ORIGINAL CONTRIBUTION Minimally Invasive Subtotal Colectomy and Ileal Pouch-Anal Anastomosis for Fulminant Ulcerative Colitis: A Reasonable Approach? Stefan D. Holubar, M.D. & David W. Larson, M.D. & Eric J. Dozois, M.D. Jirawat Pattana-arun, M.D. & John H. Pemberton, M.D. & Robert R. Cima, M.D. Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota PURPOSE: This study was designed to evaluate the safety, feasibility, and short-term outcomes of three-stage minimally invasive surgery for fulminant ulcerative colitis. METHODS: Using a prospective database, we identified all patients with ulcerative colitis who underwent minimally invasive surgery for both subtotal colectomy and subsequent ileal pouch-anal anastomosis at our institution from 2000 to 2007. Demographics and short-term outcomes were retrospectively evaluated. RESULTS: During seven years, 50 patients underwent minimally invasive subtotal colectomy for fulminant ulcerative colitis; 50 percent were male, with a median age of 34 years. All patients had refractory colitis: 96 percent were taking steroids, 76 percent were recently hospitalized, 59 percent had Q5 kg weight loss, 57 percent had anemia that required transfusions, 30 percent were on biologic-based therapy, and 96 percent had Q1 severe Truelove & Witts’ criteria. Of these 50 procedures, 72 percent were performed by using laparoscopic-assisted and 28 percent with hand-assisted techniques. The conversion rate was 6 percent. Subsequently, minimally invasive completion proctectomy with ileal pouch-anal anastomosis was performed in 42 patients with a 2.3 percent conversion rate. Median length of stay after each procedure was four days. There was one anastomotic leak and no mortality. CONCLUSIONS: A staged, minimally invasive approach for patients with fulminant ulcerative colitis is technically feasible, safe, and reasonable operative strategy, which yields short postoperative length of stay. KEY WORDS: Fulminant; Ulcerative colitis; Laparoscopic; Ileal pouch-anal anastomosis. C hronic ulcerative colitis (CUC) is a disease of mucosal inflammation with unknown etiology. Despite medical therapy, CUC may follow an un- predictable, recrudescent course with patients experienc- ing severe or even fulminant disease exacerbations. 1 It is in this setting of high-dose immunosuppressive ther- apy, or fulminant disease, that postoperative results of ileal pouch-anal anastomosis (IPAA) remain subopti- mal. 1Y5 This has led surgeons to offer such patients sub- total colectomy (STC) as an initial surgical procedure to reduce operative risks after subsequent IPAA. By defer- ring pelvic dissection, mortality from STC for fulminant ulcerative colitis is exceedingly low with acceptable com- plication rates. 5,6 In recent years, minimally invasive surgery (MIS) has been offered to patients whose severity of CUC would have previously precluded such an approach. 7Y16 MIS techniques for IPAA include hand-assisted laparoscopic surgery (HALS) and laparoscopic-assisted colectomy (LAP). 17Y19 Few reports have addressed the feasibility of both MIS-STC for fulminant CUC and subsequent MIS- IPAA. 13,16 Our goal was to evaluate the safety, technical feasibility, and short-term outcomes of an MIS three- stage approach for severe or fulminant CUC. PATIENTS AND METHODS A prospectively maintained procedural database was used to identify a cohort of adult patients with a preoperative diagnosis of CUC who underwent MIS-STC followed by MIS-IPAA between 2000 (the year the first laparoscopic STC was performed at our institution) and 2007. Patients DISEASES OF THE COLON &RECTUM VOLUME 52: 2 (2009) 187 Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 6 to 11, 2008. Address of correspondence: David W. Larson, M.D., Department of Surgery, Division of Colorectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. E-mail: larson.david2@mayo.edu Dis Colon Rectum 2009; 52: 187Y192 DOI: 10.1007/DCR.0b013e31819a5cc1 BThe ASCRS 2009 Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.