Granulocyte elastase and systemic cytokine response after laparoscopic-assisted and open resections in Crohn's disease

The Role of Active Inflammation and Surgical Therapy in Crohn's Disease Recurrence

An altered balance between effector and regulatory factors is supposed to sustain the tissue-damaging immune response in inflammatory bowel disease (IBD). Several studies demonstrate that severe active inflammation is a strong predictor for surgical complications and recurrence. Indeed, bowel resection in Crohn's disease (CD) patients has a high surgical recurrence rate. In this review, we examined the IBD inflammatory pathways, the current surgical treatments, and the almost inevitable recurrence. The question that might arise is if the cure of intestinal CD is to be found in the surgical approach. A selective search of two databases (PubMed and the Cochrane Library) has been carried out without considering a specific time horizon as inclusion criteria. The scope of this literature review was investigating on the role of inflammation in the management of CD. The following key words have been used to develop the query string: (i) inflammation; (ii) Crohn's disease; (iii) surgery; and (iv) postsurgical recurrence.

The influence of obesity on short- and long-term outcomes after laparoscopic surgery for colon cancer: a case-matched study of 152 patients

BACKGROUND

Despite the increasing prevalence of obesity and colonic diseases, the impact of obesity on short-term and oncologic outcomes of laparoscopic colorectal surgery still remains unclear.

STUDY DESIGN

Seventy-six consecutive obese patients with body mass index (BMI) ≥30 kg/m(2) who underwent laparoscopic colectomy were matched with 76 nonobese patients with BMI <30 kg/m(2). Perioperative parameters and oncologic outcomes were analyzed in the two groups.

RESULTS

Obesity was associated with greater operative time (obese vs nonobese, 182 ± 59 vs 157 ± 55 min, P = .0084) and multivariate analysis identified BMI (hazard ratio 2.11, 95% confidence interval 0.64-3.56, P = .0049) as an independent predicting factor for operative time together with cancer location (hazard ratio 28.6, 95% confidence interval 14.62-42.51, P < .0001). Obesity had no adverse influence on overall morbidity (25 vs 21%, P = .563), however, or postoperative duration of stay (median 6.0 vs 5.5 days, P = .22). Furthermore, the rate of conversion to open procedure was similar between the two groups (9 vs 9%, P > .99). Regarding oncologic outcomes, there was no statistical difference in overall and disease-free survival between the two groups (5-year overall survival rate 86 vs 89%, P = .72, 5-year disease survival rate 70 vs 77%, P = .70).

CONCLUSION

Laparoscopic colonic resection, when performed for selected patients, appears to be a safe and reasonable option in obese patients with colon cancer resulting in similar short-term and oncologic outcomes as nonobese patients.

The impact of obesity on perioperative outcomes after laparoscopic colorectal resection

OBJECTIVE

It is commonly perceived that surgery in obese patients is associated with worse outcomes than in nonobese patients. Because of the increasing prevalence of obesity and colonic diseases in the world population, the impact of obesity on outcomes of laparoscopic colectomy remains an important subject. The aim of this review was to evaluate the feasibility and safety of laparoscopic colectomy for colorectal diseases in obese patients compared with nonobese patients.

METHODS

We conducted a comprehensive review for the years 1983-2010 to retrieve all relevant articles.

RESULTS

A total of 33 studies were found to be eligible and included 3 matched case control studies and 1 review article. Obesity, often accompanied by preexisting comorbidities, was associated with longer operative times and higher rates of conversion to open procedures mainly because of the problem of exposure and difficulties in dissection. Although some studies showed obesity was associated with increased postoperative morbidity including cardiopulmonary and systemic complications, or ileus leading to longer hospital stay, there was no evidence about the negative impact of obesity on intraoperative blood loss, perioperative mortality, and reoperation rate. Whether obesity is a risk factor for wound infection after laparoscopic colectomy remains unclear. Though sometimes in obese patients, additional number of ports were necessary to successfully complete the procedure laparoscopically, obesity did not influence the number of dissected lymph nodes in cancer surgery. Lastly, the postoperative recovery of gastrointestinal function was similar between obese and nonobese patients.

CONCLUSIONS

Laparoscopic colorectal surgery appears to be a safe and reasonable option in obese patients offering the benefits of a minimally invasive approach, with no evidence for compromise in treatment of disease.

Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection

OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n = 20), remifentanil and clonidine intravenously (clonidine group, n = 20), or ropivacaine epidurally (ropivacaine group, n = 20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

Early immune outcome of retroperitoneal laparoscopic radical nephrectomy for localized renal cell carcinoma: a prospective, randomized study

OBJECTIVES

We evaluated differences in cytokine responses and T-lymphocyte subsets following retroperitoneal laparoscopic and conventional open radical nephrectomies for localized renal cell carcinoma (RCC).

