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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.
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 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 two-handed 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 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 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 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 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 over-hydrated.
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 post-operative
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.
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