Laparoscopic Ileocolic Resection Research Articles

The Use of Minimally Invasive Surgery in the Treatment of Crohn's Disease: A Systematic Review of Evidence

Minimally invasive surgery (MIS) is a groundbreaking approach for treating Crohn's disease (CD), affecting approximately 100-300 per 100,000 people. In 2015, an estimated 3.1 million people were diagnosed with Inflammatory Bowel Disease (IBD). Our research aims to consolidate previous evidence on MIS techniques, including laparoscopic techniques and robotic-assisted surgery, and compare them to traditional surgical techniques in managing CD. The practical benefits of MIS are evident in comparative studies, which consistently show that laparoscopic approaches result in shorter hospital stays and faster recovery than open surgery. MIS also demonstrates significant long-term benefits, particularly in reducing the mortality rate. Even pediatric CD patients have shown improved outcomes with laparoscopic-assisted surgery, experiencing fewer postoperative complications and better recovery. MIS applications include Laparoscopic ileocolic resections, a key MIS technique, offer comparable outcomes to other therapies like open ileocolic resection but with the added advantages of lower costs and long-term disease control. This cost-effectiveness of MIS techniques is a significant advantage. Techniques like intracorporeal anastomosis and trans colonic specimen removal have further improved postoperative recovery and cosmesis. Strictureplasty is another MIS technique, is particularly beneficial for CD patients with strictures due to its ability to preserve intestinal length and function. Lastly, laparoscopic robotic-assisted surgery is a game-changer, offering a significant reduction in postoperative pain and faster recovery compared to manual surgeries.

Endo the line: stricturing terminal ileum endometriosis

Endometriosis is the implantation and proliferation of endometrial tissue outside the uterus, and while involvement of the small bowel is rare, it is particularly unusual for it to present with terminal ileum stricture mimicking Crohn’s ileitis. We present the case of a 38-year-old female with recurrent mechanical small bowel obstruction with transition point in the terminal ileum. She was struggling with infertility issues and was not previously known to have endometriosis. The presumptive diagnosis was Crohn’s disease due history of previous anal fissure, high faecal calprotectin level, and imaging findings of terminal ileitis with stricture, despite lacking tissue confirmation from colonoscopy. She underwent laparoscopic ileocolic resection with histology showing endometrial stricture and secondary mucosal inflammation, without any established features of Crohn’s disease. This case demonstrates the potential diversity in presentation of endometriosis, including small bowel manifestations that can mimic Crohn’s ileitis. If endometrioma can be confidently diagnosed based on characteristic imaging features or tissue sample, unnecessary treatment may be avoided, whilst appropriate specialist management improves endometriosis symptoms and fertility outcomes.

Tacrolimus-Associated Terminal Ileitis After Kidney Transplantation, Mimicking Crohn Disease: A Case Report

The onset of gastroduodenal ulcers is a frequent complication after transplantation, whereas cases of intestinal ulcers are sporadic and poorly described in the literature. A patient on immunosuppressive therapy with tacrolimus and mycophenolate mofetil after kidney transplant for immunoglobulin A-related glomerulonephritis developed symptoms compatible with Crohn disease 7 months after the transplant. The patient was hospitalized for abdominal pain, diarrhea, fever, and weight loss. Imaging and a colonoscopy showed signs of idiopathic inflammatory bowel disease (IBD) affecting the terminal ileum. Behcet's disease, post-transplant lymphoma, cytomegalovirus, Epstein-Barr virus, or mycobacteria infection were excluded. Mycophenolate mofetil was suspended, and steroid therapy was increased without clinical improvement. Eleven units of blood were required for severe anemia. A further colonoscopy revealed ulcerations involving the cecal fundus, ileocecal valve, and distal ileum with bowel stenosis and suspected ischemia. The patient, therefore, underwent an emergency laparoscopic ileocolic resection. The histologic examination did not reveal clear signs of IBD, ischemia, or viral infection of the ileum. The findings seemed indicative of iatrogenic damage from immunosuppressive therapy. The postoperative course was regular, and after 12 months, the patient was asymptomatic, on low-dose tacrolimus and prednisone therapy. During immunosuppressive therapy, the onset of isolated ileal ulcers, which can mimic IBD, may be a sporadic complication.

