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Lap surgery for primary & recurrent ileocolic Crohn's disease

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14/07/2010

Laparoscopic surgery for primary & recurrent ileocolic Crohn’s disease.

 

 

 

 

 

 

B Chaudhray, D Glancy, AR Dixon

Department of Colorectal Surgery, Frenchay Hospital, Bristol BS16 1LT, UK

 

 

 

 

 

 

Correspondence

Mr Tony Dixon.

Mradixon@aol.com

 

Keywords   Crohn’s disease, recurrent Crohn’s, Laparoscopic surgery, SILS, Enhanced Recovery.

 

Abstract

Aims  

Evaluate the safety and short-term outcomes of laparoscopic surgery for primary and recurrent ileo-colic Crohn’s disease.

Methods  

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) procedures.

Results  

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 groups).

Conclusions  

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.





 

 

 

 

 

 

 

 

 

 

Introduction

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 laparoscopic approach12,13

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 disease17-20.

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.

Patients and methods

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 nutritional status.

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.

Statistical analysis

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.

 

 

 

 

 

 

 

 

 

 

 

 

Results

Patient characteristics

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)

Primary (n=29)

Median Age (years)

47 (23-86)

49 (27-88)

Median BMI (kg/m2)

23 (18-31)

23.5 (20-36)

Enteric Enteric Fistula

3

2

Enteric Colic fistula

3

2

Enteric Vesical

0

1

Abscess

2

0

ASA > 2

1

2

 

 

Table 2. Outcome data. Values are median (range)  

 

Recurrent (n=30)

Primary (n=29)

Operating time (min)

125 (50-250)

85 (45-180)

Conversion to open

2

3

Time to light diet (hrs)

13 (4-72 hrs)

24 (2-96hrs)

Return to theatre

1

2

Length of stay (days)

3 (1-7)

3 (1-21)

Complications

5

7

Readmission

1 (leak)

2 (leak & abscess)

 

Table 3. Postoperative complications (includes readmissions)

 

Recurrent (n=30)

Primary (n=29)

Enterotomy

-

1

Ileus

2

2

Abscess

-

2

Migraine

-

1

Opiate withdrawal

-

1

Wound infection

1

1

Chest infection

Acute Renal Failure

Leak

1

1

1

-

-

1

 

 

Discussion

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.

 

 

 

 

 

 

References

1.    Tan JJ, Tjandra JJ (2007) Laparoscopic surgery for Crohn’s disease: a meta-analysis. Dis Colon Rectum 50:576–585.

2.    Dosman AS, Melis M, Fichera A (2005). Metaanalysis of trials comparing laparoscopic and open surgery for Crohn’s disease. Surg Endosc 19:1549–1555.

3.    Tilney HS, Constantinides VA, Heriot AG, Nicolaou M, Athanasiou T, Ziprin P, Darzi AW, Tekkis PP (2006). Comparison of laparoscopic and open ileocecal resection for Crohn’s disease: a meta analysis. Surg Endosc 20:1036–1044

4.    Bemelman WA, Slors JFM, Dunker MS, van Hogezand RA, van Deventer SJH, Ringers J et al., Laparoscopic-assisted vs. open ileocolic resection for Crohn’s disease. A comparative study. Surg.Endosc 2000; 14: 721-725.

5.    Young-Fadok TM, Long KH, McConnell FJ, Gomez-Rey G, Cabanela RL. Advantages of laparoscopic resection for ileocolic Crohn’s disease.  Improved cosmesis and reduced costs. Surg.Endosc 2001; 15:450-454.

6.    Milsom JW, Hammerhofer KA, Böhm B, Marcello P, Elson P, Fazio VW (2001). Prospective, randomized trial comparing laparoscopic vs. conventional surgery for refractory ileocolic Crohn’s disease. Dis Colon Rectum 44:1–8

7.    Benoist S, Panis Y, Beaufour A, Bouhnik Y, Matuchansky C, Valleur P (2003). Laparoscopic ileocecal resection in Crohn’s disease: a case-matched comparison with open resection. Surg Endosc 17:814–818

8.    Fichera A, Peng SL, Elisseou NM, Rubin MA, Hurst RD (2007). Laparoscopy or conventional open surgery for patients with ileocolonic Crohn’s disease? A prospective study. Surgery 142:566–571

