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SAGES masters program: the top 10 seminal articles for the laparoscopic left and sigmoid colectomy pathway for complex disease. Surg Endosc 2023; 37:2538-2547. [PMID: 36922428 DOI: 10.1007/s00464-023-09965-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND The SAGES University Colorectal Masters Program is a structured educational curriculum that is designed to aid practicing surgeons develop and maintain knowledge and technical skills for laparoscopic colorectal surgery. The Colorectal Pathway is based on three anchoring procedures (laparoscopic right colectomy, laparoscopic left and sigmoid colectomy for uncomplicated and complex disease, and intracorporeal anastomosis for minimally invasive right colectomy) corresponding to three levels of performance (competency, proficiency and mastery). This manuscript presents focused summaries of the top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease. METHODS A systematic literature search of Web of Science for the most cited articles on the topic of laparoscopic complex left/sigmoid colectomy yielded 30 citations. These articles were reviewed and ranked by the SAGES Colorectal Task Force and invited subject experts according to their citation index. The top 10 ranked articles were then reviewed and summarized, with emphasis on relevance and impact in the field, study findings, strength and limitations and conclusions. RESULTS The top 10 seminal articles selected for the laparoscopic left/sigmoid colectomy for complex disease anchoring procedure include advanced procedures such as minimally invasive splenic flexure mobilization techniques, laparoscopic surgery for complicated and/or diverticulitis, splenic flexure tumors, complete mesocolic excision, and other techniques (e.g., Deloyers or colonic transposition in cases with limited colonic reach after extended left-sided resection). CONCLUSIONS The SAGES Colorectal Masters Program top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease anchoring procedure are presented. These procedures were the most essential in the armamentarium of practicing surgeons that perform minimally invasive surgery for complex left and sigmoid colon pathology.
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Sahyoun R, Lo BD, Zhang GQ, Stem M, Atallah C, Najjar PA, Efron JE, Safar B. Converting laparoscopic colectomies to open is associated with similar outcomes as a planned open approach among Crohn's disease patients. Int J Colorectal Dis 2022; 37:171-178. [PMID: 34611748 PMCID: PMC8492034 DOI: 10.1007/s00384-021-04020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE There has been a noted reluctance to offer laparoscopic surgery to Crohn's Disease patients due to the potential risks, and high rate, of converting the procedure to open. The purpose of this study was to compare clinical outcomes between Crohn's Disease patients undergoing a planned open colectomy, to those undergoing a laparoscopic colectomy that was converted to open. METHODS Crohn's Disease patients undergoing an elective colectomy were identified using the ACS-NSQIP database (2012-2019). Patients were stratified based on operative approach: open, laparoscopic, and laparoscopic converted to open. Multivariable logistic regression was used to assess the impact of conversion to open on overall and serious postoperative morbidity. RESULTS Among 8039 elective colectomies, 40.5% were performed open, 46.9% were completed laparoscopically, and 12.6% were converted to open. The conversion rate among all laparoscopic cases was 21.3%. On unadjusted analysis, conversion to open demonstrated similar rates of overall morbidity (P = 0.355) and serious morbidity (P = 0.724) compared to a planned open approach. On multivariable analysis, conversion to open was not associated with increased odds of overall morbidity (OR 1.12, 95% CI 0.94-1.30, P = 0.238) or serious morbidity (OR 1.20, 95% CI 0.98-1.46, P = 0.074), when compared to an open approach. CONCLUSION Among Crohn's Disease patients, cases converted from laparoscopic to open exhibited similar outcomes as a planned open approach. Despite the limitations associated with this retrospective study, our findings suggest that laparoscopic surgery may be safely pursued among Crohn's Disease patients, as the risks of conversion are potentially balanced by the benefits of laparoscopic surgery.
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Affiliation(s)
- Rebecca Sahyoun
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Brian D. Lo
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - George Q. Zhang
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Miloslawa Stem
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Chady Atallah
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Peter A. Najjar
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Jonathan E. Efron
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
| | - Bashar Safar
- grid.21107.350000 0001 2171 9311Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, MD 21287 Baltimore, USA
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Peyser DK, Carmichael H, Dean A, Baratta VM, D’Andrea AP, Kang G, Bhasin D, Greenstein AJ, Khaitov SK, Steinhagen RM, Sylla P. Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary? Surg Endosc 2022; 36:4290-4298. [PMID: 34988744 PMCID: PMC8730747 DOI: 10.1007/s00464-021-08773-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.
