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Wickramasinghe D, Carvello M, Di Candido F, Maroli A, Adegbola S, Sahnan K, Morar P, Spinelli A, Warusavitarne J. Factors associated with stoma formation in ileocolic resection for Crohn's disease and the development of a predictive scoring system. Langenbecks Arch Surg 2022; 407:2997-3003. [PMID: 35906298 DOI: 10.1007/s00423-022-02626-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE The likelihood of a stoma following ileocolic resection (ICR) for Crohn's disease (CD) is an important consideration. This study aims to identify the factors associated with an increased likelihood of a stoma and develop a predictive scoring system (SS). METHODS Patient data were collected from St. Marks Hospital, London, UK and Humanitas Clinical and Research Center, Milan, Italy, on all patients who underwent an ICR for CD from 2005 to 2017. A logistic regression analysis was used for multivariate analysis. The SS was developed from the logistic regression model. The performance of the SS was evaluated using receiver operating characteristics area under the curve (AUROC). RESULTS A total of 628 surgeries were included in the analysis. Sixty-nine surgeries were excluded due to missing data. The remaining 559 were divided into two cohorts for the scoring system's development (n = 434) and validation (n = 125). The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included sex, preoperative albumin and haemoglobin levels, surgical access and simultaneous colonic resection. The AUROC for the development and validation cohorts were 0.803 and 0.905, respectively (p < 0.0001). Youden's index suggested the cut-off score of - 95.9, with a sensitivity of 87.6% and a specificity of 62.9%. CONCLUSIONS Male sex, low preoperative albumin, anaemia, laparoscopic conversion and simultaneous colonic resection were associated with an increased likelihood of requiring a stoma and were used to develop an SS. The calculator is available online at https://rebrand.ly/CrohnsStoma .
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Affiliation(s)
- Dakshitha Wickramasinghe
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
- St. Mark's Hospital, London, UK.
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Loras C, Mañosa M, Andújar X, Sánchiz V, Martí-Gallostra M, Zabana Y, Gutiérrez A, Barreiro-de Acosta M. Position Statement. Recommendations of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the treatment of strictures in Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:315-334. [PMID: 34274357 DOI: 10.1016/j.gastrohep.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
Abstract
Despite pharmacological advances, strictures in Crohn's disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.
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Affiliation(s)
- Carme Loras
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España.
| | - Miriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Departamento de Gastroenterología, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Xavier Andújar
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Vicente Sánchiz
- Servicio de Medicina Digestiva. Hospital Clínico Universitario. Valencia, España
| | - Marc Martí-Gallostra
- Departamento de Cirugía Colorectal, General y Digestiva. Hospital Universitari de la Vall d'Hebron. Barcelona, España
| | - Yamile Zabana
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Hospital General Universitario de Alicante, Alicante, España
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Reynolds IS, Doogan KL, Ryan ÉJ, Hechtl D, Lecot FP, Arya S, Martin ST. Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection. Front Surg 2021; 8:804137. [PMID: 34977147 PMCID: PMC8718441 DOI: 10.3389/fsurg.2021.804137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.
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Affiliation(s)
- Ian S. Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
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Open versus minimally invasive small bowel resection for Crohn's disease: a NSQIP retrospective review and analysis. Surg Endosc 2021; 36:6278-6284. [PMID: 34853919 DOI: 10.1007/s00464-021-08927-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Many patients with Crohn's Disease will require surgical resection. While many studies have described outcomes following ileocecectomy, few have evaluated surgical resection of other portions of small bowel. We sought to compare open and minimally invasive surgery (MIS) approaches for small bowel resection excluding ileocecectomy of patients with Crohn's Disease using the National Surgical Quality Improvement Program (NSQIP) database. METHODS The NSQIP database was queried for patients with Crohn's disease or complications related to Crohn's disease who underwent segmental small bowel resection utilizing open or minimally invasive approaches between 2012 and 2018. Patients requiring ileocecectomy or diagnosed with ascites, disseminated cancer, pre-operative sepsis, ASA class 5, and patients requiring mechanical ventilation were excluded. The association of pre-operative variables including patient demographic information and comorbidities with surgical approach were examined using Fishers exact test. Intraoperative, and 30-day post-operative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant. RESULTS After exclusions, we found 1697 patients with Crohn's disease who underwent segmental small bowel resection, 1252 of whom underwent open surgery and 445 of whom underwent MIS. After adjusting for possible confounders with multivariable analysis, patients who underwent MIS had a lower incidence of wound events (surgical site, organ space, or deep wound infection, or dehiscence), post-operative bleeding, need for return to the operating room, and shorter total hospital length of stay despite longer operative times compared with open surgery. CONCLUSIONS This retrospective review of NSQIP shows that minimally invasive small bowel resection is associated with equivalent or improved morbidity over open surgery in select patients with small bowel Crohn's Disease. We show that in select patients minimally invasive small bowel resection can be safe and performed for patients with isolated small bowel Crohn's disease.
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The Risk Factors for Complications After Crohn's Disease Surgery. Int Surg 2021. [DOI: 10.9738/intsurg-d-21-00009.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
Crohn's disease needs a multidisciplinary approach, and surgery will ultimately be necessary for most patients. Complications usually occur after surgery.
Objective
This study aims to present complication rates in surgically treated Crohn's disease patients at a single institution and to determine possible risk factors.
Methods
A retrospective analysis of 112 consecutive surgery performed on Crohn's disease patients between 2003 and 2015. The demographic data, patient and disease characteristics, surgery type, and complications were analyzed.
Results
Of 112 patients, 64 (57.1%) were male and 48 (42.9%) were female. The mean age was 34 (range, 18–78) years. The mean follow-up was 114 ± 32.4 (range, 61–197) months. The most common early complications were intra-abdominal abscess formation (n = 10, 8.9%) and wound infection (n = 7, 6.26%). The incisional hernia was the most common late complication (n = 4, 3.6%). Nonmodifiable disease features associated with complications were colonic involvement of the disease (P = 0.001), penetrating disease character (P = 0.037), stoma formation (P = 0.000), fistula (P = 0.008), and concomitant fistula and intra-abdominal abscess existence (P = 0.043). Stoma formation was found to be an independent risk factor for complications (P = 0.001).
Conclusions
Colonic involvement, penetrating disease, fistula, concomitant abscess and fistula, and stoma formation were identified as nonmodifiable risk factors for complications after surgery for Crohn's disease.
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Carmichael H, Peyser D, Baratta VM, Bhasin D, Dean A, Khaitov S, Greenstein AJ, Sylla P. The role of laparoscopic surgery in repeat ileocolic resection for Crohn's disease. Colorectal Dis 2021; 23:2075-2084. [PMID: 33851498 PMCID: PMC10176488 DOI: 10.1111/codi.15675] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/06/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023]
Abstract
AIM Laparoscopic surgery is the preferred approach for primary uncomplicated ileocolic resection (ICR); however, its role for repeat resections is unclear. This study assessed the outcomes of primary and repeated ICRs for Crohn's disease to examine rates of laparoscopy and patient morbidity. METHODS A retrospective review of a prospectively maintained database was conducted at a tertiary centre between 2013 and 2019. All patients undergoing ICRs for Crohn's disease were included. The cohort was divided into three groups based on number of resections-primary (1R), secondary (2R) and tertiary or more (>2R) groups. The primary outcome was 30-day postoperative morbidity. RESULTS Over a 6-year period, 474 patients underwent ICR for Crohn's disease, including 369 primary (1R, 77.8%) and 105 repeat (≥2R, 22.2%) resections. A laparoscopic approach was less common in the ≥2R versus 1R groups (79.0% vs. 93.8%, P < 0.001), but rates of conversion to an open procedure were comparable. Morbidity was higher amongst repeat resections although this was not significant (20.0% vs. 14.1%, P = 0.18). Amongst cases approached laparoscopically (n = 429), rates of conversion and postoperative morbidity did not differ by stage of resection, although operative time was longer for repeat operations. Even in the group undergoing laparoscopy for tertiary or greater resections (>2R, n = 29), the rates of conversion (10%) and morbidity (14%) were relatively low. CONCLUSION In this contemporary series of primary and reoperative ICR for ileal CD, a laparoscopic approach is feasible and safe for the majority of repeat ICRs when performed at a high volume centre.
