Lap surgery for primary & recurrent ileocolic Crohn's disease
surgery for primary & recurrent ileocolic Crohn’s disease.
D Glancy, AR Dixon
of Colorectal Surgery, Frenchay Hospital, Bristol BS16 1LT, UK
Keywords Crohn’s disease, recurrent Crohn’s, Laparoscopic surgery, SILS, Enhanced
Evaluate the safety and
short-term outcomes of laparoscopic surgery for primary and recurrent ileo-colic
Between June 2002 and June 2010,
59 consecutive, unselected patients underwent laparoscopic ileocolic resection;
30 had recurrent disease. Four
primary resections and one revision were performed as single incision (SILS)
There was no difference between the
two groups in terms of age, BMI, ASA grade or the presence or absence of
fistulating disease. The median operating time was significantly longer for the
revision group (125 v 85 minutes; p<0.001). The rate of conversion was 8.5%,
morbidity 20% and mortality 0% (NS between groups). Risk factors for conversion
were complex fistulas, fibrosis and the need to carry out multiple
stricturoplasty; SILS did not increase the risk of conversion. Converted cases
had a longer stay and a higher morbidity (40%). The median hospital stay was
3 days, with a 5% return to theatre and a 5% readmission rate (NS between
Laparoscopic surgery for primary
and recurrent ileo-colic Crohn’s is challenging and complex, particularly in
the presence of fistulating disease. It is however safe and can lead to
significant short-term benefits, particularly earlier discharge. Conversion
increases length of stay and overall morbidity.
Laparoscopic resection has been shown to have
increasing utility in selected patients undergoing ileo-caecal resection for
Crohn’s disease1-4. The benefits include reduced pain; lower overall
morbidity, a shorter hospital stay, earlier return to full activity and
improved quality of life and cosmesis1-10. Benefits that is
essential to consider when managing a group of patients with benign disease who
tend to lie at the younger end of the age spectrum and have a reoperation rate
approaching 50% within 10-15 years11. However, it remains to be clarified whether or not repeated
laparoscopic surgery is feasible in patients with relapsing disease; enteric
fistula, intra-abdominal abscesses or a mass, and a history of previous
resection are considered by some as being a relative contraindication to a
Recent reports have demonstrated that in expert
hands, laparoscopy is not only feasible, but also safe in selected patients
with complicated Crohn’s14-16. Only a few studies, and most involving
only small numbers of highly selected patients have examined its use in re-operative
We set out to evaluate the safety, feasibility and
short-term outcomes of using laparoscopy in unselected and consecutive patients
with primary or recurrent ileocolic Crohn’s disease.
The data were gathered from our prospectively
collected, password protected electronic database of laparoscopic surgery
between June 2002 and 2010. All had a clinical, endoscopic and radiological assessment
(small bowel enema and CT scan) of their disease preoperatively. Patients with intra-abdominal
abscesses were initially drained percutaneously whenever feasible.
Prior to 2002, all our patients with recurrent
Crohn’s disease underwent a conventional midline laparotomy. Beginning in 2002,
our policy called for a systematic attempt to perform a laparoscopic procedure
if at all feasible in all patients, even for those who already had undergone a
previous open resection. We hypothesized that for these patients, the benefit
of laparoscopy in preserving the integrity of abdominal wall was crucial. The
primary operation of all recurrence cases had been an open resection.
Pneumoperitoneum was achieved using a 12mm umbilical
port for primary surgery; a left upper quadrant Verres needle insufflation
(replaced with 5mm optical port [Xcel,
Ethicon EndoSurgery, Bracknel, UK] and 300 laparoscope) was used
in cases of recurrent disease. Two
additional ports (12 and 5mm) were placed as directed by the
pathology/adhesions encountered and the scope changed to 10mm. In the case of
recurrent disease, adhesions (to abdominal wall and those between loops of
bowel) were divided with scissors.
Mesenteric mobilization/division was achieved using an ultrasonic
dissector. In the case of
recurrent disease (mesenteric
fibrosis) we had a low threshold of using sharp scissors/hook diathermy and a
laparoscopic stapler (vascular staples), usually after division of the small bowel
as the chosen site of division using the same articulating stapler. 10mm Hem-o-Loc
(Wyek, High Wycombe, UK) clips were
used to control bleeding as necessary.
Three primary and a recurrent resection were
completed using a single incision/port (SILS) technique21. A fifth
SILS case was converted early.
