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

Results

Patients and Procedures

From June 1998 to December 2012, 790 consecutive intestinal resections for IBD were performed on 633 patients, including 504 procedures for CD (64%), 262 for UC (33%), and 24 for indeterminate colitis (3%). Among those procedures, 574 (73%) were performed laparoscopically. Preoperative characteristics of the overall laparoscopic resections cohort are reported in Table 1.

Overall, laparoscopic procedures included 286 ileocecal resections (ICs) (48%), 118 subtotal or total colectomies (STCs) (19%), 134 ileal pouch-anal anastomoses (IPAAs) (21%), 23 segmental colectomies (SCs) (8%), and 18 abdominoperineal resections (4%). Six percent (37/574) of the procedures were performed on an emergent setting. A total of 145 complex procedures (25%) were performed, considered as such because of an operative finding of a recurrent disease at a previously performed anastomosis (n = 66, 12%), an intra-abdominal abscess (n = 45, 8%), an enteroenteric fistula (n = 41, 7%), an enterorectocolic fistula (n = 12, 2%), an enterovesical fistula (n = 8, 1%), and/or an enterocutaneous fistula (n = 7, 1%) (Table 2).

All laparoscopic ICs (n = 286) were performed for CD. Among those, ileocolic anastomosis was realized in 210 (73%) procedures. The majority were manual (148/210, 70%) side-to-side (206/210, 98%) anastomoses. If an ileocolic anastomosis was not performed, a double-end ileocolostomy was always fashioned at the specimen extraction site, in the right lower quadrant.

Laparoscopic STC (n = 118) was performed in 29 (25%) patients for CD, in 82 (70%) patients for UC, and in 7 (6%) patients for undetermined colitis. In 30 (25%) procedures, STC was performed on an emergent setting. An ileosigmoid or ileorectal anastomosis was performed in 13 (12%) STCs. An ileosigmoidostomy in the right lower quadrant was performed otherwise.[23] All were side-to-end anastomoses. A temporary diverting stoma was fashioned in 4 of 13 (33%) of the cases.

Laparoscopic IPAA (n = 134) procedures included 69 (52%) complementary proctectomies after previous STC and 65 (49%) restorative total proctocolectomies. Ileal pouch-anal anastomosis was performed in 9 patients (9%), with a preoperative diagnosis of CD. A temporary diverting stoma was performed in all IPAA cases.

Surgical Outcomes

Conversion to laparotomy was required in 67 (12%) of the 574 laparoscopic procedures. Reasons for conversion were "preventive" because of intraoperative findings of abscess or fistula (n = 23), adherences difficult to dissect (n = 19), dissection difficulties due to the importance of the inflammatory processes (n = 9), or technical difficulties due to obesity or anatomical conditions (n = 7), and "reactive" because of small bowel injury (n = 4) and intra-abdominal bleeding (n = 5). Conversion was needed in 53 (15%) patients with CD, 13 (6%) patients with UC, and 1 patient with indeterminate colitis (8%). Conversion to laparotomy was required in 47 of 286 (13%) ICs, 10 of 118 (9%) STCs, 4 of 23 (17%) SCs, 5 of 134 (4%) IPAAs, and 1 of 18 (6%) abdominoperineal resections. Among the 145 laparoscopic complex procedures, the rate of conversion was 26% (38/145) (Table 2).

Postoperative death occurred in 1 patient (0.2%), who presented a septic shock on postoperative day 3 of an STC with ileosigmoidostomy. Emergent laparotomy assessed peritonitis without digestive perforation retrieved. Acute cardiac, renal, and hepatic failures were observed on postoperative course, leading to death on postoperative day 1.

Postoperative morbidity was observed after 188 (33%) laparoscopic procedures, including 66 (13%) with severe postoperative morbidity, graded 3 or 4 according to Clavien-Dindo classification. These severe postoperative complications led to postoperative drainage of intra-abscesses under computed tomographic-guidance in 26 cases (5%) and reoperation in 33 cases (6%). Severe postoperative morbidity was observed in 22 of 286 (8%) ICs, 9 of 118 (8%) STCs, 5 of 23 (22%) SCs, 28 of 134 (21%) IPAAs, and 2 of 18 (11%) abdominoperineal resections. Regarding pathology, severe postoperative morbidity was observed in 31 (9%) patients with CD, 32 (15%) patients with UC, and 3 patients with indeterminate colitis (23%). Severe postoperative morbidity was observed after 12 (8%) of the 145 laparoscopic complex procedures (Table 2).

Mean postoperative hospital stay was 11 ± 6 days (4–6 days).

Evolving Trends

The rate of laparoscopically performed procedures significantly increased with time, ranging from 42% in period 1 to 77% in period 2, 76% in period 3, 78% in period 4, and 80% in period 5 (P < 0.001). This increasing rate was observed in both patients with CD (45% in period 1, 73% in period 2, 68% in period 3, 74% in period 4, and 75% in period 5; P < 0.001) and patients with UC (37% in period 1, 81% in period 2, 91% in period 3, 87% in period 4, and 92% in period 5; P < 0.001).

Regarding laparoscopic procedures, as reported in Table 1, mean patients' age and body mass index and sex, ASA score, and diagnosis distributions showed no difference over the 5 study periods.

As shown in Figure 1, the rate of complex procedures performed laparoscopically significantly increased over time: 16% in period 1, 17% in period 2, 24% in period 3, 28% in period 4, and 33% in period 5; P = 0.023. However, mean adjusted risk of conversion significantly decreased over time (18% ± 12 in period 1, 16% ± 14 in period 2, 12% ± 11 in period 3, 9% ± 9 in period 4, and 6% ± 5 in period 5; P < 0.001; Fig. 2). On the same way, mean adjusted risk of severe postoperative morbidity also significantly decreased over time (14% ± 11 in period 1, 16% ± 12 in period 2, 15% ± 12 in period 3, 9% ± 7 in period 4, and 8% ± 6 in period 5; P = 0.444; Fig. 3).

Figure 1.

Evolution of complex procedures rate among 574 consecutives laparoscopic resections for IBD.

Figure 2.

Evolution of mean adjusted risk of severe morbidity (Dindo ≥3) in 574 consecutives laparoscopic resections for IBD.

Figure 3.

Evolution ofmean adjusted risk of conversion in 574 consecutives laparoscopic resections for IBD.

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