Laparoscopic surgery for recurrent Crohn's disease

BACKGROUND: The aim of this study was to assess the feasibility of laparoscopic surgery for recurrent Crohn's disease, and the role of repeated laparoscopy in reoperation. METHODS: Between January 1994 and May 2002, 61 laparoscopic operations were attempted in 52 patients with ileal or ileocolonic Crohn's disease. Of these, 16 procedures were performed for recurrence at the anastomotic site (recurrent group). The remaining 45 operations were performed as primary procedures (control group). The median follow-up was 48 (range 3-90) months. RESULTS: The median time to reoperation was 46 months. The incidence of enteric fistula and the conversion rate did not differ significantly between the two groups. Although the operating time was significantly longer in the recurrent group, there were no differences in the rate of postoperative complications (three in the recurrent group and six in the control group) and hospital stay (both median 8 days). CONCLUSION: Laparoscopic surgery for recurrent Crohn's disease is feasible in selected patients without an increase in conversion rate or postoperative complications.     

Prognosis after surgery for colonic Crohn's disease

The long-term prognosis including operation rates, the incidences of recurrent disease, morbidity and mortality and current status has been analysed in a group of 360 patients with Crohn's colitis grouped according to the primary site of macroscopic disease at diagnosis. The group has been followed from diagnosis for a mean period of 14.9 years. The overall operation rate was 76 per cent. Prolonged spontaneous or drug induced remission occurred at all sites: right-sided disease (11 per cent), extensive colonic disease (21 per cent) and left-sided disease (38 per cent). The cumulative reoperation rates at 5 and 10 years after right hemicolectomy were 26 and 46 per cent, after colectomy and ileorectal anastomosis 46 and 60 per cent, and after panproctocolectomy 10 and 21 per cent, respectively. There was a twofold excess mortality rate from related Crohn's disease deaths during the period of review, but the mortality rate has fallen with time. There have only been 11 related deaths in the last decade, of which eight were probably unavoidable. The current status of most patients is good, although treatment has included a permanent stoma in less than half (41 per cent) the patients still under review. Currently all but 14 patients are well and symptom-free and only 16 are receiving specific medical treatment. Until the aetiology of Crohn's colitis is understood, if medical treatment has failed to resolve symptoms, appropriate surgical treatment in experienced hands is an effective way of restoring patients with chronic persistent symptoms to good health.     

Advantages of laparoscope-assisted surgery for recurrent Crohn's disease

Background Laparoscopic surgery has been applied to patients with primary Crohn's disease, and its beneficial outcomes have been already investigated. However, there is no systematic study of laparoscopic surgery for patients with recurrent diseases. Methods We performed reoperation for 43 patients with recurrent Crohn's disease, including 23 patients who underwent laparoscope-assisted surgery. Results For all the patients, laparoscope-assisted surgery could be performed safely, even if the patients had been treated previously by open surgery or had undergone multiple abdominal procedures. Conversion to open or hand-assisted laparoscopic surgery was necessary for 16 patients (69.6%) because of dense adhesions (11 cases) or bulky tumor (5 cases). Importantly, even if the procedure was converted, the skin incision was significantly shorter than with open surgery, and postoperative recovery was faster, especially for the patients who underwent conversion to hand-assisted laparoscopic surgery. Conclusions Laparoscope-assisted surgery is feasible and advantageous in reoperation for patients with recurrent Crohn's disease.     

克罗恩病腹腔镜手术治疗的临床研究

目的:评估克罗恩病腹腔镜(辅助)手术治疗的可行性及近期疗效。方法:对2010年2月至2012年3月在我科接受腹腔镜(辅助)手术21例克罗恩病病人的临床资料进行回顾性分析,统计分析其手术时间、术中失血量、术后进食时间、术后住院天数、中转开腹率及并发症发生率。结果:21例病人中19例成功完成腹腔镜(辅助)手术。手术方式主要为回盲部切除10例,小肠切除6例,降结肠部分切除2例,末端回肠造口1例。平均手术时间为(125±19)min,术中平均失血量(100±71)mL,术后中位进食时间6(4~14)d,术后中位住院时间9(7~40)d,中转开腹率为9.5%,并发症发生率为26.3%。结论:克罗恩病的腹腔镜手术治疗安全、有效,手术时间、中转开腹率及并发症发生率在合理可控范围,且有术后恢复快、疼痛轻和切口美观的优点,具有临床推广价值。     

Laparoscopic surgery in Crohn's disease

Laparoscopic surgeons attempting to treat Crohn's disease must have experience working with inflammatory bowel disease and advanced laparoscopic skills. Nonetheless, laparoscopy is dramatically changing all aspects of gastrointestinal surgery and inflammatory bowel disease, including Crohn's disease, is likely to benefit, as well. This article defines the role of laparoscopy in treating Crohn's disease and outlines surgical therapy.     

