doi:10.1111/codi.12885

Original article

How do patients score cosmesis after laparoscopic natural orifice specimen extraction colectomy? A. M. Wolthuis*, C. Meuleman†, C. Tomassetti†, T. D’Hooghe†, S. Fieuws‡, A. de Buck van Overstraeten* and A. D’Hoore* *Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium, †Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium and ‡Interuniversity Centre for Biostatistics and Statistical Bioinformatics, University Hospital Leuven, Leuven, Belgium Received 21 August 2014; accepted 23 November 2014; Accepted Article online 24 December 2014

Abstract Aim Laparoscopic colorectal resection results in improved cosmetic outcome and better presumed body image. Laparoscopic NOSE colectomy omits an incision for specimen extraction and is supposed to further improve postoperative cosmesis. This study aimed to assess the cosmetic benefit.

naire score was 15 for NOSE colectomy and 18 for conventional resection (P = 0.027). The respective median PSAQ scores were 56 and 71 (P = 0.002). There was a good relationship between the PSAQ score and the body image questionnaire (Spearman correlation coefficient 0.82).

Method Forty-nine patients who underwent a NOSE colectomy for bowel endometriosis from September 2009 to September 2013 were matched for age, American Society of Anesthesiologists (ASA) grade and body mass index (BMI) with patients who underwent a conventional laparoscopic colectomy for the same indication. Patients were asked to complete a questionnaire consisting of a body scale and a cosmetic scale and the Patient Scar Assessment Questionnaire (PSAQ) including five subscales (appearance, symptoms, scar consciousness, satisfaction with appearance and satisfaction with symptoms).

Conclusion Depending on the scoring system used, the cosmetic outcome may be better after NOSE colectomy than conventional laparoscopy in patients having surgery for endometriosis. The comprehensive body image questionnaire, being shorter and easier to use, could be a valid tool for assessing cosmesis after NOSE procedures.

Results Patient demographics were similar between both groups. Patients were assessed at a median postoperative follow-up of 41 months in the NOSE colectomy group and 35 months in the conventional resection group. The median body image question-

Introduction Laparoscopic segmental colectomy with natural orifice specimen extraction (NOSE colectomy) avoids a minilaparotomy to remove the specimen [1]. This may have a positive impact on the cosmetic result. Measuring the cosmetic outcome after laparoscopic surgery is difficult [2]. A nonvalidated score developed by Dunker et al.

Keywords Laparoscopy, NOSE colectomy, cosmesis, endometriosis What does this paper add to the literature? This case-matched study reports the cosmetic outcome for 49 female patients who underwent NOSE colectomy compared with conventional laparoscopic colectomy for endometriosis. Two cosmetic questionnaires were used, and they demonstrated some advantage for NOSE-colectomy. This is the first reported study comparing the cosmetic outcome between NOSE and conventional laparoscopic colectomy for the same pathology.

[3,4] was used to assess the cosmetic outcome after ileocaecal resection for Crohn’s disease. Durani et al. [5] published a reliable and validated patient-reported scar questionnaire, the Patient Scar Assessment Questionnaire (PSAQ), for scoring linear scars. The aim of this study was to compare, using these tools, the cosmetic outcome of patients with endometriosis having a NOSE colectomy with those undergoing conventional laparoscopic colectomy.

Correspondence to: A. M. Wolthuis, Department of Abdominal Surgery, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium. E-mail: [email protected]

536

Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 536–541

A. M. Wolthuis et al.

Method All 62 patients who underwent an elective NOSE colectomy for bowel endometriosis from September 2009 to September 2013 were identified from a prospective institutional review board-approved database. The control group consisted of matched patients who had a conventional laparoscopic sigmoid resection and was selected from a database of 159 patients from a total of 698 patients with endometriosis who were treated at the Leuven University Fertility Centre. They were matched for age (within 2 years), American Society of Anesthesiologists grade and body mass index (BMI;  1 kg/m2). Approval was obtained from the medical ethics committee. Both groups received two identical questionnaires by mail. All had at least 6 months of follow-up to allow for optimal wound healing. The following perioperative factors were recorded: operating time, estimated blood loss, specimen length and length of hospital stay. Postoperative care was standardized for both groups. All complications were graded according to the classification of Dindo et al. [6]. Only matched pairs returning the questionnaires were selected for further analysis.