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Affiliation(s)
- Heather Carmichael
- Department of General Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel Peyser
- Department of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Vanessa M Baratta
- Department of General Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Deepika Bhasin
- Department of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Adrienne Dean
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Sergey Khaitov
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Alexander J Greenstein
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
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Ozgur I, Kulle CB, Buyuk M, Ormeci A, Akyuz F, Balik E, Bulut T, Keskin M. What are the predictors for recurrence of Crohn's disease after surgery? Medicine (Baltimore) 2021; 100:e25340. [PMID: 33832109 PMCID: PMC8036018 DOI: 10.1097/md.0000000000025340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
Surgical resection is an unavoidable part of the current treatment options for Crohn's disease (CD), and more than half of patients develop recurrence. The aim of this study was to investigate the predictors for recurrence in the long-term follow-up of CD patients after surgery.Medical records of consecutive CD patients who were operated on between January 2003 and January 2015 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients were recorded. Recurrence was evaluated based on the Crohn's Disease Activity Index or endoscopic findings.The majority of 112 patients were males (n = 64, 57.1%), and 61 (54.4%) of them were active smokers. The median follow-up was 113 (range: 61-197) months. Disease recurrence occurred in 16 (14.3%) patients at a median of 13.5 months. The endoscopic recurrence rate was 8% (n = 9) at 1 year, 12.5% (n = 14) at 5 years, and 13.4% (n = 15) at 10 years. One (0.9%) patient underwent colonoscopic balloon dilatation at 1 year, and 7 (6.3%) patients needed re-resection at a median of 36 months. The age of the patient at the time of diagnosis (P = .033), penetrating disease behavior (P = .011), intra-abdominal abscess (P = 0.040) and, concomitant fistula and intra-abdominal abscess (P = .017) were associated with disease recurrence.Our study results suggest that the patients' age at the time of diagnosis, penetrating disease, intra-abdominal abscess, and concomitant fistula and abscess are the risk factors for CD recurrence after surgery.
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Affiliation(s)
- Ilker Ozgur
- Gastrointestinal Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University
| | - Cemil Burak Kulle
- Department of General Surgery, VKV Koc University Hospital, VKV Koc University Medicine School
| | | | - Asli Ormeci
- Gastroenterohepatology, Department of Internal Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Filiz Akyuz
- Gastroenterohepatology, Department of Internal Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, VKV Koc University Hospital, VKV Koc University Medicine School
| | - Turker Bulut
- Gastrointestinal Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University
| | - Metin Keskin
- Gastrointestinal Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University
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Kelm M, Anger F, Eichlinger R, Brand M, Kim M, Reibetanz J, Krajinovic K, Germer CT, Schlegel N, Flemming S. Early Ileocecal Resection Is an Effective Therapy in Isolated Crohn's Disease. J Clin Med 2021; 10:jcm10040731. [PMID: 33673222 PMCID: PMC7918661 DOI: 10.3390/jcm10040731] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 12/30/2022] Open
Abstract
Despite the increasing incidence and prevalence of Crohn’s Disease (CD), no curative options exist and treatment remains complex. While therapy has mainly focused on medical approaches in the past, growing evidence reveals that in cases of limited inflammation, surgery can suffice as an alternative primary treatment. We retrospectively assessed the disease course and outcomes of 103 patients with terminal Ileitis who underwent primary surgery (n = 29) or received primary medical treatment followed by surgery (n = 74). Primary endpoint was the need for immunosuppressive medication after surgical treatment (ileocecal resection, ICR) during a two-years follow-up. Rates for laparoscopic ICR were enhanced in case of early surgery, but no differences were seen for postoperative complications. In case of immunosuppressive medication, patients with ICR at an early state of disease needed significantly less anti-inflammatory medication during the two-year postoperative follow-up compared to patients who were primarily treated medically. Furthermore, in a subgroup analysis for patients with localized ileocecal disease manifestation, early surgery consistently resulted in a decreased amount of medical therapy postoperatively. In conclusion primary ICR is safe and effective in patients with limited CD, and the need for immunosuppressive medication during the postoperative follow-up is low compared to patients receiving surgery at a later stage of disease.
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Affiliation(s)
- Matthias Kelm
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Friedrich Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Robin Eichlinger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Markus Brand
- Department of Internal Medicine II, Section of Gastroenterology, Center of Internal Medicine (ZIM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany;
| | - Mia Kim
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Joachim Reibetanz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Katica Krajinovic
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Wuerzburg, 97080 Wuerzburg, Germany; (M.K.); (F.A.); (R.E.); (M.K.); (J.R.); (K.K.); (C.-T.G.); (N.S.)
- Correspondence:
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The Role of Active Inflammation and Surgical Therapy in Crohn's Disease Recurrence. Gastroenterol Res Pract 2020; 2020:2845407. [PMID: 33456458 PMCID: PMC7785378 DOI: 10.1155/2020/2845407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/30/2020] [Accepted: 12/19/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Broide E, Eindor-Abarbanel A, Naftali T, Shirin H, Shalem T, Richter V, Matalon S, Leshno M. Early Surgery Versus Biologic Therapy in Limited Nonstricturing Ileocecal Crohn's Disease-A Decision-making Analysis. Inflamm Bowel Dis 2020; 26:1648-1657. [PMID: 31909420 DOI: 10.1093/ibd/izz282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Surgery is the preferred option for patients with symptomatic localized fibrostenotic ileocecal Crohn's disease (CD) but not for those with predominantly active inflammation without obstruction. The benefit of early surgery in patients with a limited nonstricturing ileocecal CD over biologic treatment is still a debate. OBJECTIVE Our objective is to formulate a decision analysis model based on recently published data to explore whether early surgery in patients with limited nonstricturing CD is preferred over biologic treatment. METHODS We constructed a Markov model comparing 2 strategies of treatment: (1) early surgery vs (2) biologic treatment. To estimate the quality-adjusted life years (QALYs) and the costs in each strategy, we simulated 10,000 virtual patients with the Markov model using a Monte Carlo simulation 100 times. Sensitivity analyses were performed to evaluate the robustness of the model and address uncertainties in the estimation of model parameters. RESULTS The costs were $29,457 ± $407 and $50,382 ± $525 (mean ± SD) for early surgery strategy and biologic treatment strategy, respectively. The QALY was 6.24 ± 0.01 and 5.81 ± 0.01 for early surgery strategy and biologic treatment strategy, respectively. CONCLUSION The strategy of early surgery dominates (higher QALY value [efficacy] and less cost) compared with the strategy of biologic treatment in patients with limited ileocecal CD.
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Affiliation(s)
- Efrat Broide
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Eindor-Abarbanel
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Timna Naftali
- Department of Gastroenterology and Hepatology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Shirin
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tzippora Shalem
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vered Richter
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shay Matalon
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zrifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Faculty of Management, Tel Aviv University, Tel Aviv, Israel
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11
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Schmidt-Wilcke P, Knorr S, Wilhelm T. [The somewhat different cause of an obturation in stenosing terminal ileitis : Case report of a 39-year-old male patient with Crohn's disease]. Internist (Berl) 2020; 61:1298-1303. [PMID: 32945927 DOI: 10.1007/s00108-020-00872-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A possible classical complication of Crohn's disease is the formation of a stenosis, which can occur throughout the course of the disease and can present differently depending on the narrowing of the lumen. This article reports the case of a 39-year-old male patient with a stenosing terminal ileitis, which was ultimately only manifested after obstruction by a foreign body.
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Affiliation(s)
- P Schmidt-Wilcke
- Abteilung für Allgemein- und Viszeralchirurgie, St. Vinzenz Hospital Köln, Mehrheimerstr. 221-223, 50733, Köln-Nippes, Deutschland.
| | - S Knorr
- Abteilung für Allgemein- und Viszeralchirurgie, St. Vinzenz Hospital Köln, Mehrheimerstr. 221-223, 50733, Köln-Nippes, Deutschland
| | - T Wilhelm
- Abteilung für Allgemein- und Viszeralchirurgie, St. Vinzenz Hospital Köln, Mehrheimerstr. 221-223, 50733, Köln-Nippes, Deutschland
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12
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Abstract
Laparoscopic ileocecectomy is advocated as the ideal surgical approach for ileocecal Crohn's disease. Our experience suggests that equivalent outcomes are accomplished through a small right lower quadrant (RLQ) transverse incision in this patient population. We conducted a retrospective chart review of 39 patients undergoing ileocectomy for Crohn's disease using a RLQ transverse incision between 1991 and 2009. The mean operative time was 99 minutes with a mean length of hospital stay of 4.2 days and mean duration until return of bowel function of 2.9 days. There were no deaths or major complications. Long-term follow-up revealed four patients (13%) who required hospitalization for small bowel obstructions, one patient (3%) developed an incisional hernia, and no patients required an ileostomy. Ileocecectomy performed for Crohn's disease using a RLQ transverse incision yielded similar hospital lengths of stay and time to return of bowel function as those published for laparoscopic resection. This approach may result in shorter operative times when compared with the inexperienced surgeon performing a laparoscopic resection. Long-term follow-up revealed the risk for future RLQ ileostomy is low and the development of hernias or bowel obstruction is unlikely.
