky mesorectum causing difficult planes. This study aims to assess the short-term outcomes and perineal wound complications following TaMIP for Crohn’s disease. METHODS: All patients undergoing TaMIP proctectomy between 2014 and 2018, at 2 tertiary care referral centres were prospectively evaluated. Thirty-day morbidity, operative details and perineal wound complications were analysed. RESULTS:A total of 33 patients (M 42%, age 38.5 years; range 26 to 77) have undergone TaMIP for Crohn’s disease. Surgeries were performed as double single port procedures with either complete mesorectal excision or close rectal dissection. The mean operative time was 120 min (range: 60–240) for the perineal procedure and 234 min (range: 140–279) for the total procedure. One case (3%) had to be converted to an open procedure due to difficult dissection and haemorrhage. Ninety per cent of the patients were ASA II and 54.5% underwent completion proctectomy while 45.5% had a panproctocolectomy as a single procedure. Four patients (12%; II 2, III 2) had complications which were Clavien-Dindo II and above. One patient had re-intervention for a pelvic collection while another patient had a ureteric injury. Vacuum dressing was used for primary wound closure in one patient. Major perineal wound dehiscence was seen in 6% (2 of 33) of the patients while one needed vacuum therapy. In long-term follow-up one patient developed an enterocutaneous fistula at the abdominal wound while 7 (21%) chronic perineal sinuses were reported. CONCLUSIONS:Perineal Crohn’s disease poses a challenge for transanal minimally invasive surgery due to the chronic inflammation and perineal sepsis. Transanal approach offers a safe and feasible option for perineal Crohn’s disease. The commonest complication following TaMIP is the development of a chronic perineal sinus and evaluation with laparoscopic and open techniques would be useful to ascertain if this rate is different.