Can laparoscopic surgery prevent incisional hernia in patients with Crohn's disease: a comparison study of 750 patients undergoing open and laparoscopic bowel resection.

BACKGROUND: Incisional hernia (IH) is a frequent occurrence following open surgery for Crohn's disease (CD). This study compares the IH rates of patients with CD undergoing open versus laparoscopic bowel resection. METHODS: Seven hundred and fifty patients with CD operated by the authors at the Mount Sinai Medical Center, New York, USA, were reviewed from a prospectively maintained surgical database. Five hundred patients with Crohn's disease undergoing open surgery were compared to 250 patients undergoing laparoscopic bowel resection. RESULTS: The mean duration of follow-up in the study population was 6.8 years. Patients undergoing open surgery had a significantly higher age at onset of disease, age at surgery, longer duration of disease, lower serum albumin, history of multiple previous resections, were more likely to be on steroids, needed more blood transfusions, and had an increased necessity for an ileostomy during resection. Nevertheless, the incidence of IH at 36 months was nearly identical in both groups (10.8 vs. 8.4% for open vs laparoscopic). 16% of the patients in the laparoscopic group (range: 7-20%) required conversion to open surgery. Patients undergoing laparoscopic resection that required conversion to open surgery had the highest IH rate at 18%. There was a significant correlation between IH and the length of the midline vertical extraction incision. Patients undergoing laparoscopic resection with intracorporeal anastomosis and small transverse or trocar site extraction incisions had no IH. CONCLUSIONS: A marked decrease or complete elimination of IH in patients with CD undergoing bowel resection may be possible using advanced laparoscopic techniques that require intra-abdominal anastomosis and use of the smallest transverse extraction incisions.

Comparison of intracorporeal versus extracorporeal anastomosis in laparoscopic-assisted hemicolectomy.

BACKGROUND: Laparoscopic-assisted colon resection has been shown to result in earlier return of bowel function, decreased postoperative pain, decreased length of stay, and decreased morbidity when compared to open resection. Laparoscopic-assisted hemicolectomy often still involves externalization of the bowel for resection and anastomosis. The aim of this study was to determine short-term outcomes of performing intra- versus extracorporeal resection and anastomosis in laparoscopic-assisted hemicolectomy. METHODS: Retrospective chart review of 105 consecutive patients who underwent laparoscopic-assisted hemicolectomy or colectomy by a single surgeon from January 2006 through August 2008 was performed. Pearson chi(2) and Student's t test were used to test for significance. RESULTS: There were 105 patients in total who underwent laparoscopic-assisted ileocolic resection (66), right hemicolectomy (29), left hemicolectomy (9), and subtotal colectomy (1). There were more males in the extracorporeal group, but patients in the two groups were otherwise demographically comparable. An intracorporeal anastomosis was performed in 54 patients and extracorporeal in 51 patients. The operation was longer in the intracorporeal group (p

Laparoscopic subtotal colectomy for medically refractory ulcerative colitis: the time has come.

PURPOSE: To evaluate laparoscopic versus open subtotal colectomy (STC) in patients with ulcerative colitis (UC) requiring urgent or emergent operative intervention. METHODS: A retrospective review was performed of 90 patients with medically refractory UC who underwent STC with end ileostomy at The Mount Sinai Medical Center from 2002 to 2007. Patients with toxic megacolon were excluded. Univariate analysis was conducted by unpaired Student t-test and chi-square test. Results are presented as mean +/- 95% confidence interval. RESULTS: Ninety patients underwent STC, 29 by laparoscopic and 61 by open approach. In patients undergoing laparoscopic versus open STC, intraoperative blood loss was decreased (130.4 +/- 38.4 vs. 201.4 +/- 43.2 ml, p < 0.05) and operative time prolonged (216.4 +/- 20.2 vs. 169.9 +/- 14.4 min, p < 0.01). In the absence of postoperative complication, hospital length of stay (4.5 +/- 0.7 vs. 6 +/- 1.3 days, p < 0.001) was shorter in laparoscopic versus open group. No mortalities occurred. Overall morbidity, 30-day readmission, and reoperation were equivalent regardless of operative approach. Wound complications were absent in the laparoscopic group compared with 21.4% in the open group (p < 0.01). Follow-up at a mean of 36 months demonstrated no difference in restoration of gastrointestinal continuity. CONCLUSION: Laparoscopic STC confers the benefits of improved cosmesis, reduced intraoperative blood loss, negligible wound complications, and shorter hospital stay. Laparoscopy is a feasible and safe alternative to open STC in patients with UC refractory to medical therapy requiring urgent or emergent operation.

