Contemporary Surgical Management for Ileosigmoid Fistulas in Crohn’s Disease

Background  

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

Surgical Management of Peyronie’s Disease

The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.     

Outcome of Surgery for Coloduodenal Fistula in Crohn’s Disease

Background

This study was conducted to report the short- and long-term outcomes of surgery for coloduodenal fistula in Crohn’s disease and explore the effect of preoperative optimization on surgical outcome.

Methods

This is a retrospective review of 34 patients with coloduodenal fistula complicating Crohn’s disease between Jan 2008 and May 2015. Demographic information, preoperative management, and intraoperative and postoperative outcome data were collected.

Results

Primary duodenal repair was carried out in 33 patients (13 with duodenal defect >3 cm), and bypass surgery was performed in one patient with duodenal stenosis. Patients undergoing preoperative optimization (n?=?25) had decreased postoperative major (24.0 vs. 87.5 %, P?=?0.005) and intra-abdominal septic (20.0 vs. 75.0 %, P?=?0.008) complications compared to patients with emergent/semi-emergent surgery (n?=?8). No duodenal stenosis occurred on a median follow-up of 22.5 months. Patients with duodenum-ileocolic anastomosis fistula had longer postoperative stay (14.0 vs. 10.0 days, P?=?0.032) and increased possibility of refistulization of the duodenum on follow-up (30.0 vs. 0 %, P?=?0.031) compared with those with spontaneous duodenum-colonic fistula.

Conclusion

Primary duodenal repair can be safely performed in coloduodenal fistula in Crohn’s disease provided there was no duodenal stenosis, even for large duodenal defects. Preoperative optimization is associated with reduced postoperative complications. Patients with duodenum-ileocolic anastomosis fistula are more likely to have duodenum fistula recurrence compared to those with spontaneous duodenum-colonic fistula.

     

Intervention-free Interval following Strictureplasty for Crohn’s Disease

Introduction Strictureplasty is now well established as a bowel-sparing alternative for surgical treatment of complicated Crohn’s disease. Limited resection is still preferred in patients with uncomplicated disease, as subsequent reoperation rates are low. Methods A retrospective review of 26 patients who underwent surgery for small bowel Crohn’s disease between 1996 and 2004 was undertaken. A total of 96 small bowel strictureplasties had been performed; 19 patients had strictureplasties performed in isolation, and the remaining 7 patients underwent strictureplasty with concomitant limited resection. Results There was no operative mortality. The median follow-up was 41 months. Four patients developed complications that required further surgery. At 41 months, 73.3% of patients undergoing strictureplasty alone and 79.7% undergoing strictureplasty with concomitant resection were intervention-free. If followed up to 70 months or more, the same proportion of patients would remain intervention-free. Four patients developed further recrudescent disease and required surgery: strictureplasty, limited resection, or both. Of these patients, 25% were intervention-free at 41 months. Conclusions Our results show that strictureplasty alone or with concomitant resection can confer intervention-free periods of 41 months or more in 73.3% of patients, suggesting that strictureplasty can be utilized as an alternative to limited resection in uncomplicated Crohn’s disease.     

Surgical Management of Recto-Sigmoid Hirschsprung’s Disease

Introduction : Over the years, the surgical management of recto-sigmoid Hirschsprung’s disease (HD) has evolved radically and at present a single stage transanal pull-through can be done in suitable cases, which obviates the need for multiple surgeries.

Aim : The aim of this paper was to evaluate the role of transanal pull-through in the management of recto-sigmoid HD in our institution.

Material and Methods : A retrospective analysis (between January 2003 and December 2009) was carried out on all cases of Hirschsprung’s reporting to unity of pediatric surgery of Tunis Children’s Hospital that were managed by transanal pull-through as a definitive treatment. All selected patients including neonates had an aganglionic segment confined to the rectosigmoid area, confirmed by preoperative barium enema and postoperative histology. Twenty-six children (86%) had their operation done without construction of prior colostomy.

