SCACRA comprises two eras, namely, open surgery and laparoscopic surgery. Among the 32 cases reported by Sarli, Marchesi, and others [8,9,19,21-24], 17 cases had open surgery and 15 had laparoscopic surgery. In their institution, almost all recent cases received SCCRA with laparoscopic approach [20]. In 2012, Marchesi [20] compared 15 cases of laparoscopic surgery with 15 cases of open surgery. Although the cases of laparoscopic surgery had longer operation time, the postoperative pains and the days of hospital stay were significantly shorter than those of the group with open surgery. Marchesi [20] holds that laparoscopic SCCRA confirmed the very good functional results of the open approach, with significant advantages for postoperative recovery. The minimally invasive approach did not increase procedural morbidity. In our study, nine patients among all 81 patients exhibited complications at Dindo > level I (11.1%), which was close to the result of open operation (13.3%) reported by Marchesi [20]. Therefore, our results confirmed Marchesi’s point of view that “The minimally invasive approach did not increase procedural morbidity” [20].
The average days of hospital stay of the two groups were 13.02 ± 2.08 and 13.05 ± 2.14 d, which were significantly shorter than the 14.5 ± 2.5 d reported by Jiang [21]. We observed that several key parameters, such as WCS, GIQLI, APIS, APFS and ABS, of the two groups at the 12th month after the operation significantly improved compared with their pre-operative values. Both groups have no severe diarrhea and incontinence.
This result verified that with any approach of preserved length, LSCACRA is a suitable and effective alternative in the treatment of STC. Based on comparisons with earlier reports [8,9,19,24] laparoscopic surgery presents advantages, such as efficacy, smaller wounds and faster recovery.
In the beginning, we carried out LSCACRA based on the referred length of 10 cm to 15 cm according to Sarli [8]. Six patients among 42 cases did not present significant improvement in abdominal pain and abdominal bloating after the operation, and even reported subjective feelings of enhanced symptoms. They could not endure the pain and had to take long-term treatment in hospitals. They even requested for re-operations. In the barium enema test, we found cecum expansion in the patients, which was highly similar to what was reported by Marchesi [9]. We also found that these patients had the problem of cecum emptying as shown in Figure 8 (the picture was taken 72 hours after barium enema). The residual cecum and colon were shaped as a blind loop-pouch in which the feces moved inversely. Partial feces stayed for a long time in the reservoir which was hard to be emptied. We assumed that the abdominal pain and abdominal bloat were caused by the blind loop-pouch after operation. The inner pressure in the reservoir may cause abdominal bloating. The large pressure in the cecum leads to reinforced or even spasmodic contraction when the contents of the small intestine enter the colon. Given the excessive length of the blind loop, more intense and longer lasting contractions of the colon will be needed to empty residuals in the blind loop, which worsens colon spasms. The bigger the reservoir was, the more serious the illness would become. We referred to the paper of Jiang [21] in 2008 and found that the difference in the operation technique between Jiang and Sarli was a shorter preserved length of ascending colon from 10 cm to 15 cm to 5 cm to 7 cm. The incidence rate of postoperative abdominal pain was significantly lower than that reported by Marchesi and Sarli. According to Marchesi and Sarli [9], 11 (64.7%) patients had postoperative abdominal pain, among which two patients (11.8%) exhibited frequent abdominal pain. In the research of Jiang [21], although the incidence rates of abdominal pain and bloating were high (17.1% of abdominal pain, 23.5% of abdominal bloating, and 11.8% of postoperative ileus), we observed a significant decline. This result indicates that the shortened length of the colonic reservoir greatly improved the postoperative outcomes and reduced the incidence of postoperative abdominal pain.
Based on the theoretical analysis of subtotal colectomy with antiperistaltic cecorectal anastomosis, we concluded that the surgery is significant in retaining ileocecal valve and preventing rotation of blood vessel and intestine in isoperistaltic anastomosis. It is not necessary to keep longer ascending colon and cecum for the function of pouch. In the literature review, there is no final conclusion about what length of ascending colon and cecum should be retained, so theoretically it is feasible to conduct cecum shortening which also observes the surgery principle. Therefore, we at last performed the surgery of cecum shortening for these 6 patients. The purpose of the new surgery was to solve the problems of feces retention and pneumatosis in the pouch, or minimize even eliminate the pouch. We decided to shorten cecum as much as possible and at the same time guarantee ileocecal valve and original anastomotic stoma intact. This is the reason why we initially fixed 2-3 cm area above the upper edge of ileocecal valve (guaranteeing well function of ileocecal valve and minimized cecum). The patients recovered very well after the second operation and their illness were obviously relieved in three-month after operation. (Details were shown in Additional file 1) Thus, since September 2009 we changed the surgical method to preserving 2-3 cm ascending colon above the ileocecal junction.
The two groups were identical in terms of surgical methods except for the length of colonic reservoir. All operations were performed by the same doctor. Preoperative information of patients showed no significant differences through statistical analysis. The comparison of surgical and postoperative parameters of the two groups could sufficiently interpret the effect of preserved length on postoperative outcomes.
Surgical and postoperative parameters of patients did not show significant difference through statistical analysis. However, we noticed during the comparison of the variations in different parameters in two groups at each postoperative time point that the observation group showed continuous improvement in WCS, GIQLI, APIS, APFS, and ABS at 3, 6, and 12 months after the operation. At 12 months after the operation, the WCS score decreased to 1.56 ± 1.61 and was even better than the WCS score of the general population (2.1 to 3.4) [26]. All patients had WCS score < 8 at 12 months after the operation. GIQLI value was 121.23 at 12 months after the operation, which was close to the level of healthy people (average healthy value is 125.8 ± 13) [27]. Compared with the preoperative conditions, all the values of WCS, GIQLI, APFS, and ABS improved significantly (P < 0.01) in the control group at the 3rd, 6th, and 12th month after operation. APIS was greatly relieved only at the 12th month after the operation (P < 0.05). However, at different postoperative time points, the control group showed remarkable variation in parameters. The WCS score at the 3rd, 6th, and 12th month after operation was 3.78 ± 3.91, 4.05 ± 4.23, and 4.38 ± 4.93 respectively, and the improvement was not enhanced with increase in time. In addition, 10 patients had WCS score ≥ 8 at the 12th month. Although GIQLI value significantly improved, it was still 103.43 ± 16.42 at the 12th month, showing a difference compared with that of healthy people. The pre-operative APIS did not improve significantly at the 3rd and 6th months after operation, with p = 0.61 and p = 0.05, respectively. However, APIS significantly improved at the 12th month. Based on postoperative and pre-operative comparisons of the two groups, the surgical approaches of the two groups can improve the clinical symptoms of STC patients, but the observation group was superior to the control group. The results indicate that the preserved length of the ascending colon influences the postoperative outcomes of STC patients treated by LSCACRA. Patients with 2 cm to 3 cm of preserved ascending colon had better postoperative outcomes than patients with 10 cm to 15 cm of preserved ascending colon.
Since this is a single center norandomized historical control study which has some limits, multicenter randomized controlled studies are needed in the future study. At the same time, we will also perform long term follow-up to further evaluate the functional recovery of LSCCRA.