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endoscopic surveillance is critical to identify endoscopic recurrence and proactively
alter the treatment course. As newer therapies for Crohn’s disease emerge, additional
comparative effectiveness trials are needed to guide management algorithms.
Abstracted Recommendations
1. Patients who have undergone a surgically induced remission should undergo
postoperative endoscopic surveillance at 6 to 12months over no monitoring
(moderate to high quality of evidence, strong recommendation).
2. There may be a benet to early pharmacological prophylaxis over endoscopy-
guided pharmacological treatment, particularly in patients at moderate- to high-
risk for disease recurrence (moderate quality of evidence, conditional
recommendation).
3. It is not recommended to use mesalamine, budesonide, or probiotics to prevent
endoscopic recurrence (very low quality of evidence, conditional
recommendation).
4. Anti-tumor necrosis factor therapy and thiopurines are currently the rst-line
agents for early pharmacologic prophylaxis (moderate quality of evidence,
strong recommendation).
References
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17. Yamamoto T, Nakahigashi M, Umegae S, et al. The impact of long-term enteral nutrition
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26. Ewe K, Bottger T, Buhr HJ, etal. Low-dose budesonide treatment for prevention of postopera-
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Budesonide Study Group. Eur J Gastroenterol Hepatol. 1999 Mar;11(3):277–82.
27. Hellers G, Cortot A, Jewell D, etal. Oral budesonide for prevention of postsurgical recur-
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25 Preventing Postoperative Crohn’s Disease Recurrence
237
© Springer Nature Switzerland AG 2019
N. Hyman et al. (eds.), Mastery of IBD Surgery,
https://doi.org/10.1007/978-3-030-16755-4_26
N. A. Yassin
The Royal Wolverhampton Hospitals, Wolverhampton, UK
A. Spinelli (
*)
Division of Colon & Rectal Surgery, Department of Surgery,
Humanitas Clinical and Research Hospital, Milan, Italy
Department of Biomedical Sciences, Humanitas University, Milan, Italy
e-mail: antonino.spinelli@hunimed.eu
26
Role ofMinimally Invasive
Reoperative Surgery
NuhaA.Yassin andAntoninoSpinelli
Introduction
The recurrence of Crohn’s disease (CD) after surgery is one of the most crucial
challenges in the management of this disease [1]. Approximately 50% of patients
undergoing an operation for Crohn’s disease are likely to need further surgeries
within 10–15 years. Relapse of the symptoms and recurrence of the disease within
the rst 5 years after surgical resections may occur in 30–50% of patients.
Thechances of recurrence may increase to 50% to 80% within 10 years from the
primary resection [1–4].
Minimally invasive surgery, in combination with enhanced recovery programs,
offers several advantages compared to conventional open surgery. Patients experi-
ence less morbidity, better cosmesis, and reduced lengths of hospital stay.
Laparoscopic surgery is currently considered the approach of choice for primary
ileocolic Crohn’s disease. The benets have been shown to be an overall reduction
in short- and long-term morbidity and mortality, improved quality of life scores, and
equivalent recurrence rates. Those data are nevertheless predominantly obtained
from Crohn’s disease patients undergoing primary resection.
A recent consensus statement by the European Crohn’s and Colitis Organisation
(ECCO) in conjunction with the European Society of Coloproctology (ESCP) has
highlighted the fact that laparoscopic surgery should be the chosen approach for
primary ileocolic resection in patients with Crohn’s disease, and should be
238
performed for recurrent disease when the expertise is available [5–7]. While there is
wide consensus for approaching primary ileocolic Crohn’s disease with laparos-
copy, the adoption of minimally invasive techniques for recurrent Crohn’s disease is
less common and an object of debate. In this chapter, the literature pertaining to the
use of minimally invasive surgery for recurrent ileocolic Crohn’s disease is reviewed
and followed by our personal views and practice on this subject.
