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1
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Jenkin A, Edmundson A, Clark D. Surgical outcomes in ileal Crohn's disease complicated by ileosigmoid fistula. ANZ J Surg 2024; 94:1563-1568. [PMID: 39039806 DOI: 10.1111/ans.19176] [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] [Received: 03/12/2024] [Revised: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND The management of Crohn's disease (CD) complicated by ileosigmoid fistula (ISF) remains a challenge, and Australian outcomes have not previously been reported. METHODS A retrospective review of a tertiary colorectal inflammatory bowel disease unit, across public and private sites, from 2005 to 2023 to identify adult patients having undergone operative management of ISF. RESULTS Twenty-nine patients underwent surgery for ISF in the study period. Seventeen were male and the median age was 40 years. The pre-operative diagnosis of ISF was made in 76%, and patients were more likely to undergo resectional surgery if the pre-operative diagnosis was made endoscopically. Sixty-nine percent of cases were performed electively, with 76% completed laparoscopically with an 18.5% conversion rate to an open approach. The ISF was oversewn in three patients, repaired primarily in 14 patients, managed with segmental wedge resection in eight patients and resected via an anterior resection in four patients. The rate of stoma formation at the index procedure was 20.7% overall and 22% in patients being acutely managed with steroids. Emergent cases were more likely to be defunctioned with a stoma. Morbidity was 17.2% with a single anastomotic leak. CONCLUSION ISF in CD remains difficult to diagnose pre-operatively, but can be safely managed laparoscopically without formal resection, and with limited use of diverting stoma formation. The specific surgical approach to the sigmoid in ISF is difficult to pre-determine and often requires decisions to be made intra-operatively.
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Affiliation(s)
- Ashley Jenkin
- Colorectal Unit, The Royal Brisbane Hospital, Herston, Queens Land, Australia
- School of Medicine, General Surgery, University of Queensland, St Lucia, Queensland, Australia
| | | | - David Clark
- Colorectal Unit, The Royal Brisbane Hospital, Herston, Queens Land, Australia
- School of Medicine, General Surgery, University of Queensland, St Lucia, Queensland, Australia
- St Vincent's Private Hospital Northside, Chermside, Queensland, Australia
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2
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Violante T, Ferrari D, Sileo A, Sassun R, Ng JC, Mathis KL, McKenna NP, Rumer KK, Larson DW. Assessing robotic-assisted surgery versus open approach in penetrating Crohn's disease: advantages and outcomes in ileocolic resection. Tech Coloproctol 2024; 28:112. [PMID: 39167324 DOI: 10.1007/s10151-024-02985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/13/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Penetrating Crohn's disease (CD) often necessitates surgical intervention, with the open approach traditionally favored. Robotic-assisted surgery offers potential benefits but remains understudied in this complex patient population. Additionally, the lack of standardized surgical complexity scoring in CD hinders research and comparisons. METHODS We retrospectively analyzed adult patients with penetrating CD who underwent either robotic-assisted ileocolic resection (RICR) or open ileocolic resection (OICR) at our institution from January 2007 to December 2021. We assessed endpoints, including length of stay, complications, readmissions, reoperations, and other perioperative outcomes. RESULTS RICR demonstrated safety outcomes comparable to OICR. Importantly, RICR patients experienced significantly reduced estimated blood loss (p < 0.0001), shorter hospital stays (median 4.5 days versus 6.9 days; p = 0.01), lower surgical site infection rates (0% versus 15.4%; p = 0.01), and decreased 30-day readmission rates (0% versus 15.4%; p = 0.01). Linear regression analysis revealed the need for additional strictureplasties (coefficient: 84.8; p = 0.008), colonic resections (coefficient: 41.7; p = 0.008), and estimated blood loss (coefficient: 0.07; p = 0.002) independently correlated with longer operative times). CONCLUSION Robotic-assisted surgery appears to be a safe and potentially beneficial alternative for the surgical management of penetrating CD, offering advantages in perioperative outcomes reducing length of stay, blood loss, surgical site infection rates, and readmission rates. Further validation with larger cohorts is warranted.