METHODS

A total of 62 patients with T(1)N(0)M(0) staged RCC were randomized to either retro-laparoscopic (n = 31) or open (n = 31) radical nephrectomy. Plasma levels of interleukin-1β (IL-1β), IL-6, and tumour necrosis factor-alpha (TNF-α) were measured separately by enzyme linked immunosorbent assay (ELISA) preoperatively and on postoperative days 1 and 5. Levels of CD3(+), CD4(+) and CD8(+) as well as the CD4(+):CD8(+) ratio were acquired by flow cytometry at the same time points.

RESULTS

Levels of IL-1β, IL-6 and TNF-α increased significantly compared to preoperative values in both groups (p < 0.05) on postoperative day 1, and all the parameters in the open group were significantly higher than those in the retro-laparoscopy group (p < 0.05). On postoperative day 1, the levels of CD3(+) and CD4(+) and the CD4(+):CD8(+) ratio decreased markedly compared to preoperative values for both groups (p < 0.05). Elevations of the CD4(+):CD8(+) ratio in the retro-laparoscopy group (p < 0.05) and the CD8(+) level in the open group (p < 0.05) were observed when compared with the other group. On postoperative day 5, the levels of CD3(+) and CD4(+) and the CD4(+):CD8(+) ratio in the retro-laparoscopy group, as well as the level of CD8(+) in the open group, returned to about preoperative levels (p < 0.05). Follow-up ranged from 4 to 14 months postoperatively in all 62 patients with a 100% cancer-specific survival rate in both groups.

CONCLUSIONS

Retroperitoneal laparoscopic radical nephrectomy is associated with the milder cytokine responses caused by trauma and inflammation and the better preserved distribution of T-lymphocytes.

Postsurgical recurrence of ileal Crohn's disease: an update on risk factors and intervention points to a central role for impaired host-microflora homeostasis

BACKGROUND

A pressing need exists to identify factors that predispose to recurrence after terminal ileal resection for Crohn's disease (CD) and to determine effective prophylactic strategies. This review presents an up-to-date summary of the literature in the field and points to a role for bacterial overproliferation in recurrence.

METHODS

The literature (Medline, Embase, and the Cochrane Library, 1971-2009) on ileal CD and postoperative recurrence was searched, and 528 relevant articles were identified and reviewed.

RESULTS

Smoking is a key independent risk factor for recurrence. NOD2/CARD15 polymorphisms and penetrating phenotype are associated with aggressive disease and higher reoperation rates. Age at diagnosis, disease duration, gender, and family history are inconsistent predictors of recurrence. Prophylactic 5-aminosalicylic acid therapy and nitromidazole antibiotics are beneficial. Combination therapies with immunosuppressants are also effective. Anti-TNFalpha-based regimens show benefit but the evidence base is small. Corticosteroid, interleukin-10, and probiotic therapies are not effective. Wider, stapled anastomotic configurations are associated with reduced recurrence rates. Strictureplasty and laparoscopic approaches have similar long-term recurrence rates to open resection techniques. Length of resection and presence of microscopic disease at resection margins do not influence recurrence. A lack of consensus exists regarding whether the presence of granulomas or plexitis affects outcome.

CONCLUSIONS

Current evidence points to defects in mucosal immunity and intestinal dysbiosis of either innate (NOD2/CARD15) or induced (smoking) origin in postoperative CD recurrence. Prophylactic strategies should aim to limit dysbiosis (antibiotics, side-to-side anastomoses) or prevent downstream chronic inflammatory sequelae (anti-inflammatory, immunosuppressive, and immunomodulatory therapy).

The humoral response after laparoscopic versus open colorectal surgery: a meta-analysis

BACKGROUND

The local and systemic humoral response after colorectal surgery is thought to affect postoperative recovery. It is commonly claimed that laparoscopic surgery elicits a diminished inflammatory response than equivalent open surgery. Despite these claims, the evidence is conflicting. Therefore, we aimed to systematically review the results from randomized controlled clinical trials comparing the humoral response associated with laparoscopic versus open colorectal surgery.

MATERIALS AND METHODS

A high-sensitivity search was conducted independently by two of the authors with no language restriction. Studies were identified from the Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline (January 1966 to January 2009), PubMed (1950 to January 2009), and Embase (1947 to January 2009). Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager ver. 5.0.

