Laparoscopic Treatment of Crohn's Disease

Steve Wexner

Powerpoint File

Introduction:
The goal of the surgical treatment of Crohn’s disease is to improve quality of life. Surgery is generally reserved for patients who develop complications of the disease such as strictures and fistulas or who are unresponsive to or develop complications from aggressive medical therapy.
Markedly thickened bowel loops, thickened and friable mesentery, inflammatory phlegmons, fistulas, abscesses, and adhesions from previous surgeries pose a surgical challenge to the laparoscopic approach.

Results:
In 1996, Reissman et al. reported their early experience of laparoscopy in 29 patients with terminal ileitis (1). A mean length of the hospital stay was 5.2 days and an overall morbidity rate was 10%. Further study of Reissman et al. assessed a series of 51 patients with Crohn’s disease (2). The mean length of hospital stay was 5.1 days. The overall conversion and complication rates were 14% each, and there was no mortality. Alabaz et al. retrospectively compared the safety, outcome, and feasibility of laparoscopic assisted and conventional laparotomy for ileocolic resection in Crohn's disease (3). The length of hospitalization was significantly longer in the laparotomy group (9.6 vs. 7 days) with no difference in the morbidity rate (16.7% vs. 15.3%) and conversion (11%). Patients in the laparoscopically assisted group returned to work faster (3.7 weeks) compared with 8.2 weeks in the laparotomy group, had better cosmetic results and improved social and sexual lives.
Hamel et al. showed the feasibility and safety of laparoscopically assisted subtotal colectomy in patients with Crohn’s disease compared to ileocolic resection (4). Although there were more intraoperative complications in the subtotal colectomy group (29% vs. 7%), the hospital stay was similar (8.8 days) and the postoperative complication rate was not significantly different (29% and 18%, respectively).
Laparoscopic management of Crohn’s disease is complicated by fistulas, abscess, or strictures and is therefore especially challenging. Watanabe and co-workers reviewed 25 laparoscopic operations in 20 patients with a total of 31 intestinal fistulas (5). The complication and conversion rates were 16% each. The median hospital stay was 8 days.
Duepree et al. compared 21 patients who had a laparoscopic ileocolic resection with 24 patients who had an open resection (6). The median length of hospital stay was significantly shorter in the laparoscopic group compared to the open group (3 and 5 days, respectively). Resumption of oral intake and intestinal function were faster in the laparoscopic group and there was no difference in the complication rate between the groups (14.3% and 16.7%, respectively). Benoist and colleagues compared the postoperative outcome of 24 laparoscopic ileocolic resections with 32 open cases (7). There were no significant differences between the two groups in the morbidity and mortality rates, operative time, resumption of bowel function, hospital stay, and postoperative morphine requirement.
Young-Fadok et al. matched 33 cases of laparoscopic ileocolic resections with 33 open resections (8). They found significantly shorter length of hospital stay, a shorter period of narcotic use, and reduced time to regular diet in the laparoscopic group compared to the laparotomy group without any significant differences in the complication rates.
Long-term outcomes following laparoscopic ileocolic resections were assessed in several studies. Alabaz et al. reported significantly more symptomatic bowel obstructions in the laparotomy group compared to the laparoscopic group in a mean follow-up of 30 months (31% vs. 8%, respectively) (5). Bergamaschi et al. compared 39 patients who underwent laparoscopic ileocolic resection with 53 patients who had previously undergone open resection by the same surgeons at the same institution in terms of small bowel obstruction and recurrence rates at a follow-up of 5 years (9). They reported a significantly lower rate of small bowel obstruction following laparoscopy (11.1% vs. 35.4% following laparotomy) with no differences in the recurrence rates (27.7% and 29.1%, respectively).
Milsom et al. compared the short-term outcome of 31 patients in the laparoscopic group versus 29 in the laparotomy group (10). They found a significantly faster recovery of pulmonary function and fewer minor complications in the laparoscopic group compared to the laparotomy group (13% and 28%, respectively). However, there were no significant differences in the amount of morphine used, return of bowel function parameters, or the median length of stay between the two groups.
Thaler et al. showed that long-term quality of life is significantly reduced in patients with CD at long-term follow-up after both laparoscopic and open surgery and lower than in the general healthy population (11). Irrespective of the surgical procedure, recurrence was the single significant predictor of quality of life in this study.
Several studies have conducted economic analysis of surgery for ileocolic Crohn’s disease. Duepree et al. demonstrated significantly lower direct cost per case for the laparoscopic group compared to the open group (6). Young-Fadok et al. showed significantly lower direct and indirect costs in the laparoscopic group compared to the laparotomy group (8).
Laparoscopic experience has improved over recent years. However, Hamel et al. showed no differences in either morbidity or conversion between the earlier and the latter time periods of the experience, suggesting maintenance of a plateau after the initial experience (12).
Summary:
The laparoscopic approach to terminal ileal Crohn’s disease is feasible and safe even in cases complicated by fistulas or in patients with previous abdominal surgery or recurrent disease. This approach is associated with an increased operative time compared to laparotomy, however, offers significant advantages over open ileocolic resection in terms of pulmonary function, length of hospital stay, duration of postoperative ileus, cosmesis, postoperative small bowel obstruction, and early postoperative complications. Laparoscopy is also associated with decreased overall hospitalization costs and improved patient satisfaction.
Therefore, the laparoscopic approach for patients with Crohn’s disease should be considered as the preferred operative approach.

