Laparoscopy for the Treatment of Crohn’s Disease

Introduction

Crohn’s disease is a complex disease with a compli- cated natural history that differs greatly from the majority of common diseases of the gut. It is a panen- teric, incurable disease. It has a peak incidence in young people and onset in childhood is not uncom- mon. The majority of patients will need surgery with- in 10 years from diagnosis and 50% of them will undergo additional operations for recurrent disease, with 8–10% of patients recurring every year. Many patients will undergo surgery after long periods of steroid or immunosuppressive treatment and there- fore their immunological status is poor. In addition, these individuals have a high risk of receiving a stoma, either permanent or temporary (41 and 14%

respectively) [1].

For all these reasons, the laparoscopic approach, which has the theoretical advantage of preserving the abdominal wall, reducing intra-abdominal manipu- lation and thus adhesion formation and helping to reduce immunological stress, when compared to the open surgery, could be the approach of choice for the treatment of such patients.

The comparison of laparoscopy and an open approach for the surgical treatment of Crohn’s dis- ease is difficult to make, due to the difficulty of strat- ifying patients in homogenous groups, in particular those with complicated disease. The only ran- domised trial available so far is elective ileocolic resectioning for refractory non-complicated disease of the terminal ileum [2]

treatment of complicated disease so far have been cohort, or case series studies. This understandably categorises them as grade 3–4 evidence and therefore rate low in terms of recommendation (Table 1). The results and the recommendations about the use of laparoscopy for the treatment of Crohn’s disease vary according to the type and the severity of the disease, and therefore must be described separately in brief.

Ileocolic Non-Complicated Disease

The ideal patients who may benefit from laparoscopy are those undergoing elective ileocolic resection.

These patients are young and often are attracted by the advantage of smaller abdominal scars [3]. The minimally invasive nature of the laparoscopic approach has a favourable impact, as patients under- going this approach may require further surgery in the future. The outcomes of the randomised trial [2]

and of several cohort comparison studies [4–8], show that after laparoscopic ileocolic resection there is a shorter hospital stay, with a faster recovery of pul- monary function, possibly a reduced postoperative ileus and better cosmesis. Three reports conclude that the cost of laparoscopic resection is globally less than open resection [5, 7, 8]. Due to the less extensive intra-abdominal manipulation and consequent less adhesion formation, laparoscopy seems to have decreased long-term small-bowel obstruction non- related to recurrence [4].

Flogistic and Fistulous Disease

Flogistic mass is a frequent finding in Crohn’s patients, in particular in recurrent disease. Large pal- pable mass per se, especially if associated with com- plex fistulous disease or with a frozen abdomen, are often considered to be a contraindication to laparoscopy [4, 7, 9 10]

sidered possible even after previous multiple surger- ies [11, 12]. When a flogistic mass is present with thickened mesentery, the size of the minilaparotomy depends on the size of the inflamed specimen to be removed. Due to the friability of the inflamed tissue, care has to be taken in order to avoid bleeding during the extraction manoeuvres of the thickened mesen- tery and the mesentery has to be divided outside the abdominal cavity [6, 8, 13]. On the other hand, severe disease with large inflammatory masses is cause for conversion to open surgery in up to 40% of cases,

Laparoscopy for the Treatment of Crohn’s Disease

Annibale D’Annibale, Emilio Morpurgo

Table 1. Studies on laparoscopic treatment of complicated disease AuthorStudyProcedureExclusion /ConversionBloodOpHospDietComplicationsConclusions inclusion(%)losstimestay(day)(%) criteria(cc)(min)(day) ReissmannCSICR 32Exclusion for14(mass,5.114Feasible 1996Colect7obstruction,bleeding)Stoma obstr Loop ileost 6short bowel,Abscess Other6perforation,Enterotomy peritonitis,bleeding toxic colitis Canin EndersCSICR 70Elective1.21681834.21Feasible in 1999SBR13procedure(mass)complicated R HEM 3disease Colect3and reoperation Ant/sigm res 5 BemelmanCCCICRElective6130vs204130vs1045.7vs10.22.8vs3.3Similar 2000primary(Ns)morbidity ICRLonger operation Reduced stay Better cosmesis Hamel2001CSICR 109Elective ICRICR1678.8ICR 20%ICR and Colect21and colectomy(5 leaks)colectomy ColectColect18%are feasible 231(2leaks)with comparable post-op compl; compl; colect has more operat complic Milsom2001PR31ICR lapElective cases;6.3%133vs140vs5vs6Minor:13%Better 29ICR openTI +/- cecum,(adhesions,85lap,26%pulmonary single sitemass)173openfunction disease;Major:3%Shorter stay BMI<32la,3% openLess minor complications Longer operation