Laparoscopic resection for Crohn's disease: an experience with 335 cases.

BACKGROUND: Laparoscopic resection for Crohn's disease has had a slow adoption rate in gastrointestinal surgery. This is not unexpected considering the inflammatory nature of the disease, the need for reoperative surgery, and the presence of fistulas. The authors review their experience with 335 laparoscopic resections for Crohn's disease over the past 15 years. METHODS: This study is a retrospective analysis of a prospective database from one surgeon at the Mount Sinai Hospital, New York, NY. RESULTS: Since 1993, 335 patients with Crohn's disease in the current series have undergone laparoscopic resection. The mean age of the patients was 39 years, and 54% of the patients were women. In most cases, the indication for surgery was intestinal obstruction (73%) or abdominal pain (16%). The most common operation was primary ileocolic resection, performed for 178 cases (49%). Secondary ileocolic resections were performed for 20% and small bowel resections for 11% of the cases. Of the 117 patients with enteric fistulas, 45% had multiple fistulas. There were 80 enteroenteric, 51 ileosigmoid, 33 enteroabdominal wall, and 22 ileovesical fistulas. Multiple resections were performed for 33 patients (9%). Eight conversions occurred (2%), primarily because of large inflammatory masses involving the intestinal mesentery. The mean length of hospital stay was 5 days, and the mean operative time was 177 min (range, 62-400 min). There were no mortalities. The complications were primarily bowel obstruction, anastamotic leak, and postoperative bleeding, resulting in a postoperative complication rate of 13%. CONCLUSION: This review summarizes the largest series of laparoscopic resection for Crohn's disease to date. The most common operation performed was ileocolic resection. Fistulous disease is common, but it is not a contraindication to laparoscopic resection. These cases can be managed safely and with acceptable morbidity in experienced hands.

Laparoscopic retrieval of intraabdominal foreign bodies.

UNLABELLED: The use of laparoscopy has been described as the means of removing intraabdominal foreign bodies, both intraperitoneal and intraluminal, from the stomach or bowel. An early report detailed the laparoscopic removal of translocated intrauterine devices from the peritoneal cavity. Laparoscopic removal of a retained surgical sponge also has been reported. For large ingested objects that cannot be retrieved by flexible endoscopy, laparoscopic gastrotomy and foreign body removal have been described. The authors recently had three cases of laparoscopic foreign body retrieval. The first case involved a young man who had ingested latex gloves, causing gastrointestinal bleeding. Endoscopic retrieval was unsuccessful. A laparoscopic gastrotomy was performed, with the retrieval of four gloves, followed by intracorporeal, sutured closure of the gastrotomy. The second case involved the laparoscopic removal of a Penrose drain around the distal esophagus. The patient had initially undergone a laparoscopic Nissen fundoplication, vagotomy, and gastrojejunostomy for the management of reflux and a duodenal stricture. He had persistent dysphagia after surgery, prompting takedown of the fundoplication several months later. When his dysphagia did not improve, a retained Penrose drain that had been placed around the distal esophagus at the initial operation was discovered on computed tomography. This was removed laparoscopically. At this writing, 18 months after the initial operation, the patient has complete resolution of dysphagia. The third case involved a duodenojejunal fistula caused by multiple ingested magnets that had eroded through the bowel wall. The fistula was divided laparoscopically, and 16 disk-shaped magnets were removed. The duodenum and jejunum were repaired with laparoscopic suturing and stapling. All three patients did well after surgery. Laparoscopy can be an excellent method for abdominal foreign body retrieval. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi: 10.1007/s00464-006-9011-0) contains supplementary material, which is available to authorized users.

A ten-year experience with laparoscopic treatment of splenic cysts.

