LAPAROSCOPIC SURGERY FOR COMPLICATED CROHN’S DISEASE
B. Salky, Dept. Of Surgery, Mount Sinai Medical Center, New York, USA
Crohn’s disease affects more than 2,00,000 people in the United States. It is
a chronic inflammatory disease that can involve any portion of the alimentary
tract. Surgeons are often involved in the treatment of this disease. The use of
laparoscopic surgery has been relatively slow to develop because of the
inflammatory nature of the pathophysiology and all the inherent difficulties that go
with a chronic inflammatory disease. It is the purpose of this syllabus to give you
a personal perspective of a large series of patients undergoing laparoscopic
surgery for Crohn’s.
History
In 1932, Doctors Crohn, Ginsberg and Oppenheimer published the first
manuscript on the disease later called Crohn’s disease. All cases were identified
at the Mount Sinai Hospital, and all of the doctors worked there. Burrell Crohn
was a young gastroenterologist, Leon Ginsberg was a general surgeon, and
Gordon Oppenheimer was a urology resident rotating on pathology at the time of
publication. It was originally called regional ileitis. While not known for sure, the
archives at Mount Sinai recount a rather tumultuous discussion around first
authorship for this paper. Most of the patients were Dr. Ginsburg’s, and it was he
who recognized the disease as distinct from tuberculosis. In the end, the hospital
decided to list the authors in alphabetical order, not knowing that someday it
would be called Crohn’s disease. Dr. Ginsberg always called it Ginsberg’s
disease.
1
Introduction
Surgeons operate for the complications of the disease. The effects of the
pathophysiology of transmural inflammation explain these complications. The
etiology of this disease is unknown at present. The most common indications for
surgery are obstruction, fistulization and abscess formation. Free perforation and
gastrointestinal bleeding are rare indications. The transmural inflammatory
process also explains the difficulty in operating on these patients. The
combination of transmural inflammation and the medications used to treat it
(immunosuppressives) can make for difficult dissections. Recurrence after
resection is also common. Therefore, re-operative surgery is also relatively
common. These are the reasons general surgeons have been slow to embrace
laparoscopic surgery and Crohn’s disease. However, as experience has
accumulated, more patients with both straightforward and complicated disease
have undergone laparoscopic surgery. The benefits of minimally invasive
surgery have been realized in this group of patients as well.
Surgical Approach
The decision to use open or minimally invasive surgery for Crohn’s disease is
dependent upon the experience of the surgeon and the pathology found at the
time of surgery. As surgery for Crohn’s disease can encompass a variety of
pathologies and surgical procedures, the ability to complete a case
laparoscopically will vary tremendously. The other significant variable in Crohn’s
disease is that previous resection is common, and it is not rare for some patients
to have two or more previous open surgeries. The combination of previous
2
surgery and significant inflammatory disease (phlegmon, abscess, fistula, or
perforation) will affect the ability of the surgeon to complete the procedure
laparoscopically. Whether the surgery is performed open or laparoscopically, the
basic tenets of surgery are the same. Conservation of bowel is the primary goal
in surgery for Crohn’s disease. The amount of bowel resected is based on gross
disease. It is not based on microscopic involvement. As any portion of the bowel
can be involved with disease, tit is also important to run the bowel from stomach
to rectum. This can be accomplished in the laparoscopic arena as in open
surgery. A systematic approach to visualization must be adopted, and twohanded technique with atraumatic bowel instrumentation is required. As with all
inflammatory bowel disease surgery, incisions in the right lower quadrant should
be avoided, as it is a potential site of an ileostomy in the future. This is much less
an issue with laparoscopic surgery compared to open. In this authors’
experience, all Crohn’s cases are a t least started laparoscopically. Conversion
to open is based on local factors, which can preclude the sage performance of
the laparoscopic procedure. Ureteral stents are not employed in either
laparoscopic or open surgery. However, the ureters are identified. Failure to
identify the ureters is a reason for conversion to open surgery. In the authors’
experience of more than 250 laparoscopic resections for Crohn’s disease,
conversion to open for failure to identify the ureters has not occurred. The main
reason for conversion has been a thick mesentery that did not allow safe division
with any laparoscopic instrument. In each of the converted cases, the disease
process had been in place more than 20 years. Previous surgery in and of itself
has not been a reason to convert to open. In the past, Crohn’s patients
traditionally have had a relatively high incidence of wound complications
including infection and hernia. In some series, it is reported to be as high as
15%. This is thought to be secondary to the transmural nature of the disease
3
process, and the common use of immunosuprressive medication in the treatment
of the disease. The wound complications have all but disappeared in the
laparoscopic group. In the authors’ experience, the incidence of wound
complications is 2 per cent. It is a major advantage of laparoscopic resection
compared to open surgery for Crohn’s disease. Gastro-duodenal Crohn’s
disease deserves special mention as resection is not involved with this aspect of
the disease, and therefore, an assisted incision is not made. Laparoscopic
gastrojejunostomy negates nearly all the potential wound complications of open
gastrojejunostomy, and length of stay in hospital has been shortened
dramatically for this group of patients.