Goblet cell adenocarcinoma of the appendix: A case report of three cases

Introduction and importanceAppendiceal goblet cell adenocarcinoma is in 0.3–0.9 % of appendectomy specimens. There is still controversy regarding whether surgery with dissection or additional resection is necessary for goblet cell adenocarcinoma and whether adjuvant chemotherapy is practical. We present three cases of goblet cell adenocarcinomas. Case presentationCase 1: A 30-year-old woman was diagnosed with appendicitis and underwent appendicectomy. Histopathological evaluation revealed a malignant neoplasm with goblet-like cells and tumour infiltration into the subserosa. The patient underwent laparoscopic ileocecal resection, and the main lymph nodes at the root of the feeding vessels were removed. Case 2: A 50-year-old man was diagnosed with appendicitis and underwent appendicectomy. Histopathological evaluation revealed a malignant neoplasm with goblet-like cells; malignant cells were found at the surgical resection margins. The patient underwent laparoscopic ileocolic resection. Case 3: A 60-year-old man undergoing treatment for malignant melanoma. He was diagnosed with appendicitis associated with an appendiceal tumour, and emergency laparoscopic caecal resection was performed and diagnosed as goblet cell adenocarcinoma. We decided to prioritize treatment for malignant melanoma, and the patient is under follow-up for goblet cell adenocarcinoma and no metastasis was detected. Clinical discussionWe performed additional resection in two case of goblet cell adenocarcinoma. Diagnosing appendiceal goblet cell adenocarcinoma is difficult, and the prognosis of patients with positive lymph nodes is poor. Surgical treatment should be considered for the advanced stages of this disease. ConclusionGoblet cell adenocarcinoma, diagnosed after appendectomy, additional resection including lymph node dissection may provide a long-term prognosis.

Anatomical and Surgical Considerations for Ileocolic Endometriosis

We aim to review the incidence, location, and management of bowel endometriosis and demonstrate relevant surgical principles while emphasizing anatomic considerations for minimally invasive resection of ileocolic lesions. This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with symptomatic terminal ileum endometriosis and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. Institutional review board approval was not required. This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologic and colorectal surgeons. The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain and was found to have a small bowel obstruction from a 3-centimeter lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic magnetic resonance imaging was performed for preoperative planning. Laparoscopic ileocolic resection is performed using a medial-to-lateral approach for excision of a symptomatic 3-centimeter ileocecal endometrioma. The following techniques are highlighted: (1) Evaluation of the entire small bowel starting at the ligament of Treitz (2) Entry into the retroperitoneum below the ileum with cranial and caudal dissection (3) Mobilization of the ascending colon to the level of the falciform ligament (4) Extension of the umbilical incision to perform an extracorporeal ileocecal resection and anastomosis CONCLUSION: The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon [1]. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention.

Single-incision versus multi-port laparoscopic ileocolic resections for Crohn's disease: Systematic review and meta-analysis.

The aim of this systematic review and meta-analysis is to compare the outcomes of single-incision laparoscopic surgery (SILS) versus multi-port laparoscopy for ileocolic resection in patients with Crohn's disease (CD). A systematic search of multiple electronic databases was conducted. The peri- and post-operative outcomes were evaluated between Crohn's patients undergoing SILS versus multi-port laparoscopy for ileocolic resection. The primary outcomes included operative time, anastomotic leak rate, post-operative wound infections and length of hospital stay. Analysed secondary outcomes were conversion rates, ileus occurrence, intra-abdominal abscess formation, return to theatre and re-admissions. Revman 5.3 was used to perform the statistical analysis. Five observational studies with 521 patients (SILS: 211; multi-port: 310) were included in the data synthesis. Patients undergoing SILS had a reduced total operative time compared to multi-port laparoscopy (mean difference [MD]: -16.14, 95% confidence interval: [CI] -27.23 - 5.05, P = 0.004). Post-operative hospital stay was also found to be significantly less in the SILS group (MD: -0.57, 95% CI: -0.73--0.42, P < 0.0001). No significant difference was seen in the anastomotic leak rate (MD: -16.14, 95% CI: 0.18-1.71, P = 0.004) or post-operative wound infections (odds ratio: 0.78, 95% CI: 0.24 - 2.47, P = 0.67) between the two groups. Moreover, all the measured secondary outcomes were comparable. SILS seems to be a feasible alternative to multi-port laparoscopic surgery for ileocolic resection in patients with CD. Improved outcomes in terms of total operative time and length of hospital stay were observed in patients undergoing SILS surgery. Adopting this procedure into routine clinical practice constitutes the next step in the development of minimally invasive surgery.