Laparoscopic surgical procedure was otherwise not
influenced by primary or secondary resection. Briefly, mobilization of the
bowel (using a combination of lateral to medial, cephalid to cranial or visa versa
starting with the transverse colon as considered appropriate i.e., the diseased
segment was tackled from more than one angle to find a recognizable plane),
mesenteric division and bowel transection was performed intra-corporeally. The
ileocolic region is mobilized upwards more easily than downwards unless the
small bowel is fixed in the pelvis. To ensure that no enterotomy or strictures
were missed, the duodenum and entire length of the mobilised small bowel was then
walked from the DJ flexure with atraumatic forceps.
The bowel was then exteriorized by a 4-6cm midline skin
incision centered on the umbilicus (or an appropriate part of the previous
incision). Wound protector devices were used to ease “end-on” delivery of large
inflammatory masses. Any residual mesentery was divided extra-corporeally and a
side-to-side stapled ileocolic anastomosis constructed. A pelvic drain was used whenever the
dissection had been difficult.
A temporary stoma was considered preferable to an
anastomosis for high-risk patients who presented with more than one of the
following risk factors: steroids, an abscess discovered during surgery, or poor
When the laparoscopic procedure was not feasible, or
when dissection proved too difficult, the procedure was converted. A conversion
was defined as any unplanned incision or any planned incision longer than
6 cm that was necessary for simple exteriorization of the specimen and
used to fashion the anastomosis. Our post-operative “accelerated recovery”
protocol has been previously described22.
Quantitative data were expressed as medians and
ranges and qualitative data as frequency and percentage. Comparisons between
the groups were analyzed with the chi-squared or Mann–Whitney test as
appropriate: p values <0.05 were considered significant.
Between 2002 and 2010, 59 patients underwent
ileo-colonic resection for Crohn’s disease; 30 underwent surgery for recurrent
disease. There were no significant differences between the recurrent and the
primary groups in terms of age, body mass index and the extent and presentation
of the disease (Table 1.).
The outcomes are summarized in Table 2. The rate of
conversion to open surgery was 8.5% overall, and was similar in both groups. The “primary” conversions were due to
either equipment failure or the need to carry out additional multiple small
bowel stricturoplasties or a synchronous sigmoid resection; the recurrence
conversions were followed the finding of dense organised fibrosis which
prevented adequate mobilization of the mesentery.
The operative time was significantly longer in the
recurrent group. The one blood
transfusion was in the primary group. There was no difference in time to
tolerating a light diet.
Postoperative complications (including readmissions) occurred in 15
resections (25%). The
complications are outlined (Table 3.).
There was no difference between groups in either postoperative
complications or hospital stay (Tables 2 and 3). The case of acute renal
failure required ITU admission following a negative laparoscopy and developed
in response to hyperphosphateaemia and hypocalcaemia which had developed
secondary to an inappropriate prescription of phospho-soda bowel prep (oral and
two enemas). The enterotomy occurred “off screen” and presented itself on day
2. There were no duodenal
injuries. Social delays accounted
for the three-week length of stay. There was no mortality in either group.
Table 1. Patient Demographics
Recurrent (n= 30)
Median Age (years)
Median BMI (kg/m2)
Enteric Enteric Fistula
Enteric Colic fistula
ASA > 2
Table 2. Outcome data. Values are median (range)
Operating time (min)
Conversion to open
Time to light diet (hrs)
13 (4-72 hrs)
Return to theatre
Length of stay (days)
2 (leak & abscess)
Table 3. Postoperative
complications (includes readmissions)
Four randomized trials4,6,7,9 and three
recent meta-analysis1-3 of laparoscopic assisted Crohn’s resection
has clearly demonstrated short-term benefits for primary resection; a lower
morbidity rate, a more rapid recovery of bowel function and a shorter hospital
stay. However, the individual
reports used in compiling the analysis comprised only small patient series and
all were highly selected. Saying
that, the recent Mayo Clinic report23 of 109 consecutive resections
(41% re-do resections) i.e., the largest series to date concluded that laparoscopic
resection had become “their procedure of choice for Crohn’s disease; 6%
conversion, 0% mortality, reoperation rate 1%, morbidity 11% and median stay 4
days. Laparoscopic resection has also been shown to have the additional advantage
of producing better cosmesis, and when given a choice, the majority of patients
seem to prefer it 4,5,10,24.
The question as to whether these expected benefits
also can be observed for recurrent Crohn’s disease, or not, required address. Previous
authors have shown that open re-operative surgery for recurrent Crohn’s disease
is associated with higher morbidity than seen following primary resections17.
Anticipating technical difficulties, many surgeons would understandably prefer
to continue to advise an open approach for recurrent Crohn’s.
