Flogistic and Fistulous Disease

Flogistic mass is a frequent finding in Crohn's patients, in particular in recurrent disease. Large palpable mass per se, especially if associated with complex fistulous disease or with a frozen abdomen, are often considered to be a contraindication to laparoscopy [4, 7, 9 10], whereas a mininvasive approach is considered possible even after previous multiple surgeries [11, 12]. When a flogistic mass is present with thickened mesentery, the size of the minilaparotomy depends on the size of the inflamed specimen to be removed. Due to the friability of the inflamed tissue, care has to be taken in order to avoid bleeding during the extraction manoeuvres of the thickened mesentery and the mesentery has to be divided outside the abdominal cavity [6,8,13]. On the other hand, severe disease with large inflammatory masses is cause for conversion to open surgery in up to 40% of cases,

Table 1. Studies on laparoscopic treatment of complicated disease

Author

Study

inclusion criteria

(day)

(%)

Conclusions

Reissmann 1996

CS

ICR 32 Colect 7 Loop ileost 6 Other 6

Exclusion for obstruction, short bowel, perforation, peritonitis, toxic colitis

14 (mass, bleeding)

5.1

Stoma obstr Abscess Enterotomy bleeding

Feasible

Canin Enders 1999

CS

ICR 70 SBR 13 RHEM 3 Colect 3 Ant/sigm res 5

Elective procedure

(mass)

168

183

4.2

1

Feasible in complicated disease and reoperation

Bemelman 2000

CCC

ICR

Elective primary ICR

6

130 vs 204 (Ns)

130 vs 104

5.7 vs 10.2

2.8 vs 3.3

Similar morbidity Longer operation Reduced stay Better cosmesis

Ham el 2001

CS

ICR 109 Colect 21

Elective ICR and colectomy

Colect

231

8.8

ICR 20% (5 leaks) Colect 18% (2 leaks)

ICR and colectomy are feasible with comparable post-op compl; compl; colect has more operat complic

Milsom 2001

PR

31 ICR lap 29 ICR open

Elective cases; TI +/- cecum, single site disease; BMI<32

(adhesions, mass)

133 vs 173

140 vs 85

5 vs 6

Major: 3% la, 3% open

Better pulmonary function Shorter stay Less minor complications Longer operation

Author

Study

inclusion criteria

(day)

(%)

Conclusions

Young Fadok 2001

CCC

ICR

Elective ICR

5.9

147 vs 124

4 vs 7

0 vs 3

Feasible Longer operation Reduced ileus

Watanabe 2002

CS

8 SBR 12 ICR

Fistulous disease; Obvious mass or multiple previous surgeries excluded

(adhesions)

180

8

1

16%

Reduced stay Reduced cost Laparoscopy feasible in fistulous Crohn's

Evans 2002

CS

84 ICR

Exclusion for >2 previous surgeries, bowel obstruction, complex fistulas

(adhesions, mass)

145

5.6

6%

Laparoscopy is possible even in presence of mass of fistulous disease

Duepree 2002

CCC

21 ICR lap 24 ICR op

Only elective initial ICR

5%

50 vs 100

3 vs 5

0 vs 2

10 (abscess, leak)

Shorter stay Less blood loss Lower cost

Bergamaschi 2003

HNCC C

39 ICR lap 53 ICR op

Exclusion for: frozen abdomen, recurrent dis, emergency

0

185 vs 105

5.6 vs 11.2

Lap has less long term bowel obstruction (11.1 vs 35.4%) Longer op.

Shore 2003

NRCR

20 open (8 TI, 12 TI+right col)

Exclusion for previous resections for Crohn's

(adhesions)

133

4.2 vs 8.2

1.3 vs 2.7

Longer operation

CCC, concurrent cohort comparison (matched, non randomised); CS, case series; HNCC, historic non concurrent cohort case study; NRCR, non randomised comparative retrospective; PR, prospective randomised; Lap, laparoscopic; Op, open surgery; ICR, ileo-colic resection; TI, terminal ileum together with extensive abdominal adhesions in uns-elected groups of patients [9, 11, 14-19]. Nevertheless, many patients requiring conversion benefit from a preliminary laparoscopic dissection that can render the subsequent laparotomy smaller in size and more targeted [18]

In order to facilitate laparoscopic dissection, preoperative drainage of abscesses should be performed percutaneously and is suggested in several reports [10,13]. During laparoscopic lysis of adhesions, tears of the bowel may occur and therefore all the intestinal loops have to be carefully inspected, probably via minilaparotomy at the end of the procedure [15,16]. Fistulas can be approached laparoscopically in many cases and the fistula track can be divided with laparo-scopic linear staplers [11].

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