RESULTS

Thirteen randomized controlled trials were included. Meta-analysis demonstrated a significantly higher serum IL-6 on d 1 after open colorectal resection for neoplasia (n = 97) compared with laparoscopic resection (n = 76, P = 0.0008) without significant heterogeneity. Data for plasma IL-6 were heterogeneous, with no apparent difference between groups. No other significant differences were identified, and there were not enough data on local peritoneal humoral factors to allow meta-analysis.

CONCLUSION

Open colorectal resection for neoplasia is associated with higher postoperative serum levels of IL-6 on d 1 than equivalent laparoscopic surgery. The aetiology and clinical significance of this finding is uncertain, and further studies are required to elucidate any differences in the local humoral response which may be more clinically relevant in surgery for this indication.

Consequences of surgical stress on the kinetics of skin wound healing: partial hepatectomy delays and functionally alters dermal repair

The objective was to determine the significance of surgical trauma in dermal wound healing. Using intravital microscopy, we analyzed the healing kinetics of full-thickness dermal wounds in the ears of SKH1 mice. Partial hepatectomy (pHx) simulated major surgical trauma, while laparotomy only served as a sham operation (sham). Animals without abdominal surgery served as controls (control). Laparotomy wounds were analyzed for biomechanical qualities and collagen deposition. Morphological characterization of skin repair was performed by histology/immunohistochemistry. In vitro cell assays assessed the paracrine effects of surgical stress. PHx caused a transient increase in tumor necrosis factor-alpha (TNF-alpha) and interleukin (IL)-6 levels and led to weight loss, reflecting the host's overall response to surgery. Wound closure in pHx animals was delayed vs. control and sham animals, as indicated by significantly lower values of epithelialization and neovascularization over 10 days. Ear wound histology further revealed a provisional wound matrix with a reduced microvessel density. Moreover, pHx-laparotomy wounds showed a reduced bursting strength coexisting with significantly decreased collagen content. PHx and sham serum caused a significant alteration in in vitro fibroblast viability. Skin healing is dependent on the extent of surgery and is influenced by its paracrine effects. Therefore, considerable effort should be focused on the development of strategies limiting surgery-associated perturbations of dermal repair.

The immunomodulatory effects of laparoscopic surgery

Laparoscopic alternatives to conventional surgical procedures confer many advantages to patients including reduced postoperative pain, shortened convalescence and, perhaps, improved disease-related outcomes. The diminished degree of immune dysfunction apparent with these techniques may underpin these beneficial aspects. However, minimal access is accompanied by various ancillary anesthetic and mechanical associations (including the induction of a carbon dioxide pneumoperitoneum), which must be considered in addition to reduced tissue trauma when attempting to correlate cause with effect. Furthermore, the opportunity to establish causation between the immunomodulatory aspects of laparoscopy and subsequent clinical outcome by prospective, randomized study is difficult because of the rapid incorporation of minimal access techniques into clinical practice. Therefore, experimental in vitro and in vivo studies must be used to complement the limitations of clinical studies in this area. Although the initial investigations into the immunological effects of laparoscopy are encouraging, many of the intricacies associated with this approach still await elaboration.

Factors predicting postoperative infectious complications and early induction of inflammatory mediators in ulcerative colitis patients

BACKGROUND

Positive outcomes after restorative proctocolectomy are compromised by a number of specific septic complications. However, there is no useful perioperative marker predicting postoperative infectious complications (PICs) in steroid overdosed patients with ulcerative colitis (UC).

METHODS

To determine factors associated with PICs and their relation to circulating levels of pro- and anti-inflammatory cytokines and neutrophil elastase (NE), we obtained perioperative blood samples from 60 UC patients.

RESULTS

Postoperative infectious complications were identified in 47% of cases. Patients who developed PICs had significantly longer disease duration, had been administered a greater total preoperative dosage of prednisolone, and had a higher body mass index. Logistic regression analysis showed that the total preoperative dosage of prednisolone was independently associated with the development of PICs. These patients showed suppressed systemic inflammation and pro- and anti-inflammatory cytokine induction. An early increase in the NE level was found to be predictive of PICs in the high-dose group, whereas there was no significant difference in neutrophil counts between the high- and low-dose groups.

CONCLUSIONS

Circulating NE levels in the early postoperative period might be a useful predictor of PICs in immune-controlled UC patients who received high doses of steroids.

Respiratory function after laparoscopic distal gastrectomy--an index of minimally invasive surgery

BACKGROUND

As the techniques of laparoscopic surgery have improved, various institutions have performed laparoscopic gastrectomies with regional lymph node dissection, as well as open surgery. Although alleviation of postoperative pain and prompt recovery have been reported in the literature, objective indexes of the minimal invasiveness of laparoscopic procedures are as yet very few.