Surgical technique

Surgical procedures were performed under general anaesthesia in identical operating rooms according to a standardized method as previously described [1,7]. All patients had mechanical bowel preparation and antibiotic prophylaxis (2 g cefuroxime and 1.5 g metronidazole) was given intravenously at induction. A fourport technique was used for both laparoscopic and NOSE colectomy. In conventional laparoscopic sigmoid resection the specimen was retrieved through an incision measuring 3–5 cm made in the left iliac fossa using a wound protector. A standard double-stapled colorectal anastomosis was made using a circular stapler. In NOSE colectomy, the proximal part of the anastomosis was created intracorporeally by inserting the anvil into the peritoneal cavity via an upper rectotomy. The specimen was removed transrectally using a retrieval bag and a triple-stapled colorectal anastomosis was created.

Cosmesis after laparoscopic NOSE colectomy

score 20). The cosmetic scale consists of three questions assessing patient satisfaction with the physical appearance of the scar (minimum score 3, maximum score 24). We calculated the total body image questionnaire score by summing the body image scale and the reverse score of the cosmetic scale. Hence, a lower score indicated greater overall cosmetic satisfaction [8]. Patient Scar Assessment Questionnaire

The PSAQ is a validated questionnaire specifically developed for the assessment of linear scars [5]. It consists of five subscales including scar appearance, symptoms, scar consciousness, satisfaction with scar appearance and satisfaction with scar symptoms. Each subscale has a set of 4-point categorical rating items and one overall assessment item. The number of questions in each subscale determines the score range as follows: appearance (9–36), symptoms (6–24), consciousness (6–24), satisfaction with appearance (8–32) and satisfaction with symptoms (5–20). The overall assessment score ranges from 1 to 5 for appearance and symptoms and from 1 to 4 for the remaining three subscales. In conjunction with the body image questionnaire score, this means that for both total subscale score and overall assessment score, the lower the value, the better the cosmetic outcome. Statistical analysis

Values were expressed as median and interquartile range (IQR). Tests for paired data (signed rank test, exact McNemar’s test and its extension for tables of higher dimension) were used to compare operative outcome and cosmetic scores for patients who were matched for age, BMI and ASA grade. The Spearman rank correlation coefficient was used to evaluate the association between questionnaire scores. A P-value of < 0.05 was considered statistically significant. All analyses were performed using SAS software, version 9.2 of the SAS System for Windows (Copyright © 2002 SAS Institute Inc.; SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, North Carolina, USA).

Results Body image questionnaire

The body image questionnaire consists of a body image scale and a cosmetic scale [4]. The former contains five questions measuring patients’ perception of and satisfaction with their own body and their attitudes towards their bodily appearance (minimum score 5, maximum

From September 2009 to September 2013, 62 patients had a NOSE colectomy. They were matched with 62 patients who underwent a conventional laparoscopic colectomy for bowel endometriosis. The overall response rate was 82% (102/124). Complete data were available from 49 case-matched pairs (49/62, 79%).

Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 536–541

537

A. M. Wolthuis et al.

Cosmesis after laparoscopic NOSE colectomy

Patient characteristics and operative outcome

Patient characteristics were similar between the treatment groups (Table 1). There were no conversions to laparotomy in either group. Median operating time was 80 min (IQR 65–90) for NOSE colectomy vs 85 min (IQR 75–100) for conventional laparoscopic resection (P = 0.077). Estimated blood loss was comparable in both groups. The median specimen length was 13 cm (IQR 11–15) for conventional resection and 17 cm (IQR 15–22) for NOSE colectomy (P < 0.0001). There was no histological difference in the degree of invasion of endometriosis (P = 0.29). Median length of hospital stay was significantly shorter in the NOSE colectomy group: 6 days (IQR 5–7) vs 7 days (IQR 5–8) (P = 0.038). The postoperative complication rate was similar in both groups (P = 1.000). Two patients required relaparoscopy for intra-abdominal bleeding. There were no anastomotic complications or pelvic sepsis in the 124 patients originally enrolled. There were no wound infections or incisional hernias during follow-up. The median postoperative follow-up was 41.2 months (IQR 25.2–53.3) in the NOSE colectomy group and 34.9 months (IQR 23.5–51.9) in the conventional resection group (P = 0.977). Questionnaire data

