Should enteric fistulas from Crohn's disease or diverticulitis be treated laparoscopically or by open surgery? A matched cohort study

A Very Rare Case of Colosalpingeal Fistula Secondary to Diverticulitis: An Overview of Development, Clinical Features and Management

BACKGROUND

Colosalpingeal fistula is a rare complication secondary to diverticular disease. The pathogenesis is still not clearly understood. We present the case of a colosalpingeal fistula and a review of the management of this pathology.

CASE REPORT

A 69-year-old patient with uncomplicated diverticular disease was referred to our department for recurrent vaginal discharge. The clinical examination was unremarkable, hysteroscopy revealed the presence of air in the uterine cavity in the absence of a uterine fistula. A preliminary diagnosis of colosalpingeal fistula was made and was confirmed by computed tomography (CT) scan and hysterosalpingography. A one-stage surgery via laparotomy was successfully performed with remission of the symptoms.

CONCLUSION

Colotubal fistula is a rare complication resulting from intestinal diverticular disease. The purpose of this paper was to emphasize the presence of a rare, but serious complication occurring in diverticular disease with atypical symptoms and one-stage surgery treatment.

Short-term Outcomes of Laparoscopic Versus Open Treatment of Internal Enteric Fistulae: A Logistic Regression Analysis

Although laparoscopy improves outcomes for common general surgical procedures, its role in complex colorectal procedures is not clearly defined. We sought to evaluate whether laparoscopy retains its short-term benefits when used for treatment of complex intra-abdominal fistulae. A retrospective analysis was conducted including patients undergoing surgeries for enteric fistulas over a 7-year period. The χ tests, the Fisher exact tests, and Student t tests were used. Logistic regression models were used to assess the relationship between outcome and predictors. A total of 74 patients (31 open, 43 laparoscopic) were included. There was no difference in age, sex, body mass index, and comorbidities between the 2 groups. The laparoscopic group had significantly shorter length of stay, estimated blood loss, and significantly lower incidence of major complications compared with open group. Our findings suggest that laparoscopy is safe and retains its short-term benefits for treatment of complex colorectal and small bowel procedures.

Diverticular colovesical fistula: What should we really be doing?

BACKGROUND

Colovesical fistula secondary to diverticular disease is increasing in incidence. Presentation and severity may differ, but a common management strategy may be applied. The aim of this study is to evaluate the characteristics and perioperative management of patients with colovesical fistulae and determine optimal management.

METHODS

From 2003 to 2012, all charts of surgical patients with diverticular colovesical fistulae at two different institutions were reviewed. Patient and presentation characteristics and perioperative management and outcomes were recorded. Patient groups with early and late catheter removal (< 8 and ≥ 8 days) were compared with significance level set at p < 0.05.

RESULTS

Seventy-eight patient charts were reviewed. The mean duration of symptoms was 7.5 months. Laparoscopic assisted surgery was carried out in 35% of patients. Complex bladder repair was performed in 27%. Mean length of stay was 8 days. Mean urinary catheter duration was 13 days. Seventy percent of patients underwent postoperative cystogram, with 4% positive for extravasation. Patients with early catheter removal were significantly older, more likely to have received intraoperative methylene blue instillation, and less likely to have had a complex bladder repair (p < 0.05). Complication rate, length of stay, postoperative cystography, and stent use were similar for both catheter removal groups.

CONCLUSIONS

Intraoperative methylene blue bladder instillation should be utilized to limit unnecessary bladder repairs. In the setting of negative methylene blue extravasation, surgeons may confidently remove urinary catheters in 7 days or less, in some cases as early as 48 h. In complex bladder repairs, cystogram is still an important adjunct, with those patients with negative studies benefiting from catheter removal at 7 days or less.

Laparoscopic approach in complicated diverticular disease

AIM: To analyze the results of laparoscopic colectomy in complicated diverticular disease.

METHODS: This was a retrospective cohort study conducted at an academic teaching hospital. Data were collected from a database established earlier, which comprise of all patients who underwent laparoscopic colectomy for diverticular disease between 2000 and 2013. The series was divided into two groups that were compared: Patients with complicated disease (abscess, perforation, fistula, or stenosis) (G1) and patients undergoing surgery for recurrent diverticulitis (G2). Recurrent diverticulitis was defined as two or more episodes of diverticulitis regardless of patient age. Data regarding patient demographics, comorbidities, prior abdominal operations, history of acute diverticulitis, classification of acute diverticulitis at index admission and intra and postoperative variables were extracted. Univariate analysis was performed in both groups.

