Laparoscopic surgery in the management of Crohn's disease

Stapled versus hand-sewn anastomoses after bowel resection in patients with crohn disease

BACKGROUND

Anastomosis configuration is an essential step in treatment to restore continuity of the gastrointestinal tract following bowel resection in patients with Crohn's disease (CD). However, the association between anastomotic type and surgical outcome remains controversial. This retrospective study aimed to compare early postoperative complications and surgical outcome between stapler and handsewn anastomosis after bowel resection in Crohn's disease.

METHODS

Between 2001 and 2018, a total of 339 CD patients underwent bowel resection with anastomosis. Patient characteristics, intraoperative data, early postoperative complications, and outcomes were analyzed and compared between two groups of patients. Group 1 consisted of patients with stapler anastomosis and group 2 with handsewn anastomosis.

RESULTS

No significant difference was found in the incidence of postoperative surgical complications between the stapler and handsewn anastomosis groups (25% versus 24.4%, p = 1.000). Reoperation for complications and postoperative hospital stay were similar between the two groups.

CONCLUSION

Our analysis showed that there were no differences in anastomotic leak, nor postoperative complications, mortality, reoperation for operative complications, or postoperative hospital stay between the stapler anastomosis and handsewn anastomosis groups.

Single-incision versus multi-port laparoscopic ileocolic resections for Crohn's disease: Systematic review and meta-analysis

Introduction

The aim of this systematic review and meta-analysis is to compare the outcomes of single-incision laparoscopic surgery (SILS) versus multi-port laparoscopy for ileocolic resection in patients with Crohn's disease (CD).

Patients and Methods

A systematic search of multiple electronic databases was conducted. The peri- and post-operative outcomes were evaluated between Crohn's patients undergoing SILS versus multi-port laparoscopy for ileocolic resection. The primary outcomes included operative time, anastomotic leak rate, post-operative wound infections and length of hospital stay. Analysed secondary outcomes were conversion rates, ileus occurrence, intra-abdominal abscess formation, return to theatre and re-admissions. Revman 5.3 was used to perform the statistical analysis.

Results

Five observational studies with 521 patients (SILS: 211; multi-port: 310) were included in the data synthesis. Patients undergoing SILS had a reduced total operative time compared to multi-port laparoscopy (mean difference [MD]: -16.14, 95% confidence interval: [CI] -27.23 - 5.05, P = 0.004). Post-operative hospital stay was also found to be significantly less in the SILS group (MD: -0.57, 95% CI: -0.73--0.42, P < 0.0001). No significant difference was seen in the anastomotic leak rate (MD: -16.14, 95% CI: 0.18-1.71, P = 0.004) or post-operative wound infections (odds ratio: 0.78, 95% CI: 0.24 - 2.47, P = 0.67) between the two groups. Moreover, all the measured secondary outcomes were comparable.

Conclusion

SILS seems to be a feasible alternative to multi-port laparoscopic surgery for ileocolic resection in patients with CD. Improved outcomes in terms of total operative time and length of hospital stay were observed in patients undergoing SILS surgery. Adopting this procedure into routine clinical practice constitutes the next step in the development of minimally invasive surgery.

Redo ileocolic resection for recurrent Crohn's disease: A review and meta-analysis of surgical outcomes

BACKGROUND

Recurrence of postoperative Crohn's disease neccesitating repeat ileocolic resection is a common problem. The aim of this meta-analysis was to present the collective evidence on the surgical outcomes of this procedure.

METHODS

PubMed, Scopus, and Google Scholar were searched for eligible studies that reported the surgical outcomes of redo ileocolic resection for Crohn's disease. The primary outcomes were overall and major complication rates. The secondary outcome was anastomotic leak and conversion rate. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies - of Interventions tool.

RESULTS

This meta-analysis included 12 studies comprising 1,203 patients (50% men). The weighted mean rate of overall complications was 31.8% (95% confidence interval, 25-38.6) and rate of major complications was 8% (95% confidence interval, 5.7-10.2). The weighted mean rate of conversion was 20.9%, and the weighted mean rate of anastomotic leak was 3% (95% confidence interval, 1.8%-4.3%; inconsistency = 0). Male sex (slope coefficient = 0.0001; P = .01), American Society of Anesthesiologists score >3 (slope coefficient = 0.001; P = .04), smoking (slope coefficient = 0.0001; P = .008), preoperative use of steroid therapy (slope coefficient = 0.0001; P = .009), open approach (slope coefficient = 0.0001; P = .005), and having ≥2 previous resections (slope coefficient = 0.0001; P = .02) were significant risk factors for major complications.

CONCLUSION

Although redo ileocolic resection for patients with recurrent Crohn disease has a relatively high overall complication rate, a majority of these complications are minor and anastomotic leak rate is relatively low. Further prospective multicenter trials are warranted to confirm the conclusions of this meta-analysis.