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Affiliation(s)
- Michael J. Campbell
- From the Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Nathaniel B. Paull
- From the Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Richard C. Thirlby
- From the Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
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13
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Ryan ÉJ, Orsi G, Boland MR, Syed AZ, Creavin B, Kelly ME, Sheahan K, Neary PC, Kavanagh DO, McNamara D, Winter DC, O'Riordan JM. Meta-analysis of early bowel resection versus initial medical therapy in patient's with ileocolonic Crohn's disease. Int J Colorectal Dis 2020; 35:501-512. [PMID: 31915984 DOI: 10.1007/s00384-019-03479-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early bowel resection (EBR) in ileocolonic Crohn's disease (CD) may be associated with more durable remission compared with initial medical therapy (IMT) even when biologic therapy is included. AIM To compare the efficacy of EBR versus IMT for ileocolonic CD METHODS: A systematic search was performed to identify studies that compared EBR (performed < 1 year from initial diagnosis) or IMT for the management of ileocolonic CD. Log hazard ratios (InHR) for relapse-free survival (RFS) and their standard errors were calculated from Kaplan-Meier plots and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (OR). Quality assessment of the included studies was performed using the Newcastle-Ottawa (NOS) and Jadad scales. RESULTS A total of 7 studies with 1863 CD patients (EBR n = 581, 31.2%; IMT n = 1282, 68.8%) were eligible for inclusion. There was a moderate-to-high risk of bias. The median NOS was 8 (range 7-9). There was a reduced likelihood of overall (OR, 0.53; 95% confidence interval (95% CI), 0.34, 0.83; p = 0.005) and surgical (OR, 0.47; 95% CI, 0.24, 0.91; p = 0.03) relapse with EBR. There was also a less requirement for maintenance biologic therapy (OR, 0.24; 95% CI, 0.14, 0.42; p < 0.0001). Patients who underwent EBR had a significantly improved RFS than those who underwent IMT (HR, 0.62; 95% CI, 0.52, 0.73; p < 0.001). There was no difference in morbidity (OR, 1.67; 95% CI, 0.44, 6.36; p = 0.45) between the groups. CONCLUSION EBR may be associated with less relapse and need for maintenance biologic therapy than IMT. 'Upfront' or early resection may represent a reasonable and cost-effective alternative to biologic therapy, especially in biologic-resistant subpopulations.
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Affiliation(s)
- Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland. .,School of Medicine, University College Dublin, Dublin, Ireland.
| | - Gabriel Orsi
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Adeel Zafar Syed
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland
| | - Ben Creavin
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Michael E Kelly
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Kieran Sheahan
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Histopathology, St. Vincent's University Hospital, Dublin, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - Des C Winter
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - James M O'Riordan
- Department of Surgery, Tallaght University Hospital, Tallaght, D24 NR0A, Dublin, Ireland.,School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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14
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Schwartzberg DM, Remzi FH. The Role of Laparoscopic, Robotic, and Open Surgery in Uncomplicated and Complicated Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2019; 29:563-576. [PMID: 31078253 DOI: 10.1016/j.giec.2019.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The incidence of inflammatory bowel disease is increasing and despite advances in medical therapy, patients continue to require operations for complications of their disease. Minimally invasive surgical options have impacted postoperative morbidity dramatically with reduction of pain, length of stay and adhesion formation, but additionally, this population of patients are not only concerned with successful operative therapy but also the ability to return to their lifestyle and cosmetics. Laparoscopic and robotic surgery for Crohn's disease has proven to benefit patients with ileocolic or colonic disease, however complicated disease with phlegmon, abscess or fistulae is best served with a hybrid approach. Ulcerative colitis treatment has seen advancements with laparoscopic and robotic platforms, however the benefits of minimally invasive surgery must be balanced with producible and durable outcomes.
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Affiliation(s)
- David M Schwartzberg
- Department of Surgery, Inflammatory Bowel Disease Center, New York University Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 20016, USA
| | - Feza H Remzi
- Department of Surgery, Inflammatory Bowel Disease Center, New York University Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 20016, USA.
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15
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Bouquot M, Maggiori L, Hain E, Prost A la Denise J, Bouhnik Y, Panis Y. What is the outcome for patients undergoing more than two ileocolonic resections for recurrent Crohn's disease? A comparative study of 569 consecutive procedures. Colorectal Dis 2019; 21:563-569. [PMID: 30659742 DOI: 10.1111/codi.14562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 12/31/2018] [Indexed: 12/23/2022]
Abstract
AIM To assess the outcome for patients undergoing repeated ileocolonic resection for recurrent Crohn's disease (CD). METHOD All patients undergoing ileocolonic resection for terminal ileal CD between 1998 and 2016 in our tertiary care centre were retrospectively reviewed. RESULTS Between 1998 and 2016, 569 ileocolonic resections were performed for CD: 403 of these were primary resections (1R, 71%), 107 second resections (2R, 19%) and 59 were third (or more) resections (> 2R, 10%). The laparoscopic approach rate was significantly less in the > 2R group (20/59, 34%) compared with the 2R (71/107, 66%; P = 0.002) and 1R (366/403, 91%) groups. However, conversion to an open approach did not show any difference between the three groups [1R group 46/366 (13%) vs 2R group 14/71 (20%) vs > 2R group 3/20 (15%); 1R vs > 2R P = 0.750; 2R vs > 2R P = 0.633]. Postoperative morbidity was significantly increased in the > 2R (28/59, 52%) group compared with the 1R group (115/403, 29%; P < 0.001) but showed no difference compared with the 2R group (43/107, 40%; P = 0.365). There was no difference between the groups in the incidence of severe postoperative morbidity (Clavien-Dindo ≥ 3) [1R group n = 24 (6%); 2R group n = 6 (6%); > 2R group n = 4, 7%; 1R vs > 2R P = 0.865, 2R vs > 2R P = 0.761]. CONCLUSION Although the overall morbidity rate was higher, repeated surgery for recurrent CD in patients undergoing three or more ileocolonic resections was not associated with an increased risk of severe postoperative morbidity in our series.
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Affiliation(s)
- M Bouquot
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - E Hain
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - J Prost A la Denise
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - Y Bouhnik
- Department of Gastro-enterology, Inflammatory Bowel Disease and Nutritive Assistance, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP), University Denis Diderot (Paris VII), Clichy, France
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16
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Zambonin D, Giudici F, Ficari F, Pesi B, Malentacchi C, Scaringi S. Preliminary study of short- and long-term outcome and quality of life after minimally invasive surgery for Crohn's disease: Comparison between single incision, robotic-assisted and conventional laparoscopy. J Minim Access Surg 2019; 16:364-371. [PMID: 31031322 PMCID: PMC7597873 DOI: 10.4103/jmas.jmas_61_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The feasibility of minimally invasive approach for Crohn's disease (CD) is still controversial. However, several meta-analysis and retrospective studies demonstrated the safety and benefits of laparoscopy for CD patients. Laparoscopic surgery can also be considered for complex disease and recurrent disease. The aim of this study was to investigate retrospectively the effect of three minimally invasive techniques on short- and long-term post-operative outcome. Patients and Methods We analysed CD patients underwent minimally invasive surgery in the Digestive Surgery Unit at Careggi University Hospital (from January 2012 to March 2017). Short-term outcome was evaluated with Clavien-Dindo classification and visual analogue scale for post-operative pain. Long-term outcome was evaluated through four questionnaires: Short Form Health Survey (SF-36), Gastrointestinal Quality Of Life Index (GIQLI), Body Image Questionnaire (BIQ) and Hospital Experience Questionnaire (HEQ). Results There were 89 patients: 63 conventional laparoscopy, 16 single-incision laparoscopic surgery and 10 robotic-assisted laparoscopy (RALS). Serum albumin <30 g/L (P = 0.031) resulted to be a risk factor for post-operative complications. HEQ had a better result for RALS (P = 0.019), while no differences resulted for SF-36, BIQ and GIQLI. Conclusions Minimally invasive technique for CD is feasible, even for complicated and recurrent disease. Our study demonstrated low rates of post-operative complications. However, it is a preliminary study with a small sample size. Further studies should be performed to assess the best surgical technique.