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Affiliation(s)
- T Violante
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- School of General Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - D Ferrari
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - A Sileo
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - R Sassun
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - J C Ng
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - N P McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - K K Rumer
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
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3
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Liu W, Zhou W. Minimally invasive surgery in Crohn's disease: state-of-the-art review. Front Surg 2023; 10:1216014. [PMID: 37529660 PMCID: PMC10388240 DOI: 10.3389/fsurg.2023.1216014] [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] [Received: 05/03/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Surgery for Crohn's disease (CD) has undergone significant advancements over the last two decades, especially minimally invasive surgery. In addition to its feasibility and safety, minimally invasive surgery provides manifold advantages, including a decreased hospitalization duration, improved aesthetic results, and fewer occurrences of intra-abdominal adhesions. Due to the special intraoperative characteristics of CD, such as chronic inflammation, a thickened mesentery, fistulas, abscesses and large masses, a minimally invasive approach seems to be challenging. Complete implementation of this technique for complex disease has yet to be studied. In this review, we provide a review on the applicability of minimally invasive surgery in CD and future perspectives for the technical advances in the field.
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Oh SY, Kim YI, Yoon YS, Cho MS, Park MY, Ryoo SB, Lee JL, Kim CW, Park IJ, Lim SB, Yu CS. Optimal surgical management of duodenal fistula in Crohn's disease: a Korean multicenter cohort study. Int J Colorectal Dis 2023; 38:106. [PMID: 37074597 DOI: 10.1007/s00384-023-04387-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE Duodenal fistula in Crohn's disease (CDF) is a rare condition with an unclear optimal surgical management approach. We reviewed a Korean multicenter cohort of CDF surgery cases and assessed their perioperative outcomes to evaluate the effectiveness of the surgical interventions. METHODS The medical records of patients who underwent CD surgery between January 2006 and December 2021 from three tertiary medical centers were retrospectively reviewed. Only CDF cases were included in this study. The demographic and preoperative characteristics, perioperative details, and postoperative outcomes were analyzed. RESULTS Among the initial population of 2149 patients who underwent surgery for CD, 23 cases (1.1%) had a CDF operation. Fourteen of these patients (60.9%) had a history of previous abdominal surgery, and 7 had duodenal fistula at the previous anastomosis site. All duodenal fistulas were excised and primarily repaired via a resection of the originating adjacent bowel. Additional procedures such as gastrojejunostomy, pyloric exclusion, or T-tube insertion were performed in 8 patients (34.8%). Eleven patients (47.8%) experienced postoperative complications including for anastomosis leakages. Fistula recurrence was noted in 3 patients (13%) of which one patient required a re-operation. Biologics administration was associated with fewer adverse events by multivariable analysis (P = 0.026, odds ratio = 0.081). CONCLUSION Optimal perioperative conditioning of patients receiving a primary repair of a fistula and resection of the original diseased bowel can successfully cure CDF. Along with primary repair of the duodenum, other complementary additional procedures should be considered for better postoperative outcomes.
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Affiliation(s)
- Soo Young Oh
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Min Soo Cho
- Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Young Park
- Division of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung-Bum Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
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McKenna NP, Kelley SR, Bews KA, Behm KT, Mathis KL. Surgical Management of Enterovesical Fistula in Crohn's Disease in the Biologic Era. Inflamm Bowel Dis 2023; 29:480-482. [PMID: 35751558 DOI: 10.1093/ibd/izac133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 12/09/2022]
Abstract
Lay Summary
Enterovesical fistula in Crohn’s disease that require surgery may be managed safely laparoscopically with similar morbidity to open repair and a shorter length of stay. Preoperative biologic exposure does not affect surgical morbidity.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott R Kelley
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Katherine A Bews
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kevin T Behm
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kellie L Mathis
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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Abdalla S, Abd El Aziz MA, Calini G, Saeed H, Merchea A, Shawki S, Behm KT, Larson DW. Perioperative outcomes of minimally invasive ileocolic resection for complicated Crohn disease: Results from a referral center retrospective cohort. Surgery 2022; 172:522-529. [PMID: 35337682 DOI: 10.1016/j.surg.2022.01.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease. METHODS A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group). RESULTS Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188). CONCLUSION Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.