References:

1. Reissman P, Salky BA, Pfeifer J, Edye M, Jagelman DG, Wexner SD. Laparoscopic surgery in the management of inflammatory bowel disease. Am J Surg 1996; 171(1): 47-50.
2. Reissman P, Salky BA, Edye M, Wexner SD. Laparoscopic surgery in Crohn's disease. Indications and results. Surg Endosc 1996; 10(12): 1201-3.
3. Alabaz O, Iroatulam AJ, Nessim A, Weiss EG, Nogueras JJ, Wexner SD. Comparison of laparoscopically assisted and conventional ileocolic resection for Crohn's disease. Eur J Surg 2000; 166(3): 213-7.
4. Hamel CT, Hildebrandt U, Weiss EG, Feifelz G, Wexner SD. Laparoscopic surgery for inflammatory bowel disease. Surg Endosc 2001; 15(7): 642-5.
5. Watanabe M, Hasegawa H, Yamamoto S, Hibi T, Kitajima M. Successful application of laparoscopic surgery to the treatment of Crohn's disease with fistulas. Dis Colon Rectum 2002; 45(8): 1057-61.
6. Duepree HJ, Senagore AJ, Delaney CP, Brady KM, Fazio VW. Advantages of laparoscopic resection for ileocecal Crohn's disease. Dis Colon Rectum 2002; 45(5): 605-10.
7. Benoist S, Panis Y, Beaufour A, Bouhnik Y, Matuchansky C, Valleur P. Laparoscopic ileocecal resection in Crohn's disease: a case-matched comparison with open resection. Surg Endosc 2003; 17(5): 814-8.
8. Young-Fadok TM, HallLong K, McConnell EJ, Gomez Rey G, Cabanela RL. Advantages of laparoscopic resection for ileocolic Crohn's disease. Improved outcomes and reduced costs. Surg Endosc 2001; 15(5): 450-4.
9. Bergamaschi R, Pessaux P, Arnaud JP. Comparison of conventional and laparoscopic ileocolic resection for Crohn's disease. Dis Colon Rectum 2003; 46(8): 1129-33.
10. Milsom JW, Hammerhofer KA, Bohm B, Marcello P, Elson P, Fazio VW. Prospective, randomized trial comparing laparoscopic vs. conventional surgery for refractory ileocolic Crohn's disease. Dis Colon Rectum 2001; 44(1): 1-8.
11. Thaler K, Dinnewitzer A, Oberwalder M, Weiss EG, Nogueras JJ, Wexner SD. Assessment of long-term quality of life after laparoscopic and open surgery for Crohn's disease. Colorectal Dis 2005; 7(4): 375-81
12. Hamel CT, Pikarsky AJ, Wexner SD. Laparoscopically assisted hemicolectomy for Crohn's disease: are we still getting better? Am Surg 2002; 68(1): 83-6.