BACKGROUND AND OBJECTIVES: The management of symptomatic splenic cysts lacks clear, evidence-based guidelines due to its low incidence. Recently, laparoscopic treatment has been described. We present our experience with the laparoscopic management of solitary splenic cysts with a review of the existing literature, and recommendations for therapy. METHODS: All patients who underwent laparoscopic treatment of splenic cysts over a 10-year period were identified. The medical records of these 9 patients were reviewed. RESULTS: All surgeries were performed laparoscopically, with no conversions. Two patients underwent cyst decapsulation, and 7 patients underwent cyst unroofing. No major complications occurred. Recurrence occurred in 33.3% of patients; unroofing had a recurrence rate of 42.9% compared with 0% after decapsulation. Pseudocysts were found in 66.7% of patients and true cysts on final pathology were found in 33.3%. CONCLUSIONS: Laparoscopic decapsulation and unroofing of splenic cysts are safe procedures that confer the advantages of both splenic preservation and minimally invasive surgery. Cyst unroofing has a high recurrence and should be selectively used. Laparoscopic cyst decapsulation is associated with longer operative time, but should be considered as first-line therapy.

Laparoscopic surgery for diverticular disease complicated by fistulae.

OBJECTIVES: Elective laparoscopic surgery for recurrent, uncomplicated diverticular disease is considered safe and effective; however, little data exist on complicated cases. We investigated laparoscopic sigmoid resection for diverticulitis complicated by fistulae. METHODS: We conducted a retrospective review of patients who underwent laparoscopic treatment of enteric fistulae complicating diverticular disease performed by 4 surgeons at the Mount Sinai Medical Center. RESULTS: From 1994 to 2004, 14 patients underwent elective laparoscopic sigmoid resections for diverticular disease complicated by enteric fistulae. Patients' mean age was 62 and 4 were female. Multiple fistulae were present in 21%. Types of fistulae included 8 colovesical, 5 enterocolic, 2 colovaginal, 1 colosalpingal, and 1 colocutaneous. All patients successfully underwent sigmoidectomy, and 14% required additional bowel resections. No cases were proximally diverted. Conversion to open was necessary in 36% of cases, all due to dense adhesions and severe inflammation. The mean operative time was 209 minutes, and the mean blood loss was 326 mL. Two (14%) postoperative complications occurred, including one anastomotic bleed and one prolonged ileus. No anastomotic leaks or mortalities occurred. The mean postoperative stay was 6 days. CONCLUSION: Laparoscopic management of diverticular disease complicated by fistulae can be performed effectively and safely. The conversion rate is higher than traditionally accepted rates of uncomplicated cases of diverticulitis and is associated with severe adhesions and inflammation.

Laparoscopic splenectomy: a selected retrospective review.

Previous investigators have suggested that laparoscopic splenectomy should be the procedure of choice for the treatment of benign hematologic disorders unresponsive to medical therapy. To evaluate the safety and utility of laparoscopic splenectomy for a variety of splenic disorders, we reviewed our collective experience at 2 institutions. We studied our 8-year experience by retrospective chart review. Patient demographic data, splenic pathology, intraoperative events, concomitant procedures, and all adverse perioperative events were recorded. A total of 131 patients had laparoscopic splenectomy, and there were 8 conversions to open surgery. Pathology included 63 with idiopathic thrombocytopenic purpura (ITP), 23 malignancies, 12 thrombotic thrombocytopenic purpura (TTP), 10 autoimmune hemolytic anemia (AIHA), and 23 others. Accessory spleens were noted in 21 patients (16%). Concomitant surgical procedures included 12 hepatic biopsies, 4 distal pancreatectomies, 4 cholecystectomies, and 7 others. Mean operative time was 170 minutes. There were 16 major complications in 16 patients and 2 deaths. Median postoperative length of stay was 3 days. Conversions, due mostly to bleeding, are related to splenic pathology and medical comorbidity and are not temporally related to surgical experience (learning curve). The morbidity, mortality, and conversion rates were low. Laparoscopic splenectomy permits an appropriate abdominal exploration and is associated with a short hospital stay. It is the procedure of choice for most indications for splenectomy.

Surgical management and outcomes of patients with duodenal Crohn's disease.