METHODS

We performed distal gastrectomy with regional lymph node dissection for gastric cancer patients using three kinds of procedures, namely, open gastrectomy, hand-assisted laparoscopic surgery (HALS), and totally laparoscopic gastrectomy. Ablation of the stomach, lymph node dissection, and reconstruction of the digestive tract were all carried out intracorporeally with or without HALS in the laparoscopic procedures. The ordinary respiratory function test was performed pre- and postoperatively for 50 patients operated on by each procedure, and the reduced percentages of the measured values were calculated.

RESULTS

Postoperative respiratory function was consistently excellent, with minimal loss of vital capacity and forced expiratory volume per second in the totally laparoscopic group compared to HALS or open cases.

CONCLUSIONS

Although it may be a complicated technique, totally laparoscopic distal gastrectomy is considered a minimally invasive procedure for gastric cancer from the viewpoint of postoperative respiratory function.

Is there any difference in recurrence rates in laparoscopic ileocolic resection for Crohn's disease compared with conventional surgery? A long-term, follow-up study

PURPOSE

The long-term outcome of laparoscopic ileocolic resection in patients with Crohn's disease is not well defined. This study was designed to define the surgical recurrence rate after laparoscopic ileocolic resection for Crohn's disease and to compare it with that seen after open ileocolic resection.

METHODS

A retrospective review of 113 records of patients who underwent index ileocolic resection for terminal ileal Crohn's disease was performed (1987-2003). Recurrence was defined as development of new preanastomotic Crohn's disease requiring surgical intervention. Details of recurrence and use of chemoprophylaxis was determined by phone interview and chart review.

RESULTS

Sixty-three patients (26 males; mean age, 35.2 years) underwent laparoscopic ileocolic resection and 50 had open ileocolic resection (17 males; mean age, 37.1 years). Surgical recurrence developed in 6 of 63 patients (9.5 percent) in the laparoscopic ileocolic resection group (mean follow-up, 62.9 months) and in 12 of 50 patients (24 percent) in the open ileocolic resection group (mean follow-up, 81.8 months). Rates of chemoprophylaxis were similar between groups (laparoscopic ileocolic resection, 39 percent; open ileocolic resection, 54 percent; P = not significant). Median times to recurrence after laparoscopic ileocolic resection and open ileocolic resection were 60 (range, 36-72) months and 62 (range, 12-180) months, respectively. Fifty percent of the recurrences in the laparoscopic ileocolic resection group and 4 of 12 in the open ileocolic resection group were able to be retreated laparoscopically. Re-recurrence occurred in 4 of 12 open ileocolic resection patients (33 percent) at a mean of 63.6 months, and one patient had a third recurrence at 28 months.

CONCLUSIONS

In this study, the long-term outcome after laparoscopic ileocolic resection was not shown to be statistically different from that of open ileocolic resection. The relatively low recurrence rates in both groups may be explained by our aggressive use of chemoprophylaxis.

Quantitative detection of changes in cytokine gene expression in peripheral blood mononuclear cells correlates with and precedes acute rejection in renal transplant recipients

Immunological monitoring of transplant recipients is an attractive concept. Cytokines provide an obvious focus for research, as they are central to the human immune response. This study aimed to identify cytokines whose sequential gene expression differentiated rejectors from non-rejectors immediately following renal transplantation. Forty-five renal transplant recipients (15 rejectors) and 13 living donors were recruited. Total RNA was extracted from the peripheral blood mononuclear cells and reverse transcribed. Cytokine gene expression levels of IL-4, IL-10, TNF-alpha and TGF-beta1 were measured using TaqMan. IL-10 expression increased significantly following donor surgery. IL-4 and TNF-alpha patterns clearly differentiated between rejectors and non-rejectors. In the rejectors significant increases occurred more than 48 h before clinical graft dysfunction. Negative predictive values were 76% and 80% for IL-4 and TNF-alpha, respectively. This study has identified two cytokines (IL-4 and TNF-alpha) whose gene expression patterns differentiate between rejecting and non-rejecting renal transplant recipients making immunological monitoring possible.

Laparoscopic TME: better vision, better results?

