laparoscopic treatment of crohn’s disease: is it the standard approach? steven d wexner, md, facs,...

Laparoscopic Treatment of Crohn’s Disease: Is It the Standard Approach?

Steven D Wexner, MD, FACS, FRCS, FRCS (Ed)Chairman, Department of Colorectal Surgery

21st Century Oncology Chair in Colorectal SurgeryChief of Staff

Cleveland Clinic FloridaProfessor of Surgery, Ohio State University

Health Sciences Center at theCleveland Clinic FoundationClinical Professor of Surgery,

University of South Florida College of MedicineClinical Professor of Biomedical Science

Department of Biomedical ScienceFlorida Atlantic University College of Medicine

Marat Khaikin, MDClinical Research Fellow

Cleveland Clinic Florida

Laparoscopy for Crohn’s disease

Case Series

Author N Conversion (%)

Morbidity (%)

Hospital Stay (days)

Milsom, Surg Laparosc Endosc ‘93 9 0 0 7

Bauer, DCR ‘95 18 22 11 6.6

Reissman, Surg Endosc ‘96

51 14 14 5.1

Ludwig, Am J Surg ‘96

31 19 3 6

Canin-Endres,Surg Endosc ‘99

88 1 8 4.2

Schmidt, Ann Surg ‘01

110 40 13 6

Hamel, Am Surg ‘02

130 18 11 8.8

Evans, DCR ‘02 84 18 10.7 5.6


Comparative StudiesAuthor Study Lap/Open

(n)Oper.time

(min)Conversion

(%)Morbidity

(%)Hospital

stay (days)

Bemelman, 2000 Case-control 30/48 138/104 6.6 10/14.6 5.7/10.2

Alabaz, 2000 Case-control 26/48 150/90.5 11.5 15.4/16.7 7/9.6

Milsom, 2001 RCT 31/29 140/85 6 12.9/27.6 5/6

Young-Fadok, 2001

Case-match 33/33 147/124 5.9 - 4/7

Msika, 2001 Prospective

Case-control20/26 302/244.7 0 9.5/18.5 8.3/13.2

Duepree, 2002 Case-control 21/24 75/98 4.8 14.3/16.7 3/5

Bergamaschi, 2003 Case-control 39/53 185/105 0 10.2/9.4 5.6/11.2

Shore, 2003 Case-control 20/20 145/133.5 5 0/5 4.25/8.25

Benoist, 2003 Case-match 24/32 179/198 17 20/10 7.7/8

Huilgol, 2004 Case-control 21/19 136/119.5 4.8 19/15.8 6.4/8.2Bold, statistically significant difference (p<0.05)

Laparoscopy for Crohn’s Disease

Variable Laparotomy Laparoscopy P Value

N 48 26

Age (years) 41.6 40 NS

Gender (m/f) 31/17 18/8 NS

Duration (years) 6.8 5.9 NS

Operative time (min) 90.5 150 <0.0001

Hospital Stay (days) 9.6 7 <0.05

Charges ($) 28,259 34,657 NS

Alabaz et al. Eur J Surg 2000Alabaz et al. Eur J Surg 2000



Postoperative narcotics (days)

6.3 2.1 <0.001

“Good cosmesis” 13 (42%) 14 (88%) 0.004Social/Sexual

(vs preoperative) 5 (16%) 8 (50%) 0.02

Return to normal activity (weeks)

8.2 3.7 <0.05

Return to work (weeks)

9.3 4.4 <0.05




Bowel obstruction(symptomatic)

15 (31%) 2 (8%) <0.05

Relaparotomy 4 (8%) 1 (4%) NS

Adhesions 2 1

Recurrence 2 0



Conclusion

• Better cosmesis

• Lower incidence of postoperative bowel obstruction

• Greater than 50% reduction in the disability duration

• More rapid return to social and sexual interaction



Variable p Laparoscopy Laparotomy

N 21 24

Age (years) <0.05 31 39

Male (%) <0.05 57 37

Hospital (days) <0.05 3 5

30-day readmission NS 9.6 0

Morbidity (%) NS 14.3 16.7

Reoperation (%) NS 9.6 0

Direct Cost ($) <0.05 2,547 2,985

Duepree et al. DCR 2002Duepree et al. DCR 2002


• Prospective randomized trial

• January 1994 – March 1998

• 60 patients

• Ileal +/- Cecal Crohn’s Disease

Milsom et al. DCR 2001 Milsom et al. DCR 2001


Variable Laparoscopy

( + ) ( - )