RESULTS: Two hundred and sixty patients were included: 28% (72 patients) belonged to G1 and 72% (188 patients) to G2. The mean age was 57 (27-89) years. The average number of episodes of diverticulitis before surgery was 2.1 (r 0-10); 43 patients had no previous inflammatory pathology. There were significant differences between the two groups with respect to conversion rate and hospital stay (G1 18% vs G2 3.2%, P = 0.001; G1: 4.7 d vs G2 3.3 d, P < 0.001). The anastomotic dehiscence rate was 2.3%, with no statistical difference between the groups (G1 2.7% vs G2 2.1%, P = 0.5). There were no differences in demographic data (body mass index, American Society of Anesthesiology and previous abdominal surgery), operative time and intraoperative and postoperative complications between the groups. The mortality rate was 0.38% (1 patient), represented by a death secondary to septic shock in G2.

CONCLUSION: The results support that the laparoscopic approach in any kind of complicated diverticular disease can be performed with low morbidity and acceptable conversion rates when compared with patients undergoing laparoscopic surgery for recurrent diverticulitis.

Is laparoscopic surgery the best treatment in fistulas complicating diverticular disease of the sigmoid colon? A systematic review. Int J Surg. 2015;24:95-100. [PMID: 26584958 DOI: 10.1016/j.ijsu.2015.11.007]

INTRODUCTION

Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open surgery. Aim of this review is to assess the possible advantages deriving from a laparoscopic approach in the treatment of diverticular fistulas of the colon.

METHODS

Studies presenting at least 10 adult patients who underwent laparoscopic surgery for sigmoid diverticular fistula were reviewed. Fistula recurrence, reintervention, Hartmann's procedure or proximal diversion, conversion to laparotomy were the outcomes considered.

RESULTS

11 non randomized studies were included. Rates of fistula recurrence (0.8%), early reintervention (30 days) (2%) and need for Hartmann's procedure or proximal diversion (1.4%) did not show significant difference between laparoscopy and open technique.

DISCUSSION

there is still concern about which surgery in complicated diverticulitis should be preferred. Laparoscopic approach has led to less postoperative pain, shorter hospital stay, faster recovery and better cosmetic results. Laparoscopic resection and primary anastomosis is a possible approach to sigmoid fistulas but its advantages in terms of lower mortality rate and postoperative stay after colon resection with primary anastomosis should be interpreted with caution. When there is firm evidence supporting it, it is likely that minimally invasive surgery should become the standard approach for diverticular fistulas, thus achieving adequate exposure and better visualization of the surgical field.

CONCLUSION

The lack of RCTs, the small sample size, the heterogeneity of literature do not allow to draw statistically significant conclusions on the laparoscopic surgery for fistulas despite this approach is considered safe.

Laparoscopic management of diverticular colovesical fistula: experience in 15 cases and review of the literature. Int Surg. 2013;98:101-109. [PMID: 23701143 DOI: 10.9738/intsurg-d-13-00024.1]

Colovesical fistulas secondary to diverticular disease may be considered a contraindication to the laparoscopic approach. The feasibility of laparoscopic management of complicated diverticulitis and mixed diverticular fistulas has been demonstrated. However, few studies on the laparoscopic management of diverticular colovesical fistulas exist. A retrospective analysis was performed of 15 patients with diverticular colovesical fistula, who underwent laparoscopic-assisted anterior resection and bladder repair. Median operating time was 135 minutes and median blood loss, 75 mL. Five patients were converted to an open procedure (33.3%) with an associated increase in hospital stay (P = 0.035). Median time to return of bowel function was 2 days and median length of stay, 6 days. Overall morbidity was 20% with no major complications. There was no mortality. There was no recurrence during median follow-up of 12.4 months. These results suggest that laparoscopic management of diverticular colovesical fistulas is both feasible and safe in the setting of appropriate surgical expertise.

Laparoscopy in diverticular disease: Controversies

A minimally invasive approach to the management of diverticular disease has gained acceptance over the last number of years. Certainly, in the elective setting, laparoscopic sigmoid resection compares favourably with open surgery. The use of laparoscopy in the context of emergency surgery for complicated diverticular disease remains controversial however recent studies have demonstrated a defined role for laparoscopy in the acute setting.