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Affiliation(s)
- Daniela Zambonin
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Francesco Giudici
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Ferdinando Ficari
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Benedetta Pesi
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Cecilia Malentacchi
- Department of Experimental and Clinical Biomedical Sciences (SBSC) 'Mario Serio', University of Florence, Florence, Italy
| | - Stefano Scaringi
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
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17
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Laparoscopic resection for primary and recurrent Crohn's disease: A case series of over 100 consecutive cases. Int J Surg 2017; 47:69-76. [DOI: 10.1016/j.ijsu.2017.09.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 12/11/2022]
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18
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Ponsioen CY, de Groof EJ, Eshuis EJ, Gardenbroek TJ, Bossuyt PMM, Hart A, Warusavitarne J, Buskens CJ, van Bodegraven AA, Brink MA, Consten ECJ, van Wagensveld BA, Rijk MCM, Crolla RMPH, Noomen CG, Houdijk APJ, Mallant RC, Boom M, Marsman WA, Stockmann HB, Mol B, de Groof AJ, Stokkers PC, D'Haens GR, Bemelman WA. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol 2017; 2:785-792. [PMID: 28838644 DOI: 10.1016/s2468-1253(17)30248-0] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/09/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment of patients with ileocaecal Crohn's disease who have not responded to conventional therapy is commonly scaled up to biological agents, but surgery can also offer excellent short-term and long-term results. We compared laparoscopic ileocaecal resection with infliximab to assess how they affect health-related quality of life. METHODS In this randomised controlled, open-label trial, in 29 teaching hospitals and tertiary care centres in the Netherlands and the UK, adults with non-stricturing, ileocaecal Crohn's disease, in whom conventional therapy has failed were randomly allocated (1:1) by an internet randomisation module with biased-coin minimisation for participating centres and perianal fistula to receive laparoscopic ileocaecal resection or infliximab. Eligible patients were aged 18-80 years, had active Crohn's disease of the terminal ileum, and had not responded to at least 3 months of conventional therapy with glucocorticosteroids, thiopurines, or methotrexate. Patients with diseased terminal ileum longer than 40 cm or abdominal abscesses were excluded. The primary outcome was quality of life on the Inflammatory Bowel Disease Questionnaire (IBDQ) at 12 months. Secondary outcomes were general quality of life, measured by the Short Form-36 (SF-36) health survey and its physical and mental component subscales, days unable to participate in social life, days on sick leave, morbidity (additional procedures and hospital admissions), and body image and cosmesis. Analyses of the primary outcome were done in the intention-to-treat population, and safety analyses were done in the per-protocol population. This trial is registered at the Dutch Trial Registry (NTR1150). FINDINGS Between May 2, 2008, and October 14, 2015, 73 patients were allocated to have resection and 70 to receive infliximab. Corrected for baseline differences, the mean IBDQ score at 12 months was 178·1 (95% CI 171·1-185·0) in the resection group versus 172·0 (164·3-179·6) in the infliximab group (mean difference 6·1 points, 95% CI -4·2 to 16·4; p=0·25). At 12 months, the mean SF-36 total score was 112·1 (95% CI 108·0-116·2) in the resection group versus 106·5 (102·1-110·9) in the infliximab group (mean difference 5·6, 95% CI -0·4 to 11·6), the mean physical component score was 47·7 (45·7-49·7) versus 44·6 (42·5-46·8; mean difference 3·1, 4·2 to 6·0), and the mean mental component score was 49·5 (47·0-52·1) versus 46·1 (43·3-48·9; mean difference 3·5, -0·3 to 7·3). Mean numbers of days of sick leave were 3·4 days (SD 7·1) in the resection group versus 1·4 days (4·7) in the infliximab group (p<0·0001), days not able to take part in social life were 1·8 days (6·3) versus 1·1 days (4·5; p=0·20), days of scheduled hospital admission were 6·5 days (3·8) versus 6·8 days (3·2; p=0·84), and the number of patients who had unscheduled hospital admissions were 13 (18%) of 73 versus 15 (21%) of 70 (p=0·68). Body-image scale mean scores in the patients who had resection were 16·0 (95% CI 15·2-16·8) at baseline versus 17·8 (17·1-18·4) at 12 months, and cosmetic scale mean scores were 17·6 (16·6-18·6) versus 18·6 (17·6-19·6). Surgical intervention-related complications classified as IIIa or worse on the Clavien-Dindo scale occurred in four patients in the resection group. Treatment-related serious adverse events occurred in two patients in the infliximab group. During a median follow-up of 4 years (IQR 2-6), 26 (37%) of 70 patients in the infliximab group had resection, and 19 (26%) of 73 patients in the resection group received anti-TNF. INTERPRETATION Laparoscopic resection in patients with limited (diseased terminal ileum <40 cm), non-stricturing, ileocaecal Crohn's disease in whom conventional therapy has failed could be considered a reasonable alternative to infliximab therapy. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - E Joline de Groof
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Emma J Eshuis
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | | | - Patrick M M Bossuyt
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre, Amsterdam, Netherlands
| | - Ailsa Hart
- Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | | | | | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, Zuyderland Hospital, Sittard, Netherlands; VU University Medical Centre, Amsterdam, Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, Netherlands
| | | | | | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | | | - Casper G Noomen
- Department of Gastroenterology and Hepatology, Medical Centre Alkmaar, Alkmaar, Netherlands
| | | | - Rosalie C Mallant
- Department of Gastroenterology and Hepatology, Flevo Hospital, Almere, Netherlands
| | - Maarten Boom
- Department of Surgery, Flevo Hospital, Almere, Netherlands
| | - Willem A Marsman
- Department of Gastroenterology, Kennemer Gasthuis, Haarlem, Netherlands
| | | | - Bregje Mol
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - A Jeroen de Groof
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Pieter C Stokkers
- Department of Gastroenterology and Hepatology, OLVG West, Amsterdam, Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands.
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Abstract
Laparoscopic colorectal surgery has now become widely adopted for the treatment of colorectal neoplasia, with steady increases in utilization over the past 15 years. Common minimally invasive techniques include multiport laparoscopy, single-incision laparoscopy, and hand-assisted laparoscopy, with the choice of technique depending on several patient and surgeon factors. Laparoscopic colorectal surgery involves a robust learning curve, and fellowship training often lays the foundation for a high-volume laparoscopic practice. This article provides a summary of the various techniques for laparoscopic colorectal surgery, including operative steps, the approach to difficult patients, and the learning curve for proficiency.
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Affiliation(s)
- James Michael Parker
- Department of Surgery, Middlesex Hospital Surgical Alliance, 520 Saybrook Road, Suite S-100, Middletown, CT 06457, USA
| | - Timothy F Feldmann
- Department of Surgery, Capital Medical Center, 3900 Capital Mall Drive Southwest, Olympia, WA 98502, USA
| | - Kyle G Cologne
- Division of Colorectal Surgery, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA.
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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21
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Parés D, Shamali A, Flashman K, O’Leary D, Senapati A, Conti J, Parvaiz A, Khan J. Cirugía laparoscópica en el tratamiento de la enfermedad de Crohn del área ileocecal: impacto de la obesidad en los resultados postoperatorios inmediatos. Cir Esp 2017; 95:17-23. [DOI: 10.1016/j.ciresp.2016.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 11/06/2016] [Accepted: 12/03/2016] [Indexed: 01/26/2023]
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22
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Duraes LC, Stocchi L, Rottoli M, Costedio MM, Gorgun E, Kessler H. What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis? Colorectal Dis 2016; 18:264-72. [PMID: 26709096 DOI: 10.1111/codi.13248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/17/2015] [Indexed: 02/08/2023]
Abstract
AIM The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohn's disease have not been clearly described; such a description is the aim of this study. METHOD An institutional database was queried to identify patients undergoing laparoscopic resection for Crohn's disease through midline incision between 1995 and 2013. Perioperative outcomes were compared among cases completed through their initial extraction site (L), completed after increasing the length of the initial extraction site (IL) for specimen exteriorization, and cases converted to open surgery (C). Univariate and multivariate statistical analyses were performed. RESULTS Out of 309 patients, 52 required IL and 36 required C. Heavier, older, male patients were more likely to require IL or C. There were no differences in disease behaviour (P = 0.260), procedures performed (P = 0.12) or postoperative morbidity (P = 0.33). IL and L groups had a comparable initial length of hospital stay (LOS), which was shorter than in the C group. While there were no significant differences in causes of readmission (P = 0.31), IL had increased readmission rates compared with L [odds ratio (OR) 2.80, P = 0.021] or C (OR 13.89, P = 0.015). When combining initial and readmission LOS, C and IL groups had comparable overall LOS [median ratio (MR) 1.09, P = 0.57], which was significantly longer than in the L group (MR 1.27, P = 0.02). CONCLUSION Extraction site enlargement during laparoscopic surgery for enteric Crohn's disease had no impact on primary LOS. However, the shorter initial LOS was offset by increased readmission rates when compared with formal conversion. The threshold to convert in case of anticipated difficulty due to a large specimen should be low.