N 31 29

Blood loss (mean; ml)* 173 133

Operative time (min)* 140 85

Incision (cm)* 5.3 12.7

Milsom et al. DCR 2001Milsom et al. DCR 2001*p<0.0001


Variable LaparoscopyAnalgesic use

Morphine sulfatemg/kg/day *

( + ) ( - )

Day 0 1.3 1.4

Day 1 0.9 1.0

Day 2 0.8 0.6

Day 3 0.5 0.6

Hospital Stay (days) ** 5.0 6.0

Milsom et al. DCR 2001Milsom et al. DCR 2001*p>0.3 all days, **p=0.14


Type of FunctionLaparoscopic Group

(n=31)Conventional Group

(n=29)

Flatus 3* 3.3

Bowel Movement 4 4

Milsom et al. DCR 2001Milsom et al. DCR 2001Figures – median (range) days*p=0.07, log-rank test


• Prospective randomized 3-center trial

• January 2000 – October 2003

• 60 patients

• Ileocecal Crohn’s Disease

Maartense et al. Ann Surg Feb Maartense et al. Ann Surg Feb 20062006


• Inclusion Criteria– Elective surgery– Terminal ileum ± cecum disease

• Exclusion Criteria– Prior median laparotomy– Fixed palpable inflammatory mass– Prior bowel resection

Maartense et al. Ann Surg Feb 2006Maartense et al. Ann Surg Feb 2006



(n=30)

Laparotomy

(n=30)

P Value

Gender (m:f) 14:16 12:18 0.602

Age (years) 28 31 0.137

BMI (kg/m²) 21.9 22.5 0.994

Steroids 15 19 0.183

5-ASA 7 7 0.874

Immunosuppressive medications

5 13 0.017



(n=30)

Laparotomy

(n=30)

P Value

Gender (m:f) 14:16 12:18 0.602

Age (years) 28 31 0.137

BMI (kg/m²) 21.9 22.5 0.994

Steroids 15 19 0.183

5-ASA 7 7 0.874

Immunosuppressive medications

5 13 0.017



(n=30)

Laparotomy

(n=30)

P Value

Operative time (min)

115 90 0.003

Conversions (n) 3 (10%) -

Additional procedures (n)

7 (23%) 5 (17%) 0.519

Hospital stay (days) 5 7 0.008

Complications (pts) 3 (10%) 10 (33%) 0.028




(n=11)

Laparotomy

(n=12)

P value

Morphine (mg)

0 – 24 (hrs) 28 45 0.15

24 – 48 (hrs) 7 19 0.18

48 – 72 (hrs) 0 5 0.68

0 – 72 (hrs) 29 62 0.27

Diet

Liquid >1000 ml (days)

Normal (days)

N=30

2

3.8

N=30

3

5

0.039

0.003

Maartense et al. Ann Surg Feb Maartense et al. Ann Surg Feb 20062006


Direct Costs Laparoscopy Laparotomy P Value

Operative

(Euro)

1,103 744 <0.001

Overall* (Euro)

6,412 8,196 0.042

*Relaparotomies,hospital stay, and readmission costsMaartense et al. Ann Surg Feb Maartense et al. Ann Surg Feb 20062006


• Quality of lifeQuality of life in both groups in both groups (SF-36/GIQLI*)

• Decline in the 1 week

• Return to baseline after 2 weeks

• Improvement during the 3-month follow-up

compared to preoperative levels

(SF-36, p<0.001; GIQLI, p<0.001)

**Gastrointestinal Quality of Life Index

No significant differences between laparoscopic andNo significant differences between laparoscopic and

open groupsopen groupsMaartense et al. Ann Surg Feb Maartense et al. Ann Surg Feb 20062006