Patient Selection and Evaluation
The indications for surgery in patients with Crohn’s disease are the same
whether performed laparoscopically or open. Surgery is indicated for the
complications of the disease. The most common are obstruction, infection
(abscess and phlegmon), fistulization, and free perforation (rare). Table 1 All of
the complications are based on the pathophysiology of this disease. Regarding
obstruction, it is much easier to do laparoscopic-assisted bowel surgery in the
elective situation. Acute obstruction requiring surgical intervention has been
uncommon in the author’s experience. This is almost always an on-going acute
inflammatory process that should be treated first. This always includes
intravenous antibiotics and, frequently, nasogastric tube decompression. I
encourage all patients with obstructive symptoms to think about elective surgery,
if they have been treated medically and have failed to respond. Infectious
complications such as abscess and phlegmon should be treated with intravenous
antibiotics. True abscess formation should be drained percutaneously prior to
4
surgery. This will decrease the inflammatory process, and it will ease the
technical aspects of the surgery. ‘This is true in both laparoscopic and traditional
surgery. If an abscess develops, then a fistula will be present. In the author’s
experience, abscess will almost always require resection to treat. Recurrence is
very high unless the diseased portion of bowel that caused it is removed.
Fistulization is commonplace in Crohn’s disease. Fistulas in and of themselves
are usually not indications for surgery. However, they frequently cause
symptoms, which can only be treated by resection. There is a lot of interest in
the medical closure of fistulas. In some cases, they can be closed without
surgery. However, fistulization to the bladder, vagina, stomach or skin usually
are surgically treated, because patients don’t like to have them for any length of
time. If patients have had previous open surgery, they are still candidates for the
laparoscopic approach. If possible, the original operative report should be
reviewed so that the type of anastomosis is known in advance. It will make it
easier to recognize it at the time of surgery. Diagnostic laparoscopy also has a
role in the diagnosis of Crohn’s disease. A small group of patients need
confirmation of disease before institution of therapy. It is a mistake to treat with
immunosuppressive therapy without confirmation of disease. These are patients
who do not have the terminal ileum diseased, and the small bowel series may not
pick up the inflammatory segment. Colonoscopy will not confirm disease in these
patients either. There has been a lot of interest in capsule endoscopy in just this
setting. Recent reports are favorable with this new modality. All patients with
Crohn’s disease requiring surgery are considered potential candidates for
laparoscopic-assisted resection or bypass. Table II lists the procedures
performed in the author’s series. As can be clearly seen, previous surgery is not
a contraindication to laparoscopic surgery. Patients with multiple areas of
involvement are also potential candidates for laparoscopic surgery. Table III
5
details the multiple procedures performed in this series. It is important to have
experience in the straightforward cases before attempting the more complex
cases. The best operative case in Crohn’s disease is limited terminal ileal
disease (less the 12 inches) without fistula, phlegmon, or abscess. In fact, the
shorter the disease process, the more benefit the patient will likely have with
surgery (compared to medical therapy). There is some interest in medical
circles to resect short segment disease, thereby making the patient grossly
disease free. Then, patients are treated prophylactically to delay or prevent
recurrence of disease. The preoperative evaluation of these patients is
important, including a good history and physical exam. It is especially important
to know if the patient is taking exogenous steroids, and whether or not the patient
has had previous surgery. The presence of a palpable mass (phlegmon or
abscess) usually indicates a difficult dissection. Contrast studies of both the
upper and lower gastrointestinal tracts are important. CT scan of the abdomen
should be done with contrast. Capsule endoscopy is becoming more prevalent in
clinical practice, but its role in Crohn’s disease is not yet established with
certainty. EGD and colonoscopy are commonplace. Colonoscopy is performed
before surgery in all patients to identify fistulous disease in the colon. It is not
uncommon to pick up an incidental ileosigmoid fistula. Table IV details the
various fistulas present in this series. Table V lists the abscesses encountered.
Anesthetic Considerations
I prefer that nitrous oxide not be used for bowel cases. This is especially true
with Crohn’s patients, as intestinal obstruction is a common indication for the
surgery. If the anesthesiologist insists, then it can be instituted after the bowel
has been resected, and the assisted incision has been closed. The other issue
6
has to do with fluid replacement and maintenance during the procedure and in
the post anesthesia care unit. All patients have undergone bowel prep, and by
definition, are dehydrated. However, I prefer to keep the patients on the “dry”
side. There is data to support fewer complications when patients are not overhydrated.
Postoperative Care
A nasogastric tube is not utilized in these patients. The Foley® catheter is
removed the next morning, if the patient is not having a lot of pain, and there is
wasn’t a bladder fistula. Oral oxycodone and intravenous Toradol® are used for
pain relief. In 95% of the patients, this is all that is required. Patient controlled
analgesia is not used routinely. The patients are out of bed on the first
postoperative night. This is possible in more than 80% of the patients.