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Affiliation(s)
- L C Duraes
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M Rottoli
- Department of Colorectal Surgery, University College of London Hospital, London, UK
| | - M M Costedio
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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23
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Surgical aspects of inflammatory bowel diseases in pediatric and adolescent age groups. Int J Colorectal Dis 2016; 31:301-5. [PMID: 26410260 DOI: 10.1007/s00384-015-2388-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is increasingly encountered in children. Early disease is associated with higher complication rate with increased incidence of surgical intervention. PATIENTS AND METHODS From January 2010 to June 2015, 25 patients in the pediatric and adolescent age groups with IBD underwent surgical intervention in our center. They were classified into two groups. Group I included 15 patients with ulcerative colitis where 5 cases had left colon disease underwent left colectomy, while 10 cases had pancolonic disease underwent total colectomy and anal mucosectomy with ileo-anal or ileal pouch-anal anastomosis with covering ileostomy. Group II included 10 cases with Crohn's disease where the indications for surgery were intestinal obstruction in seven cases, fulminant perianal infection with septic shock in one, perianal fistula and ulcers in one, and growth failure due to resistant intestinal fistula in one. RESULTS Group I included eight males and seven females; mean age at surgery was 10.6 years. There were postoperative complications in seven cases in the form of pelvic abscess and wound infection in one, wound infection in two, and recurrent pouchitis in four cases. Group II contained eight males and two females; mean age at surgery was 6.6 years. Two cases had recurrent symptoms after stricturoplasty. The mean length of time from diagnosis to surgery was 2.4 years (ranging from 6 to 36 months). CONCLUSION A multidisciplinary team is mandatory for proper management of IBD cases. The risk of the disease and the expected surgical complications determine the timing of surgical interference.
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Birindelli A, Tugnoli G, Beghelli D, Siciliani A, Biscardi A, Bertarelli C, Selleri S, Lombardi R, Di Saverio S. Emergency laparoscopic ileo-colic resection and primary intracorporeal anastomosis for Crohn's acute ileitis with free perforation and faecal peritonitis: first ever reported laparoscopic treatment. SPRINGERPLUS 2016; 5:16. [PMID: 26759755 PMCID: PMC4703595 DOI: 10.1186/s40064-015-1619-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/14/2015] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Laparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn's Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy. CASE DESCRIPTION We report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome. CONCLUSIONS Complicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis.
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Affiliation(s)
- A. Birindelli
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
| | - G. Tugnoli
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
| | - D. Beghelli
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
| | - A. Siciliani
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
| | - A. Biscardi
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
| | - C. Bertarelli
- />Maggiore Hospital Pathology Department–Bologna Local Health District, Bologna, Italy
| | - S. Selleri
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
| | - R. Lombardi
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
| | - S. Di Saverio
- />Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy
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Fornaro R, Caratto E, Caratto M, Fornaro F, Caristo G, Frascio M, Sticchi C. Post-operative recurrence in Crohn's disease. Critical analysis of potential risk factors. An update. Surgeon 2015; 13:330-47. [DOI: 10.1016/j.surge.2015.04.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 04/22/2015] [Accepted: 04/26/2015] [Indexed: 12/15/2022]
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Mahida JB, Asti L, Deans KJ, Minneci PC, Nwomeh BC. Laparoscopic bowel resection for pediatric inflammatory bowel disease. J Surg Res 2015; 199:130-6. [DOI: 10.1016/j.jss.2015.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/24/2015] [Accepted: 04/02/2015] [Indexed: 12/14/2022]
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Kuroyanagi H, Inomata M, Saida Y, Hasegawa S, Funayama Y, Yamamoto S, Sakai Y, Watanabe M. Gastroenterological Surgery: Large intestine. Asian J Endosc Surg 2015; 8:246-62. [PMID: 26303730 DOI: 10.1111/ases.12222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 04/10/2015] [Accepted: 04/10/2015] [Indexed: 01/16/2023]
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Widmar M, Cummings DR, Steinhagen E, Samson A, Barth AR, Greenstein AJ, Greenstein AJ. Oversewing staple lines to prevent anastomotic complications in primary ileocolic resections for Crohn's disease. J Gastrointest Surg 2015; 19:911-6. [PMID: 25773759 DOI: 10.1007/s11605-015-2792-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 03/02/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Oversewing staple lines may be a novel way to reduce anastomotic complications after primary ileocolic resections for Crohn's disease (CD). STUDY DESIGN This is a single-institution, non-concurrent cohort study of CD patients undergoing primary ileocolic resections (ICR) with stapled anastomoses from 2007 to 2013. Demographic and clinical characteristics were collected. Propensity scores were calculated for oversewing versus not. Postoperative outcomes within 30 days of surgery were collected. Anastomotic leak, intra-abdominal abscess, small bowel obstruction, and anastomotic bleed were considered major anastomotic complications (MACs). Multivariate analysis controlling for inverse probability weights was used to identify predictors of MACs. RESULTS A total of 269 patients were included, of which 120 had undergone oversewing (OS). After controlling for propensity scores, not oversewing (NOS) and OS groups were similar in all preoperative characteristics with the exception of more laparoscopic resections and intracorporeal anastomoses in the NOS group. On univariate analysis, OS was protective against MACs (odds ratio (OR) 0.29, p < 0.01). In a multivariable model using inverse propensity weights and controlling for laparoscopic and intracorporeal approaches, oversewing remained a significant predictor of reduced MACs (OR 0.37, p < 0.001), while intracorporeal anastomoses increased their likelihood (OR 3.7, p < 0.001). CONCLUSIONS After controlling for clinical and surgical factors, oversewing staple lines in primary ICRs for CD is correlated with reduced MACs.
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Affiliation(s)
- Maria Widmar
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1259, New York, NY, 10029, USA,
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Bellinger J, Munoz-Bongrand N, Pariente B, Baudry C, Chirica M, Gornet JM, Allez M, Cattan P. Endoscopic and Clinical Recurrences After Laparoscopic or Open Ileocolic Resection in Crohn's Disease. J Laparoendosc Adv Surg Tech A 2014; 24:617-22. [DOI: 10.1089/lap.2014.0121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Justine Bellinger
- Department of General, Digestive, and Endocrine Surgery, University Paris VII Denis-Diderot, Paris, France
| | - Nicolas Munoz-Bongrand
- Department of General, Digestive, and Endocrine Surgery, University Paris VII Denis-Diderot, Paris, France
| | - Benjamin Pariente
- Department of Gastro-enterology, Hôpital Saint-Louis, University Paris VII Denis-Diderot, Paris, France
| | - Clotilde Baudry
- Department of Gastro-enterology, Hôpital Saint-Louis, University Paris VII Denis-Diderot, Paris, France
| | - Mircea Chirica
- Department of General, Digestive, and Endocrine Surgery, University Paris VII Denis-Diderot, Paris, France
| | - Jean-Marc Gornet
- Department of Gastro-enterology, Hôpital Saint-Louis, University Paris VII Denis-Diderot, Paris, France
| | - Matthieu Allez
- Department of Gastro-enterology, Hôpital Saint-Louis, University Paris VII Denis-Diderot, Paris, France
| | - Pierre Cattan
- Department of General, Digestive, and Endocrine Surgery, University Paris VII Denis-Diderot, Paris, France
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Lim JY, Kim J, Nguyen SQ. Laparoscopic surgery in the management of Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:200-204. [PMID: 25133022 PMCID: PMC4133519 DOI: 10.4291/wjgp.v5.i3.200] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 04/09/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Crohn’s disease is a chronic inflammatory bowel disease with surgery still frequently necessary in its treatment. Since the 1990’s, laparoscopic surgery has become increasingly common for primary resections in patients with Crohn’s disease and has now become the standard of care. Studies have shown no difference in recurrence rates when compared to open surgery and benefits include shorter hospital stay, lower rates of wound infection and decreased time to bowel function. This review highlights studies comparing the laparoscopic approach to the open approach in specific situations, including cases of complicated Crohn’s disease.
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Abstract
Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.
