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

Discussion

Laparoscopic approach can be regarded as one of the major technical advances in colorectal surgery over the last 20 years. It has now become the standard of care in many colorectal diseases such as colon cancer,[7–9,30] diverticulitis,[11,31] and more recently rectal cancer.[32–34] The feasibility of this minimally invasive approach for IBD surgical management has, however, been initially questioned, mainly because of the importance of inflammatory lesions observed, the frequent preoperative malnutrition and steroids therapy, and the common presence of intra-abdominal adhesions resulting from previous surgery. Despite these initial concerns, several studies and meta-analyses have highlighted the safety of laparoscopic approach for CD[13–18] and for UC.[19] In the light of these reports, we have progressively adopted, in our department, laparoscopic approach as an alternative to open approach for IBD surgical management. We aimed in this study to report this experience and to assess evolution of trends over time and growing expertise.

We reported here 574 consecutives laparoscopic abdominal procedures for IBD. We observed an overall rate of 13% of conversion to open approach and an overall morbidity rate of 33%, including 13% of severe postoperative morbidity. Furthermore, we highlighted that, with growing experience, the rate of laparoscopically managed complex procedures increased, with significant lower rates of both conversion to open surgery and severe postoperative morbidity.

Several objectives prompted this study. First, we wanted to assess overall outcomes of IBD surgical management from a laparoscopic-driven tertiary care center. Indeed, if safety and efficacy of laparoscopic approach, as compared with open approach, has been highlighted in many studies, the large majority of the published articles focused on a procedure-specific point of view. Hitherto, the emphasis has been, therefore, placed on which IBD settings can be safely performed by laparoscopic approach. We adopted a different, paradigm-shifted, point of view, as we see laparoscopic approach as the standard approach for IBD surgical management, considering open approach as an exception. The surgical outcomes reported in this study may be seen as the results of such policy.

We reported here a postoperative mortality rate of 0.2% and a morbidity rate of 33%, including 13% of severe postoperative morbidity. Although the analysis of these rates is difficult, considering the heterogeneity of IBD settings and procedures included, they compare favorably to previous procedure-specific studies focusing on IC,[3,35–37] STC,[20,22,38] or IPAA.[19] These results have also to be considered in the light of the important rate of procedures involving a recurrent disease, which is a suggested postoperative complication risk factor.[39] On the contrary, the overall rate of conversion to laparotomy reported in this study is 13%, which might be regarded as relatively high, as compared with most recent reports. Nguyen et al[40] reported a 2% conversion after 335 consecutive laparoscopically managed CDs, and The university of Chicago reported a 10.9% conversion rate after laparoscopic management of CD colitis.[41] However, this study included a significant rate of complex cases, presenting recurrent CD (12%)[24,39] or intra-abdominal sepsis such as abscess and/or fistula (16%),[42] which have been suggested to be associated with a higher rate of conversion. Interestingly, the rates of conversion for these complex patients with CD are, in this study, higher than those observed with technically demanding rectal procedures such as IPAA. Finally, the mean adjusted risk of conversion in this study significantly decreased with time, reaching a low rate of 6% in period 5.

The second main objective of this work was to assess evolution of trends over time and growing expertise. From period 1 (1998–2001) to period 5 (2011–2012), the number of laparoscopically managed patients with IBD significantly raised from 40% to 80%. Laparoscopic approach was proposed initially to carefully selected patients, as mirrored by the very low rate of complex cases (16%) in period 1. Thus, laparoscopic approach was initially proposed only for ileocolic resection in patients with CD with noninflammatory stenosis. With time, indication for laparoscopic approach slowly extended to acute colitis, pouch surgery, and eventually complex patients with CD with abscesses and/or fistula. Therefore, as we progressively shifted from open to laparoscopic approach as the standard approach, the rate of complex cases significantly raised from 16% to 33%, highlighting the progressive withdraw of selection criteria for laparoscopic approach. Nowadays, in our routine practice, we have completely shifted the paradigm and apply selection criteria for open approach. As a result, we consider patients presenting only complicated acute IBD colitis (ie, perforated colitis, massive hemorrhage, or toxic megacolon), patients with a history of multiple laparotomies and/or major postoperative hernias, patients with comorbidities contraindicating the laparoscopic approach, and patients with CD with multiple stenosis and/or multiple complex fistula all along the small bowel, as good candidates for open approach.

Obviously, this extended policy of laparoscopic approach for patients with IBD, even in complex cases, implies to carefully monitor safety and to know when to convert in front of intraoperative complication or difficulty. In the first half of this study period, as the rate of laparoscopically managed complex cases raised from 16% in period 1 to 17% in period 2, we observed a parallel rising of our mean adjusted risk of severe postoperative morbidity, ranging from 14% in period 1 to 16% in period 2. However, later in our learning curve, although laparoscopically managed complex cases continued to rise slowly, reaching 33% in period 5, we observed a significant decreasing of the mean adjusted severe morbidity rate, reaching only 8% in period 5. These data suggest a better expertise over time of IBD-specific laparoscopic technical difficulties, such as thickened mesentery, inflammatory mass, and fistulous disease.

This study presents several limitations. First, mainly because of the policy we report here, we were not able to perform a comparative study, as our number of straight open IBD cases is limited. Second, we still have no data on long-term outcomes, mainly because an important rate of the included patients was operated on after 2007. Finally, the design of this prospective study led to a heterogeneous included population with various procedures, diseases, IBD settings, and medication.

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