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Affiliation(s)
- Solafah Abdalla
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Giacomo Calini
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL
| | - Sherief Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
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Pak SJ, Kim YI, Yoon YS, Lee JL, Lee JB, Yu CS. Short-term and long-term outcomes of laparoscopic vs open ileocolic resection in patients with Crohn's disease: Propensity-score matching analysis. World J Gastroenterol 2021; 27:7159-7172. [PMID: 34887635 PMCID: PMC8613650 DOI: 10.3748/wjg.v27.i41.7159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/08/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopic ileocolic resection (LICR) is the preferred surgical approach for primary ileocolic Crohn's disease (CD) because it has greater recovery benefits than open ICR (OICR). AIM To compare short- and long-term outcomes in patients who underwent LICR and OICR. METHODS Patients who underwent ICR for primary CD from 2006 to 2017 at a single tertiary center specializing in CD were included. Patients who underwent LICR and OICR were subjected to propensity-score matching analysis. Patients were propensity-score matched 1:1 by factors potentially associated with 30-d perioperative morbidity. These included demographic characteristics and disease- and treatment-related variables. Factors were compared using univariate and multivariate analyses. Long-term surgical recurrence-free survival (SRFS) in the two groups was determined by the Kaplan-Meier method and compared by the log-rank test. RESULTS During the study period, 348 patients underwent ICR, 211 by the open approach and 137 laparoscopically. Propensity-score matching yielded 102 pairs of patients. The rate of postoperative complication was significantly lower (14% versus 32%, P = 0.003), postoperative hospital stay significantly shorter (8 d versus 13 d, P = 0.003), and postoperative pain on day 7 significantly lower (1.4 versus 2.3, P < 0.001) in propensity-score matched patients who underwent LICR than in those who underwent OICR. Multivariate analysis showed that postoperative complications were significantly associated with preoperative treatment with biologics [odds ratio (OR): 3.14, P = 0.01] and an open approach to surgery (OR: 2.86, P = 0.005). The 5- and 10-year SRFS rates in the matched pairs were 92.9% and 83.3%, respectively, with SRFS rates not differing significantly between the OICR and LICR groups. The performance of additional procedures was an independent risk factor for surgical recurrence [hazard ratio (HR): 3.28, P = 0.02]. CONCLUSION LICR yielded better short-term outcomes and postoperative recovery than OICR, with no differences in long-term outcomes. LICR may provide greater benefits in selected patients with primary CD.
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Affiliation(s)
- Shin Jeong Pak
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Young Il Kim
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Yong Sik Yoon
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Jong Lyul Lee
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
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Yoon YS, Stocchi L, Holubar S, Aiello A, Shawki S, Gorgun E, Steele SR, Delaney CP, Hull T. When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn's disease? Surg Endosc 2021; 35:2543-2557. [PMID: 32468260 DOI: 10.1007/s00464-020-07670-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn's disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity. METHODS Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination. RESULTS For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5 kg/m2 (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times. CONCLUSIONS LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.