Management and Outcomes of Colovesical Fistula Repair

This large retrospective study presents the largest colovesical fistula (CVF) series to date. We report on recurrence risk factors and patient satisfaction based on quality of life after CVF repair. Approval was obtained from The Mount Sinai School of Medicine Institutional Review Board, and a retrospective review was performed from 2003 to 2010 involving 72 consecutive patients who underwent a colovesical fistula repair. The CVF recurrence rate was 11 per cent. Ten percent of our patients who had a history of radiation therapy were at a significantly higher risk of developing a recurrence. Noted recurrence rates were significantly higher in advanced bladder repairs compared with simple repair ( P = 0.022). The modified (Gastrointestinal Quality of Life Index) surveys showed overall patient satisfaction score was 3.6, out of a maximum score of 4, regardless of the type of repair or any postoperative complications. Our study found the CVF recurrence rate to be 11 per cent. Patients at higher risk of recurrence include those needing advanced bladder repair, those with “complex” CVF, and those whose fistulas involve the urethra. Patient satisfaction was found to be more closely linked to the resolution of CVF symptoms, irrespective of the type of repair performed or development of postoperative complications.

Laparoscopic management of diverticular disease

Despite its potential advantages, laparoscopic management of diverticular disease is currently performed by a minority of surgeons on a small group of patients. However, the role for laparoscopy in diverticular disease continues to develop. At present, adequate evidence exists for the routine use of laparoscopy for uncomplicated diverticular disease. Complicated disease, including fistulizing disease and free perforation requires additional expertise and study. As the experience grows among individual surgeons and institutions, it can be expected that the complication and conversion rates will continue to decline allowing even further evolution of laparoscopy for the treatment of this challenging disease process.

Enterovesical fistulas: diagnosis and management

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.

Contemporary surgical management for ileosigmoid fistulas in Crohn's disease

BACKGROUND

Current diagnostic modalities and surgical treatments for ileosigmoid fistulas (ISF) in Crohn's disease (CD) are not well characterized.

METHODS

ISF patients operated during 2000-2007 in a prospectively collected CD surgery database were included. Disease extent, diagnostic studies, medications, and smoking status were retrospectively reviewed.

RESULTS

One hundred four CD patients with ISF (median age 37) underwent ileocolic resection (75 open, 29 laparoscopic). Sigmoid colon was treated with primary repair (26), segmental resection (71), and subtotal colectomy (7). Thirty-eight patients required additional surgery for CD manifestations (ileovesical fistula (11), enterocutaneous fistula (11), and synchronous small bowel disease (22)). Overall sensitivity of studies for ISF detection was 63% (66/104) (colonoscopy 35% (31/89), CT scan 41% (31/76), fluoroscopy 53% (31/58)). Stoma diversion (53 patients, 51%) occurred more with open surgery (81% vs. 63%, p = 0.04), intraoperative ureteral stents (28% vs. 2%, p < 0.0001), additional small bowel procedures (42% vs. 18%, p = 0.008), longer overall length of stay (10 vs. 6 days, p < 0.0001), preoperative steroid use > or =20 mg prednisone (40% vs. 18%, p = 0.02), and preoperative albumin < or =3.5 gm/dl (43% vs. 22%, p = 0.02). Mortality was nil. Overall morbidity was 37% with anastomotic leak 4%. Neither was affected by stoma diversion, laparoscopy use, or sigmoid colon treatment.

CONCLUSIONS

While most ISF in CD are found preoperatively, some are still incidental surgical findings. Sigmoid resection and primary repair have comparable morbidity if appropriately individualized. Laparoscopic treatment is acceptable in select cases without added morbidity.

Laparoscopic resection for Crohn's disease: an experience with 335 cases

BACKGROUND

Laparoscopic resection for Crohn's disease has had a slow adoption rate in gastrointestinal surgery. This is not unexpected considering the inflammatory nature of the disease, the need for reoperative surgery, and the presence of fistulas. The authors review their experience with 335 laparoscopic resections for Crohn's disease over the past 15 years.

METHODS

This study is a retrospective analysis of a prospective database from one surgeon at the Mount Sinai Hospital, New York, NY.

RESULTS

Since 1993, 335 patients with Crohn's disease in the current series have undergone laparoscopic resection. The mean age of the patients was 39 years, and 54% of the patients were women. In most cases, the indication for surgery was intestinal obstruction (73%) or abdominal pain (16%). The most common operation was primary ileocolic resection, performed for 178 cases (49%). Secondary ileocolic resections were performed for 20% and small bowel resections for 11% of the cases. Of the 117 patients with enteric fistulas, 45% had multiple fistulas. There were 80 enteroenteric, 51 ileosigmoid, 33 enteroabdominal wall, and 22 ileovesical fistulas. Multiple resections were performed for 33 patients (9%). Eight conversions occurred (2%), primarily because of large inflammatory masses involving the intestinal mesentery. The mean length of hospital stay was 5 days, and the mean operative time was 177 min (range, 62-400 min). There were no mortalities. The complications were primarily bowel obstruction, anastamotic leak, and postoperative bleeding, resulting in a postoperative complication rate of 13%.

