Diagnostic laparoscopy in childhood Crohn's disease

Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review

The incidence of paediatric inflammatory bowel disease (PIBD) has dramatically increased in the last 20 years. Although first reported in mid 1970s’, diagnostic laparoscopy has started to be routinely adopted in paediatric surgical practice since late 1990s’. Minimally invasive surgery was first limited to diagnostic purposes. After 2002 it was also applied to the radical treatment of PIBD, either Crohn’s disease (CD) or Ulcerative colitis. During the last decade minimally invasive approaches to PIBD have gained popularity and have recently became the “gold standard” for the treatment of such invalidating and troublesome chronic diseases. The authors describe and track the historical evolution of minimally invasive surgery for PIBD and address all available opportunities, including most recent advancements such as robotic surgery, single port approaches and minimally invasive treatment of perianal fistulising CD. A systematic review of all series of PIBD treated with minimally invasive approaches published so far is provided in order to determine the incidence and type of patients’ complications reported up to present days. The authors also describe their experience with minimally invasive surgery for PIBD and will report the results of 104 laparoscopic procedures performed in a series of 61 patients between January 2006 and December 2014.

Outcomes after laparoscopic surgery in children with inflammatory bowel disease

BACKGROUND

The utility and efficacy of the laparoscopic approach to the management of inflammatory bowel disease (IBD) in children are not clearly known.

METHODS

We conducted a retrospective descriptive cohort study of children with a diagnosis of IBD who underwent a laparoscopic or laparoscopy-assisted procedure at a quaternary pediatric referral center between 1999 and 2007.

RESULTS

One-hundred thirty-six children underwent 154 operations (85 small bowel/ileocolic and 69 colorectal) over the 8 years of the study. Median age was 14.8 years (range = 1.8-18.8). The diagnosis was Crohn's disease in 83, ulcerative colitis in 50, and indeterminate colitis in 3. Median time to regular diet was 5 days (range = 1-19), and median postoperative stay was 7 days (range = 1-70). Seven patients undergoing a small bowel/ileocolic resection (8.2%) were converted to an open procedure. Overall morbidity for the small bowel/ileocolic procedures was 27.1%. The conversion rate during subtotal colectomy (STC) was 7.1% (3/42), and it was 0% for the 22 patients who underwent ileal pouch-anal anastomosis (IPAA) procedures. Overall morbidity associated with STC was 62.8%, and following IPAA it was 63.6%. Sixteen percent (7/69) of those who underwent a colorectal procedure developed a late postoperative bowel obstruction with three patients requiring operative intervention.

CONCLUSION

A laparoscopic approach is feasible with a low conversion rate in most children with IBD. Despite superior cosmesis, perioperative morbidity is similar to that seen with open procedures. Laparoscopic colorectal IBD procedures are associated with an unexpectedly high incidence of postoperative bowel obstruction, although the rates are comparable to those seen with open surgery.

The "creeping fat sign"-really diagnostic for Crohn's disease?

BACKGROUND

Focal or regionally prominent mesenteric fat adjacent to wall-thickened bowel loops can be readily identified by computed tomography. The so-called creeping fat of the right lower quadrant is usually considered to be an important clue for diagnosing Crohn's disease. However, when the sign is isolated, indistinct, and not set in the proper clinical context, the radiologist should consider other inflammatory conditions of the bowel and its appendages.

CONCLUSION

Controlled studies are needed to confirm the diagnostic use of the "creeping fat sign" in clinical practice.

Review article: the diagnosis and management of Crohn's disease in populations with high-risk rates for tuberculosis

BACKGROUND

Distinguishing Crohn's disease from intestinal tuberculosis in endemic areas is challenging as both conditions have overlapping clinical, radiological, endoscopic and histological characteristics. Furthermore, high rates of latent tuberculosis confer a considerable risk of reactivation once therapy for established Crohn's disease is started.

AIM

To review current strategies in differentiating these two conditions, and in managing Crohn's disease, in populations with high rates of tuberculosis.

METHODS

Literature review and clinical experience.

RESULTS

While various clinical, radiological, endoscopic and histological parameters may aid in differentiating Crohn's disease from intestinal tuberculosis, these remain imperfect and as treatment options differ misdiagnosis has grave consequences. We propose a diagnostic algorithm, based on currently available evidence and experience, to aid in this dilemma. We also discuss approaches to the management of Crohn's disease, including agents targeting tumour necrosis factor-alpha, in patients at risk of developing tuberculosis.

CONCLUSIONS

A diagnosis of Crohn's disease in individuals at risk for tuberculosis should only be made after careful interpretation of clinical signs, abdominal imaging and systematic endoscopic and histological assessment. Newer techniques for the diagnosis of latent tuberculosis still need to be validated in this environment, and guidelines on the treatment of latent tuberculosis in this setting require clarification.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

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

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Care of the laparoscopic colectomy patient

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

Laparoscopic surgery in children

The surgeon should be aware of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide surgical care in association with either outpatient or short-stay hospitalizations appear to be cost-effective and appropriate state-of-the-art medical care. Because the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will continue to become increasingly available.

Adipocyte macrophage colony-stimulating factor is a mediator of adipose tissue growth

Adipose tissue growth results from de novo adipocyte recruitment (hyperplasia) and increased size of preexisting adipocytes. Adipocyte hyperplasia accounts for the severalfold increase in adipose tissue mass that occurs throughout life, yet the mechanism of adipocyte hyperplasia is unknown. We studied the potential of macrophage colony-stimulating factor (MCSF) to mediate adipocyte hyperplasia because of the profound effects MCSF exerts on pluripotent cell recruitment and differentiation in other tissues. We found that MCSF mRNA and protein were expressed by human adipocytes and that adipocyte MCSF expression was upregulated in rapidly growing adipose tissue that encircled acutely inflamed bowel and in adipose tissue from humans gaining weight (4-7 kg) with overfeeding. Localized overexpression of adipocyte MCSF was then induced in rabbit subcutaneous adipose tissue in vivo using adenoviral-mediated gene transfer. Successful overexpression of MCSF was associated with 16-fold increases in adipose tissue growth compared with a control adenovirus expressing beta-galactosidase. This occurred in the absence of increased cell size and in the presence of increased nuclear staining for MIB-1, a marker of proliferation. We conclude that MCSF participates in adipocyte hyperplasia and the physiological regulation of adipose tissue growth.

Laparoscopy to correctly diagnose and treat Crohn's disease of the ileum

A 27-year-old woman with a past history of pulmonary tuberculosis presented with right iliac fossa pain and low-grade fever. She was empirically treated for Crohn's disease despite undergoing multiple investigations that failed to provide a strongly suspected diagnosis. After 3 days of therapy, her symptomatology aggravated, and signs suggestive of intestinal obstruction developed. Placing the patient in the left lateral decubitus position before sterile draping, intracorporeal laparoscopy was performed, and Crohn's disease involving the terminal ileum but sparing its most distal 25 cm was confirmed. During the procedure, creeping mesenteric fat, a characteristic feature of Crohn's disease, was seen. Also, some adhesions in the right iliac fossa and a firm 3-cm inflammatory mass were found. Both division of mesentery along with terminal ileum resection and ileocolonic anastomosis were successfully performed intracorporeally, without need to convert to open surgery. In select cases of right iliac fossa pain in which diagnostic and therapeutic results are inconclusive or equivocal, laparoscopy can be useful to correctly diagnose and treat inflammatory bowel disorders such as Crohn's disease. Moreover, we suggest that intracorporeal laparoscopic surgery can be effective in the treatment of these conditions even in some cases with intestinal complications such as inflammatory masses and adhesions.