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Affiliation(s)
- Yong Sik Yoon
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Colorectal Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Desk A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandra Aiello
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sherief Shawki
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Nevo Y, Zippel D, Segev L, Ben Yaacov A, Meron Eldar S, Hazzan D. Totally Laparoscopic Ileocolic Resection for Complex Enterovisceral Fistulas in Crohn's Disease: A Comparative Study. Surg Laparosc Endosc Percutan Tech 2021; 31:539-542. [PMID: 33710102 DOI: 10.1097/sle.0000000000000928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 10/07/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In primary Crohn's disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. However, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex enterovisceral fistulas.The aim of this study is to assess the feasibility and safety of laparoscopic surgery for complex enterovisceral fistulas, and compare it with CD patients who underwent primary laparoscopic ileocolic resection. PATIENTS AND METHODS All patients who underwent laparoscopic primary ileocolic resection (LICR) for complex enterovisceral fistulas between July 2006 and July 2017 were included. They were compared with all consecutive patients who underwent LICR for nonfistulizing CD in the same period of time. Patients with previous bowel resections or recurrent disease were excluded. RESULTS Nineteen patients with 20 enterovisceral fistulas (group I) were compared with 61 patients who underwent LICR for nonfistulizing disease (group II). There were no differences between the groups in age, sex, preoperative body mass index, nutritional status, and American Society of Anesthesiology score. There was no conversion to open surgery in both groups.There were no significant differences between groups in terms of operative time [120 (range: 65 to 232) vs. 117 (range: 62 to 217) min, P=0.7], hospital stay [6 (5 to 8) vs. 7 (5 to 65) days, P=0.56], overall morbidity 26.3% versus 16.4% (P=0.33), major morbidity (Clavien-Dindo >3) 15.7% versus 10% (P=0.66) and reoperation rates 5.3% versus 4.9% (P=0.9). There was no mortality in both groups. CONCLUSIONS Our experience shows that the laparoscopic approach for complex enterovisceral fistulas in selected CD patients is both feasible and safe in the hands of experienced inflammatory bowel disease surgeons with extensive expertise in laparoscopic surgery. Larger study cohorts are needed to confirm these findings.
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Affiliation(s)
- Yehonatan Nevo
- Department of Surgery C
- Minimally Invasive and Robotic Surgery, Sheba Medical Center, Tel Hashomer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Douglas Zippel
- Department of Surgery C
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Segev
- Department of Surgery C
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Almog Ben Yaacov
- Department of Surgery C
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Meron Eldar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hazzan
- Department of Surgery C
- Minimally Invasive and Robotic Surgery, Sheba Medical Center, Tel Hashomer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Abstract
BACKGROUND There are no specific guidelines for ventral hernia management in Crohn's disease (CD) patients. We aimed to assess the risk of septic morbidity after mesh repair in CD. METHODS This was a retrospective multicentre study comparing CD and non-CD patients undergoing mesh repair for ventral hernia (primary or incisional hernia). Controls were matched 1:1 for the presence of a stoma, history of surgical sepsis, hernia size and Ventral Hernia Working Group (VHWG) score. All demographic, pre-, intra- and postoperative data were retrieved, including long-term data. RESULTS We included 234 patients, with 114 CD patients. Both groups had comparable VHWG scores (p = 0.12), hernia sizes (p = 0.11), ASA scores ≥ 3 (p = 0.70), body mass index values (p = 0.14), presence of stoma (CD 21.9% vs. controls 15%, p = 0.16), history of sepsis (14% vs. 6.7%, p = 0.23), rates of malnutrition (4.4% vs. 1.7%, p = 0.46), rates of incisional hernia (93% vs. 95%, p = 0.68) and concomitant procedures (18.4% vs. 11.7%, p = 0.12). CD patients carried a higher risk of postoperative septic morbidity (18.4% vs. 5%, p = 0.001), entero-prosthetic fistula (7% vs. 0, p < 0.01) and mesh withdrawals (5.3% vs. 0, p = 0.011). Ventral hernia recurrence rates were similar (14% vs. 8.3%, p = 0.15). In the univariate analysis, the risk factors for septic morbidity were CD (p = 0.001), malnutrition (p = 0.004), use of biological mesh (p < 0.0001) and concomitant procedure (p = 0.004). The mesh position, the means used for mesh fixation as well as the presence of a stoma were not identified as risk factors. CONCLUSIONS CD seems to be a risk factor for septic morbidity after mesh repair.