Our study reports one of the largest personal series
of unselected and consecutive patients undergoing laparoscopic adhesiolysis and
ileocolic resection in the management of their recurrent Crohn’s disease after
a primary open resection. Furthermore, the 30 laparoscopic re-operations were
compared with 29 primary laparoscopic ileocolic resections. The principle
findings were that although the surgery is challenging and complex, a
laparoscopic approach is not only feasible, but also more importantly safe and
supports similar conclusions reported by others15,18-20. There was
no increased risk of intra-operative enterotomy and the mortality and morbidity
rates were similar to those observed in other studies where laparoscopy was
used for primary resection.
The risk factors for our failure in completing a laparoscopic
approach were the need to carry out concurrent multiple small bowel
stricturoplasties (in our view
impossible to carry out laparoscopically), and the finding of dense mesenteric
fibrosis that prevents adequate mobilization sufficient for specimen delivery. As
one might have intuitively predicted, the use of laparoscopy in patients with
recurrent disease is associated with a significantly longer operative
time. It is not however associated
with a greater blood loss, a higher complication rate or a delayed discharge.
To date, only one other study comparing laparoscopy
for primary resection and recurrent Crohn’s disease has been reported18.
In our study, the morbidity rate
after laparoscopic re-resection was similar to that reported after both open
and laparoscopic primary ileo-caecal resection6,9. However, a failure
to complete the laparoscopic procedure occurred in 8.5% of cases (6.6% for
recurrent resection) and twice what we usually counsel our patients undergoing
laparoscopic segmental colorectal resection25 and highlights the
complexity of these procedures.
Conversion is required to carry out a stricturoplasty or to mobilize the
dense intra-peritoneal adherence of a severely fibrotic mesentery due to the
disease process. Nevertheless, the conversion rate we report remains close to
that already reported after primary ileo-caecal resection12,13,23
and is similar to that reported in the widely quoted 16 re-resections of
Hasegawa’s series18. It is some way short of 70% conversions
reported from Osaka 26 .
The Leeds group recently reported a 7% conversion rate in 27 patients
undergoing recurrent resection27.
Unlike the reports from other groups19,20,
our morbidity increased to 40% in the five converted patients (leak from a
small bowel strictureoplasty and a readmission with an anastomotic leak). The former patient leaked after a
further open stricturoplasy was performed it a quaternary referral centre 6
months later. Independent risk
factors for conversion in laparoscopic surgery carried out for recurrent
Crohn’s include the intra-operative discovery of an internal fistula and bowel injury
during surgery20. Factors that one might consider predictable, and similar
to those reported by earlier studies of patients undergoing primary laparoscopic
resection12,13, i.e., intra-abdominal abscess or internal fistula.
Surprisingly, the number of previous interventions was unrelated to conversion12.
In Brouquet’s study of 29 laparoscopic
re-interventions 20, intra-operative intestinal injury occurred in 17%
and was associated with a significantly higher conversion rate (5/5 vs. 0/24
for primary resection; p = 0.0002). The authors concluded that
the enterotomies were largely due to dense adhesions, and were the principal
cause of conversion (5 of 9 converted procedures). Univariate analysis did not
show any relationship between the presence of intra-peritoneal adhesions and
conversion20. Whilst the majority of adhesions, no matter there
intensity, can be dissected safely using laparoscopy and sharp scissors28,
inadvertent “off screen” enterotomy, as seen in our series is always a risk25.
In this series, we have like others23, 27
shown that the anticipated benefits of laparoscopy, i.e., lower morbidity and
shorter hospital stay, are not only seen following primary resection for Crohn’s
disease1-3 but can also equally apply to recurrent Crohn’s resection,
and that enhanced recovery programmes are still applicable in this sub set of
patients. This was not so in Bouquet’s
paper20 that reported a median hospital stay of 9 days for both open
and laparoscopic revisional surgery and followed a complication rate of 15% (open
group) versus 10% in the laparoscopic group.
Although a randomized study would answer the question
about the merits of laparoscopy in re-operative surgery for Crohn’s, it is
unlikely to succeed due to the heterogeneity of the patients requiring surgery.
On the basis of this experience, our current policy
like the Mayo Clinic23 is to continue to discuss a laparoscopic
approach with all patients who have ileo-colic Crohn’s disease; that said we
would consider that a history of multiple laparotomies (≥2) an absolute
contraindication. It is our continued
view that repeated small bowel stricturoplasty does not lend itself easily to a
laparoscopic technique. The principles of enhanced recovery are still
applicable and patients accrue the other expected benefits of laparoscopy.
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