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46–0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46–0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49–0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

Stapled side-to-side anastomosis might be benefit in intestinal resection for Crohn's disease: A systematic review and network meta-analysis

BACKGROUND AND AIM

Intestinal anastomosis is an essential step in the intestinal resection in patients with Crohn's disease (CD). Anastomotic configuration such as handsewn end-to-end anastomosis (HEEA), stapled side-to-side anastomosis (SSSA) and so on may be a predictor of prognosis for postoperative CD patients. However, the association between anastomotic types and surgical outcomes are controversial. The aim of this review is to identify the optimal anastomosis for intestinal resection in patients with CD.

METHODS

Clinical trials comparing anastomosis after intestinal resection in patients with CD were searched in the database of MEDLINE, EMBASE, and the Cochrane Library. Outcomes such as postoperative hospital stay, complications, mortality, recurrence, and reoperation were evaluated. Pairwise treatment effects were estimated through a random-effects network meta-analysis based on the frequency framework by using the STATA software and reported as the estimated summary effect for each comparison between the 2 treatments in the network with a 95% credible interval.

RESULTS

A total of 1113 patients in 11 trials were included. In pair-wise comparisons between groups, for overall postoperative complications, SSSA showed a more probability of superiority to HEEA; for complications other than anastomotic leak, anastomotic leak, wound infection, postoperative hospital stay and mortality, there were no significant difference between groups; for clinical recurrence, SSSA showed a more probability of superiority to HEEA; for reoperation, SSSA showed a more probability of superiority to HEEA. The number of eligible randomized controlled trails (RCTs) was small, and more than half of the included trials were retrospective studies; selection bias may lead to a less power in this assessment; follow-up time between different groups was different, which may possibly have affected the interpretation of the analysis of long-term outcome.

CONCLUSION

By comprehensive analyzing all the postoperative outcomes, SSSA appeared to be the optimal anastomotic strategy after intestinal resection for patients with CD.

Current management of intestinal bowel disease: the role of surgery

Inflammatory bowel disease (IBD) is a chronic affection, in which the two main phenotypical components are Crohn's disease and ulcerative colitis. In both diseases, medical treatment has the main role; in some phases of the natural history of IBD, surgery becomes an important therapeutic tool. The IBD represents a model of multidisciplinary management. Timing represents the key issue for proper management of IBD patients. For acute and severe IBD, the surgery can be a salvage procedure. Today, the laparoscopic approach plays an important role in armamentarium of the surgeon. Several articles compared the short- and long-term results between laparoscopic and open approaches in IBD. The aim of this review is to focus the role of surgery in IBD as well as the role of laparoscopic approach, and principally, the "state of the art" for surgical treatment, sometimes very challenging for surgeon, in all clinical features of IBD by a review of literature highlighted by the most recent international guidelines.

Emergency laparoscopic ileo-colic resection and primary intracorporeal anastomosis for Crohn's acute ileitis with free perforation and faecal peritonitis: first ever reported laparoscopic treatment

INTRODUCTION

Laparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn's Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy.

CASE DESCRIPTION

We report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome.

CONCLUSIONS

Complicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis.

Laparoscopy improves clinical outcome of gastrointestinal fistula caused by Crohn's disease

BACKGROUND

Benefits of laparoscopic surgery in the management of gastrointestinal fistula caused by Crohn disease need to be fully elucidated. We conducted this retrospective study to investigate the safety and feasibility and emphasize the advantages of laparoscopy compared with that of laparotomy for patients with gastrointestinal fistula caused by Crohn disease.

MATERIALS AND METHODS

A total of 1213 patients with gastrointestinal fistula in our center were screened, and 318 qualified patients were enrolled and divided into laparoscopy (n = 122) and laparotomy (n = 196) groups. Postoperative complications, length of hospital stay, systemic stress responses to surgery, postoperative mortality, and economic burden were collected and compared.

RESULTS

A total of 125 laparoscopic interventions were performed with a conversion rate of 20.0%. Fifteen versus 84 postoperative complications were obtained in laparoscopy and laparotomy groups, respectively (P = 0.0033). Total hospitalization was 22.7 d and 38.0 d in laparoscopy and laparotomy groups, respectively (P < 0.0001). Postoperative hospitalization was 10.9 d and 24.8 d in two groups, respectively (P < 0.0001). Elevation curve of serum C-reactive protein and procalcitonin in response to laparoscopy was significantly lower than that to laparotomy. Reduced postoperative mortality (P = 0.0292) and postoperative cost (P = 0.0292) were observed in laparoscopy instead of laparotomy group.

CONCLUSIONS

Laparoscopic approach is safe and feasible and could improve clinical outcome in gastrointestinal fistula patients with Crohn disease.

Surgical recurrence in Crohn’s disease: Are we getting better?

Crohn’s disease (CD) still remains a challenging chronic inflammatory disorder, both for colorectal surgeons and gastroenterologists. The need for recurrent surgery following primary intestinal resection is still considerable, though recent evidence suggested a declining rate of recurrence. Several conflicting surgical parameters have been identified that might impact on the postoperative outcome positively, such as access to the abdomen, anastomotic configuration or type of disease. Additionally, promising results have been achieved with the increased use of immunosuppressive medications in CD. Consequently, the question arises if we are getting better as a result of novel medical and surgical strategies.