CONCLUSION

This review summarizes the largest series of laparoscopic resection for Crohn's disease to date. The most common operation performed was ileocolic resection. Fistulous disease is common, but it is not a contraindication to laparoscopic resection. These cases can be managed safely and with acceptable morbidity in experienced hands.

Crohn's disease--when to operate?

Crohn's disease is a chronic bowel condition, which can present as a number of different clinical and pathological presentations, depending on localization and activity of the inflammatory process. The aethiology of the disease has not been explained. In each case the treatment should be individually tailored depending on the type of the changes. The indications for surgical intervention are continuous bleedings, recurrent ileus, perforation of the intestine, abscesses, fistulas, failure of pharmacological treatment, resistance to steroids and steroid dependence. In case of the mild type of the disease with few symptoms pharmacological treatment is the right choice In case of the mild type of the disease with few symptoms pharmacological treatment is the right choice process. In malign form of Crohn's disease lack of improvement after 7-10 days of intensive treatment is generally accepted indication for surgical treatment. Fulminant form of the disease is still a clear-cut indication for immediate surgical intervention. Decision on surgical intervention is more difficult and controversial when patient presents with series of subileus recurrences subsiding after conservative treatment. Patients with stenotic form of Crohn's disease usually require multiple operations most of which are bowel resections. Patients with stenotic form of Crohn's disease usually require multiple operations most of which are bowel resections therapy. External and internal asymptomatic fistulas should be treated conservatively. The timing of surgical treatment is essential in Crohn's disease however the prevention from recurrences is also fundamental. It is well proved that preventive administration of 5-ASA (especially mesalazine) and metronidazol can reduce the risk of early recurrences after surgery.

Laparoscopic colectomy for diverticulitis is not associated with increased morbidity when compared with non-diverticular disease

BACKGROUND AND AIMS

It was the aim of this prospective study to compare the outcome of laparoscopic sigmoid and anterior resection for diverticulitis and non-diverticular disease.

PATIENTS AND METHODS

All patients who underwent laparoscopic colectomy for benign and malignant disease within a 10-year period were entered into the prospective PC database registry. For outcome analysis, patients who underwent laparoscopic sigmoid and anterior resection for diverticular disease were compared with patients who underwent the same operation for non-inflammatory (non-diverticular) disease. The parameters analyzed included age, gender, co-morbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion, morbidity including major (requiring reoperation), minor (conservative treatment) and late-onset (postdischarge) complications, stay in the ICU, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t-test and chi-square analysis (p<0.05 was considered statistically significant).

RESULTS

A total of 676 patients were evaluated including 363 with diverticular disease and 313 with non-inflammatory disease. There were no significant differences in conversion rates (6.6 vs. 7.3%, p>0.05), so that the laparoscopic completion rate was 93.4% (n=339) in the diverticulitis group and 92.7% (n=290) in the non-diverticulitis group. The two groups did not differ significantly in age or presence of co-morbid conditions (p>0.05). In the diverticulitis group, recurrent diverticulitis (58.4%), and complicated diverticulitis (27.7%) were the most common indications, whereas in the non-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%) were the main indications. The most common procedure was laparoscopic sigmoid resection, followed by sigmoid resection with rectopexy and anterior resection. No significant differences were documented for major complications (7.4 vs. 7.9%), minor complications (11.5 vs. 14.5%), late-onset complications (3.0 vs. 3.5), reoperation (8.6 vs. 9.3%) or mortality (0.6 vs. 0.7%) between the two groups (p>0.05). In the postoperative course, no differences were noted in terms of stay in the ICU, postoperative ileus, parenteral analgesics, oral feeding, and length of hospitalization (p>0.05).

CONCLUSION

These data indicate that laparoscopic sigmoid and anterior resection can be performed with acceptable morbidity and mortality for both diverticular disease and non-diverticular disease. The results show in particular that laparoscopic resection for inflammation is not associated with increased morbidity.