Body image and cosmetic score There was no significant difference in body image score when comparing NOSE and conventional laparoscopic colectomy (Table 2). The median body image score was 6 (IQR 5–8) for NOSE and 7 (IQR 6–9) for conventional laparoscopic colectomy (P = 0.106). The median cosmetic scores were 8 (IQR 6–12) and 11 (IQR 8–

14), respectively (P = 0.032), and the median combined body image questionnaire scores were 15 (IQR 11–21) and 18 (IQR 15–22), respectively (P = 0.027).

Patient Scar Assessment Questionnaire The median PSAQ score was lower in the NOSE group [56 (IQR 52–67) vs 71 (IQR 62–79), P = 0.002] and the scores in each subscale of the PSAQ were lower (Table 2). Appearance, scar consciousness and satisfaction with appearance were significantly lower after NOSE colectomy (P-values 0.0003, 0.009 and 0.006, respectively); symptoms and satisfaction with symptoms did not differ between the two groups (P = 0.154 and P = 0.289, respectively).

Relation between PSAQ and body image questionnaire There was a good correlation between overall PSAQ and the body image questionnaire (correlation coefficient 0.82; Fig. 1). The correlation of the body image questionnaire with each of the five PSAQ subscales (appearance, symptoms, scar consciousness, satisfaction with appearance and satisfaction with symptoms) was 0.71, 0.51, 0.74, 0.79 and 0.42, respectively.

Discussion Minimizing abdominal wall trauma is a major aim of minimally invasive surgery [9–12]. Natural orifice specimen extraction has the potential to minimize access trauma because mini-laparotomy is avoided and it also has the possible advantage of improving the cosmetic result. This was borne out by the present study. Multidisciplinary minimally invasive surgery is the standard of care for the surgical treatment of bowel endometriosis [13]. A recent randomized trial comparing

Table 1 Characteristics of patients undergoing NOSE colectomy and conventional laparoscopic colectomy for bowel endometriosis. NOSE colectomy (n = 49) Age (years)* BMI (kg/m2)* ASA score Grade I Grade II Operating time (min)* Estimated blood loss (ml)* Specimen length (cm)* Duration of hospital stay (days)* Follow-up (months)*

33 (31–35) 23 (22–24) 27 22 80 10 17 6 41.2

(65–90) (0–20) (15–22) (5–7) (25.2–53.3)

Laparoscopic colectomy (n = 49) 33 (31–36) 23 (21–24) 30 19 85 20 13 7 34.9

P 0.832 0.771 0.581

(75–100) (10–50) (11–15) (5–8) (23.5–51.9)

0.077 0.1 < 0.0001 0.038 0.977

BMI, body mass index; ASA, American Society of Anesthesiologists. *Values are expressed as median (interquartile range).

538

Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 536–541

A. M. Wolthuis et al.

Cosmesis after laparoscopic NOSE colectomy

Table 2 Case-matched comparison of cosmetic outcome with two different scar assessment scoring systems in patients undergoing NOSE colectomy or conventional laparoscopic colectomy for bowel endometriosis.

Body image scale Cosmetic scale Body image questionnaire PSAQ overall Appearance Symptoms Scar consciousness Satisfaction with appearance Satisfaction with symptoms

NOSE-colectomy (n = 49)

Conventional laparoscopic colectomy (n = 49)

P

6 8 15 56 14 7 9 13 6

7 11 18 71 16 8 11 16 8

0.106 0.032 0.027 0.002 0.0003 0.154 0.009 0.006 0.289

(5–8) (6–12) (11–21) (52–67) (13–17) (6–9) (8–10) (8–16) (5–10)

(6–9) (8–14) (15–22) (62–79) (15–21) (6–9) (9–12) (14–17) (6–10)

Values are expressed as median (interquartile range).