One of the most controversial discussions on laparoscopic surgery deals with the question of whether to apply this technique to malignant disease and specifically to rectal cancer. The four major issues are the adequacy of oncologic resection, recurrence rates and patterns, long-term survival and quality of life. There is evidence, from nonrandomized studies, suggesting that margins of excision and lymph node harvest achieved laparoscopically reached comparable results to those known from conventional open resection. Our own experience of laparoscopic surgery on rectal cancer is based on 52 patients treated with curative intent. Focusing on the postoperative long-term run, we gained the following results: The median age of patients was 66.7 years and ranged from 42-88. Anastomotic leakage was seen in 6.1% of cases. In a median follow-up of 48 months (36-136), we reached an overall 3-year survival rate of 93% and a 5-year survival rate of 62%. Local recurrence was 1.9%, distant metastasis occurred in 11.5% of cases. We saw no port-site metastasis. To evaluate functional results following laparoscopic surgery a matched pair analysis was carried out. Matching of patients after laparoscopic and conventional open surgery was performed according to sex, age, type of resection, time period of surgery, and stage of disease classified by UICC. Regarding bladder and sexual dysfunction, using the EORTC QLQ CR38 score we found no statistical significant difference between the examined groups. As far as can be seen, laparoscopic surgery in rectal carcinoma may achieve the same or, in selected patients, even better results than open surgery. However, at present no published study has shown much evidence. Many more studies are necessary to define the place of laparoscopic technique in rectal cancer surgery, regarding appropriate selection of patients and evaluating adjuvant or neoadjuvant treatment in combination with the laparoscopic approach.

The net immunologic advantage of laparoscopic surgery

The trauma of surgery evokes a variety of physiologic and immunologic alterations that should contribute to host defense. However, an exaggerated response to injury may result in immunosuppression and lead to significant postoperative morbidity and mortality. Laparoscopic surgery may result in less induced surgical trauma than conventional open surgery. Decreased postoperative pain and speedy functional recovery of laparoscopic patients may be attributable to the reduced inflammatory response and minimal immunosuppression. Inflammation, an early protective homeostatic immune response to injury, is characterized by the production of proinflammatory cytokines and by activation of cellular and humoral immune mechanisms. Postoperative levels of the inflammatory cytokines have been consistently lower after laparoscopic procedures, indicating a smaller degree of surgical insult and acute inflammatory reaction. Surgical stress derails the functions of both polymorphonuclear and mononuclear cells, which may lead to an increased risk of postoperative infection. Comparative studies of cellular immunity after laparoscopic and conventional surgery demonstrate immunologic advantage conferred by laparoscopy. Exaggerated activation of peritoneal immunity may lead to a relative local immunosuppression, resulting in ineffective intraperitoneal bacterial clearance and serious postoperative infections. Functions of the peritoneal macrophages are better preserved when laparotomy is avoided. Decreased perioperative stress may be particularly important for oncologic patients. Laparoscopic approaches may result in diminished perioperative tumor dissemination and better cancer outcomes. Although laparoscopy is "minimally invasive," systemic immune responses still are undeniably activated. However, laparoscopic surgery appears to induce a smaller injury, resulting in proportionally decreased immunologic changes. In addition to improved cosmesis and faster functional recovery, a patient undergoing laparoscopic surgery may benefit most from a net immunologic advantage.

Surgical trauma: hyperinflammation versus immunosuppression?

BACKGROUND

Experimental and clinical studies have brought evidence that surgical trauma markedly affects the immune system, including both the specific and the non-specific immune response.

MATERIALS AND METHODS

This report reviews the present knowledge on the mechanisms of surgical trauma-induced immune dysfunction and outlines experimental and clinical approaches to find effective treatment strategies.

RESULTS

Major surgical trauma induces an early hyperinflammatory response, which is characterized by (1) pro-inflammatory tumour necrosis factor alpha (TNF), interleukin (IL)-1, and IL-6 cytokine release and (2) neutrophil activation and microvascular adherence, as well as (3) uncontrolled polymorphonuclear (PMN) and macrophage oxidative burst. The massive and continuous IL-6 release induces an acute phase response, but, more importantly, also accounts for the up-regulation of major anti-inflammatory mediators, such as prostaglandin (PG) E2, IL-10 and transforming growth factor (TGF)-ss. This results in surgical, trauma-induced, immunosuppression, as indicated by (1) monocyte deactivation, reflected by the lack of monocytic TNF- production upon lipopolysaccharide (LPS) stimulation, and (2) a shift of the Th1/Th2 ratio towards a Th2-dominated cytokine pattern. The imbalance between pro-inflammatory and anti-inflammatory cytokines and immuno-competent cells determines the phenotype of disease and should help the physician to compose the therapeutic strategy. In fact, recent clinical studies have shown that both the initial uncontrolled hyperinflammation and the continued cell-mediated immunosuppression represent primary targets to counteract post-surgery immune dysfunction. The balance between inflammatory and anti-inflammatory forces may be restored by interferon gamma (IFN-gamma) to counteract monocyte deactivation; the anti-inflammatory PGE2 may be inhibited by indomethacin to attenuate immunosuppression; or the initial hyperinflammation may be targeted by administration of anti-inflammatory substances, such as granulocyte colony-stimulating factor (G-CSF), hydoxyethyl starch, or pentoxifylline.