Search Strategy
The published literature was searched through PubMed (January 1966 to July 2018),
the Cochrane Database, and EMBASE (January 1947 to July 2018). The MeSH terms
used in the search were: Crohn Disease, Crohn's Disease, complex, recurrent, surgery,
colorectal surgery, conventional, reoperation, laparoscopy, laparoscopic, open and
minimally invasive. A combination of the search terms as well as the search engine
operators was employed to ensure comprehensive and full capture of all relevant litera-
ture. Searches were limited to human adult studies published in the English language.
The abstracts of all potentially relevant studies were consulted to identify studies suit-
able for inclusion. Studies were excluded if they did not meet the PICO (population,
intervention, comparator and outcomes) inclusion criteria set for this search (see
Table26.1). Articles were excluded if they did not focus on surgery for Crohn’s dis-
ease; focused only on open surgery; focused on only primary surgery for Crohn’s dis-
ease; focused on all surgery for Crohn’s disease with no mention of re-do ileocolic
resection; failed to mention post-operative complications or length of in-hospital post-
operative stay. The full-texts of all eligible articles were retrieved. Additional search
strategies included searching the cited references of selected articles.
Results
Although several publications in the literature describe the use of a minimally inva-
sive approach in the form of laparoscopic surgery for primary ileocolic Crohn’s
disease [5, 8, 9], data are sparse when it comes to studies focusing in recurrent dis-
ease. Very few studies compare laparoscopic surgery for recurrent disease to the
conventional open approach, with most studies reporting on the feasibility and out-
comes of laparoscopic surgery for recurrent ileocolic disease either as the primary
aim or as part of sub-group analyses. Table26.2 highlights the studies investigating
surgery for recurrent ileocolic disease.
Table 26.1 PICO criteria for the literature search strategy and study design
P
(Patient Population)
I
(Intervention)
C
(Comparator)
O
(Outcomes Studied)
Crohn's patients requiring
re-operative ileocolic resection
Laparoscopic
surgery
Open surgery Post-op complications
[8], length of stay
N. A. Yassin and A. Spinelli
239
Table 26.2 Studies evaluating laparoscopic surgery for recurrent Crohn’s disease
Study
Patient population:
recurrent CD (N) Intervention Comparator
Study
design Outcomes
Quality of
evidence
Wu etal. (1997)
[10]
N=10 VLS Open surgery
(n=70)
R LOS 3.9 days
Conversion to open 20%
Morbidity 10%
Low
Hasegawa etal.
(2003) [11]
N=16 VLS VLS (n=52) for
primary CD
R LOS (median, range) days
8 (6–14)
Conversion to open 12.5%
Complications: (SSI):18.7%
Low
Moorthy etal.
(2004) [12]
N=26 VLS VLS (n=57) for
primary CD
R LOS (median, range) days
8 (4–47)
Conversion to open 42.3% (higher
after previous open surgery)
Complications 15%
Low
Uchikoshi etal.
(2004) [13]
N=43 VLS (n=17)
HALS (n=6)
Open surgery
(n=20) for recurrent
CD
R LOS (median, range) days
(p<0.01)
Open: 42.5 (21–90)
VLS: 22.4 (11–34)
HALS: 16.4 (9–24)
Complications (SSI)
Open 5 (25%)
VLS 3 (18%)
HALS 0
Conversion 43.4% (VLS)
Low
Lawes etal. (2006)
[14]
N=55 VLS (n=15) for
recurrent CD after
primary VLS
VLS (n=40) for
recurrent CD after
primary open surgery
R LOS (median, range) days
4·5 (3–13)
Conversion:
0% if primary VLS;
17.5% if primary open
Complications p=1.000
Low
(continued)
26 Role ofMinimally Invasive Reoperative Surgery
240
Table 26.2 (continued)
Edden etal. (2008)
[15]
N=34 (31 secondary, 3
tertiary resection)
VLS VLS for primary CD
(n=133)
R LOS 5.9 days
7.4 days for converted to open
(p<0.05)
Conversion to open 61% in
recurrence CD
Complications=no statistically
signicant difference between
redo and primary VLS
Low
Brouquet etal.