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Affiliation(s)
- Daniel K. Peyser
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Heather Carmichael
- Department of General Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Adrienne Dean
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Vanessa M. Baratta
- Department of Surgery, Yale University School of Medicine, New Haven, USA
| | - Anthony P. D’Andrea
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Gurpawan Kang
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Deepika Bhasin
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Sergey K. Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | - Patricia Sylla
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029 USA
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Trends and consequences of surgical conversion in the United States. Surg Endosc 2021; 36:82-90. [PMID: 33409592 DOI: 10.1007/s00464-020-08240-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures. METHODS All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m2). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort. RESULTS Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21-2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67-3.05], and 30-day mortality (OR 2.28; 95% CI [1.72-3.02]). CONCLUSION This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications.
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Abstract
OBJECTIVE To identify preoperative characteristics to help in selecting laparoscopy or laparotomy in Crohn disease (CD). SUMMARY BACKGROUND Laparoscopy in CD is associated with high rates of conversion. METHODS All patients undergoing abdominal surgery for CD in 2004 to 2016 by the senior author. Patients operated by laparoscopy, laparotomy, and converted to open were compared. RESULTS Four hundred fifty-eight procedures were performed in 427 patients [F:M 1:1; median age = 41 (12-95) yrs], through laparotomy (n = 157, 34%) or laparoscopy (n = 301, 66%). Laparotomy rates decreased over time. Concomitant surgical procedures requiring laparotomy continued to dictate an open approach throughout the study. Sixty-five cases (21.6%) required conversion to laparotomy which occurred within 15' from start of case in 77%. Most common reasons for conversion included dense adhesions (34%), pelvic sepsis with fistulizing disease (26%), large inflammatory mass (18%), and thickened mesentery (9%). After multivariate analysis, predictive factors for conversion included recurrent disease after previous small bowel resection, thickened mesentery, large inflammatory mass, and extensive disease. CONCLUSION Despite the increasing experience with laparoscopy in CD, one-fifth of selected cases still need conversion. Recurrent disease with dense adhesions, pelvic sepsis with fistulizing disease, large inflammatory mass, and thickened mesentery are all conditions predisposing to a conversion. When the severity of these conditions is known preoperatively or a simultaneous procedure requires a laparotomy, an open approach should be considered; if laparoscopy is selected, conversion to laparotomy can be decided early in the performance of the case.
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Zambonin D, Giudici F, Ficari F, Pesi B, Malentacchi C, Scaringi S. Preliminary study of short- and long-term outcome and quality of life after minimally invasive surgery for Crohn's disease: Comparison between single incision, robotic-assisted and conventional laparoscopy. J Minim Access Surg 2019; 16:364-371. [PMID: 31031322 PMCID: PMC7597873 DOI: 10.4103/jmas.jmas_61_19] [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] [Indexed: 11/04/2022] Open
Abstract
Background The feasibility of minimally invasive approach for Crohn's disease (CD) is still controversial. However, several meta-analysis and retrospective studies demonstrated the safety and benefits of laparoscopy for CD patients. Laparoscopic surgery can also be considered for complex disease and recurrent disease. The aim of this study was to investigate retrospectively the effect of three minimally invasive techniques on short- and long-term post-operative outcome. Patients and Methods We analysed CD patients underwent minimally invasive surgery in the Digestive Surgery Unit at Careggi University Hospital (from January 2012 to March 2017). Short-term outcome was evaluated with Clavien-Dindo classification and visual analogue scale for post-operative pain. Long-term outcome was evaluated through four questionnaires: Short Form Health Survey (SF-36), Gastrointestinal Quality Of Life Index (GIQLI), Body Image Questionnaire (BIQ) and Hospital Experience Questionnaire (HEQ). Results There were 89 patients: 63 conventional laparoscopy, 16 single-incision laparoscopic surgery and 10 robotic-assisted laparoscopy (RALS). Serum albumin <30 g/L (P = 0.031) resulted to be a risk factor for post-operative complications. HEQ had a better result for RALS (P = 0.019), while no differences resulted for SF-36, BIQ and GIQLI. Conclusions Minimally invasive technique for CD is feasible, even for complicated and recurrent disease. Our study demonstrated low rates of post-operative complications. However, it is a preliminary study with a small sample size. Further studies should be performed to assess the best surgical technique.