Laparoscopy for Recurrent Crohn’s Disease

Variable Primary Recurrent

n 45 16

Age (years) 30 32

BMI (kg/m2) 19.8 19.7

Enteric fistula 24 6

Conversion 3 2

Median Time (min) 180 210

Hospital stay (days) 8 8

Hasegawa et al. Br J Surg 2003Hasegawa et al. Br J Surg 2003

Laparoscopy for ComplicatedCrohn’s Disease

• 20 Patients – 31 Fistulas

• Follow-up - 48 (5 – 77) months

• Morbidity - 16%

• Conversion - 16%

• Median hospital stay - 8 days

Watanabe et al. DCR 2002Watanabe et al. DCR 2002

Laparoscopy for ComplicatedCrohn’s Disease

• 73 resections: 90% - Crohn’s fistulas (10% - diverticular disease)

• Multiple fistulas – 30%

• Previous surgery – 39.7%

• Multiple resections – 12.3%

• Conversion – 4.1%

• Overall complication rate – 11%

• Hospital stay – 5.2 daysRegan et al. Surg Endosc 2004Regan et al. Surg Endosc 2004


Long-term Outcome

• Alabaz et al. Eur J Surg 2000Eur J Surg 2000

Mean follow-up – 30 months

Bowel obstructionsBowel obstructions

Laparoscopy Laparotomy

8% 31% (p=0.02)

• Bergamaschi et al. DCR 2003DCR 2003

Follow-up – 5 years 11.1% 35.4% (p=0.02)

Recurrence rateRecurrence rate - no difference (27.7% vs. 29.1%)

Laparoscopy for Crohn’s DiseaseSurgical Recurrence

• Lowney et alLowney et al DCR Jan 2006DCR Jan 2006

- Retrospective study

- Laparoscopic vs. open ileocolic resection

- Long-term follow-up (62.9/81.8 months)


LICR (n=63) OICR (n=50)

Age at surgery (yrs)Age at surgery (yrs) 35.2 37.1

Disease duration (yrs)Disease duration (yrs) 7.2 7.6

Male/female ratioMale/female ratio 26/37 17/33

Previous abdominal surgeryPrevious abdominal surgery 7 11

Preoperative medical treatmentPreoperative medical treatment

NoneNone

SteroidsSteroids

23

29

17

25

Immunosuppressive agentsImmunosuppressive agents 15 13

Lowney et al, DCR Jan 2006Lowney et al, DCR Jan 2006


LICR (n=63) OICR (n=50) P value

Surgical recurrence (%) 6 (9.5) 12 (24) 0.18

Median time to recurrence (mo) 59.7 61.6 NS

Re-recurrence (%) 0 4 (33) NS

Third recurrence 0 1

Postoperative

chemoprophylaxis (%)25 (39) 27 (54) 0.61

No. of pts with recurrence while taking chemoprophylaxis (%)

4 (67) 5 (42) NS

Lowney et al, DCR Jan 2006Lowney et al, DCR Jan 2006


• PPulmonary function

• Length of hospital stay

• Duration of postoperative ileus

• Cosmesis

• Postoperative small bowel obstructions

• Early morbidity

• Overall hospitalization costs

BenefitsBenefits

Laparoscopy and Open Ileocecal Resection for Crohn’s Disease:

a Metaanalysis

Tilney et al, Surg Endosc 2006

• 20 studies identified by literature review

• 15 satisfied inclusion criteria

• 783 patients

• 338 (43.2%) underwent laparoscopic resection

Laparoscopy and Open Ileocecal Resection for Crohn’s Disease: a Metaanalysis


Outcome ofInterest

No of studies

No. of patients

OR/WMD 95% CIP

ValueHG

chi-squareHG

p Value

Operative outcomes

Operative time10 569 29.59 11.27, 47.90 0.002 128.30 <0.001

Postoperative recovery

Tolerates oral fluid

2 106 -2.66 -3.44, -1.89 <0.001 2.15 0.14

Tolerates oral diet

7 340 -1.47 -2.18, -0.76 <0.001 16.08 0.01

Time to first flatus

4 191 -0.68 -1.20, -0.17 0.009 5.91 0.12

Length of stay 11 588 -2.97 -3.89, -2.04 <0.001 50.32 <0.001


•Overall conversion rate of 6.8%

•Operative time was significantly longer in the

laparoscopic group

•Blood loss and complications in the two groups

were similar

•Laparoscopic patients had a significantly shorter

time for enteric function recovery and shorter

hospital stay




•Laparoscopic ileocecal resection is associated with equal adverse

events than open surgery

•Postoperative recovery was enhanced

•Length of hospital stay was reduced

•Short incision was associated with improvement in perceived

cosmetic results

•Long-term follow-up evaluation is required

•Contraindications to laparoscopy for Crohn's disease remain

poorly defined


Cosmesis and Body Image• 34 patients, age - 32 (17-52) years

– Open ileocolic resection - 11– Laparoscopic - 11– No resection - 12

• 7 day outpatient diary– Crohn’s disease index (CDAI)– Activity index (AI)– Inflammatory bowel disease questionnaire (IBDQ)

