Patients and methods
Patients with ulcerative colitis or familial polyposis coli eligible for elective restorative proctocolectomy in a previously conducted randomized controlled trial were prospectively evaluated. In the original study, the patients were randomized in a 1:1 ratio to either hand-assisted laparoscopic or open restorative proctocolectomy. Short-term results regarding perioperative parameters and postoperative recovery 3 months after surgery have been previously published [
5]. Methodological and operative details can be found in the original article.
The primary end points of the current study were body image and cosmesis. The secondary end points were morbidity, functional outcome, and QOL. Body image was assessed both pre- and postoperatively, whereas cosmesis and morbidity were assessed only postoperatively. The postoperative assessments of body image, cosmesis, and morbidity after LRP versus ORP were performed in January 2005 for all the patients, a median of 2.7 years after restorative proctocolectomy. Quality of life and functional outcome were assessed exactly 1 year postoperatively for each individual patient.
Functional outcome
Functional outcome in terms of day- and nighttime defecation frequency, incontinence, and sexual (dys)function was evaluated 1 year after surgery using a self-report gastrointestinal functional outcome questionnaire [
15].
Quality of life
Overall QOL was measured by the Short Form-36 Health Survey (SF-36). The SF-36, a well-validated generic questionnaire for measuring QOL, consists of eight multi-item scales assessing physical functioning, role physical, bodily pain, general health perceptions, vitality, social functioning, role emotional, and mental health [
16].
Quality of life related to the gastrointestinal tract was assessed by the total score of the Gastrointestinal Quality of Life Index (GIQLI) [
17]. The GIQLI, a more disease-specific validated QOL questionnaire, consists of 36 questions with 5 response categories. The GIQLI responses are summed to give a total numeric score. Data from both the SF-36 and GIQLI 1 year postoperatively were compared with data 3 months postoperatively.
Body image and cosmesis
To evaluate body image and cosmesis, the Body Image Questionnaire (BIQ) was used. Body image can be defined as a multidimensional construct that represents how patients think, feel, and behave with regard to their own physical attributes, including their incisional scar(s) [
18]. Cosmesis was defined as the degree of explicit satisfaction with the incisional scar(s).
The BIQ has been described previously [
19]. In summary, the BIQ consists of eight questions combined to form two scales: a body image scale and a cosmesis scale. Five questions regarding body image assess patients’ perception of their own body and their satisfaction with that perception, while also evaluating patients’ attitude toward their bodily appearance. The body image scale ranges from 5 (lowest body image score) to 25 (highest body image score).
Three questions regarding the cosmetic result after the operation assess the degree of satisfaction with respect to the physical appearance of the incisional scar(s). First, patients were asked to give a score to their scar(s) on a scale from 1 (lowest score) to 10 (highest score). Then the patients were asked to grade the extent to which they were satisfied with their scar on a Likert scale ranging from 1 (very unsatisfied) to 7 (very satisfied). Finally, the patients were asked to describe their scar on a Likert scale ranging from 1 (very repulsive) to 7 (very beautiful). The combined scores of these three questions resulted in the cosmesis scale ranging from 3 (lowest satisfaction) to 24 (highest satisfaction). To evaluate the validity of the BIQ, the internal consistency coefficients for both the body image and cosmesis scale were assessed.
A photo series questionnaire (PSQ) was administered to assess whether a patient’s degree of satisfaction with or preference for the two surgical approaches would be affected if he or she were shown photographs of the cosmetic results for the same and alternative approaches, respectively. The PSQ consists of six questions and two photographs of patients who underwent the open approach as well as two photographs of patients who underwent the laparoscopic approach.
The photographs of each procedure were concealed in two different envelopes. First, the patients were asked to give a score to their own incisional scar(s) on a scale of 1 (lowest score) to 10 (highest score). Then they were asked to give a score to the scar(s) on the photographs: first to the photographs of the same procedure, then to the photographs of the alternative procedure. After thus seeing the cosmetic results for the same and alternative surgical approaches, the patients were asked to score their own scar(s) again. In addition, they were asked their preference for one of the two surgical approaches if, hypothetically, they had the choice.
The patients who favored the laparoscopic approach were asked whether and how much they were willing to spend extra in terms of euros to have the laparoscopic operation, supposing that the only differences between the two approaches were the cosmetic result and the costs (higher cost for the laparoscopic approach).
Morbidity
Morbidity was defined as any complication related to the original disease (ulcerative colitis or familial polyposis coli) or the operative procedure in the period beyond 30 days after restorative proctocolectomy. This included readmission or reoperation for clinically significant small bowel obstruction or incisional hernia. For this purpose, patients’ medical files were reviewed. Any complication related to the original disease (ulcerative colitis or familial polyposis coli) or the operation was recorded.
To exclude whether patients were treated in other hospitals, an additional questionnaire regarding potential readmissions or reoperations was sent to all patients. The patients who did not complete the questionnaire were contacted by telephone to obtain the requested information. If a patient did not complete the questionnaire and could not be contacted by phone, follow-up evaluation was considered incomplete. In that case, the patient was not included for the analysis of morbidity.
Statistical analysis
All data are presented as mean and range unless otherwise specified. The nonparametric Mann–Whitney U test was used to compare discrete and continuous variables between the two groups. The chi-square test or Fisher’s exact test was used when appropriate to compare categorical or dichotomous variables between the two groups. To test for differences between continuous and discrete variables within a group, the nonparametric Wilcoxon signed ranks test was used. For a comparison of QOL results from different time points, a repeated measures multivariate analysis of variance (ANOVA) procedure was used.