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Affiliation(s)
- Hope T Jackson
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Timothy D Kane
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA; Surgical Residency Training Program, Division of Pediatric Surgery, Department of Surgery, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Avenue, Northwest, Washington, DC 20010-2970, USA.
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Fleshman JW, Roberts WC. James Walter Fleshman Jr., MD: a conversation with the editor. Proc (Bayl Univ Med Cent) 2014; 27:263-75. [PMID: 24982584 DOI: 10.1080/08998280.2014.11929133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- James W Fleshman
- Departments of Surgery (Fleshman), Pathology (Roberts), and Internal Medicine, Division of Cardiology (Roberts), Baylor University Medical Center at Dallas
| | - William C Roberts
- Departments of Surgery (Fleshman), Pathology (Roberts), and Internal Medicine, Division of Cardiology (Roberts), Baylor University Medical Center at Dallas
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Aarons CB. Laparoscopic surgery for crohn disease: a brief review of the literature. Clin Colon Rectal Surg 2014; 26:122-7. [PMID: 24436660 DOI: 10.1055/s-0033-1348051] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Crohn disease remains a challenging clinical entity, both medically and surgically. It frequently presents in early adulthood and imposes a lifetime exposure to chronic inflammation that can affect the entire gastrointestinal tract. Although the mainstay of therapy is treatment with immunomodulating drugs, ∼70 to 90% of patients with Crohn disease will ultimately require surgery. Furthermore, there are high rates of symptomatic recurrences that may also require surgical intervention over time. There is no definitive cure for Crohn disease and surgery is reserved for failed medical therapy or the complications of the disease, namely, obstruction, septic complications (abscess, perforation), and fistulas. However, the robust inflammatory environment during these periods is not always conducive to a minimally invasive surgical approach. Despite the inherent technical challenges, the literature has increasingly shown that laparoscopy for Crohn disease, in the appropriate setting, is feasible and safe. In fact, it offers many advantages, which are particularly beneficial to this subset of patients, such as fewer wound complications, a shortened hospital course, less tissue trauma and subsequent adhesion formation, and earlier resumption of oral intake and bowel function.
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Affiliation(s)
- Cary B Aarons
- Division of Colon and Rectal Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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Maggiori L, Panis Y. Laparoscopy in Crohn's disease. Best Pract Res Clin Gastroenterol 2014; 28:183-94. [PMID: 24485265 DOI: 10.1016/j.bpg.2013.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 10/19/2013] [Accepted: 11/20/2013] [Indexed: 01/31/2023]
Abstract
In Crohn's disease (CD) surgical management, laparoscopic approach offers several theoretical advantages over the open approach. However, the importance of inflammatory lesions associated with CD, and the frequent presence of adhesions from previous surgery have initially questioned its feasibility and safety. In the present review article we will discuss the role of laparoscopic approach for Crohn's disease surgical management, along with its potential benefits as compared to the open approach.
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Affiliation(s)
- Léon Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), 100 boulevard du Général Leclerc, 92110 Clichy, France.
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Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Is laparoscopic ileocecal resection a safe option for Crohn's disease? Best evidence topic. Int J Surg 2013; 12:22-5. [PMID: 24246171 DOI: 10.1016/j.ijsu.2013.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/15/2013] [Accepted: 11/02/2013] [Indexed: 12/13/2022]
Abstract
A best evidence topic was constructed according to a structured protocol. The question addressed was whether laparoscopic ileocecal resection for Crohn's disease is associated with higher morbidity rates in comparison to open surgery. From a total of 123 articles, 11 studies provided the best available evidence on this topic. Five observational studies, two randomized trials, three follow up studies and a meta-analysis were identified. The primary author, date and country of publication, study type, patient group characteristics, relevant outcome parameters and results of these papers were tabulated. Perioperative morbidity was either similar between the laparoscopic and the open group, or favored the laparoscopic approach. Convalescence was consistently reported to be shorter in the laparoscopic treatment arm, at cost of longer duration of surgery. Limited evidence suggests lower incidence of small bowel obstruction and disease recurrence for laparoscopy, although follow up data are of poor quality. It may be concluded that laparoscopic ileocecal resection is a safe alternative approach to open surgery for uncomplicated Crohn's disease, provided laparoscopic expertise is available.
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Affiliation(s)
- Stavros A Antoniou
- Center for Minimally Invasive Surgery, Hospital Neuwerk, Dünner Str. 214-216, 41066 Mönchengladbach, Germany; Department of General Surgery, University General Hospital of Heraklion, Panepistimiou Ave., 71500 Heraklion, Crete, Greece.
| | - George A Antoniou
- Department of Vascular Surgery, Red Cross Hospital, Athanasaki 1 & Erythrou Stavrou, Ampelokipi, 11526 Athens, Greece
| | - Oliver O Koch
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Seilerstätte 4, 4010 Linz, Austria
| | - Rudolph Pointner
- Department of General and Visceral Surgery, Hospital Zell am See, Paracelsusstr. 8, 5700 Zell am See, Austria
| | - Frank A Granderath
- Center for Minimally Invasive Surgery, Hospital Neuwerk, Dünner Str. 214-216, 41066 Mönchengladbach, Germany
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36
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Chirurgische Behandlung des M. Crohn. COLOPROCTOLOGY 2013. [DOI: 10.1007/s00053-013-0346-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Patel SV, Patel SVB, Ramagopalan SV, Ott MC. Laparoscopic surgery for Crohn's disease: a meta-analysis of perioperative complications and long term outcomes compared with open surgery. BMC Surg 2013; 13:14. [PMID: 23705825 PMCID: PMC3733939 DOI: 10.1186/1471-2482-13-14] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 05/20/2013] [Indexed: 12/13/2022] Open
Abstract
Background Previous meta-analyses have had conflicting conclusions regarding the differences between laparoscopic and open techniques in patients with Crohn’s Disease. The objective of this meta-analysis was to compare outcomes in patients with Crohn’s disease undergoing laparoscopic or open surgical resection. Methods A literature search of EMBASE, MEDLINE, The Cochrane Central Register of Controlled Trials and the US National Institute of Health’s Clinical Trials Registry was completed. Randomized clinical trials and non-randomized comparative studies were included if laparoscopic and open surgical resections were compared. Primary outcomes assessed included perioperative complications, recurrence requiring surgery, small bowel obstruction and incisional hernia. Results 34 studies were included in the analysis, and represented 2,519 patients. Pooled analysis showed reduced perioperative complications in patients undergoing laparoscopic resection vs. open resection (Risk Ratio 0.71, 95% CI 0.58 – 0.86, P = 0.001). There was no evidence of a difference in the rate of surgical recurrence (Rate Ratio 0.78, 95% CI 0.54 – 1.11, P = 0.17) or small bowel obstruction (Rate Ratio 0.63, 95% CI 0.28 – 1.45, P = 0.28) between techniques. There was evidence of a decrease in incisional hernia following laparoscopic surgery (Rate Ratio 0.24, 95% CI 0.07 – 0.82, P = 0.02). Conclusions This is the largest review in this topic. The results of this analysis are based primarily on non-randomized studies and thus have significant limitations in regards to selection bias, confounding, lack of blinding and potential publication bias. Although we found evidence of decreased perioperative complications and incisional hernia in the laparoscopic group, further randomized controlled trials, with adequate follow up, are needed before strong recommendations can be made.
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Affiliation(s)
- Sunil V Patel
- Division of General Surgery, The University of Western Ontario London, Ontario, ON, Canada.
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Abstract
Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.
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Zoccali M, Fichera A. Minimally invasive approaches for the treatment of inflammatory bowel disease. World J Gastroenterol 2012; 18:6756-63. [PMID: 23239913 PMCID: PMC3520164 DOI: 10.3748/wjg.v18.i46.6756] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/13/2012] [Accepted: 08/04/2012] [Indexed: 02/06/2023] Open
Abstract
Despite significant improvements in medical management of inflammatory bowel disease, many of these patients still require surgery at some point in the course of their disease. Their young age and poor general conditions, worsened by the aggressive medical treatments, make minimally invasive approaches particularly enticing to this patient population. However, the typical inflammatory changes that characterize these diseases have hindered wide diffusion of laparoscopy in this setting, currently mostly pursued in high-volume referral centers, despite accumulating evidences in the literature supporting the benefits of minimally invasive surgery. The largest body of evidence currently available for terminal ileal Crohn’s disease shows improved short term outcomes after laparoscopic surgery, with prolonged operative times. For Crohn’s colitis, high quality evidence supporting laparoscopic surgery is lacking. Encouraging preliminary results have been obtained with the adoption of laparoscopic restorative total proctocolectomy for the treatment of ulcerative colitis. A consensus about patients’ selection and the need for staging has not been reached yet. Despite the lack of conclusive evidence, a wave of enthusiasm is pushing towards less invasive strategies, to further minimize surgical trauma, with single incision laparoscopic surgery being the most realistic future development.