9.    Maartense S, Dunker MS, Slors JF, Cuesta MA, Pierik EG, Gouma DJ, Hommes DW, Sprangers MA, Bemelman WA (2006). Laparoscopic-assisted versus open ileocolic resection for Crohn’s disease: a randomized trial. Ann Surg 243:143–149

10.Eshuis EJ, Polle SW, Slors JF, Hommes DW, Sprangers MA, Gouma DJ, Bemelman WA (2008) Long-term surgical recurrence, morbidity, quality of life, and body image of laparoscopic-assisted vs. open ileocolic resection for Crohn’s disease: a comparative study. Dis Colon Rectum 51:858–867

11.Borley NR, Mortenson NJ, Jewell DP. Preventing postoperative recurrence of Crohn’s disease. Br.J.Surg 1997; 84: 1493-1502.

12.Schmidt CM, Talamini MA, Kaufman HS, Lilliemoe KD, Learn P, Bayless T (2001). Laparoscopic surgery for Crohn’s disease: reasons for conversion. Ann Surg 233:733–739

13.Alves A, Panis Y, Bouhnik Y, Marceau C, Rouach Y, Lavergne-Slove A, Vicaut E, Valleur P (2005). Factors that predict conversion in 69 consecutive patients undergoing laparoscopic ileocecal resection for Crohn’s disease: a prospective study. Dis Colon Rectum 48:2302–2308.

14.Goyer P, Alves A, Bouhnik Y, Bretagnol F, Panis Y (2009) Impact of complicated Crohn’s disease on the outcome of laparoscopic ileocecal resection: a comparative clinical study in 124 patients. Dis Colon Rectum 52:205–210.

15.Regan JP, Salky BA (2004). Laparoscopic treatment of enteric fistulas. Surg Endosc 18:252–254

16.Pokala N, Delaney CP, Brady KM, Senagore AJ (2005). Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases. Surg Endosc 19:222–225

17.Heimann TM, Greenstein AJ, Lewis B, Kaufman D, Heimann DM, Aufses AH Jr (1998) Comparison of primary and reoperative surgery in patients with Crohn’s disease. Ann Surg 227:492–495.

18.Hasegawa H, Watanabe M, Nishibori H, Okabayashi K, Hibi T, Kitajima M (2003). Laparoscopic surgery for recurrent Crohn’s disease. Br.J.Surg 90:970–973

19.Holubar SD, Doxois EJ, Privitera A, Cima RR, Pemberton JH, Young-Fadok T, Larson DW. (2009). Laparoscopic surgery for recurrent ileocolic Crohn’s disease. Inflamm.Bowel.Dis. Dec 21. [Epub ahead of print]

20.Brouquet A, Bretagnol F, Soprani A, Valleur P, Bouhnik Y, Panis Y (2010). A laparoscopic approach to iterative ileocolic resection for the recurrence of Crohn’s disease. Surg.Endosc. 24: 879-87.

21.Chambers W, Bicsak M, Lamparelli M, Dixon AR. Single incision laparoscopic surgery (SILS) in complex colorectal surgery: a technique offering potential and not just cosmesis. Colorectal Dis.[Epub ahead of print].

22.Zafar N, DaviesR, Greenslade GL, Dixon AR. (2010). The evolution of analgesia in an “accelerated” recovery programme: “TAP Lap and Go”.  Colorectal Dis; 12: 119-24.

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26.Uchikoshi F, Ito T, Nezu R, Tanemura M, Kai Y, Nakajima K, Tamagawa H, Matsuda C, Matsuda H (2004). Advantages of laparoscopie-assisted surgery for recurrent Crohn’s disease. Surg.Endosc; 18: 1675-9.

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32.Yamamoto T, Allan RN, Keighley MR (2000). Risk factors for intraabdominal sepsis after surgery in Crohn’s disease. Dis Colon Rectum 43:1141–1145.

33.Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P (2007). Risk factors for intraabdominal septic complications after a first ileocecal resection for Crohn’s disease: a multivariate analysis in 161 consecutive patients. Dis Colon Rectum 50:331–336.

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