Laparoscopic Approach for Inflammatory Bowel Disease Is a Real Alternative to Open Surgery

An Experience With 574 Consecutive Patients

Léon Maggiori, MD; Antoine Khayat, MD; Xavier Treton, MD, PhD; Yoram Bouhnik, MD, PhD; Eric Vicaut, MD, PhD; Yves Panis, MD, PhD

Disclosures

Annals of Surgery. 2014;260(2):305-310. 

In This Article

Abstract and Introduction

Abstract

Objective: This study aimed to report a 14-year experience of laparoscopic approach for inflammatory bowel disease (IBD), including complicated and recurrent cases.

Background: Feasibility of laparoscopic approach for IBD surgical management has been questioned.

Methods: From 1998 to 2012, all patients undergoing colorectal resection for IBD were prospectively enrolled. Adjusted risks of conversion and severe postoperative morbidity after laparoscopic resection were computed, according to a multivariate regression logistic model.

Results: A total of 790 consecutive resections for IBD were performed on 633 patients. Laparoscopic approach was performed in 574 (73%) procedures, including 286 ileocecal resections (48%), 118 subtotal colectomies (19%), 134 ileal pouch-anal anastomoses (21%), 23 segmental colectomies (8%), and 18 abdominoperineal resections (4%). A total of 145 (25%) complex laparoscopic procedures were performed, considered as such because of iterative surgery for IBD recurrence (n = 66, 12%) or because of intra-abdominal-abscess or fistula (n = 93, 16%). Conversion to laparotomy occurred in 67 procedures (12%). Postoperative death occurred in 1 patient (0.2%). Severe postoperative morbidity occurred in 66 laparoscopic procedures (13%). Splitting the study in 5 time periods, the rate of laparoscopic procedures significantly increased from 42% in period 1 to 80% in period 5 (P < 0.001). With time, the rate of complex procedures performed laparoscopically significantly increased (P = 0.023), whereas both mean adjusted risks of conversion and severe postoperative morbidity significantly decreased (P < 0.001).

Conclusions: Laparoscopic approach is a safe and effective alternative to open surgery for IBD management. With growing experience, the rate of laparoscopic complex procedures increased, whereas adjusted risks of conversion and severe postoperative morbidity significantly decreased.

Introduction

The importance of inflammatory lesions (including thickened bowel loops, inflammatory mass, thickened and fragile mesentery, and unexpected fistulas or abscesses), the frequent preoperative malnutrition and steroids therapy, and the common presence of adhesions rising from previous surgery have initially questioned the feasibility and safety of the laparoscopic approach for inflammatory bowel disease (IBD) surgical management.[1] However, for patients with IBD, laparoscopy offers several theoretical advantages over open approach: (1) patients with IBD are often young and active patients, for whom quick return to normal activity and cosmetic results are mandatory; (2) reduction of adhesions after laparoscopic approach[2] might facilitate recurrent resection, as recurrence of Crohn disease (CD) is often observed after surgery, and half of the patients will require more than 1 surgical procedure during their lifetime;[3,4] (3) reduction of pelvic adhesions might improve postoperative female fecundity, as we and others recently published;[5,6] (4) short-term benefits of the laparoscopic approach, demonstrated for malignant disease[7–10] and for diverticulitis,[11] might be also observed for IBD; and finally, (5) laparoscopic approach might reduce long-term risk of small bowel obstruction and postoperative hernia.[12]

The results of 4 meta-analyses[13–16] and 2 randomized controlled trials[17,18] have now demonstrated the safety of laparoscopic ileocolonic resection for CD, with no increase in postoperative complications, shorter postoperative ileus, and shorter hospital stay, as compared with open approach. On the same way, feasibility of laparoscopic approach for ulcerative colitis (UC) has been demonstrated for both subtotal colectomy and restorative proctocolectomy in a recent meta-analysis.[19] Furthermore, we and others have suggested that laparoscopic approach might be a safe alternative to open approach even in the emergent setting of medically refractory acute colitis[20–23] and in complex cases of CD, such as localized abscess, fistula, or recurrent disease.[24]

Since 1998, we have, therefore, progressively adopted laparoscopic approach as the standard approach for IBD surgical management. Nowadays, this standard laparoscopic approach includes all patients, whatever the clinical situation or the surgical procedure performed, with the only exception being complicated acute colitis (ie, perforated colitis, massive hemorrhage, or toxic megacolon).

The aim of this study was to report this 14-year experience and to assess evolution of trends over time and growing expertise.

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