Rho = 0.82 P ≤ 0.0001 N = 98

Patient scar assessment questionnaire (PSAQ)

120 110 100 90 80 70 60 50 40 30 8

12

16

20

24

28

32

36

40

44

BIQ Dunker: 8 items (BIS+CS)

Figure 1 Relation between the body image questionnaire (BIQ) according to Dunker et al. [4] and the Patient Scar Assessment Questionnaire according to Durani et al. [5].

laparoscopic-assisted and open colorectal resection for endometriosis showed improved short-term outcome, a higher spontaneous pregnancy rate and improvement in quality of life in the laparoscopic group [14]. Laparoscopic colorectal surgery has various advantages over open colorectal surgery, including better cosmesis and body image [3,4,15]. Recently, single-port surgery and NOSE colectomy have been introduced in an attempt to further reduce abdominal wall trauma and to improve cosmesis, but scoring and measuring the postoperative cosmetic outcome is difficult because of a lack of adequate scoring questionnaires. Moreover, the subjective nature of this cosmesis often leads to different interpretations of the resulting appearance [2]. The authors therefore undertook a case-matched analysis using questionnaires to assess cosmetic outcome in a matched group of patients with endometriosis who underwent NOSE colectomy and another that underwent standard laparoscopic colectomy. NOSE colectomy was followed by a shorter length of hospital stay and an improved cosmetic result. This

was more associated with body image rather than the actual scars. Although PSAQ is a validated scar assessment tool, the symptom subscale required further refinement in the original study by Durani et al. [5]. This might explain why we did not observe a significant difference between the subscales. Other groups have used the body image questionnaire and PSAQ after thyroid surgery, open and minimally invasive kidney surgery and after laparoscopic cholecystectomy [8,16,17]. To date, however, there are no other studies comparing the cosmetic outcome of these two forms of colectomy. The authors acknowledge some limitations of the present study. Patients evaluated their own scars without any reference or framework to other possible cosmetic end-points. This could have been solved by including pictures of alternative surgical access, but this was not done. Another limitation is that all patients received mechanical bowel preparation. Although recent studies have shown that this might not be necessary for laparoscopic colectomy [18,19] and fast-track protocols omit mechanical bowel preparation [20,21], our unit still gives it as part of the multidisciplinary endometriosis surgery protocol [13]. Moreover, contamination of the peritoneal cavity might occur due to intra-operative rectotomy [22,23], although there were no cases of pelvic sepsis. The study was not randomized and was limited by small sample size, but its strength was a perfect match of age, BMI, and pathology. Moreover, due to the long median follow-up in both groups, it is reasonable to assume that any wound complications had settled by the time of assessment [24]. Thus the cosmetic score truly reflected the patients’ appreciation of body image. In addition, there was a good correlation between PSAQ and each of its five subscales and the body image questionnaire.

Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 536–541

539

A. M. Wolthuis et al.

Cosmesis after laparoscopic NOSE colectomy

In conclusion, the comprehensive body image questionnaire limited to eight items is a useful and userfriendly tool for evaluating cosmetic outcome after minimally invasive laparoscopic surgery, especially NOSE colectomy. The body image questionnaire is a good alternative to the PSAQ, but this original study highlights the need to study cosmesis and patient satisfaction after NOSE procedures.

7

8

Acknowledgement 9

The authors thank Mrs Isabelle Terrasson, clinical trial assistant, for collecting the data. 10

Conflicts of interest All authors have no conflicts of interest or financial ties to disclose.

11

Author contributions AMW contributed to all works including study design, acquisition of data, data analysis, manuscript drafting and critical discussion. CM, CT and TDH supervised all works including study design, data analysis, critically revising of the manuscript and discussion. SF contributed mainly to data analysis, manuscript drafting and critical discussion. AdBvO and ADH contributed to study design and execution, analysis, manuscript drafting and critical discussion.

