Laparoscopy for inflammatory bowel disease: pushing the envelope

Laparoscopy for Crohn's disease: A comprehensive exploration of minimally invasive surgical techniques

BACKGROUND

Along with the unceasing progress of medicine, Crohn's disease (CD), especially complex CD, is no longer a taboo for minimally invasive surgery. However, considering its special disease characteristics, more clinical trials are needed to confirm the safety and feasibility of laparoscopic surgery for CD.

AIM

To investigate the safety and feasibility of laparoscopic enterectomy for CD, assess the advantages of laparoscopy over laparotomy in patients with CD, and discuss comprehensive minimally invasive surgical techniques in complex CD.

METHODS

This study prospectively collected clinical data from patients with CD who underwent enterectomy from January 2017 to January 2020. It was registered in the Chinese clinical trial database with the registration number ChiCTR-INR-16009321. Patients were divided into a laparoscopy group and a traditional laparotomy group according to the surgical method. The baseline characteristics, operation time, intraoperative blood loss, temporary stoma, levels of abdominal adhesion, pathological characteristics, days to flatus and soft diet, postoperative complications, hospitalization time, readmission rate within 30 d, and hospitalization cost were compared between the two groups.

RESULTS

A total of 120 eligible patients were enrolled into the pre-standardized groups, including 100 in the laparoscopy group and 20 in the laparotomy group. Compared with the laparotomy group, the postoperative hospitalization time in the laparoscopy group was shorter (9.1 ± 3.9 d vs 11.0 ± 1.6 d, P < 0.05), the days to flatus were fewer (2.8 ± 0.8 d vs 3.5 ± 0.7 d, P < 0.05), the days to soft diet were fewer (4.2 ± 2.4 d vs 6.2 ± 2.0 d, P < 0.05) and the intraoperative blood loss was less (103.3 ± 80.42 mL vs 169.5 ± 100.42 mL, P < 0.05). There were no statistically significant differences between the two groups in preoperative clinical data, operation time (149.0 ± 43.8 min vs 159.2 ± 40.0 min), stoma rate, levels of abdominal adhesion, total cost of hospitalization, incidence of postoperative complications [8.0% (8/100) vs 15.0% (3/20)], or readmission rate within 30 days [1.0% (1/100) vs 0.00 (0/20)].

CONCLUSION

Compared with laparotomy, laparoscopic enterectomy promotes the recovery of gastrointestinal function, shortens the postoperative hospitalization time, and does not increase the incidence of postoperative complications. Laparoscopic enterectomy combined with varieties of minimally invasive surgical techniques is a safe and acceptable therapeutic method for CD patients with enteric fistulas.

Video-laparoscopic assessment of the small bowel in Crohn's disease: a comparative study to evaluate surgeons' inter-observer variability

BACKGROUND

Assessment of the entire small bowel is advocated during Crohn's disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic "walkthrough".

METHODS

A survey on laparoscopic assessment of the small bowel in patients with CD, including items adapted from the MREnterography or ultrasound in Crohn's disease (METRIC) study and from the classification of severity of mesenteric disease was developed by an invited committee of colorectal surgeons. Anonymous laparoscopic videos demonstrating the small bowel "walkthrough" in ileocolonic resection for primary and recurrent CD were distributed to the committee members together with the anonymous survey. The primary outcome was the rate of inter-observer variability on assessment of strictures, dilatations, complications and severity of mesenteric inflammation.

RESULTS

12 assessors completed the survey on 8 small bowel walkthrough videos. The evaluation of the small bowel thickening and of the mesenteric fat wrapping were the most reliable assessments with an overall agreement of 87.1% (k = 0.31; 95% CI - 0.22, 0.84) and 82.7% (k = 0.35; 95% CI - 0.04, 0.73), respectively. The presence of strictures and pre-stenotic dilatation demonstrated agreement of 75.2% (k = 0.06: 95% CI - 0.33, 0.45) and 71.2% (k = 0.33; 95% CI 0.15, 0.51), respectively. Evaluation of fistulae had an overall agreement of 75.3%, while there was a significant variation in the evaluation of mild, moderate and severe mesenteric disease with overall agreement ranging from 33.3 to 100%.

CONCLUSION

Laparoscopic assessment of the small bowel thickening and of the presence of mesenteric fat wrapping is reliable for the intraoperative evaluation of CD with high inter-rater agreement. There is significant heterogeneity in the assessment of the severity of the mesenteric disease involvement.