Colovesical fistula: not a contraindication to elective laparoscopic colectomy

PURPOSE

Traditionally, diverticular fistula was thought to be a contraindication for laparoscopic colectomy. The advent of hand-assisted laparoscopy has allowed repair of a diverticular fistula to be technically feasible laparoscopically. We present our experience with laparoscopic colectomy in patients with diverticular fistulas.

METHODS

Patients with colovesical or colovaginal fistulas secondary to diverticular disease were consecutively entered into a database over a five-year period. All operations were electively performed by a single group of colorectal surgeons. Patient demographics, American Society of Anesthesiologists classification, type of surgery, operating time, hospital length of stay, and early and late complications were recovered by chart review. These results were then compared to results from a group of patients who had undergone elective laparoscopic colectomy for recurrent diverticulitis during the same period by the same group of surgeons.

RESULTS

Altogether, 40 consecutive operations for diverticular fistulas were performed, 36 of which were started laparoscopically (90 percent). The average patient age was 65 years and the average American Society of Anesthesiologists class was 2. Patient demographics were similar among the group with recurrent diverticulitis (n = 149). The average hospital stay was 6.2 days for the fistula group and 4.4 days in the recurrent diverticulitis group. The average operating time was 220 minutes for the fistula group vs. 176 minutes for the uncomplicated group (P < 0.002). The conversion rate was significantly higher in the fistula group (25 percent vs. 5 percent, P < 0.001). There were no postoperative anastomotic leaks or bleeding episodes requiring reoperation in the fistula group.

CONCLUSIONS

Diverticular fistula should no longer be considered a contraindication for laparoscopic colectomy. These cases are more complex, as evidenced by the longer operating times and higher conversion rates when compared with resections for uncomplicated recurrent diverticulitis. Although the length of hospital stay was longer for patients who underwent laparoscopic colectomy for diverticular fistula, those whose operations were completed laparoscopically had the same outcome as patients with uncomplicated disease. We anticipate that minimally invasive surgery will become the standard of care for colovesical fistula, as it now is for uncomplicated diverticular disease.

Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases

BACKGROUND

Laparoscopic surgery has been applied to the management of various colorectal conditions, with shorter recovery periods than reported for open surgery. This study reviewed the feasibility and outcome of laparoscopic surgery for benign internal enteric fistulas.

METHODS

All the patients undergoing laparoscopic surgery for colovesical, colovaginal, enterovesical, and enterocolic fistulas caused by diverticulitis or Crohn's disease from 1995 to 2003 were identified from the prospective laparoscopic surgery database and retrospectively analyzed. Crohn's ileo-ileal fistulas were excluded from the study because these are generally resected more simply en bloc with the terminal ileum.

RESULTS

This study enrolled 43 patients (23 men and 20 women) with median age of 43 years, a mean body mass index of 24.5, and in American Society of Anesthesiology (ASA) distribution of 3/33/8/0 (class 1/2/3/4). The diagnosis was diverticular for 24 patients and Crohn's disease for 19 patients. The mean operative time was 163 +/- 80 min (155 in completed and 180 in converted cases), and the mean length of hospital stay was 5.2 +/- 4.7 days (3.9 in completed and 7.9 days in converted cases). A total of 14 patients (32.6%) required conversion for dense adhesions (n = 8), duodenal involvement (n = 3), multiple fistulae (n = 1), fecal leak (n = 1), and additional pathology (n = 1). Conversion rates, analyzed by fistula type, were duodenal (100%), vaginal (66.7%), sigmoid (27.7%), bladder (15.4%), enterocolic (0%), and colocolic (0%). There were six major complications (14%) including anastomotic leak (n = 3), abscesses (n = 2), and postoperative bleeding (n = 1). There were seven minor complications (16.3%) including postoperative ileus (n = 2), transient pleural effusion (n = 1), wound infection (n = 1), transient small bowel obstruction (n = 2), and brachial plexus neuralgia (n = 1). There was no significant difference in the complication (p = 0.57), reoperation (p = 0.3), or readmission (p = 0.4) rates between the completed and converted cases.

CONCLUSIONS

Laparoscopic surgery for benign internal enteric fistula offers the earlier recovery seen with other laparoscopic colorectal operations. Duodenal and vaginal involvement by the fistula is associated with a higher conversion rate. A low threshold toward early conversion is useful in these difficult cases to reduce delays in the operating room and the unnecessary use of hospital resources.

Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients

BACKGROUND

It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease.

METHODS

All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience.