Results : Transanal pull-through was performed in 31 children. Mean operating time was 150 minutes (range 64 to 300 minutes). No patients required laparotomy because all patients including neonates had an aganglionic segment confined to the rectosigmoid area. Blood loss ranged between 20 to 56 ml without blood replacement. Since all children were given an epidural caudal block, the requirement of analgesia in these cases was minimal. Postoperative complications included perianal excoriation in 7 out of 31 patients lasting from 3 weeks to 6 months. Complete anorectal continence was noted in 21 of 31 (67%) children in follow up of 3–5 years.

Conclusions : Transanal endorectal pull-through procedure for the management of rectosigmoid HD is now a well-established and preferred approach. Parental satisfaction is immense due to the lack of scars on the abdomen. As regards the continence, a long-term follow-up is necessary to appreciate better the functional results of this surgery.     

Management of Crohn’s disease and ulcerative colitis

Crohn’s disease and ulcerative colitis (UC) are complex, contrasting disease processes that require multidisciplinary team management. The treatment modalities in inflammatory bowel disease are varied and the indications and threshold for surgery quite different in patients with UC compared with Crohn’s disease. We discuss the panoply of surgical techniques available to the surgeon and IBD patient while highlighting the potential sequelae, complimentary medical therapies, nutritional considerations and innovative techniques for reconstruction of the gastrointestinal tract.     

Surgical Considerations in the Treatment of Small Bowel Crohn’s Disease

Journal of Gastrointestinal Surgery - Surgery remains a cornerstone of the management of Crohn’s disease (CD). Despite the rise of biologic therapy, most CD patients require surgery for...     

National Trends and Outcomes for the Surgical Therapy of Ileocolonic Crohn’s Disease: A Population-Based Analysis of Laparoscopic vs. Open Approaches

Purpose  The laparoscopic approach to Crohn’s disease has demonstrated benefits in several small series. We sought to examine its use and outcomes on a national level. Methods  All admissions with a diagnosis of Crohn’s disease requiring bowel resection were selected from the 2000–2004 Nationwide Inpatient Sample. Regression analyses were used to compare outcome measures and identify independent predictors of undergoing laparoscopy. Results  Of 396,911 patients admitted for Crohn’s disease, 49,609 (12%) required surgical treatment. They were predominately Caucasian (64%), female (54%), and with ileocolic disease (72%). Most had private insurance (71%) and had surgery in urban hospitals (91%). Laparoscopic resection was performed in 2,826 cases (6%) and was associated with lower complications (8% vs. 16%), shorter length of stay (6 vs. 9 days), lower charges ($27,575 vs. $38,713), and mortality (0.2% vs. 0.9%, all P < 0.01). Open surgery was used more often for fistulas (8% vs. 1%) and when ostomies were required (12% vs. 7%). Independent predictors of laparoscopic resection were age <35 [odds ratio (OR) = 2.4], female gender (OR = 1.4), admission to a teaching hospital (OR = 1.2), ileocecal location (OR = 1.5), and lower disease stage (OR = 1.1, all P < 0.05). Ethnic category, insurance status, and type of admission (elective vs. non-elective) were not associated with operative method (P > 0.05). Conclusions  A variety of patient- and system-related factors influence the utilization of laparoscopy in Crohn’s disease. Laparoscopic resection is associated with excellent short-term outcomes compared to open surgery. “The views expressed in the article (book, speech, etc.) are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the US Government.” “The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.”     

Laparoscopic ileocecal resection in Crohn’s disease

Background: Despite some encouraging preliminary results, the role of laparosropic surgery in the treatment of Crohns disease (CD) is a subject of controversy and still under evaluation. The aim of this case-matched study was to compare the postoperative course of laparoscopic and open ileocecal resection in patients with CD in order to define the potential role of laparoscopic surgery in CD. Methods: From 1998 to 2001, 24 consecutive patients with isolated Crohns terminal ileitis treated by laparoscopic ileocecal resection (laparoscopy group) were compared with 32 patients matched for age, gender, duration of disease, preoperative steroid treatment, fistulizing disease, and associated surgical procedure, and treated by open resection (open group). Results: In the laparoscopy group, four procedures (17%) were converted. There were no deaths. The morbidity rate was 20% in the laparoscopy group and 10% in the open group (NS). There was no significant difference between the two groups in operating time, size of bowel resection and resection margin, postoperative morphine requirement, resumption of intestinal function, tolerance of solid diet, or length of hospital stay. Conclusions: Laparoscopic ileocecal resection in CD is safe and effective, even for fistulizing disease. There are no significant differences between laparoscopic and open ileocecal resection, especially in terms of the mortality and mortality rates. Consequently, because laparoscopic surgery seems to offer cosmetic advantages, it should be considered the procedure of choice for patients with ileocecal CD.     