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Aytac E, Stocchi L, Remzi FH, Kiran RP. Is laparoscopic surgery for recurrent Crohn's disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study. Surg Endosc 2012; 26:3552-6. [PMID: 22648125 DOI: 10.1007/s00464-012-2361-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/24/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients undergoing abdominal surgery for Crohn's disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn's through midline laparotomy is controversial. METHODS Patients with previous open resection for intestinal Crohn's disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5 years), gender, body mass index (±2 kg/m(2)), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3 years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data. RESULTS 26 patients undergoing laparoscopic ileocolectomy (n = 14), proctocolectomy (n = 5), small bowel resection (n = 4), abdominoperineal resection (n = 1), extended right colectomy (n = 1), and strictureplasty (n = 1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158 min, p = 0.94), estimated blood loss (222 versus 427 ml, p = 0.32), overall morbidity (39 versus 69%, p = 0.051), reoperation rates (8 versus 0%, p = 0.5), postoperative return of bowel function (3.5 ± 1.4 versus 3.9 ± 1.7 days, p = 0.3), mean length of hospital stay (6.4 ± 6.2 versus 6.9 ± 3.5 days, p = 0.12), and readmission rates (8 versus 12%, p = 0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27%, p = 0.01). CONCLUSIONS Surgery for recurrent Crohn's disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.
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Affiliation(s)
- Erman Aytac
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA.
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De Cruz P, Kamm MA, Prideaux L, Allen PB, Desmond PV. Postoperative recurrent luminal Crohn's disease: a systematic review. Inflamm Bowel Dis 2012; 18:758-77. [PMID: 21830279 DOI: 10.1002/ibd.21825] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/15/2011] [Indexed: 12/20/2022]
Abstract
Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.
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Affiliation(s)
- Peter De Cruz
- Department of Gastroenterology and Medicine, St Vincent's Hospital, Melbourne, Australia
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Shaffer VO, Wexner SD. Surgical management of Crohn's disease. Langenbecks Arch Surg 2012; 398:13-27. [PMID: 22350642 DOI: 10.1007/s00423-012-0919-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 01/27/2012] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Crohn's disease is an inflammatory bowel disease that can affect the entire gastrointestinal tract. It is chronic and incurable, and the mainstay of therapy is medical management with surgical intervention as complications arise. Surgery is required in approximately 70% of patients with Crohn's disease. Because repeat interventions are often needed, these patients may benefit from bowel-sparing techniques and minimally invasive approaches. Various bowel-sparing techniques, including strictureplasty, can be applied to reduce the risk of short-bowel syndrome. METHODS A review of the available literature using the PubMed search engine was undertaken to compile data on the surgical treatment of Crohn's disease. RESULTS AND CONCLUSION Data support the use of laparoscopy in treating Crohn's disease, although the potential technical challenges in these settings mandate appropriate prerequisite surgical expertise.
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Affiliation(s)
- Virginia Oliva Shaffer
- Division of General and GI Surgery, Colorectal Surgery, Emory University, 1365 Clifton Rd. NE, Suite 3300, Atlanta, GA 30322, USA.
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Abstract
The surgical and medical management of inflammatory bowel disease (IBD) has significantly evolved over the course of the last two decades. On the medical side, the introduction of biologic therapy has significantly changed the characteristics of the patients undergoing surgery for Crohn's disease (CD), while its impact on the need for surgical intervention and the surgical outcomes of these patients is still debated. On the surgical side, the introduction of and the growing experience with minimally invasive approaches to IBD have had a significant impact on outcomes and quality of life in this patient population. During the past three decades the evidence has been accumulating in favor of a minimally invasive approach to CD. Clearly, this is probably one of the most challenging diseases to treat laparoscopically for the colorectal surgeon, especially when the disease is located in the colon and involves multiple segments.
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Affiliation(s)
- Alessandro Fichera
- Department of Surgery, University of Chicago Pritzker Medical School, MC 5095, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Abstract
Crohn's disease (CD) is a pan-gastrointestinal illness. It is notorious for recurrences which can develop in any segment of the gastrointestinal tract. There are many indications and surgical options for intestinal Crohn's disease . We discuss these options based on the current literature. It is important to note however, that operative treatment is based on the correct diagnosis, clinical presentation, sphincter function and patient motivation. Early and timely referral to a surgeon is paramount. The goals of continued medical therapy need to be clearly defined as do the criteria for referral to surgery.
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Alessandroni L, Bertolini R, Campanelli A, Di Castro A, Natuzzi G, Saraco E, Scotti A, Tersigni R. Video-assisted versus open ileocolic resection in primary Crohn's disease: a comparative case-matched study. Updates Surg 2011; 62:35-40. [PMID: 20845099 DOI: 10.1007/s13304-010-0001-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite the technical difficulties, laparoscopic ileocolic resection for Crohn's disease (CD) has become widely accepted in recent years, due to its potential benefits. There are numerous reports concerning the use of laparoscopy in successfully treating CD, including two randomized trials and few comparative studies. For the most part, these reports outline use of laparoscopic approach in primary distal ileal or ileocolic disease, with a careful selection of the patients. The purpose of this comparative case-control study was to point out potential advantages and disadvantages in short- and long-term outcomes of the laparoscopic approach compared with the open one. From January 1999 to January 2004, 200 patients were admitted in our Surgical Unit for complicated primary CD. 100 patients (group 1) underwent a laparoscopic ileocolic resection, 100 patients (group 2), with alike demographic and clinical characteristics, underwent the same procedure using a traditional approach. The incidence of perforative disease was 32 and 40% in groups 1 and 2, respectively. Average operative time was 140 min (range 90-245 min) in the video-assisted group and 98 min (range 65-255 min) in group 2 (P < 0.05). Postoperative morbidity was 6 and 8% in groups 1 and 2, respectively (P = NS). Recovery of peristalsis occurred within 2-3 days in group 1 and 3-4 days in group 2 (P = NS). Median postoperative hospitalization was 7 days (range 5-18 days) in group 1 and 9 days (range 7-22 days) in control group (P < 0.05). The overall rate of surgical relapse of CD was 8 and 13% in groups 1 and 2, respectively (P = NS), at a mean follow-up of 52 and 60 months, respectively. The 1-year surgical recurrence rate was similar (3%) for the two groups. In conclusions, in spite of the technical difficulties, video-assisted surgery for CD offers advantages over laparotomy, including less postoperative pain, reduced postoperative hospital stay, less disability of the patient, and better cosmetic results. Potential advantages are: easier approach for re-resection, lower rate of postoperative adhesions and bowel obstruction, and lower rate of wound complications.
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Affiliation(s)
- Luciano Alessandroni
- General and Oncologic Surgery Unit, Department of Surgery, San Camillo - Forlanini Hospitals, C.ne Gianicolense 86, 00152 Rome, Italy.
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Pinto RA, Shawki S, Narita K, Weiss EG, Wexner SD. Laparoscopy for recurrent Crohn's disease: how do the results compare with the results for primary Crohn's disease? Colorectal Dis 2011; 13:302-7. [PMID: 19912288 DOI: 10.1111/j.1463-1318.2009.02133.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To assess the feasibility and outcomes of reoperative laparoscopic-assisted surgery for recurrent Crohn's disease compared with index laparoscopic resections. METHOD A retrospective analysis of a prospectively maintained database was performed from 2001 to 2008 on patients who had primary laparoscopy (group I) or reoperative laparoscopy for Crohn's disease (group II). Data collection included demographic and surgical data, and postoperative outcomes. RESULTS One hundred and thirty patients were included in this study, distributed as follows: group I, 80 patients with a mean age of 35 years; and group II, 50 patients with a mean age of 42 years. Preoperative American Society of Anesthesiologists score and body mass index were similar in both groups. Patients in group II had a longer period of disease (15.5 vs 8.9 years in groups I and II, respectively; P = 0.0002). Immunosuppressive therapy had been utilized in 66 (82.5%) and in 42 (84%) patients in groups I and II, respectively. Ileocolic resection was the most commonly performed procedure in both groups (82%), followed by subtotal colectomy. Conversion rates were 18.7 and 32% in groups I and II, respectively (P = 0.09). The mean operative time (182 vs 201 min) and mean blood loss (161 vs 202 ml) were not significantly different (P > 0.05); however, the overall incisional length was significantly longer in group II (6.7 vs 11.4 cm, P = 0.045). A stoma was created in 17 and 16% of patients in groups I and II, respectively. Overall, early postoperative complications were not statistically significantly different between the two groups (P > 0.05); anastomotic leak occurred in four (5%) and one (2%) patients (P = 0.65), and abdominal abscess in three (3.75%) and four (8%) patients (P = 0.56), in groups I and II, respectively. Reoperative rates were 10 and 6% (P = 0.53), and mean hospital stay was similar in groups I and II respectively (6.7 vs 7.5 days, respectively; P = 0.3266). There was no mortality. CONCLUSION The results of laparoscopic-assisted resection for recurrent Crohn's disease are similar to those for primary resection.