RESULTS

A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% ( n=27), so that laparoscopic completion rate was 93.2% ( n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection ( n=279), followed by anterior resection ( n=36) and left colectomy ( n=29). Total complication rate was 18.4% ( n=68). Major complication rate was 7.6% ( n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% ( n=12). Anastomotic leakage occurred in 1.6% ( n=6). Minor complications were noted in 10.7% ( n=40), late-onset complications occurred in 2.7% ( n=10). Mortality was 0.5% ( n=2). Mean duration of surgery was 193 (range 75-400) min, return to normal diet was completed after 6.8 (range 3-19) days. Mean hospital stay was 11.8 (range 4-71) days. No recurrence of diverticulitis occurred.

CONCLUSION

Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.

Laparoscopic treatment of enteric fistulas

BACKGROUND

Elective laparoscopically assisted sigmoid colectomy for diverticular disease and ileocolic resection for terminal ileal Crohn's disease are safe and beneficial procedures in many patients. However, few data exist regarding the laparoscopic management of enteric fistulas from diverticular and Crohn's disease.

METHODS

We completed a retrospective chart review of patients who underwent laparoscopic treatment of enteric fistulas complicating diverticular and Crohn's disease.

RESULTS

During an 8-year period (1994-2002), 72 patients underwent 73 laparoscopically assisted bowel resections for enteric fistulas by one surgeon at the Mount Sinai Medical Center. Ninety percent of patients had Crohn's disease, the average age was 39, and the male/female ratio was 38/34. Patients had a history of prior abdominal surgery in 39.7% of cases. Multiple fistulas were present in 30% of patients and 12.3% underwent multiple resections at the time of operation. Mean operating time was 199 min, and the conversion rate was 4.1%. Average length of stay was 5.2 days. There were no mortalities in the series. Overall morbidity was 11%.

CONCLUSIONS

Laparoscopic management of enteric fistula disease is safe and effective. Low morbidity and short hospital stay demonstrate the safety and benefit of the minimally invasive approach for even complicated fistula disease in patients with history of prior abdominal surgery and multiple fistulas, or in patients requiring multiple resections for fistulas from diverticular and Crohn's disease.

Laparoscopic surgery for recurrent Crohn's disease

BACKGROUND

The aim of this study was to assess the feasibility of laparoscopic surgery for recurrent Crohn's disease, and the role of repeated laparoscopy in reoperation.

METHODS

Between January 1994 and May 2002, 61 laparoscopic operations were attempted in 52 patients with ileal or ileocolonic Crohn's disease. Of these, 16 procedures were performed for recurrence at the anastomotic site (recurrent group). The remaining 45 operations were performed as primary procedures (control group). The median follow-up was 48 (range 3-90) months.

RESULTS

The median time to reoperation was 46 months. The incidence of enteric fistula and the conversion rate did not differ significantly between the two groups. Although the operating time was significantly longer in the recurrent group, there were no differences in the rate of postoperative complications (three in the recurrent group and six in the control group) and hospital stay (both median 8 days).

CONCLUSION

Laparoscopic surgery for recurrent Crohn's disease is feasible in selected patients without an increase in conversion rate or postoperative complications.

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

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

Minilaparotomy approach to terminal ileal Crohn's disease

The feasibility and safety of a minilaparotomy approach to terminal ileal Crohn's disease have not been fully elucidated. The purpose of this study was to compare early outcomes utilizing this technique as an alternative to conventional approaches. Nine patients with terminal ileal Crohn's disease (but no complicating enteric fistulas) who underwent minilaparotomy between January 1998 and September 2000 were studied prospectively. The minilaparotomy approach entails a complete surgical procedure performed through a skin incision of less than 7 cm. Ten similar patients who underwent conventional laparotomy between January 1995 and December 1997 served as the control group. Age, gender, body weight, height, body mass index, number of prior laparotomies, operating times, operative blood loss, and types of operative procedure were similar for cases and controls. The length of the laparotomy incision in the minilaparotomy approach group was significantly shorter than that in the conventional approach group (median length 6.0 vs. 16.5 cm; p <0.05). Postoperative intervals until initial standing and walking were significantly shorter for minilaparotomy patients than conventional surgery patients (p <0.05 and p <0.05, respectively), whereas postoperative intervals until passing flatus, urinary catheter removal, and tolerance of liquids and solids did not differ for the two groups, nor did the analgesic requirement or postoperative hospital stay. Postoperative complications developed in two conventional-group patients; none was noted with the minilaparotomy approach. Our data suggest that the minilaparotomy approach to terminal ileal Crohn's disease without an enteric fistula is feasible, safe, and less invasive than the conventional approach.