Laparoscopic total colectomy for ulcerative colitis after liver transplantation is feasible

Abstract

Ulcero-haemorrhagic rectocolitis can occur after liver transplantation for sclerosing cholangitis. Total colectomy with or without proctectomy may be indicated in case of chronic drug-resistant colitis, dysplasia or cancer. Today, laparoscopic approach is the standard for such procedure in non-operated patients. We performed a completely laparoscopic total colectomy 5 years after a liver transplantation. There were a few peritoneal adherences, and we could safely perform the procedure almost as usual. It provided all the advantages of the laparoscopic approach in the post-operative course.

INTRODUCTION

At present, laparoscopic approach is the standard for total colectomy. However, it is rarely performed when a patient had a previous laparotomy. Total colectomy for ulcero-haemorrhagic rectocolitis (UHRC) may be indicated in some patients who previously had a liver transplantation for primary sclerosing cholangitis (PSC). We report a case of a patient who underwent total colectomy by laparoscopic approach 7 years after orthotopic liver transplantation.

CASE REPORT

We diagnosed multiple lesions of low-grade to high-grade dysplasia on the left, transverse and right colon of a 67-year-old patient suffering from PSC associated to UHRC. This patient had a history of orthotopic liver with Roux-en-Y hepaticojejunostomy 7 years before. Post-operative recoveries of this procedure were uneventful under immunosuppressive treatment (prolonged-release tacrolimus, steroids).

The colonoscopy identified colonic lesions in the setting of chronic colitis. There was no lesion in the rectum. A laparoscopic total colectomy without proctectomy was decided.

An open coelioscopy was performed in the right flank to establish the pneumoperitoneum. The other ports were placed as usual: 5 mm ports in the left-upper quadrant and the right-lower quadrant, 10 mm port through the umbilicus [Figure 1]. A few adhesions were found between the transverse colon and the Makuuchi scar and easily transected. We then mobilised the left colon. The section of the meso-sigmoid was performed with a Harmonic^® scalpel (Ethicon SAS, Issy-les-Moulineaux, France). The inferior mesenteric artery was ligated with vascular clips. The colorectal junction was then stapled and transected. The other parts of the colon were mobilised from inside to outside, taken care to preserve the Roux-en-Y hepaticojejunostomy passing through the transverse meso-colon. A 5 mm port in the right upper quadrant was added to mobilise the right colon. After having fully mobilised the colon, the terminal ileum was transected. A short incision on the horizontal part of the previous scar was needed to extract the operative specimen and to put the ileal anvil to perform a laparoscopic mechanic ileorectal anastomosis.

Figure 1.

Abdominal wall on day 7. Five millimetres port scars in the right-upper, left-upper and right-lower quadrants. Ten millimetres port scars in the umbilicus and the right side. Drain scar in the left inferior quadrant. Extraction laparotomy (lap) in the horizontal part of the Makuuchi scar

Post-operative recoveries were uneventful. The patient had his first bowel movements on day 4 and was discharged home on day 7. There was no scar infection and no liver failure. The pathological report revealed multiple low-grade to high-grade lesions and one superficial cancer (TisN0M0).

DISCUSSION

PSC is a chronic liver disease that may lead to cirrhosis and cholangiocarcinoma. Its evolution can be slowed down by drugs, such as ursodeoxycholic acid, azathioprine, steroids or tacrolimus, but today the only curative treatment is liver transplantation.[1] Besides, PSC is associated in 70% of the cases to a UHRC.[2] It may lead to a chronic drug-resistant colitis, dysplasia or cancer. In these situations, a total colectomy and a proctectomy may be indicated. At present, the laparoscopic approach is the standard for such procedures. Only one case of hand-assisted laparoscopic total colectomy after liver transplantation has been reported,[3] but no completely laparoscopic procedure has been previously described.

The most expected difficulty was peritoneal adherences. It is very common to experience such difficulties after complex procedures by laparotomy. There is nowadays no efficient means of preventions.[4] However, it is commonly thought that the immunosuppressive treatment (steroids in particular) can prevent peritoneal adherences formation despite no trial proved it.

The second expected difficulty was the dissection of the Roux-en-Y jejunal loop passing through the transverse meso-colon. This kind of biliary reconstruction is usually performed in case of PSC to resect the main biliary duct. The main goal is to prevent biliary stricture although a recent study showed that a duct-to-duct reconstruction could bring excellent results.[5] During the described procedure, we found the intestinal loop very easily and we cut the transverse meso-colon in front of the jejunal loop way.

Because of the previous laparotomy, we had to change the placement of the scars. We used the horizontal part of the Makuuchi scar to extract the operative specimen, instead of performing a Pfannenstiel laparotomy. In this way, we decreased the number of scars and avoided a new weakness of the abdominal wall. The laparoscopic ports were placed as usual. We added a 5 mm one to help the dissection of the hepatic flexure of the right colon, but this one was not as useful as we thought.

Laparoscopic total colectomy after liver transplantation is feasible, even in case of transmesocolic Roux-en-y hepaticojejunostomy. This approach should be proposed in first attempt to these patients at risk of post-operative complications and incisional hernias because of the immunosuppressive treatment.

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Nil.

Conflicts of interest

There are no conflicts of interest.