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11
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Yu ZL, Lin DZ, Hu JC, Chen YF, Cai ZR, Zou YF, Ke J, Guo XF, Lan P, Wu XJ. Laparoscopic Surgery for Complex Crohn's Disease: A Meta-Analysis. J Laparoendosc Adv Surg Tech A 2019; 29:1397-1404. [PMID: 31414963 DOI: 10.1089/lap.2019.0398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Zhao-liang Yu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - De-zheng Lin
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Ambulatory Surgery Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian-cong Hu
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Ambulatory Surgery Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu-feng Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ze-rong Cai
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yi-feng Zou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xue-feng Guo
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Ambulatory Surgery Center, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao-jian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Surgical Techniques and Differences in Postoperative Outcomes for Patients With Crohn's Disease With Ileosigmoid Fistulas: A Single-Institution Experience, 2010-2016. Dis Colon Rectum 2019; 62:1222-1230. [PMID: 31490831 DOI: 10.1097/dcr.0000000000001451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical treatment of ileosigmoid fistulas in Crohn's disease is poorly characterized. OBJECTIVE The purpose of this study was to identify differences in patient postoperative outcomes for isolated ileosigmoid fistulas by surgical approach (laparoscopic versus open) and sigmoid colon repair type (sigmoid resection versus primary repair). DESIGN Using a prospectively collected database, we gathered perioperative data from chart reviews to calculate differences and associations between treatment groups. SETTINGS The study was conducted at a single tertiary care center. PATIENTS Patients with Crohn's disease who underwent surgery for isolated ileosigmoid fistulas between July 1, 2010, and June 30, 2016 were included. RESULTS We identified 84 patients, with an average age of 37 years. A total of 51 were men and 33 were women; 34 underwent a sigmoid resection, whereas 50 had a primary repair of the sigmoid. All of the patients underwent an ileocolic resection. A total of 67 surgeries were initially attempted laparoscopically, of which 17 (25.4%) were converted to open, with 50 (59.5%) completed laparoscopically. There were no significant differences in length of stay or incidence of postoperative complications by surgical approach (laparoscopic versus open). For patients who underwent a primary sigmoid repair versus a sigmoid resection, there were no significant differences in postoperative complications, but there was a significant difference in the length of stay (6.36 vs 9.56 d for primary repair versus resection; multivariate p value of 0.022). MAIN OUTCOME MEASURES Postoperative complications and length of stay were measured. LIMITATIONS The study was limited by its small sample size, cross-sectional nature of the data, and limited information about preoperative outpatient medical treatment. CONCLUSIONS Laparoscopic surgery for isolated ileosigmoid fistulas in Crohn's disease is safe and does not result in a different length of stay or incidence of postoperative complications. Primary repair (rather than resection) of the sigmoid colon in these cases, when feasible, appears to be safe and is likely to be cost-effective given the reduced length of stay. See Video Abstract at http://links.lww.com/DCR/A993. TÉCNICAS QUIRÚRGICAS Y DIFERENCIAS EN LOS RESULTADOS POSTOPERATORIOS PARA LOS PACIENTES CON ENFERMEDAD DE CROHN CON FÍSTULAS ILEO-SIGMOIDEAS: UNA EXPERIENCIA EN UNA SOLA INSTITUCIÓN, 2010-2016: El tratamiento quirúrgico de las fístulas ileo-sigmoideas en la enfermedad de Crohn está mal caracterizado. OBJETIVO Identificar las diferencias en los resultados postoperatorios de los pacientes para las fístulas ileo-sigmoideas aisladas por abordaje quirúrgico (laparoscópica versus abierta) y tipo de reparación de colon sigmoide (resección sigmoidea versus reparación primaria). DISEÑO:: Utilizando una base de datos recopilada de forma prospectiva, se recopilaron datos perioperatorios de las revisiones de los gráficos para calcular las diferencias y las asociaciones entre los grupos de tratamiento. AJUSTE Un solo centro de atención terciaria. PACIENTES Pacientes con enfermedad de Crohn que se sometieron a una cirugía para fístulas ileo-sigmoideas aisladas entre el 1 de julio de 2010 y el 30 de junio de 2016. RESULTADOS Se identificaron 84 pacientes, con una edad promedio de 37 años. Un total de 51 eran hombres y 33 mujeres; 34 se sometieron a una