CONCLUSIONS

When drawing up the therapeutic regimen the physician should not consider hyperinflammation versus immunosuppression, but hyperinflammation and immunosuppression, aiming at restoring an appropriate mediator- and immune cell-associated balance.

Current concepts and controversies in surgery for IBD

Surgery improves the quality of life in patients with Crohn's disease (CD) and cures patients with chronic ulcerative colitis (CUC). There are several surgical controversies primarily involving techniques and long-term outcomes. Some debates are long standing; whether to perform a double-stapled ileal pouch-anal anastomosis (IPAA) or a mucosectomy and hand-sewn anastomosis, and whether to divert or not to divert in patients with CUC undergoing an IPAA. Other issues are more recent, such as the effects of age, pregnancy, pouch salvage, and laparoscopic IPAA. In patients with Crohn's disease the anastomosis technique, the management of perianal disease, and the role of laparoscopic surgery are topics of debate. This review shows the current concepts and controversies in the surgical management of patients with CUC or CD.

Laparoscopic-assisted bowel resection offers advantages over open surgery for treatment of segmental Crohn's disease in children

BACKGROUND/PURPOSE

Minimally invasive approaches have been shown to decrease hospital length of stay (LOS), decrease postoperative pain, and speed return to normal activity for a number of intraabdominal procedures. In this study, laparoscopic (LAP)-assisted bowel resection is compared with an open technique for patients undergoing an initial bowel resection.

METHODS

A retrospective review was conducted of 28 patients (12 LAP, 16 open) undergoing initial bowel resection for segmental Crohn's disease.

RESULTS

Patients in the LAP group had decrease LOS (5.5 days v 11.5 days) decreased days of parenteral narcotics (3 days v 5 days) and more rapid return to regular diet (3 days v 5 days).

CONCLUSIONS

The data suggest that the laparoscopic approach may offer advantages to pediatric patients undergoing an initial bowel resection for segmental Crohn's disease.

Laparoscopic colectomy in obese and nonobese patients

Obese patients carry a higher risk of wound complications and cardiopulmonary complications along with a higher incidence of comorbidity, all of which have the potential to affect outcome after a variety of surgical procedures. The data regarding outcomes after laparoscopic colectomy in obese and nonobese patients are limited. The purpose of this report was to compare the outcome of laparoscopic bowel resection in obese and nonobese patients. All patients prospectively entered into a laparoscopic bowel resection database from March 1999 to December 2001, who underwent a segmental colectomy for any pathologic condition, were analyzed. Patients with a body mass index above 30 were defined as obese, and patients with a body mass index below 30 were defined as nonobese. Data collected included age, sex, duration of operation, body mass index, American Society of Anesthesiologists score, operative procedure, diagnosis, complications relating to length of hospital stay, mortality, and readmission within 30 days of discharge. Statistical analysis consisted of Student's t test and chi-square analysis where appropriate, with significance set at P < 0.05. A total of 260 patients were evaluated (201 [77.3%] in the nonobese group and 59 [22.7%] in the obese group). There were no significant differences between the two groups with respect to age, sex, operative procedure, length of hospital stay, or readmission rates. The obese group had significantly more conversions to an open procedure (23.7% vs. 10.9%), a longer operative duration (109 minutes vs. 94 minutes), a higher morbidity rate (22% vs. 13%) and a higher anastomotic leakage rate (5.1% vs. 1.2%). This large experience with laparoscopic colectomy for a variety of conditions demonstrates that despite higher conversion rates, an increased risk of pulmonary complications, and anastomotic leakage rates in obese laparoscopic patients that parallel those of open surgery, laparoscopic colectomy can be performed safely in both obese and nonobese patients with the similar benefit of a shorter hospital stay in both groups.

What role, if any, for laparoscopic surgery in Crohn's disease of the hindgut?

An outsider to the field of surgery would probably take it for granted that surgeons have a highly developed rationale for choosing a laparoscopic approach to Crohns disease. After all, an increasing number of surgeons are performing laparoscopic surgery for Crohns disease as witnessed by several articles published in the 1990s (Table). In fact this is not quite true. Most papers are case reports or series without controls, capable only of suggesting feasibility. Furthermore, comparison studies often feature selection flaws, and therefore beg the question of whether laparoscopic surgery should or not be considered as standard care. An attempt is made herein to give readers a concise insight of the evidence available in the English language literature. It does not pretend to offer a comprehensive review of the topic rather, it highlights some relevant issues, and then outlines what role, if any, laparoscopic surgery should play in Crohn's disease. There are at least 6 categories for discussion.