12

13

14

References 1 Wolthuis AM, Penninckx F, D’Hoore A. Laparoscopic sigmoid resection with transrectal specimen extraction has a good short-term outcome. Surg Endosc 2011; 25: 2034– 8. 2 Durani P, McGrouther DA, Ferguson MW. Current scales for assessing human scarring: a review. J Plast Reconstr Aesthet Surg 2009; 62: 713–20. 3 Dunker MS, Bemelman WA, Slors JF, van Duijvendijk P, Gouma DJ. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum 2001; 44: 1800–7. 4 Dunker MS, Stiggelbout AM, van Hogezand RA, Ringers J, Griffioen G, Bemelman WA. Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn’s disease. Surg Endosc 1998; 12: 1334–40. 5 Durani P, McGrouther DA, Ferguson MW. The Patient Scar Assessment Questionnaire: a reliable and valid patientreported outcomes measure for linear scars. Plast Reconstr Surg 2009; 123: 1481–9. 6 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a

540

15

16

17

18

19

cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205–13. Wolthuis AM, Meuleman C, Tomassetti C et al. Laparoscopic sigmoid resection with transrectal specimen extraction: a novel technique for the treatment of bowel endometriosis. Hum Reprod 2011; 26: 1348–55. Park SK, Olweny EO, Best SL, Tracy CR, Mir SA, Cadeddu JA. Patient-reported body image and cosmesis outcomes following kidney surgery: comparison of laparoendoscopic single-site, laparoscopic, and open surgery. Eur Urol 2011; 60: 1097–104. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008; 248: 189–98. Wolthuis AM, Van Geluwe B, Fieuws S, Penninckx F, D’Hoore A. Laparoscopic sigmoid resection with transrectal specimen extraction: a systematic review. Colorectal Dis 2012; 14: 1183–8. Vlug MS, Wind J, Hollmann MW et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 2011; 254: 868–75. Laurent C, Leblanc F, Bretagnol F, Capdepont M, Rullier E. Long-term wound advantages of the laparoscopic approach in rectal cancer. Br J Surg 2008; 95: 903–8. Meuleman C, Tomassetti C, Wolthuis A et al. Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg 2014; 259: 522– 31. Darai E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M. Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility. Ann Surg 2010; 251: 1018–23. Eshuis EJ, Polle SW, Slors JF et al. Long-term surgical recurrence, morbidity, quality of life, and body image of laparoscopic-assisted vs. open ileocolic resection for Crohn’s disease: a comparative study. Dis Colon Rectum 2008; 51: 858–67. Bignell M, Hindmarsh A, Nageswaran H et al. Assessment of cosmetic outcome after laparoscopic cholecystectomy among women 4 years after laparoscopic cholecystectomy: is there a problem? Surg Endosc 2011; 25: 2574–7. Economopoulos KP, Petralias A, Linos E, Linos D. Psychometric evaluation of Patient Scar Assessment Questionnaire following thyroid and parathyroid surgery. Thyroid 2012; 22: 145–50. Guenaga KK, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2009: CD001544. Slim K, Vicaut E, Launay-Savary MV, Contant C, Chipponi J. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009; 249: 203–9.

Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 536–541

A. M. Wolthuis et al.

20 Wind J, Polle SW, Fung Kon Jin PH et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006; 93: 800–9. 21 Chestovich PJ, Lin AY, Yoo J. Fast-track pathways in colorectal surgery. Surg Clin North Am 2013; 93: 21– 32. 22 Costantino FA, Diana M, Wall J, Leroy J, Mutter D, Marescaux J. Prospective evaluation of peritoneal fluid

Cosmesis after laparoscopic NOSE colectomy

contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections. Surg Endosc 2012; 26: 1495–500. 23 Leroy J, Costantino F, Cahill RA et al. Laparoscopic resection with transanal specimen extraction for sigmoid diverticulitis. Br J Surg 2011; 98: 1327–34. 24 Witte MB, Barbul A. General principles of wound healing. Surg Clin North Am 1997; 77: 509–28.

Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 17, 536–541

541

How do patients score cosmesis after laparoscopic natural orifice specimen extraction colectomy?

Laparoscopic colorectal resection results in improved cosmetic outcome and better presumed body image. Laparoscopic NOSE colectomy omits an incision f...
99KB Sizes 0 Downloads 6 Views