resección sigmoidea, mientras que 50 tuvieron una reparación primaria del sigmoide. Todos los pacientes fueron sometidos a resección ileocólica. Inicialmente, un total de 67 círugias se intentaron por vía laparoscópica, de las cuales 17 (25,4%) se convirtieron en cirugías abiertas, y 50 (59,5%) se completaron por vía laparoscópica. No hubo diferencias significativas en la duración de la estancia o la incidencia de complicaciones postoperatorias por abordaje quirúrgico (laparoscópica versus abierta). Para los pacientes que se sometieron a una reparación sigmoidea primaria versus una resección sigmoidea, no hubo diferencias significativas en las complicaciones postoperatorias, pero sí hubo una diferencia significativa en la duración de la estancia hospitalaria (6,36 versus a 9,56 días para la reparación primaria frente a la resección; p multivariable -valor de 0.022). PRINCIPALES MEDIDAS DE RESULTADOS Complicaciones postoperatorias y duración de la estancia. LIMITACIONES Tamaño de muestra pequeño, naturaleza transversal de los datos e información limitada sobre el tratamiento médico ambulatorio preoperatorio del paciente. CONCLUSIONES La cirugía laparoscópica para fístulas ileo-sigmoideas aisladas en la enfermedad de Crohn es segura y no ocasiona una duración diferente de la estancia hospitalaria ni una incidencia diferente de complicaciones postoperatorias. La reparación primaria (en lugar de la resección) del colon sigmoide en estos casos, cuando es posible, parece ser segura y es probable que sea rentable, dada la duración reducida de la estancia. Vea el Resumen del Video en http://links.lww.com/DCR/A993.
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Abstract
Minimally invasive approaches are safe, feasible, and often recommended as the initial choice in the surgical management of Crohn's disease. However, a consensus has not been reached as the ideal approach in the surgical treatment of complex and recurrent Crohn's disease. Laparoscopy may provide advantages such as shorter length of stay and decreased postoperative pain and result in less adhesion formation in patients with complex disease. Robotic techniques may be beneficial in selected patients for completion proctectomy, providing better visualization in the narrow pelvis and increased dexterity. Decision of surgical technique should be made on a case-by-case basis.
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Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Short-term Outcomes of Laparoscopic Versus Open Treatment of Internal Enteric Fistulae: A Logistic Regression Analysis. Surg Laparosc Endosc Percutan Tech 2018; 28:250-255. [PMID: 29975354 DOI: 10.1097/sle.0000000000000557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Maeda K, Nagahara H, Shibutani M, Fukuoka T, Nakao S, Yamagami H, Kamata N, Muguruma K, Tanaka H, Toyokawa T, Hirakawa K, Ohira M. The feasibility and short-term clinical outcomes of single-incision laparoscopic surgery for patients with complex Crohn’s disease. Surg Today 2017; 48:242-247. [DOI: 10.1007/s00595-017-1581-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/31/2017] [Indexed: 01/21/2023]
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Manabe T, Ueki T, Nagayoshi K, Moriyama T, Yanai K, Nagai S, Esaki M, Nakamura K, Nakamura M. Feasibility of laparoscopic surgery for complex Crohn's disease of the small intestine. Asian J Endosc Surg 2016; 9:265-269. [PMID: 27121153 DOI: 10.1111/ases.12287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 02/16/2016] [Accepted: 02/29/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND The laparoscopic approach for complex Crohn's disease (CD), which involves abscess formation, fistula formation, and recurrent CD, is controversial. The aim of this study was to investigate the feasibility and safety of the laparoscopic approach for complex CD. METHODS Fifty-six patients who had undergone surgery for CD of the small bowel from January 2007 to August 2014 were divided into two groups: the laparoscopic approach for complex CD group (LC group, n = 31) and the laparoscopic approach for simple CD group (LS group, n = 25). The preoperative data and surgical outcomes of the LC group were compared with those of the LS groups. RESULTS There were no significant differences in preoperative data and operating time between the two groups. Blood loss was not significantly different between the LC and LS groups. The incision length was longer in the LC group than the LS group (P = 0.004). The incidence of severe postoperative complications in the LC group was higher than in the LS group (P = 0.026). The length of postoperative stay was similar in the LC and LS groups. CONCLUSIONS The laparoscopic approach for complex CD is feasible and provides good cosmesis that is comparable to that offered by simple CD.