Laparoscopic surgery in Crohn's disease

Background: An effort was made to assess the feasibility, safety, and outcome of laparoscopic procedures performed in patients with Crohn's disease. Methods: A prospectively maintained laparoscopic database was analyzed regarding operation time, intra- and postoperative complications, conversion to laparotomy, and length of hospitalization. Fifty-one patients (23 males and 28 females) with a mean age of 36 (20–79) years underwent a laparoscopic or laparoscopic-assisted procedure for Crohn's disease. The indications included terminal ileitis in 31 patients, colitis in 11, perianal disease in four, duodenal Crohn's disease in three, and rectovaginal and rectourethral fistula in one patient each. Thirty-two patients underwent an ileocolic resection; total abdominal colectomy with ileorectal anastomosis was performed in six patients with end ileostomy in one, take down of end ileostomy and ileorectal anastomosis in three, duodenal bypass gastrojejunostomy in three, and loop ileostomy in six patients. Results: The mean operating time was 2.4 (0.6–4.5) h and the mean length of hospital stay was 5.1 (3–18) days. Eight complications were noted in seven patients (14%), which included enterotomy in two patients, bleeding in two, stoma obstruction in two, pelvic sepsis in one, and efferent limb obstruction in one. The procedure was converted to laparotomy in seven patients (14%) due to a large inflammatory mass in five and to bleeding in two patients; there was no mortality. Conclusion: Laparoscopic surgery is a feasible, versatile, and safe modality in the surgical management of Crohn's disease. Despite the often-malnourished state of these steroid-dependent patients with intraabdominal inflammatory conditions, morbidity, procedural length, and length-of-hospitalization data are all similar to results previously reported for less-challenging laparoscopic colorectal procedures.     

Laparoscopic surgery for Crohn's disease: reasons for conversion

OBJECTIVE: To examine factors influencing conversion from a laparoscopic to an open procedure in patients requiring surgery for Crohn's disease. SUMMARY BACKGROUND DATA: Laparoscopic management of patients with complications of Crohn's produces better outcomes than traditional open approaches, but it is difficult to determine before surgery who will be amenable to laparoscopic management. In this series, a laparoscopic approach was offered to virtually all patients to determine reasons for laparoscopic failure. METHODS: Data regarding patients who underwent attempted laparoscopic procedures for Crohn's (January 1993 to June 2000) were collected prospectively. The bowel was mobilized laparoscopically and extracorporeal anastomoses were performed. Conversion to open surgery was defined as creation of an incision of more than 5 cm. RESULTS: One hundred ten patients (age 37 +/- 1.1 years, 58% female) underwent 113 attempted laparoscopic interventions. Indications for surgery included obstruction (77%), failure of medical management (35%), fistula (27%), and perineal sepsis (4%). Sixty-eight procedures (60%) were completed laparoscopically. Procedures completed laparoscopically included ileocecectomy (n = 46), small bowel resection (n = 22), fecal diversion (n = 7), intestinal stricturoplasty (n = 7), resection of prior ileocolonic anastomosis (n = 5), segmental colectomy (n = 1), and lysis of adhesions (n = 1). Forty-five procedures (40%) were converted as a result of adhesions (n = 21), extent of inflammation or disease (n = 9), size of the inflammatory mass (n = 7), inability to dissect a fistula (n = 5), or inability to assess anatomy (n = 3). Factors associated with conversion were internal fistula as an indication for surgery, smoking, steroid administration, extracecal colonic disease, and preoperative malnutrition. In laparoscopic patients, mean times to passage of flatus and first bowel movement were 3.6 +/- 0.2 days and 4.4 +/- 0.2 days, respectively. Mean time to discharge was 6 +/- 0.2 days. CONCLUSIONS: Attempted laparoscopic management is safe and effective if there is an appropriate threshold for conversion to an open procedure. Conversion factors identified in this study largely reflect technical challenge and severity of disease. Patients taking steroids and those with known fistulas or colonic involvement threaten laparoscopic failure, but many of these patients can be managed laparoscopically and have better outcomes. By understanding the reasons for conversion, it is hoped that the chances of laparoscopic success can be improved by modifying standard preoperative medical management or using additional technological capabilities (e.g., robotics).     

Outcome of surgery for rectovaginal fistula due to Crohn's disease

Background:

This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing.

Methods:

Fifty‐six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti‐TNF treatment.

Results:

Four patients with a healed fistula still had a stoma at final follow‐up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti‐TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0·037) and previous extended colonic resection (P < 0·001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0·001). Late recurrence developed in four patients.

Conclusion:

Fistula closure was achieved in most patients, but more than one operation was often required. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.