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Affiliation(s)
- R A Pinto
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA
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Dasari BV, McKay D, Gardiner K. Laparoscopic versus Open surgery for small bowel Crohn's disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [PMID: 21249684 DOI: 10.1002/14651858.cd006956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic inflammatory bowel disease that most commonly involves the terminal ileum and colon (55 percent). Surgical treatment is required in approximately 70 percent of patients. Multiple procedures and repeat operations are required in 30 - 70 percent of all patients (Duepree 2002) but the disease remains incurable.Laparoscopy has gained wide acceptance in gastrointestinal surgery with potential advantages of faster return to normal activity and diet, reduced hospital stay, reduced postoperative pain, better cosmesis (Duepree 2002, Dunker 1998, Milsom 2001, Reissman 1996), improved social and sexual interaction (Albaz 2000) and its use is accepted in benign and malignant colorectal diseases. Laparoscopic surgery offers additional advantage of smaller abdominal fascial wounds, low incidence of hernias, and decreased rate of adhesive small-bowel obstruction (Albaz 2000) compared with conventional surgery reducing the need for non-disease-related surgical procedures in CD population.There are concerns about missing occult segments of disease and critical proximal strictures due to limited tactile ability, earlier recurrence due to possible reduced immune response induced by laparoscopy, technical difficulty due to fragile inflamed bowel and mesentery and the existence of adhesions, fistulas, and abscesses (Uchikoshi 2004). It is therefore important to evaluate the potential benefits and risks of laparoscopic surgery versus open surgery in patients with small bowel CD (Lowney 2005). OBJECTIVES To determine if there is a difference in the perioperative outcomes and re-operation rates for disease recurrence following laparoscopic surgery compared to open surgery in small bowel CD. SEARCH STRATEGY Published and unpublished randomised controlled trials were searched for in the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) 2010 issue 2 The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects (DARE) 2010 issue 2 The Cochrane Colorectal Cancer Group Controlled Trials Register Ovid MEDLINE (1990 to 2010) EMBASE (1990 to 2010) Health Technology Assessment (HTA) Database (1990 to 2010) SELECTION CRITERIA Randomised controlled trials (RCT) comparing laparoscopic and open surgery for small bowel CD were included. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies and extracted data. RevMan 5.0 was used for statistical analysis. MAIN RESULTS Two RCTs comparing laparoscopic and open surgery for small bowel CD were identified. Long term outcomes of the patients in both the trials were published separately and these were included in the review.Laparoscopic surgery appeared to be associated with reduced number of wound infections (1/61 vs 9/59), reoperation rates for non disease related complications (3/57 vs 7/54 ) but the difference was not statistically significant [p values were 0.23 and 0.19 respectively]. There was no statistically significant difference between any of the compared outcomes between laparoscopic and open surgery in the management of small bowel CD. AUTHORS' CONCLUSIONS Laparoscopic surgery for small bowel CD may be as safe as the open operation. There was no significant difference in the perioperative outcomes and the long term reoperation rates for disease-related or non-disease related complications of CD.
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Affiliation(s)
- Bobby Vm Dasari
- The Royal Hospitals, Belfast Health Care and Social Trust / NIMDTA, 15, Boulevard, Wellington Square, Belfast, UK, BT7 3LW
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Abstract
BACKGROUND Crohn's disease (CD) is a chronic inflammatory bowel disease that most commonly involves the terminal ileum and colon (55 percent). Surgical treatment is required in approximately 70 percent of patients. Multiple procedures and repeat operations are required in 30 - 70 percent of all patients (Duepree 2002) but the disease remains incurable.Laparoscopy has gained wide acceptance in gastrointestinal surgery with potential advantages of faster return to normal activity and diet, reduced hospital stay, reduced postoperative pain, better cosmesis (Duepree 2002, Dunker 1998, Milsom 2001, Reissman 1996), improved social and sexual interaction (Albaz 2000) and its use is accepted in benign and malignant colorectal diseases. Laparoscopic surgery offers additional advantage of smaller abdominal fascial wounds, low incidence of hernias, and decreased rate of adhesive small-bowel obstruction (Albaz 2000) compared with conventional surgery reducing the need for non-disease-related surgical procedures in CD population.There are concerns about missing occult segments of disease and critical proximal strictures due to limited tactile ability, earlier recurrence due to possible reduced immune response induced by laparoscopy, technical difficulty due to fragile inflamed bowel and mesentery and the existence of adhesions, fistulas, and abscesses (Uchikoshi 2004). It is therefore important to evaluate the potential benefits and risks of laparoscopic surgery versus open surgery in patients with small bowel CD (Lowney 2005). OBJECTIVES To determine if there is a difference in the perioperative outcomes and re-operation rates for disease recurrence following laparoscopic surgery compared to open surgery in small bowel CD. SEARCH STRATEGY Published and unpublished randomised controlled trials were searched for in the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) 2010 issue 2 The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects (DARE) 2010 issue 2 The Cochrane Colorectal Cancer Group Controlled Trials Register Ovid MEDLINE (1990 to 2010) EMBASE (1990 to 2010) Health Technology Assessment (HTA) Database (1990 to 2010) SELECTION CRITERIA Randomised controlled trials (RCT) comparing laparoscopic and open surgery for small bowel CD were included. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies and extracted data. RevMan 5.0 was used for statistical analysis. MAIN RESULTS Two RCTs comparing laparoscopic and open surgery for small bowel CD were identified. Long term outcomes of the patients in both the trials were published separately and these were included in the review.Laparoscopic surgery appeared to be associated with reduced number of wound infections (1/61 vs 9/59), reoperation rates for non disease related complications (3/57 vs 7/54 ) but the difference was not statistically significant [p values were 0.23 and 0.19 respectively]. There was no statistically significant difference between any of the compared outcomes between laparoscopic and open surgery in the management of small bowel CD. AUTHORS' CONCLUSIONS Laparoscopic surgery for small bowel CD may be as safe as the open operation. There was no significant difference in the perioperative outcomes and the long term reoperation rates for disease-related or non-disease related complications of CD.
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Affiliation(s)
- Bobby Vm Dasari
- The Royal Hospitals, Belfast Health Care and Social Trust / NIMDTA, 15, Boulevard, Wellington Square, Belfast, UK, BT7 3LW
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Araújo SEA, Dias AR, Seid VE, Campos FG, Nahas SC. Videocirurgia no manejo da doença de Crohn intestinal. ACTA ACUST UNITED AC 2010. [DOI: 10.1590/s0101-98802010000300001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A doença de Crohn é uma moléstia com um amplo espectro de manifestações. Seu tratamento é complexo e freqüentemente os pacientes portadores desta afecção necessitam de intervenções cirúrgicas. Com o surgimento da laparoscopia e sua popularização no tratamento das afecções intestinais, demonstrando resultados superiores ao acesso convencional e quebrando paradigmas como sua utilização no tratamento do câncer colorretal, passou-se a cogitar se esse acesso seria indicado também nas doenças inflamatórias intestinais. Ainda hoje, a utilização desta via de acesso na doença de Crohn é tema controverso. Devido à natureza inflamatória desta patologia, o grau de dificuldade cirúrgico está aumentado e muitas dúvidas persistem: há benefício para o paciente? A taxa de conversão não está exageradamente aumentada? É possível indicar esse acesso em casos complicados? Qual o grupo de pacientes que se beneficia da técnica? Nesta revisão apresentamos os dados mais recentes e as evidências científicas que sustentam a indicação da via de acesso laparoscópica no tratamento cirúrgico da doença de Crohn.
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Ernährung und Chirurgie als Säulen der CED-Behandlung. Monatsschr Kinderheilkd 2010. [DOI: 10.1007/s00112-010-2197-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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