BACKGROUND: Duodenal Crohn's disease (DCD) has been reported to occur in 0.5% to 4% of patients with Crohn's disease. When patients fail to respond to conservative therapy or severe narrowing of the duodenum develops, operation is required. The recent literature is limited in description of surgical treatment of such patients. We reviewed our experience with surgical management and outcomes in patients with DCD, including outcomes of laparoscopic bypass procedures. STUDY DESIGN: A retrospective review was undertaken of all patients who underwent surgical intervention for DCD between 1995 and 2006. Data collected included demographics, clinical presentation, operative and hospital course, and postoperative followup. RESULTS: Thirty patients had surgical intervention for DCD during the selected period. Four patients had duodenoenteric fistulas, resulting from complications of their disease in the distal gastrointestinal tract. Operations done for intrinsic DCD were: open bypass (n = 11), laparoscopic bypass (n = 13), and stricturoplasty (n = 2). Only one vagotomy was done. Mean followup was 58 months (range 6 to 144 months). Patients resumed oral diet 3.0 days after laparoscopic bypass, with mean discharge of 6.9 days, as compared with 4.4 days and 12.2 days after open bypass, respectively. In the early postoperative period (0 to 30 days), six major complications (n=5, 19%): persistent obstruction, anastomotic leak, small bowel obstruction, anastomotic bleeding (two patients), and respiratory failure, developed in four patients in the open (36%) and one patient in the laparoscopic (8%) bypass group. There were two more complications during longterm followup, for an overall major morbidity rate of 27%. Two patients experienced recurrence requiring revision (one in the open group and one in the laparoscopic group). Gastroduodenal ulcers requiring operation did not develop in any of the patients. CONCLUSIONS: Surgery is a viable and safe option for patients with intractable duodenal Crohn's disease. The laparoscopic approach during a bypass procedure, as opposed to an open bypass, may result in faster recovery, less morbidity, and comparable recurrence rate. There is no role for vagotomy in bypass procedures.

Laparoscopy in Crohn's disease.

Crohn's disease represents a challenging operative dilemma. The nature of the disease increases the technical complexity of operations, their morbidity, and the likelihood of multiple operations. In this setting, the advantages of laparoscopic surgery, including shorter hospital stays, less adhesion formation, fewer wound complications, and faster recovery of bowel function, are particularly beneficial to the patient. Patients with Crohn's disease requiring operations in the elective and semi-elective setting can all be approached initially laparoscopically. The surgeon's skill set should include extensive experience in advanced laparoscopic bowel surgery as well as open management of Crohn's disease and its complications. Strict adherence to the basic tenet of bowel preservation is imperative. The operations most commonly performed for Crohn's disease include diagnostic laparoscopy, stricturoplasty, small bowel resection, ileocolic resection, colectomy, repair of fistulae, and gastrojejunostomy for bypass of gastric or duodenal disease. Postoperative management includes resumption of steroids, typically without the need for "stress-dosing," bowel rest for a short period, and pain control, which is also less than that experienced with a laparotomy.

Presentation, treatment, and outcome of type 1 gastric carcinoid tumors.

BACKGROUND AND OBJECTIVES: The aim of this study was to review the presentation, treatment, and outcome of patients with Type 1 gastric carcinoid tumors. METHODS: A retrospective review of 1,600 carcinoid patients was analyzed to identify patients with gastric carcinoid tumors. RESULTS: Eighteen patients were found to have biopsy-confirmed Type 1 gastric carcinoid tumors on upper endoscopy. Reasons for endoscopy included abdominal pain (n = 4), gastrointestinal bleeding (n = 4), surveillance for pernicious anemia (n = 8), and other (n = 2). The mean pre-treatment serum gastrin and chromogranin A levels were 1,436 ng/ml (+/-771 ng/ml) and 91.6 ng/ml (+/-68.6 ng/ml), respectively. Imaging revealed evidence of gastric carcinoid in 4 of 10 patients undergoing CT scanning and 3 of 10 patients undergoing octreotide scintigraphy. Of the 18 patients, 8 were treated medically (acidification or octreotide) and 10 were treated with surgery (laparoscopic antrectomy or partial gastrectomy). Mean gastrin levels decreased by 37.2% in the medically treated group (median follow-up 6 months), versus 94.0% in the surgically treated patients (median follow-up 5 months). Mean chromogranin A levels decreased by 56.2% in patients undergoing surgery. CONCLUSIONS: Gastric antrectomy is the most efficacious treatment for Type 1 gastric carcinoid, leading to a significant reduction in serum gastrin levels and regression of carcinoid tumors.