Pneumatic compression stocking are used while the patients are in bed. Clear
fluid diet is begun on the first evening, and it is advanced to solid food (low
residue) as soon as the patient passes flatus. Full fluids are not used.
Intravenous fluids are kept to a minimum averaging 75cc/hr the first two days
post operatively. Anti nausea medication is occasionally needed the first postoperative night, but rarely required past that time. Antibiotics are not used unless
there is a specific reason to do so. Forty percent of the patients in this series are
on immunosuppressive medication of some sort. Approximately 20% of the
patients were on steroids. With laparoscopic surgery, there has been no need to
boost steroids. These patients are placed back on their preoperative level
immediately post surgery, and a gradual taper is begun while in the hospital.
This is distinctly different from open surgery where the stress response requiring
a steroid boost is more marked. Table VI details the complications in this series.
7
Table I
INDICATIONS
N
Diagnosis
14
Obstruction
171
Pain (fistula)
46
Abscess
7
Perforation
2
Duodenal
9
obstruction
249
8
Table II
Procedure
N
Diagnostic
14
Gastrojejunostomy
9
1_ ileocolic
119
2_ ileocolic
53
3_ ileocolic
12
4_ ileocolic
3
SB resection (1 Secondary)
27
R hemicolectomy
8
Sigmoid resection
9
Subtotal colectomy
9
9
L hemicolectomy
8
Anterior resection
4
Total colectomy
1
Stricturoplasty
2
Ileo-rectal (Hartmann’s)
1
TABLE III
Ileocolic +
Small bowel resection+
Small bowel resection (27)
Ileostomy revision
Sigmoid resection (5)
BSO. Stricturoplasty
Cholecystectomy (3)
Tubal ligation (1)
Left Colon resection (1)
10
TABLE IV
Site
N
Entero-entero
52
Entero-abdominal wall
29
Ileo-sigmoid
32
Ileo-vesical
13
Ileo-tranverse colon
6
Colo-vesical
2
Colo-duodenal
2
TABLE V
ABSCESS
N
Right lower quadrant ( 3 psoas)
11*
Pelvic
4**
*
9 primary ileocolic, 2 secondary ileocolic
11
** 3 sigmoid disease, 1 ileal disease
TABLE VI
COMPLICATION
*
N
SB obstruction
12*
Intestinal leak
4**
Post-op bleed
2***
Wound infection
1
UTI
1
C. Diff
1
5 Reoperations (3 laparoscopic, 2 traditional
** 2 Reoperations
*** 1 Immediate reoperation
12
Suggested Readings
1.
Bernstein Cn, Blanchard JF, Rawsthorne P et al. Crohn’s disease and
ulcerative colitis in a central Canadian province: a population based
study. Am J Epidemiol
1999; May 15(10): 916-24.
2.
Duepree HJ, Senagore AJ, Delaney CP et al. Advantages of laparoscopic
resection
of ileocecal Crohn’s disease. Dis Colon Rectum 2002; May 45(5): 605-10.
3.
Hasegawa H, Watanabe M, Okabayaski et al. Laparoscopic surgery for
recurrent
Crohn’s disease. Br J Surg 2003; Aug 90(8): 970-73.
4.
Reissman P, Salky BA, Edye M et al. Laparoscopic surgery in Crohn’s
disease.
Indications and results. Surg Endosc 1996; Dec 10(12): 201-3.
5.
Wu JS, Birnbaum EH, Kodner IJ et al. Laparoscopic-assisted ileocolic
resection in
patients withCroohn’s disease: are abscesses, phlegmonns or recurrent
disease contraindications? Surgery 1997; Oct 122(4): 682-8.
6.
Milsom JW, Hammerhofer KA, Bohm B et al. Prospective, randomized trial
comparing laparoscopic surgery vs. conventional surgery for refractory
ileocolic
Crohn’s disease. Dis colon Rectum 2001; Jan 44(1) 1-8.
13
7.
Canin-Endres J, Salky B, Gattorno F et al. Laparoscopically assisted
intestinal resection in 88 patients with Crohn’s disease. Surg Endosc
1999; 13: 595-99.
8.
Moorthey K, Shaul T, Foley RJ. Factors that predict conversion in patients
undergoing laparoscopic surgery for Crohn’s disease. Am J Surg 2004;
Jan 187(1): 47-51.
9.
Schmidt CM, Talamini MA, Kaufman HS et al. Laparoscopic surgery for
Crohn’s disease: reasons for conversions. Ann Surg 2001; 6: 733-39.
10. Brandstrup B, Tonnesen H, Beier-Holgersen R et al. Effects of intravenous
fluid
Restriction on postoperative complications: Comparison of two
perioperative
Fluid regimens: A randomized assessor-blinded multicenter trial. Ann
Surg 2003;
Nov 2328(5): 641-48.
14