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Affiliation(s)
- Tatsuya Manabe
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan.
| | - Takashi Ueki
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kosuke Yanai
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Shuntaro Nagai
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kazuhiko Nakamura
- Department of Medicine and Bioregulatory Science, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
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Ballester-Pla N, Pous-Serrano S, Palasí-Giménez R, García-Granero E. Use of a linear stapler for the treatment of ileocolic fistula in Crohn's disease. Colorectal Dis 2016; 18:O385-O387. [PMID: 27454329 DOI: 10.1111/codi.13471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 06/08/2016] [Indexed: 02/08/2023]
Abstract
AIM The study reports an easy technique for surgical management of some forms of ileocolic fistula in Crohn's disease. METHOD Five patients with Crohn's disease with ileocolic fistula (2011-2014) have been managed by the application of linear stapler devices. RESULTS Postoperative course was satisfactory in all patients. At 1 year there was no evidence of stricture or fistula formation and no patient had required reoperation. CONCLUSION The technique is easy and effective and can be used in open and laparoscopic surgery.
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Affiliation(s)
- N Ballester-Pla
- General Surgery Department, Coloproctology Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - S Pous-Serrano
- General Surgery Department, Coloproctology Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - R Palasí-Giménez
- General Surgery Department, Coloproctology Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - E García-Granero
- General Surgery Department, Coloproctology Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Kristo I, Stift A, Argeny S, Mittlböck M, Riss S. Minimal-invasive approach for penetrating Crohn's disease is not associated with increased complications. Surg Endosc 2016; 30:5239-5244. [PMID: 27334961 PMCID: PMC5112282 DOI: 10.1007/s00464-016-4871-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/10/2016] [Indexed: 12/16/2022]
Abstract
Background Laparoscopic surgery for penetrating Crohn’s disease (CD) still remains highly conflicting due to a lack of sufficient data. Therefore, the following large study was designed to compare postoperative outcomes after minimal-invasive resections for penetrating and non-penetrating CD. Methods Consecutive patients, who underwent laparoscopic intestinal resection for symptomatic CD at a tertiary academic referral center, were included. Patients were divided according to perioperative findings in penetrating and non-penetrating type of disease. All clinical data were obtained from an institutional database and analyzed retrospectively. Results Of 234 patients enrolled, 101 patients [females: n = 54 (53.5 %)] were operated on for non-penetrating CD and 133 patients [females: n = 50 (37.6 %)] for penetrating CD. Fistulas (p < 0.001), inflammatory mass (p < 0.001) and abscess formation (p < 0.001) were observed more frequently in the perforating group. Ileocolic resections were performed predominantly in both groups [perforating CD: n = 110 (82.7 %), non-perforating CD: n = 82 (81.2 %)], with more complex resections (>1 intestinal resection) found in perforating CD (p < 0.001). Conversion rates did not differ significantly. Notably, 30-day postoperative morbidity was comparable for both groups [perforating CD: n = 20 (15 %), non-perforating CD: n = 19 (18.8 %), p = 0.44]. Postoperative complication rates graded according to the Clavien–Dindo classification showed no difference too (p = 0.49). Conclusion Laparoscopic surgery can be conducted safely in selected patients with penetrating CD without increasing the risk of postoperative complications. This finding needs to be implemented in future guidelines.