Readmission After Abdominal Surgery for Crohn’s Disease: Identification of High-Risk Patients

Background

Although many predictive factors for postoperative morbidity are known, few data are available about readmission after abdominal surgery for Crohn’s disease (CD). The objective of this study is to identify predictive factors and high-risk patients for readmission after abdominal CD surgery.

Methods

All patients who underwent abdominal surgery for CD in one tertiary referral center between January 2004 and December 2016 were included. Patients who required readmission and those without were compared. Perineal procedures, elective readmissions, and abdominal procedures for non-Crohn’s indications were not included.

Results

Nine hundred eight abdominal procedures were performed in 712 patients. Readmission rates were 8, 8.5, 8.6, 8.8, and 8.9% at 30, 60, and 90 days and 12 and 60 months, respectively. The main reasons were wound infection (14%), deep abscess (13%), small-bowel obstruction (13%), and dehydration (11%). Eight (11%) patients required percutaneous drainage and 19 (27%) underwent an unplanned surgery. After multivariate analysis, three independent predictive factors for readmission were identified: older age (OR 1.02, 95%CI 1.005–1.04; p?<?0.006), a history of previous proctectomy (OR 3, 95%CI 1.2–9, p?<?0.02), and higher blood loss volume during surgery (OR 1.0001, 95%CI 1–1.002, p?<?0.05).

Conclusion

Readmission occurred in 8–9% of abdominal procedures for CD within 1–3 months after surgery and it required unplanned reoperation in a quarter of them. Identification of high-risk groups and knowledge of the more common postoperative complications requiring readmission help in increasing postoperative vigilance to select patients who may benefit from early interventions.

     

Laparoscopic Colectomy for Crohn’s Colitis. A Large Prospective Comparative Study

Introduction

The purpose of this study was to compare short-term outcomes of laparoscopic (LC) vs open colectomy (OC) in patients with Crohn’s colitis.

Materials and Methods

We collected data on all patients undergoing colectomy for primary or recurrent Crohn’s disease confined to the colon from July 2002 to August 2008. Patient and disease-specific characteristics and perioperative and short-term postoperative outcomes were prospectively collected and analyzed.

Results

A total of 125 patients underwent colectomy during the study period, 55 (44%) LC. There were six conversions (10.9%). Median operative time was shorter in the LC group (212 min, interquartile range (IQR) 180–315 LC vs 286 min, IQR 231–387 OC, p?=?0.032). Estimated blood loss was less for the LC group (100 ml, IQR 90–250 LC vs 250 ml, IQR 100–400 OC, p?=?0.002). Earlier return of bowel function was noted in the LC group (3 days vs 4 days, OC). Length of post-op stay was shorter in the LC group (6 days, IQR 5–8 vs 8 days, IQR 6–10 OC, p?=?0.001). There was one death in the OC group. Postoperative complications occurred in eight (14.5%) LC patients vs 16 (22.9%) OC. Disease recurrence rate was 16%, 10.9% LC and 20% OC, respectively.

Conclusions

Laparoscopic colectomy is a safe and effective technique in the hands of experienced surgeons. Benefits of laparoscopic colectomy in Crohn’s disease include reduced operative blood loss, quicker return of bowel function, and shorter hospital length of stay.     

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

Background

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

Methods

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

Results

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

Conclusion

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

Long-term efficacy of strictureplasty for Crohn’s disease

Purpose  

Strictureplasty (SP) is an established surgical option for the management of obstructive Crohn’s disease (CD) to avoid an extended resection. This study reviewed this department’s extensive experience with SP as treatment for obstructive CD to clarify its long-term efficacy and recurrence.