Laparoscopic Approach Is feasible in Crohn's Complex Enterovisceral Fistulas: A Case-Match Review

1 Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France 2 Department of Public Health, Hôpital la Timone, Assistance Publique - Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France 3 Department of Gastroenterology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France.
Diseases of the Colon & Rectum (Impact Factor: 3.75). 02/2013; 56(2):191-7. DOI: 10.1097/DCR.0b013e31826fedeb
Source: PubMed


: Complex enterovisceral fistulas are internal fistulas joining a "diseased" organ to any intra-abdominal "victim" organ, with the exception of ileoileal fistulas. Few publications have addressed laparoscopic surgery for complex fistulas in Crohn's disease.
: The aim of this study was to evaluate the feasibility of such an approach.
: This study is a retrospective, case-match review.
: This study was conducted at a tertiary academic hospital.
: All patients who underwent a laparoscopic ileocecal resection for complex enterovisceral fistulas between January 2004 and August 2011 were included. They were matched to a control group undergoing operation for nonfistulizing Crohn's disease according to age, sex, nutritional state, preoperative use of steroids, and type of resection performed. Matching was performed blind to the peri- and postoperative results of each patient.
: The 2 groups were compared in terms of operative time, conversion to open surgery, morbidity and mortality rates, and length of stay.
: Eleven patients presenting with 13 complex fistulas were included and matched with 22 controls. Group 1 contained 5 ileosigmoid fistulas (38%), 3 ileotransverse fistulas (23%), 3 ileovesical fistulas (23%), 1 colocolic fistula (8%), and 1 ileosalpingeal fistula (8%). There were no significant differences between the groups in terms of operative time (120 (range, 75-270) vs 120 (range, 50-160) minutes, p = 0.65), conversion to open surgery (9% vs 0%, p = 0.33), stoma creation (9% vs 14%, p = 1), global postoperative morbidity (18% vs 32%, p = 0.68), and major complications (Dindo III: 0% vs 9%, p = 0.54; Dindo IV: 0% vs 0%, p = 1), as well as in terms of length of stay (8 (range, 7-32) vs 9 (range, 5-17) days, p = 0.72). No patients died.
: This is a retrospective review with a small sample size.
: A laparoscopic approach for complex fistulas is feasible in Crohn's disease, with outcomes similar to those reported for nonfistulizing forms.

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    • "110 patients 113 procedures (68 completed vs. 45 converted) Alves et al. 2005 P 69 (all lap) Moorthy et al. 2004 R 48 (57 procedures) Canedo et al. 2010 R 213 (all lap) Fistulizing and recurrent Crohn's disease Goyer et al. 2009 P 124 (54 complex vs. 70 non-complex) Okabayashi et al. 2007 R 107 patients, 91 lap procedures Melton et al. 2009 R 104 (29 lap vs. 75 open) Uchikoshi et al. 2004 R 43 (23 lap vs. 20 open) Holubar et al. 2010 R 40 (30 lap vs. 10 converted) Brouquet et al. 2010 R 57 patients, 62 reoperations (29 lap vs. 33 open) Pinto et al. 2011 R 130 (50 recurrent vs. 80 primary operations) Aytac et al. 2012 R 52 (26 lap vs. 26 open) Huang et al. 2012 R 130 (48 with prior surgery vs. 82 without prior surgery) Beyer-Berjot et al. 2013 R 33 (13 with fistula vs. 22 controls) Alternative specimen extraction techniques Holder-Murray et al. 2012 P 83 (52 lap vs. 32 open) Kroesen et al. 2008 R 8 Eshuis et al. 2010 R 10 Gardenbroek et al. 2012 R 10 Intracorporeal anastomosis Bergamaschi et al. 2009 P 80 lap ileocolic resections El-Gazzaz et al. 2010 R 456 with Crohn's disease (228 lap vs. 228 open) Chang et al. 2012 R 84 with Crohn's disease (all lap) Single incision Rijcken et al. 2012 SR 150 Rijcken et al. 2012 R 20 (10 SILS vs. 10 lap) Moftah et al. 2012 R 5 with Crohn's disease (all SILS) M meta-analysis, SR systematic review, PRCT prospective randomized controlled trial, P prospective study, R retrospective study, lap laparoscopic, SILS single-incision laparoscopic surgery, HALS hand-assisted laparoscopic surgery, open conventionally operated patients "
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    ABSTRACT: Purpose: Minimally invasive surgery is increasingly utilized in treatment for refractory or complicated Crohn's disease, and new developments aim at further reducing the abdominal trauma and improving the outcome. This review evaluates current literature about minimally invasive surgery for patients with Crohn's disease, latest advances in single-incision surgery, and methods of specimen extraction. Methods: Literature was reviewed with focus on the following topics: indications, surgical procedures, conversions, complications, and short- as well as long-term outcomes of laparoscopic compared to open surgery for refractory, complicated, and recurrent Crohn's disease. Results: Short-term benefits such as shorter hospital stay and faster postoperative recovery are accompanied by long-term benefits such as better cosmetic results and lower treatment-associated morbidity. Single-incision surgery and minimally invasive methods of specimen extraction help to further reduce the surgical trauma and are gradually implemented in the treatment. Conclusion: In experienced centers, laparoscopic surgery for Crohn's disease is safe and as feasible as open operations, even for selected cases with operations for complicated or recurrent disease. However, accurate analysis of the data is complicated by the heterogeneity of clinical presentations as well as the variety of performed procedures. Additional long-term data are needed for evaluation of true benefits of the new techniques.
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