Discussion
The current study demonstrated that the open approach for restorative proctocolectomy had a significant negative impact on body image and cosmesis in female patients compared with those who underwent a laparoscopic approach. Although a relatively small number of patients were included, this is the only randomized study reporting on long-term morbidity, functional outcome, and QOL after laparoscopic versus traditional open restorative proctocolectomy.
The results for functional outcome and QOL 1 year after the laparoscopic approach were comparable with those after the open approach. For QOL, this was not unexpected because there also were no differences between the two groups at the 3-month time point. Although a difference in functional outcome between the two procedures was not expected, no studies have ever reported on functional outcome after LRP versus ORP. In accordance with studies reporting on QOL after ORP, the QOL for these patients was comparable with that for the general population [
20‐
22].
Restorative proctocolectomy is a major colorectal operation associated with considerable morbidity. Small bowel obstruction caused by adhesions is one of the most commonly encountered complications after restorative proctocolectomy, as shown by both short- and long-term postoperative follow-up assessments. Small bowel obstruction is reported to occur in 13% to 35% of the patients, depending both on its definition and the length of the postoperative follow-up period [
9‐
10,
23,
24].
Only a minority of obstructive episodes require surgical intervention. Laparoscopy may decrease the incidence of small bowel obstruction because fewer adhesions are expected to develop than after a laparotomy [
25]. In the current study, 7 (15.2%) of the 46 patients were readmitted for suspected small bowel obstruction within a median follow-up period of 2.7 years. These numbers are relatively low compared with those of other studies with a comparable follow-up period [
9‐
24,
26,
27]. In the current study, however, only clinically significant episodes were recorded. Only two patients, one from each group, actually required reoperation for this reason. These numbers are too small for conclusions to be drawn.
It is possible that the open proctectomy through a Pfannenstiel incision after the hand-assisted laparoscopic colectomy, which was the operative procedure for these patients, counterbalanced some of the potential advantages of the minimally invasive approach in relation to adhesion formation. To test this hypothesis, a total laparoscopic proctocolectomy (i.e., a combined laparoscopic colectomy and laparoscopic proctectomy) should be compared with the hand-assisted approach as adopted for the patients in this study [
6‐
28]. Several studies have shown that restorative proctocolectomy can be performed by a total laparoscopic approach as well. Whether there are clinically relevant advantages for one of the two approaches remains to be determined.
In contrast to cosmetic surgery, body image and cosmesis are unconventional outcomes in the field of general surgery. Accelerated postoperative recovery, lower morbidity, and shorter hospital stay are considered the fundamental advantages of laparoscopy. It must be realized that for the patient, these are only nonpersisting short-term benefits. Conversely, improved cosmesis and body image, usually mentioned only as additional advantages, may be long-lasting advantages of the laparoscopic approach. As demonstrated in this study, body image and cosmesis were better after LRP than after ORP.
The internal consistency of the BIQ was high, and it was able to detect a difference between open and laparoscopic restorative proctocolectomy and between the sexes, which indicates its validity for evaluation of body image and cosmesis. The differences were most prominent in female patients. This is consistent with the reports in the literature about gender differences. In the general population, men experience much less body dissatisfaction than women [
29,
30].
A potential confounding factor could be that patients in the open group were significantly older (median age, 38 vs 29 years in ORP vs LRP, respectively;
p = 0.023). There are data suggesting that age indeed plays a role in body image. There is some evidence that older women have higher levels of body satisfaction than younger women [
31]. Although this may appear contradictory, it is possible that cognitive strategies in these older women protect their self-concept and self-esteem from the influence of body dissatisfaction [
32]. Given these data, it can be hypothesized that if females in the open group had been younger, their body image scores would have been lower. The difference in body image between the two approaches then would be even more evident.
Another potential confounding factor could be a difference in body image before the operation. The preoperative assessment showed that this was not the case, however. The importance of an improved body image and cosmesis is further substantiated by the increasing popularity of plastic and cosmetic surgery and by the fact that almost all patients from this study treated with laparoscopic surgery would now prefer the laparoscopic approach if they had the choice, even if they had to pay a personal fee. The majority of the patients who underwent the operation by an open approach would choose laparoscopy as well.
The fact that patients in both groups rated the photographs of the cosmetic result for the alternative procedure comparable with the personal ratings indicates that the photographs were representative. The decreased satisfaction of patients with their own scar after seeing the cosmetically superior results of the laparoscopic approach was expected in the open group. This decrease was not significant. These patients might have been influenced in their acceptance by the open approach they had. Conversely, it could be expected that the patients in the laparoscopic group would be more satisfied with their own cosmetic result after seeing the cosmetically inferior results of the open approach. This was not the case, however. Possibly, there was a ceiling effect, which means that the superior cosmetic result of the laparoscopic approach was the reference in these patients beforehand.
It could be debated whether the advantage of an improved cosmesis and body image outweigh the longer operating times and higher costs. After all, QOL after ORP is excellent even without the superior body image and cosmesis of a laparoscopic approach. Nonetheless, the QOL questionnaires including the SF-36 do not cover body image and cosmesis after surgery. Given the findings of the current study, the clinician could decide to offer the laparoscopic approach particularly to female patients.
The current study has shown that 1 year after surgery, the QOL and functional outcome results after LRP and ORP are comparable. During a median follow-up period of almost 3 years, morbidity in terms of small bowel obstruction and incisional hernia is comparable.
The most important finding of this study is that LRP results in a superior body image and cosmesis, especially for women. Particularly for female patients, a laparoscopic approach may be considered the procedure of choice.