In clinic• Hospital experience questionnaire (HEQ)• Photo series questionnaire (PSQ)

Dunker et al. Surg Endosc 1998Dunker et al. Surg Endosc 1998


Cosmesis and Body Image

No differences inNo differences in

• CDAI scores

• AI scores

• Age

• Gender

• Colonic involvement

• Perianal diseaseDunker et al. Surg Endosc 1998Dunker et al. Surg Endosc 1998


Cosmesis and Body Image

Laparoscopy - significantly better:Laparoscopy - significantly better:• Body image scale• Cosmetic scale• Self-confidence after surgery

Only 3/34 (8.8%) patients preferred open surgery:Only 3/34 (8.8%) patients preferred open surgery: (for cosmetic advantage)(for cosmetic advantage)

• 2/12 - no resection group• 1/11 - open group• 0/11 - laparoscopic group

Dunker et al. Surg Endosc 1998Dunker et al. Surg Endosc 1998


Cosmesis and Body ImageEven with a hypothetical risk to ureter of 5% Even with a hypothetical risk to ureter of 5% during laparoscopy:during laparoscopy:

• 21/132 (82%) preferred laparoscopy• 7/12 - no resection group• 4/11 - open group• 10/11 - laparoscopic group24/32 (75%) would pay more even if the only difference24/32 (75%) would pay more even if the only differencewas cosmetic:was cosmetic:• 10/12 - no resection group• 7/10 - open group• 7/10 - laparoscopy group Dunker et al. Surg Endosc 1998Dunker et al. Surg Endosc 1998


Cost Analysis

Variable Laparoscopy Laparotomy P

Hospital Stay (days) 4.0 7.0 0.0001

Direct Costs ($) 8,684 11,373 <0.01

Indirect Costs ($) 1,358 2,349 <0.001

Total Costs ($) 9,895 13,268 <0.001

Young-Fadok et al. Surg Endosc 2001Young-Fadok et al. Surg Endosc 2001


Cost Analysis

Laparoscopy Laparotomy p

Direct Cost ($) 2,547 2,985 <0.05

Duepree et al. DCR 2002Duepree et al. DCR 2002

Laparoscopy Laparotomy p

Mean Hospital Charges ($)

9,614 17,079 <0.05

Shore et al. Arch Surg 2003Shore et al. Arch Surg 2003


Influence of Experience

Group 1 2 3 pTime interval (months) 24 15 12

Patients (n) 28 28 28

*Complex (%) 64 46 64 0.296

**Multiple difficulties (%) 21 10 43 0.005

Mean Operative Time (min) 166 129 141 0.001

Conversion (%) 32 4 21 0.007

Hospital Stay (days) 5.9 6.4 4.9 0.025

Morbidity (%) 7 14 11 0.68

*Fistula, mass, abscess, or previous resection**Any two or more of fistula, mass, abscess, or previous resection

Evans et al. DCR 2002Evans et al. DCR 2002


Influence of Experience

• Evans et al. DCR 2002DCR 2002

No differences in patients outcome, complication, or

conversion rates between early and late experience

• Hamel et al. Am Surg 2002Am Surg 2002

Plateau after initial experience - no differences in

morbidity or conversion rates


CONCLUSIONSCONCLUSIONS

• FeasibleFeasible andand safesafe

even in cases complicated by fistulas or in patients with previous

surgery or recurrent disease

• DisadvantagesDisadvantages

increased operative time


CONCLUSIONSCONCLUSIONS

• BenefitsBenefits

pulmonary function

length of hospital stay

duration of postoperative ileus

cosmesis

postoperative small bowel obstructions

early morbidity

overall hospitalization costs


Laparoscopic approach is the Laparoscopic approach is the

preferred approach for patients preferred approach for patients

with Crohn’s diseasewith Crohn’s disease

laparoscopic treatment of crohn’s disease: is it the standard approach? steven d wexner, md, facs,...

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