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Affiliation(s)
- Ivan Kristo
- Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Anton Stift
- Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Stanislaus Argeny
- Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Martina Mittlböck
- Center for Medical Statistics, Informatics and Intelligent Systems, Vienna, Austria
| | - Stefan Riss
- Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Strong S, Steele SR, Boutrous M, Bordineau L, Chun J, Stewart DB, Vogel J, Rafferty JF. Clinical Practice Guideline for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2015; 58:1021-36. [PMID: 26445174 DOI: 10.1097/dcr.0000000000000450] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Ren J, Liu S, Wang G, Gu G, Ren H, Hong Z, Li J. Laparoscopy improves clinical outcome of gastrointestinal fistula caused by Crohn's disease. J Surg Res 2015; 200:110-6. [PMID: 26286894 DOI: 10.1016/j.jss.2015.07.036] [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] [Received: 05/16/2015] [Revised: 07/11/2015] [Accepted: 07/21/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Benefits of laparoscopic surgery in the management of gastrointestinal fistula caused by Crohn disease need to be fully elucidated. We conducted this retrospective study to investigate the safety and feasibility and emphasize the advantages of laparoscopy compared with that of laparotomy for patients with gastrointestinal fistula caused by Crohn disease. MATERIALS AND METHODS A total of 1213 patients with gastrointestinal fistula in our center were screened, and 318 qualified patients were enrolled and divided into laparoscopy (n = 122) and laparotomy (n = 196) groups. Postoperative complications, length of hospital stay, systemic stress responses to surgery, postoperative mortality, and economic burden were collected and compared. RESULTS A total of 125 laparoscopic interventions were performed with a conversion rate of 20.0%. Fifteen versus 84 postoperative complications were obtained in laparoscopy and laparotomy groups, respectively (P = 0.0033). Total hospitalization was 22.7 d and 38.0 d in laparoscopy and laparotomy groups, respectively (P < 0.0001). Postoperative hospitalization was 10.9 d and 24.8 d in two groups, respectively (P < 0.0001). Elevation curve of serum C-reactive protein and procalcitonin in response to laparoscopy was significantly lower than that to laparotomy. Reduced postoperative mortality (P = 0.0292) and postoperative cost (P = 0.0292) were observed in laparoscopy instead of laparotomy group. CONCLUSIONS Laparoscopic approach is safe and feasible and could improve clinical outcome in gastrointestinal fistula patients with Crohn disease.
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Affiliation(s)
- Jianan Ren
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Song Liu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gefei Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Guosheng Gu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Huajian Ren
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhiwu Hong
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Abstract
Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.
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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: 9] [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
In primary Crohn's disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex CD involving localized abscess, fistula or recurrent disease. The aim of this systematic literature review was to assess the feasibility and safety of laparoscopic surgery for complex or recurrent CD. In the current literature, there are nine non-randomized cohort studies, two of which were case-matched. The mean rate of conversion to open laparotomy reported in these series ranged from 7% to 42%. Morbidity rate and hospital stay following laparoscopic resection for complex CD were similar to those for initial resection or for non-complex CD. In summary, even though strong evidence is lacking and more contributions with larger size are needed, the limited experiences available from the literature confirm that the laparoscopic approach for complex CD is both feasible and safe in the hands of experienced IBD surgeons with extensive expertise in laparoscopic surgery. Further studies are required to confirm these results and determine precisely patient selection criteria.
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Affiliation(s)
- M Tavernier
- Service de chirurgie digestive, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen, France
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24
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Current status of laparoscopic surgery for patients with Crohn's disease. Int J Colorectal Dis 2013; 28:599-610. [PMID: 23588872 DOI: 10.1007/s00384-013-1684-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Minimally invasive surgery is increasingly utilized in treatment for refractory or complicated Crohn's disease, and new developments aim at further reducing the abdominal trauma and improving the outcome. This review evaluates current literature about minimally invasive surgery for patients with Crohn's disease, latest advances in single-incision surgery, and methods of specimen extraction. METHODS Literature was reviewed with focus on the following topics: indications, surgical procedures, conversions, complications, and short- as well as long-term outcomes of laparoscopic compared to open surgery for refractory, complicated, and recurrent Crohn's disease. RESULTS Short-term benefits such as shorter hospital stay and faster postoperative recovery are accompanied by long-term benefits such as better cosmetic results and lower treatment-associated morbidity. Single-incision surgery and minimally invasive methods of specimen extraction help to further reduce the surgical trauma and are gradually implemented in the treatment. CONCLUSION In experienced centers, laparoscopic surgery for Crohn's disease is safe and as feasible as open operations, even for selected cases with operations for complicated or recurrent disease. However, accurate analysis of the data is complicated by the heterogeneity of clinical presentations as well as the variety of performed procedures. Additional long-term data are needed for evaluation of true benefits of the new techniques.
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