Laparoscopic surgery for inflammatory bowel disease: current concepts

BACKGROUND

The aim of a laparoscopic approach is reduced pain scores, early mobilization, virtual absence of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital and return to normal activity and improved cosmetics. Potential advantages are fewer complications due to adhesion formation, viz. small-bowel obstruction, infertility and chronic abdominal pain-advantages that are of particular importance to patients with inflammatory bowel disease (IBD) since they are young and in the middle of building up their socio-economic life. This review highlights the current status of laparoscopic surgery for patients with IBD.

METHODS

Virtually all abdominal procedures carried out in patients with IBD can be done laparoscopically, and vary from stoma formation to restorative proctocolectomy.

RESULTS

Conversion rates and operating times depend on the surgical expertise and patient-related factors, viz. prior laparotomy, the presence of intestinal fistula or inflammatory masses. Morbidity rates are similar to those of open surgery provided that the procedures are done by expert laparoscopic surgeons. The observed earlier recovery contributed to laparoscopic surgery has not been proved in well-conducted trials; however, an advantage can be expected. A very obvious feature of laparoscopic surgery is the improved cosmetics, which might turn out to be the most important advantage of the laparoscopic approach in this relatively young patient group.

CONCLUSION

The laparoscopic approach can be considered the procedure of first choice in patients with IBD provided the surgery is done by expert laparoscopists ensuring low conversion rates, acceptable operating times and low morbidity.

Care of the laparoscopic colectomy patient

Laparoscopic bowel surgery has demonstrated patient care benefits of decreased duration of hospital stay, smaller incisions, lower risk of cardiopulmonary complications, and reduced risk of small-bowel obstruction. Resection of complicated diverticular disease and inflammatory bowel disease can be technically challenging and may be associated with higher conversion rates. The applicability of these techniques to colon cancer is supported by a growing body of evidence that demonstrates similar survival and recurrence rates obtained by open resection and the exaggeration of the risk of port site recurrences. Laparoscopic colorectal surgery has also challenged much of the standard postoperative care plans used for colectomy. Optimal postoperative care of the laparoscopic colectomy patient requires an appreciation of the faster recovery enjoyed by these patients and the fact that ambulation and dietary advancement need to be accelerated. Coordination between the surgical team and the postoperative care team is essential to obtain all the benefits associated with this new approach to the management of colorectal disease.

Comparison of surgical stress between laparoscopy and open surgery in the field of urology by measurement of humoral mediators

BACKGROUND

Recently, laparoscopic procedures have become more common in urological surgery, and are suggested to be less stressful compared with open surgery; however, little data on objective evaluation of surgical stress after laparoscopic surgery are available. The objective of this study was to compare surgical stress between laparoscopic and open surgery in the field of urology by measurement of humoral mediators.

METHODS

Blood samples were obtained from 25 patients who underwent laparoscopic surgery (laparoscopic radical prostatectomy, 10; retroperitoneoscopic nephrectomy or nephroureterectomy, seven; laparoscopic adrenalectomy, five; and hand-assisted laparoscopic radical nephrectomy, three) and 10 who underwent open surgery (retropubic radical prostatectomy, four; radical cystectomy, three; and radical nephrectomy, three), 48 h before surgery, during surgery, and 24, 48 and 96 h after surgery. Serum levels of interleukin (IL)-6, IL-10 and granulocytic elastase in these samples were measured, and the results were analyzed with respect to several clinical factors.

RESULTS

In both groups, IL-6 and granulocytic elastase levels increased during surgery and reached maximum levels 24 h after surgery; the increase in granulocytic elastase tended to be prolonged compared with that of IL-6. Changes in IL-10 levels in the open surgery group were similar to those of IL-6 and granulocytic elastase levels, whereas IL-10 levels in the laparoscopic surgery group reached a maximum level during surgery and then decreased to the same level as at 48 h before surgery, on the first postoperative day. The maximum levels of these three mediators in the laparoscopic surgery group were significantly lower than those in the open surgery group. IL-6 was closely associated with the interval of fasting and duration of hospitalization after surgery.

CONCLUSION

Although the present study was based on retrospective and non-randomized analysis, the findings suggest that serum levels of IL-6, IL-10 and granulocytic elastase are useful as objective markers of surgical stress, and that laparoscopic surgery is markedly less stressful than open surgery.

Laparoscopic-assisted versus open ileocolic resection for adolescent Crohn disease

BACKGROUND

Laparoscopic-assisted ileocolic resection for Crohn disease has been reported as an acceptable alternative to the open procedure in adults. We evaluated our experience with this procedure in the adolescent population.