continue AuthorStudyProcedureExclusion /ConversionBloodOpHospDietComplicationsConclusions inclusion(%)losstimestay(day)(%) criteria(cc)(min)(day) Young FadokCCCICRElective ICR5.9147vs4vs70vs3Feasible 2001124Longer operation Reduced ileus WatanabeCS8SBRFistulous16%1808116%Reduced stay 200212ICRdisease;(adhesions)Reduced cost Obvious massLaparoscopy or multiplefeasible in previous surgeriesfistulous excludedCrohn’s Evans2002CS84ICRExclusion for18%1455.66%Laparoscopy >2previous(adhesions,is possible surgeries,mass)even in bowelpresence of obstruction,mass of complex fistulasfistulous disease Duepree2002CCC21ICR lapOnly elective5%50vs3vs50vs210(abscess,Shorter stay 24ICR opinitial ICR100leak)Less blood loss Lower cost BergamaschiHNCC39ICR lapExclusion for:0185vs5.6vsLap has 2003C53ICR opfrozen10511.2less long abdomen,term bowel recurrent dis,obstruction emergency(11.1vs35.4%) Longer op. Shore2003NRCR20lap (14TI,Exclusion for5%77vs145vs4.2vs1.3vs2.7Feasible. 6TI+rightprevious(adhesions)2651338.2Longer colon)resections foroperation 20open (8TI,Crohn’s 12TI+right col) CCC, concurrent cohort comparison (matched, non randomised); CS, case series; HNCC, historic non concurrent cohort case study; NRCR, non randomised comparative retrospective;PR, prospective randomised; Lap, laparoscopic; Op, open surgery; ICR, ileo-colic resection; TI, terminal ileum

together with extensive abdominal adhesions in uns- elected groups of patients [9, 11, 14–19]

less, many patients requiring conversion benefit from a preliminary laparoscopic dissection that can render the subsequent laparotomy smaller in size and more targeted [18]

In order to facilitate laparoscopic dissection, pre- operative drainage of abscesses should be performed percutaneously and is suggested in several reports [10, 13]. During laparoscopic lysis of adhesions, tears of the bowel may occur and therefore all the intestin- al loops have to be carefully inspected, probably via minilaparotomy at the end of the procedure [15, 16].

Fistulas can be approached laparoscopically in many cases and the fistula track can be divided with laparo- scopic linear staplers [11]

Skip Lesions

Skip lesions are a frequent feature of Crohn’s disease and with laparoscopy there is the theoretical risk of overlooking them due to less precise tactile sensation compared to open surgery [8, 13]. Preoperative stud- ies (small-bowel follow through and CT scans) can be done pre-operatively, but the small bowel has to be thoroughly run from the ligament of Treitz to the caecum, if necessary, through the minilaparotomy.

Perianal and Colonic Crohn’s Disease

When isolated perianal Crohn’s disease is present, loop ileostomy is often offered to patients as a tem- porary or definitive solution. Laparoscopic ileostomy construction is easily performed [20] and at the same time it gives the possibility of performing a complete abdominal exploration in order to detect additional sites of disease. Bowel obstruction due to bowel twisting is a possible complication and therefore par- ticular care has to be taken to mark the bowel in order to exteriorise it in the proper manner and with the proper orientation. As a general rule, during sur- gery for Crohn’s disease, all the scars and all the port sites must be positioned in areas distant from possi- ble sites that may have to be used in the future for stoma creation.

Conclusions

From the data currently available, firm and absolute recommendations cannot be drawn for the use of laparoscopy in the surgical treatment of Crohn’s dis- ease, due to the heterogeneous features of the dis- ease.

For elective ileocolic resections, laparoscopy offers better immediate post-operative results possi- bly at a lower global cost and with potentially less incidence of small-bowel obstructions due to adhe- sions in the long-term. For complex disease, laparoscopy can be offered as a trial to all patients.

Inflammatory masses, presence of fistulas and reop- eration for recurrence are not absolute contraindica- tions for this approach, even though they are the most significant cause of conversion. Pre-operative percutaneous drainage of abscesses together with accurate pre-operative medical therapy can be used to render surgery less demanding. For isolated peri- anal Crohn’s disease, laparoscopy can be considered the approach of choice for stoma construction.

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