(2010) [16]
N=29 VLS Open (n=33) R LOS (median, range) days
VLS=9 (6–63)
Open=9 (6–44)
Conversion 31%
Complications
VLS=38%
Open=30%
Low
Holubar etal.
(2010) [23]
N=40 VLS VLS converted
(n=10)
R LOS (median, range) days
(p=0.002)
VLS=4 (3–10)
Converted 7 (5–11)
Conversion=25%
Complications
VLS=10%
Converted=30%
Low
Study
Patient population:
recurrent CD (N) Intervention Comparator
Study
design Outcomes
Quality of
evidence
N. A. Yassin and A. Spinelli
241
Chaudhary etal.
(2011) [24]
N=30 VLS VLS for primary CD
(n=29)
P LOS (median, range) days
Recurrent 3 (1–7)
Primary 3 (1–21)
Conversion
Recurrent 6.6%
Primary 10.3%
Complications
Recurrent 17%
Primary 24%
Low
Pinto etal. (2011)
[25]
N=50 VLS VLS for primary CD
(n=80)
R
LOS (mean, SD) days
Recurrent 7.4+4.3
Primary 6.7+3.8
Conversion
Recurrent 32%
Primary 18.7%
Complications
Recurrent 40% (severe 12%)
Primary 36.2% (severe 12.5%)
Low
Bandyopadhyay
etal. (2011) [26]
N=27 VLS No comparator R LOS (median, range) days
4 (2–7)
Conversion 7.4%
Morbidity 7.4%
Low
Huang etal. (2012)
[19]
N=48 VLS VLS for primary CD
(n=82)
R LOS—unstated
Conversion
Recurrence 20.8%
Primary 17.1%
Complications
Recurrence 27.1%
Primary 15.9%
Low
(continued)
26 Role ofMinimally Invasive Reoperative Surgery
242
Aytac etal. (2012)
[18]
N=26 VLS Open (matched,
n=26)
R LOS (mean, SD) days
VLS 6.4+6.2
Open 6.9+3.5
Conversion 11.5%
Complications
VLS 38.4%
Open 69.2%
Low
Moftah etal.
(2014) [20]
N=10 SPLS No comparator R LOS (median, range) days
6 (3–33)
Conversion 33%
Complications83.3%
Low
Leo etal. (2017)
[21]
N=18 SPLS SPLS for primary
CD (n=27)
P LOS (median, range) days
Recurrent 7 (5–14)
Primary 6 (3–28)
Conversion
Recurrent 0.3%
Primary 0.3%
Complications
Recurrent 11%
Primary11%
Low
Table 26.2 (continued)
Study
Patient population:
recurrent CD (N) Intervention Comparator
Study
design Outcomes
Quality of
evidence
N. A. Yassin and A. Spinelli
243
Panteleimonitis
etal. (2017) [27]
N=19 VLS VLS for primary CD
(n=87)
P LOS (median, range) days
Recurrent 5 (4.2–7.7)
Primary 4 (3–6)
Conversion
Recurrent 5.3%
Primary 4.6%
30-day readmission rate:
Recurrent 26.3%
Primary 14.9%
30-day reoperation rate
Recurrent 0%
Primary 6.9%
Anastomotic leak rate
Recurrent 0%
Primary 1.4%
Low
Celentano etal.
(2018) [22]
N=29 (recurrent CD
and history of 2 or more
previous laparotomies)
VLS Primary and no
previous surgery
(n=90)
P LOS (median, range) days
Recurrent 6 (2–49)
Primary 5.5 (2–22)
Conversion
Recurrent 3.4%
Primary 4.44%
Complications
Recurrent 24.1%
Primary 25.5%
Readmissions
Recurrent 17.2%
Primary 17.2%
Reoperations
Recurrent 3.4%
Primary 5.5%
Low
CD Crohn Disease, VLS video-laparoscopic surgery, SPLS single port laparoscopic surgery, HALS hand-assisted laparoscopic surgery, LOS length of stay
R retrospective; P prospective
26 Role ofMinimally Invasive Reoperative Surgery