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Affiliation(s)
- Daniela Zambonin
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Francesco Giudici
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Ferdinando Ficari
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Benedetta Pesi
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Cecilia Malentacchi
- Department of Experimental and Clinical Biomedical Sciences (SBSC) 'Mario Serio', University of Florence, Florence, Italy
| | - Stefano Scaringi
- Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
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Robotic-assisted ileocolic resection for Crohn’s disease: outcomes from an early national experience. J Robot Surg 2018; 13:429-434. [DOI: 10.1007/s11701-018-0887-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/26/2018] [Indexed: 12/14/2022]
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8
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Laparoscopic resection for primary and recurrent Crohn's disease: A case series of over 100 consecutive cases. Int J Surg 2017; 47:69-76. [DOI: 10.1016/j.ijsu.2017.09.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/13/2017] [Accepted: 09/16/2017] [Indexed: 12/11/2022]
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Leo CA, Samaranayake SF, Chandrasinghe PC, Shaikh IA, Hodgkinson JD, Warusavitarne JH. Single Port Laparoscopic Surgery for Complex Crohn's Disease Is Safe with a Lower Conversion Rate. J Laparoendosc Adv Surg Tech A 2017; 27:1095-1100. [PMID: 28475480 DOI: 10.1089/lap.2016.0567] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Cosimo Alex Leo
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
- Imperial College of London, London, United Kingdom
| | - Sanjeev F. Samaranayake
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
| | - Pramodh C. Chandrasinghe
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
| | - Irshad A. Shaikh
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
| | - Jonathan D. Hodgkinson
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
- Imperial College of London, London, United Kingdom
| | - Janindra H. Warusavitarne
- Department of Surgery, St. Mark's Hospital Academic Institute, London North West NHS Trust, Harrow, United Kingdom
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Can laparoscopic surgery prevent incisional hernia in patients with Crohn’s disease: a comparison study of 750 patients undergoing open and laparoscopic bowel resection. Surg Endosc 2017; 31:5201-5208. [DOI: 10.1007/s00464-017-5588-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/02/2017] [Indexed: 12/24/2022]
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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: 2.1] [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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Ohtsuka K, Takenaka K, Kitazume Y, Fujii T, Matsuoka K, Kimura M, Nagaishi T, Watanabe M. Magnetic resonance enterography for the evaluation of the deep small intestine in Crohn's disease. Intest Res 2016; 14:120-6. [PMID: 27175112 PMCID: PMC4863045 DOI: 10.5217/ir.2016.14.2.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 03/10/2016] [Accepted: 03/10/2016] [Indexed: 12/12/2022] Open
Abstract
For the control of Crohn's disease (CD) a thorough assessment of the small intestine is essential; several modalities may be utilized, with cross-sectional imaging being important. Magnetic resonance (MR) enterography, i.e., MRE is recommended as a modality with the highest accuracy for CD lesions. MRE and MR enteroclysis are the two methods performed following distension of the small intestine. MRE has sensitivity and specificity comparable to computed tomography enterography (CTE); although images obtained using MRE are less clear compared with CTE, MRE does not expose the patient to radiation and is superior for soft-tissue contrast. Furthermore, it can assess not only static but also dynamic and functional imaging and reveals signs of CD, such as abscess, comb sign, fat edema, fistula, lymph node enhancement, less motility, mucosal lesions, stricture, and wall enhancement. Several indices of inflammatory changes and intestinal damage have been proposed for objective evaluation. Recently, diffusion-weighted imaging has been proposed, which does not need bowel preparation and contrast enhancement. Comprehension of the characteristics of MRE and other modalities is important for better management of CD.
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Affiliation(s)
- Kazuo Ohtsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshio Kitazume
- Department of Radiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshimitsu Fujii
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Maiko Kimura
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Nagaishi
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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Duraes LC, Stocchi L, Rottoli M, Costedio MM, Gorgun E, Kessler H. What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis? Colorectal Dis 2016; 18:264-72. [PMID: 26709096 DOI: 10.1111/codi.13248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/17/2015] [Indexed: 02/08/2023]
Abstract
AIM The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohn's disease have not been clearly described; such a description is the aim of this study. METHOD An institutional database was queried to identify patients undergoing laparoscopic resection for Crohn's disease through midline incision between 1995 and 2013. Perioperative outcomes were compared among cases completed through their initial extraction site (L), completed after increasing the length of the initial extraction site (IL) for specimen exteriorization, and cases converted to open surgery (C). Univariate and multivariate statistical analyses were performed. RESULTS Out of 309 patients, 52 required IL and 36 required C. Heavier, older, male patients were more likely to require IL or C. There were no differences in disease behaviour (P = 0.260), procedures performed (P = 0.12) or postoperative morbidity (P = 0.33). IL and L groups had a comparable initial length of hospital stay (LOS), which was shorter than in the C group. While there were no significant differences in causes of readmission (P = 0.31), IL had increased readmission rates compared with L [odds ratio (OR) 2.80, P = 0.021] or C (OR 13.89, P = 0.015). When combining initial and readmission LOS, C and IL groups had comparable overall LOS [median ratio (MR) 1.09, P = 0.57], which was significantly longer than in the L group (MR 1.27, P = 0.02). CONCLUSION Extraction site enlargement during laparoscopic surgery for enteric Crohn's disease had no impact on primary LOS. However, the shorter initial LOS was offset by increased readmission rates when compared with formal conversion. The threshold to convert in case of anticipated difficulty due to a large specimen should be low.
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Affiliation(s)
- L C Duraes
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M Rottoli
- Department of Colorectal Surgery, University College of London Hospital, London, UK
| | - M M Costedio
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
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