Stepwise Training in Laparoscopic Surgery for Complex Ileocolonic Crohn's Disease: Analysis of 127 Training Episodes

INTRODUCTION

The inflammation encountered in Crohn's disease makes a minimally invasive approach challenging due to a thickened mesentery, fistulas, abscesses, and large phlegmons with high reported rates of conversion and septic complications. Aim of this study was to evaluate the feasibility of a stepwise approach to training in laparoscopic surgery for complex Crohn's disease.

METHODS

Every surgical procedure was divided in 4 different training tasks: access and exposure, bowel mobilization, division of the mesentery, anastomosis. Extensive adhesiolysis and division and repair of fistulae were considered as additional tasks when present. The laparoscopic competence assessment tool was used to evaluate the safety and proficiency of the surgical performance. The primary outcome was the rate of training tasks successfully completed by surgical trainees.

RESULTS

One hundred and twenty seven training episodes were included and 86 were performed by trainees (67.7%). Fistula division was the less commonly performed training task (25%), while mobilisation and anastomosis were performed by the supervised trainee in 90% and 85% of the cases. Safety and proficiency scores were significantly higher for senior trainees compared to junior trainees.

CONCLUSIONS

Laparoscopic surgery for complex Crohn's disease can be safely performed in a supervised setting with acceptable operating time, postoperative length of hospital stay, and 30 day morbidity.

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46–0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46–0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49–0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

Laparoscopic Redo Ileocolic Resection for Crohn's Disease in Patients with Previous Multiple Laparotomies

PURPOSES:

Over 80% of patients with primary ileocolic Crohn's disease have a surgical resection within 10 years of diagnosis, and 40%-50% of them need further surgery within 15 years. Laparoscopic surgery can be challenging due to a thickened mesentery and the potential for fistulas, abscesses, and phlegmons. Aim of this study is to analyze the short-term outcomes of laparoscopic redo ileocolic resections for Crohn's disease in patients with previous multiple laparotomies.

METHODS:

All patients undergoing laparoscopic surgery for ileocolic Crohn's disease from March 2006 to February 2017 were prospectively evaluated. Short term outcomes of laparoscopic ileocolic resection were compared between patients with previous multiple major surgeries and recurrent Crohn's disease, and patients undergoing surgery for the first presentation of Crohn's disease and no history of previous surgery. Conversion rate and 30-day morbidity were the primary outcomes. Reoperations, readmissions, operating time and length of stay were the secondary outcomes.

RESULTS:

29 patients with recurrent Crohn's disease and previous multiple laparotomies were included: the number of laparotomies these patients previously underwent was 2 in 19 cases (65.5%), 3 in 9 (31%), and 4 in 1 (3.5%). In total, 90 patients with no history of any previous abdominal surgery, who underwent laparoscopic ileocecal resection for Crohn's disease, represented the control group. No differences were found in morbidity and conversion rate. Operating time was longer in patients with history of previous abdominal surgery.

CONCLUSION:

Laparoscopic redo ileocolic resection for Crohn's disease is feasible and safe in patients with previous multiple laparotomies at the expense of longer operating time.

Laparoscopic surgery in the management of Crohn's disease

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.

Laparoscopic surgery for crohn disease: a brief review of the literature

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.

Laparoscopic Approach in Patients with Recurrent Crohn's Disease

The purpose of this study is to review our experience with laparoscopic management of Crohn's disease including patients with prior Crohn's-related abdominal surgery. All cases of Crohn's patients who underwent laparoscopic attempt for management of disease from April 2005 to October 2010 (n = 130) at a single institution were retrospectively reviewed. Evaluated datapoints include: prior abdominal surgery for Crohn's disease, operative time, rate of conversion, and complication rate. Of the 130 patients, 82 (63.1%) patients had no prior abdominal surgery and 48 (36.9%) patients had previous bowel surgery with mean age of 35.3 (3.5–79) and 41.3 (15–66) years, respectively. Operative time with no prior surgery was 106 (23–245) minutes, and with prior surgery was 100 (26–229) minutes. Estimated blood loss with no prior surgery was 116 (5–800) mL, and with prior surgery was 123 (5–800) mL. Conversion from laparoscopic to open surgery in those with no prior surgery was 17.1 per cent and in those with prior surgery, 20.8 per cent ( P = 0.64). Postoperative complications were found in 13 patients (15.9%) without prior abdominal surgery and 13 patients (27.1%) with prior surgery ( P = 0.17). The most common postoperative complication in both groups was infection/abscess (8.5%). The laparoscopic management of recurrent Crohn's disease is a safe and technically feasible option, even in those patients with prior history of Crohn's-related abdominal surgery, with a low complication rate and low conversion rate. The utility of the laparoscopic approach in Crohn's patients faced with repeat abdominal procedures may be beneficial in the long-term and should be considered as a method to limit morbidity.