Anatomical and Surgical Considerations for Ileocolic Endometriosis

<h3>Study Objective</h3> We aim to review the incidence, location, and management of bowel endometriosis, as well as demonstrate anatomical considerations for surgical resection of ileocolic lesions. <h3>Design</h3> This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with a symptomatic ileocolic endometriosis lesion and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. <h3>Setting</h3> This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologists and colorectal surgeons. <h3>Patients or Participants</h3> The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain, nausea and vomiting associated with her menses, and was found to have a small bowel obstruction from a 3cm lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic MRI was performed for preoperative planning. <h3>Interventions</h3> Laparoscopic ileocolic resection is performed utilizing a medial-to-lateral approach for excision of a symptomatic 3cm ileocecal endometrioma. <h3>Measurements and Main Results</h3> Successful excision of the endometrioma with a side-to-side ileocolic anastomosis was performed with resolution of the patient's symptoms. <h3>Conclusion</h3> The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention. We present a case of a 44-year-old female with acute bowel obstruction from a 3cm ileocecal endometrioma and demonstrate a medial-to-lateral surgical technique for ileocolic resection while emphasizing the relevant anatomical structures.

Short-term and long-term outcomes of laparoscopic vs open ileocolic resection in patients with Crohn's disease: Propensity-score matching analysis

BACKGROUNDLaparoscopic ileocolic resection (LICR) is the preferred surgical approach for primary ileocolic Crohn’s disease (CD) because it has greater recovery benefits than open ICR (OICR).AIMTo compare short- and long-term outcomes in patients who underwent LICR and OICR.METHODSPatients who underwent ICR for primary CD from 2006 to 2017 at a single tertiary center specializing in CD were included. Patients who underwent LICR and OICR were subjected to propensity-score matching analysis. Patients were propensity-score matched 1:1 by factors potentially associated with 30-d perioperative morbidity. These included demographic characteristics and disease- and treatment-related variables. Factors were compared using univariate and multivariate analyses. Long-term surgical recurrence-free survival (SRFS) in the two groups was determined by the Kaplan-Meier method and compared by the log-rank test. RESULTSDuring the study period, 348 patients underwent ICR, 211 by the open approach and 137 laparoscopically. Propensity-score matching yielded 102 pairs of patients. The rate of postoperative complication was significantly lower (14% versus 32%, P = 0.003), postoperative hospital stay significantly shorter (8 d versus 13 d, P = 0.003), and postoperative pain on day 7 significantly lower (1.4 versus 2.3, P < 0.001) in propensity-score matched patients who underwent LICR than in those who underwent OICR. Multivariate analysis showed that postoperative complications were significantly associated with preoperative treatment with biologics [odds ratio (OR): 3.14, P = 0.01] and an open approach to surgery (OR: 2.86, P = 0.005). The 5- and 10-year SRFS rates in the matched pairs were 92.9% and 83.3%, respectively, with SRFS rates not differing significantly between the OICR and LICR groups. The performance of additional procedures was an independent risk factor for surgical recurrence [hazard ratio (HR): 3.28, P = 0.02].CONCLUSIONLICR yielded better short-term outcomes and postoperative recovery than OICR, with no differences in long-term outcomes. LICR may provide greater benefits in selected patients with primary CD.

Totally Laparoscopic Ileocolic Resection for Complex Enterovisceral Fistulas in Crohn's Disease: A Comparative Study.

In primary Crohn's disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. However, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex enterovisceral fistulas.The aim of this study is to assess the feasibility and safety of laparoscopic surgery for complex enterovisceral fistulas, and compare it with CD patients who underwent primary laparoscopic ileocolic resection. All patients who underwent laparoscopic primary ileocolic resection (LICR) for complex enterovisceral fistulas between July 2006 and July 2017 were included. They were compared with all consecutive patients who underwent LICR for nonfistulizing CD in the same period of time. Patients with previous bowel resections or recurrent disease were excluded. Nineteen patients with 20 enterovisceral fistulas (group I) were compared with 61 patients who underwent LICR for nonfistulizing disease (group II). There were no differences between the groups in age, sex, preoperative body mass index, nutritional status, and American Society of Anesthesiology score. There was no conversion to open surgery in both groups.There were no significant differences between groups in terms of operative time [120 (range: 65 to 232) vs. 117 (range: 62 to 217) min, P=0.7], hospital stay [6 (5 to 8) vs. 7 (5 to 65) days, P=0.56], overall morbidity 26.3% versus 16.4% (P=0.33), major morbidity (Clavien-Dindo >3) 15.7% versus 10% (P=0.66) and reoperation rates 5.3% versus 4.9% (P=0.9). There was no mortality in both groups. Our experience shows that the laparoscopic approach for complex enterovisceral fistulas in selected CD patients is both feasible and safe in the hands of experienced inflammatory bowel disease surgeons with extensive expertise in laparoscopic surgery. Larger study cohorts are needed to confirm these findings.