METHODS

All adolescents undergoing ileocolic resection for Crohn disease during a 3-year period were retrospectively reviewed. Intraoperative and early postoperative results were analyzed, comparing those undergoing the laparoscopic-assisted approach with those having open resection.

RESULTS

Eleven patients (mean age, 15.6 years) underwent open and 12 patients (mean age, 16.5 years) underwent laparoscopic-assisted resection. None had undergone previous resection. The two groups did not differ with respect to time from diagnosis to surgery, indications for surgery, preoperative medical therapy, operative time, or length of intestine resected. One patient in the laparoscopic-assisted group was converted to an open procedure. There were no intraoperative complications in either group. Although no statistically significant differences were noted for number of days on narcotic, total dosage of narcotic, and time to regular diet, patients undergoing laparoscopic-assisted resection were discharged 2.2 days earlier (5.4 vs. 7.6; P < 0.05). There was one wound infection and one intraabdominal abscess in the open resection group, and a single patient in the laparoscopic-assisted group with postoperative fever and a wound infection.

CONCLUSIONS

Laparoscopic-assisted ileocolic resection is a safe alternative to open surgery in adolescent patients with Crohn disease.

Can laparoscopy reduce hospital stay in the treatment of Crohn's disease?

PURPOSE

The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohn's disease who underwent laparoscopy compared with open surgery.

METHODS

Among 51 consecutive patients with inflammatory bowel disease (1996-2000), 46 with Crohn's disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures).

RESULTS

There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes) vs. the open group (244.7 minutes) (P < 0.05), but this difference disappeared when data were adjusted for the extra time required to perform the laparoscopic hand-sewn anastomoses (288.2 minutes vs. 244.7 minutes). Bowel function returned more quickly in the laparoscopic group vs. the open group in terms of passage of flatus (3.7 vs. 4.7 days) (P < 0.05) and resumption of oral intake (4.2 vs. 6.3 day) (P < 0.01). There were significantly fewer postoperative complications in the laparoscopic group (9.5 percent) vs. the open group (18.5 percent) (P < 0.05); the length of stay was significantly shorter in the laparoscopic group (8.3 days) vs. the open group (13.2 days) (P < 0.01); and the cost of hospital admission was significantly lower in the laparoscopic group ($6106, United States dollars) vs. the open group ($9829, United States dollars) (P < 0.05).

CONCLUSION

There is a reduction in the postoperative ileus, length of stay, cost of hospital admission, and postoperative complication rate in the laparoscopic group. Laparoscopic surgery for Crohn's disease is safe, and it is potentially more cost-effective than traditional open surgery.

Effect of laparoscopy on immune function

BACKGROUND

Laparoscopic surgery is believed to lessen surgical trauma and so cause less disturbance of immune function. This may contribute to the rapid recovery noted after many laparoscopic operations. Preservation of both systemic and intraperitoneal immunity is particularly important in surgery for sepsis or cancer and so an understanding of the impact of laparoscopy on immune function is relevant.

METHODS

Literature on immunological changes following laparoscopy and open surgery was identified from Medline, along with cross-referencing from the reference lists of major articles on the subject.

RESULTS AND DISCUSSION

Despite a few contradictory reports, systemic immunity appears to be better preserved after laparoscopic surgery than after open surgery. However, the local intraperitoneal immune system behaves in a particular way when exposed to carbon dioxide pneumoperitoneum; suppression of intraperitoneal cell-mediated immunity has been demonstrated in a number of studies. This feature may be clinically important and should be acknowledged when considering laparoscopic surgery in patients with malignancy or sepsis.

Lessons from laparoscopic surgery-a fresh look at post-operative management after major colorectal procedures

OBJECTIVE

Laparoscopy holds promise of exciting advances in colorectal surgery, yet the data we require to draw appropriate evidence-based conclusions on its apparent advantages are sadly lacking. In the meantime, our focus on improved recovery after major colorectal resections has changed the way we manage patients after open surgery.

METHODS

A literature review was undertaken to collect published data on laparoscopic colorectal surgery. In addition, data on newer developments in open colorectal surgery were collected.

RESULTS

Although there are many published data in laparoscopic colorectal surgery, very few are randomized and controlled. It is clear that, at least in the short to medium term, oncological outcomes are comparable to open surgery. There are data suggesting advantages, including less immune suppression, faster recovery with earlier feeding, less ileus, shorter length of stay and earlier return to normal activity.

CONCLUSION

Unfortunately, due to study design the data are largely not comparable with open surgery data, and open surgery itself has changed to some extent recently. We must encourage recruitment of patients into current ongoing randomized controlled trials of laparoscopic and open surgery and await the results.