When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn's disease?

The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn's disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity. Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination. For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5kg/m2 (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times. LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.

AB007. Near-infrared bowel perfusion angiography during laparoscopic ileocolic resection for Crohn’s disease—video vignette

Background: Medical management remains the initial management strategy in the majority of Crohn’s disease. With improved pharmacological agents, the requirement for emergent operative intervention is declining. However, there are cases that are refractory to medical therapy and necessitate surgical management. Insufficient perfusion is a well-recognized concern in bowel anastomotic healing. The use of intra-operative near infrared perfusion angiography provides the surgeon with real time information regarding both arterial inflow and venous outflow of the anastomotic site. It aids in deciding level of anastomosis, and vulnerability of just created anastomosis.

The ACS National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative: Design, Implementation, and Validation of a Disease-specific Module.

Surgery for inflammatory bowel disease (IBD) involves a complex interplay between disease, surgery, and medications, exposing patients to increased risk of postoperative complications. Surgical best practices have been largely based on single-institution results and meta-analyses, with multicenter clinical data lacking. The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) has revolutionized the way in which large-volume surgical outcomes data have been collected. Our aim was to employ the ACS-NSQIP to collect disease-specific variables relevant to surgical outcomes in IBD. A collaborative of 13 high-volume IBD surgery centers was convened to collect 5 IBD-specific variables in NSQIP. Variables included biologic and immunomodulator medications usage, ileostomy utilization, ileal pouch anastomotic technique, and colonic dysplasia/neoplasia. A sample of the Surgical Clinical Reviewer collected data was validated by a colorectal surgeon at each institution, and kappa's agreement statistics generated. Over 1 year, data were collected on a total of 956 cases. Overall, 41.4% of patients had taken a biologic agent in the 60 days before surgery. The 2 most commonly performed procedures were laparoscopic ileocolic resections (159 cases) and subtotal colectomies (151 cases). Overall, 56.8% of cases employed an ileostomy, and 134 ileal pouches were constructed, of which 92.4% used stapled technique. A sample of 214 (22.4%) consecutive cases was validated from 8 institutions. All 5 novel variables were shown to be reliably collected, with excellent agreement for 4 variables (kappa ≥ 0.70) and very good agreement for the presence of colonic dysplasia (kappa = 0.68). We report the results of the initial year of implementation of the first disease-specific collaborative within NSQIP. The selected variables were demonstrated to be reliably collected, and this collaborative will facilitate high-quality, large case-volume research specific to the IBD patient population.

A successful case of laparoscopic colorectal cancer resection in an elderly patient with factor XI deficiency

BackgroundCongenital XI factor deficiency is a rare disease caused by autosomal recessive inheritance. Clinically, there are few spontaneous hemorrhages, which can cause abnormal bleeding after trauma, surgery, and tooth extraction. We experienced a colon cancer patient with congenital XI factor deficiency who was successfully treated by laparoscopic approach with the administration of the preoperative fresh frozen plasma (FFP).Case presentationThe patient was an 82-year-old woman who complained of right lower abdominal pain for a period of 2 months with no previous history of abnormal hemostasis. She received colonoscopy and was diagnosed with ascending colon cancer. Preoperative blood tests resulted in prolongation of activated partial thromboplastin time (APTT). After further investigation, factor XI (FXI) activity was found to be abnormal at 3.0% and congenital FXI deficiency was diagnosed. By replenishing FXI by FFP, APTT was improved to 37 s so perioperative abnormal bleeding could be avoided and an operation for ascending colon cancer performed. The patient received laparoscopic ileocolic resection and was discharged on a postoperative day 7 uneventfully.ConclusionIt is important to detect coagulation disorders such as FXI deficiency during routine preoperative checkups, and it is also important to consider unrecognized coagulation disorders if we encounter unexplained abnormal bleeding after surgery or trauma. In patients who have already been diagnosed with FXI deficiency, appropriate treatment including administration of FFP should be considered before surgery, and laparoscopic approach has a possibility to bring safety outcomes as an effect of the reduction of the intraoperative bleeding.

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46-0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46-0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49-0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.

Mo1836 Predictors of Laparoscopic vs Open Ileocolic Resection in Crohn's Disease

Mo1836 Predictors of Laparoscopic vs Open Ileocolic Resection in Crohn's Disease

Emergency laparoscopic ileo-colic resection and primary intracorporeal anastomosis for Crohn's acute ileitis with free perforation and faecal peritonitis: first ever reported laparoscopic treatment.

IntroductionLaparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn’s Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy.Case descriptionWe report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome.ConclusionsComplicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-1619-x) contains supplementary material, which is available to authorized users.

Body mass index predicts operative time in elective colorectal procedures

BackgroundObesity currently affects more than a third of the United States population and is associated with increased surgical complications. Compared to all other subspecialties, colorectal surgery is the most affected by the increasing trend in obese surgical patients. Operative time has been found to have the greatest impact on hospital costs and physician workload. This study was conducted to determine whether obesity has a direct impact on operative time in elective colorectal procedures using a high-powered, nationally representative patient sample. MethodsA retrospective analysis was conducted on 45,362 patients who underwent open and laparoscopic ileocolic resections, partial colectomies, and low pelvic anastomoses using American College of Surgeons National Surgical Quality Improvement Program data from 2005–2009. Operative time was the main outcome variable, whereas body mass index (BMI) was the main independent variable. BMI was divided into three classes as follows: normal (<25), overweight and/or obese (25–35), and morbidly obese (>35). A univariate linear model was used to analyze the relationship while controlling for confounding factors such as demographics and preoperative conditions. Statistical significance was established at P ≤ 0.05. ResultsMorbidly obese patients were found to have longer operative times than did normal patients across each individual colorectal procedure (P < 0.001), ranging from a mean difference of 17.8 min for open ileocolic resections to 56.6 min for laparoscopic low pelvic anastomoses with colostomies. ConclusionsBMI, as an objective measure of obesity, is a direct, statistically significant independent predictor of operative time across elective colorectal procedures.

Dynamic article: combined endoscopic-laparoscopic surgery for complex colonic polyps: postoperative outcomes and video demonstration of 3 key operative techniques.

Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection. The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps. This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries. This study was conducted at a single institution. All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp. Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured. Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days. This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up. Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.

Laparoscopic surgery for complex Crohn's disease

In primary Crohn's disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. At this time, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex CD involving localized abscess, fistula or recurrent disease. The aim of this systematic literature review was to assess the feasibility and safety of laparoscopic surgery for complex or recurrent CD. In the current literature, there are nine non-randomized cohort studies, two of which were case-matched. The mean rate of conversion to open laparotomy reported in these series ranged from 7% to 42%. Morbidity rate and hospital stay following laparoscopic resection for complex CD were similar to those for initial resection or for non-complex CD. In summary, even though strong evidence is lacking and more contributions with larger size are needed, the limited experiences available from the literature confirm that the laparoscopic approach for complex CD is both feasible and safe in the hands of experienced IBD surgeons with extensive expertise in laparoscopic surgery. Further studies are required to confirm these results and determine precisely patient selection criteria.

A laparoscopic approach reduces short‐term complications and length of stay following ileocolic resection in Crohn’s disease: an analysis of outcomes from the NSQIP database

Studies to date examining the impact of laparoscopy in resection for Crohn's disease on short-term morbidity have been limited by small study populations. The aim of this study was to establish the impact of the operative approach (laparoscopic or open) on outcomes after ileocolic resection for Crohn's disease. Ileocolic resections for Crohn's disease were identified using Current Procedural Terminology (CPT) and International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes from the National Surgical Quality Improvement Program (NSQIP) database (2005-2009). Complications were categorized as major (organ system damage and systemic sepsis) or minor (incisional and urinary infections). Multivariate 30-day outcomes and length of stay were determined using linear models adjusting for patient characteristics, comorbidities and operative approach. Of 1917 ileocolic resections, 644 (34%) were performed laparoscopically. At baseline, the open group was significantly older, had more comorbidities, higher American Society of Anesthesiology (ASA) classes, and more intra-operative transfusions (all variables, P<0.05). On multivariate analysis, laparoscopic ileocolic resections were associated with a decrease in major (OR=0.629, 95% CI: 0.430-0.905, P=0.014) and minor (OR=0.576, 95% CI: 0.405-0.804, P=0.002) complications compared with open resections. Laparoscopy was associated with a significant reduction in adjusted length of stay compared with the open approach (-1.08±0.29 days, P=0.0002). After adjusting for comorbidities and perioperative factors, such as preoperative sepsis, higher ASA class and higher transfusion rates in the open group, laparoscopic ileocolic resection for Crohn's disease was found to be a safer choice than the open approach, resulting in fewer complications and length of stay. All other things being equal, such patients should be offered the laparoscopic approach as a first-choice option.