Laparoscopic Ileocecectomy in Pediatric Patients with Crohn's Disease

Introduction

The definitive management for most children with medically refractory Crohn's disease is resection of the symptomatic segment with primary anastomosis. Minimally invasive approaches for bowel resection in patients with Crohn's disease have shown to be effective and beneficial in adults. There is a relative paucity of data in the pediatric population. We therefore audited our experience with laparoscopic ileocecectomy in patients with medically refractory ileocecal Crohn's disease to evaluate outcomes and to document this experience.

Methods

After obtaining institutional review board approval, we retrospectively reviewed the records of all pediatric patients who underwent laparoscopic ileocecal resection for medically refractory Crohn's disease from January 2000 to October 2009. Data collected included patient demographics, evaluation and medical management, indication for surgery, perioperative use of steroids and total parental nutrition (TPN), operative variables, complications, outcome, and follow-up.

The standard laparoscopic operation was usually performed with a 10- or 12-mm port in the umbilicus, a 5-mm port in the left lower quadrant, and another 5-mm suprapubic port. The ileum and right colon were completely mobilized laparoscopically and brought up for extracorporeal resection, division of the mesenteric vessels, and anastomosis. The single-incision approach was typically done with a 5-mm port in the center of the umbilicus for the camera and two stab incisions in the fascia 1 cm above and below the camera port for working instruments, which is a modification of the traditional single-incision surgical approach. The mobilization was completed laparoscopically. The three incisions were connected for extracorporealization and then subsequent division of the mesenteric vessels.

Results

Review of our records identified 30 patients who underwent laparoscopic ileocecectomy for medically refractory Crohn's disease, 5 of them being operated on using single-incision laparoscopic approach. The mean age at the time of surgery was 15.3 years, with a range of 10–18 years, and the mean weight was 50 ± 15.5 kg (mean body mass index of 18.9) at the time of surgery. There were 16 girls and 14 boys. The mean duration of symptoms was 2.8 years (range: 13 days to 11.7 years).

The indications for surgery were obstruction/stricture (21), pain (10), abscess (3), fistula (3), perforation (2), and bleeding (1). Some patient's had multiple indications. There were a total of 5 patients who had abscesses at the time of operation. Eight patients were on total parenteral nutrition TPN at the time of resection. Twenty-five patients (83.3%) were on steroids at the time of operation, including prednisone (13), methylprednisolone (6), and other steroids (6). Eight patients received 5-ASA/mesalamine at the time of surgery, and 12 patients received azathioprine, 10 received remicade, and 4 were on mercaptopurine at the time of surgery.

Twenty-five patients had the diseased segment exteriorized through the umbilicus. In the other 5 patients, the diseased segment was exteriorized through the right lower quadrant port, which was early in the experience. The final length of the incision is determined by the inflammatory mass. The anastomosis was stapled in 26 patients and hand-sewn in 4. No patients required a diverting ileostomy. All cases were completed laparoscopically, as none required conversion to an open procedure.

Of the 5 patients who underwent a single-site operation, 3 were operated on for obstruction/stricture and 2 for perforation. There were no intraoperative complications.

The mean length of hospitalization was 10 ± 6.9 days (median: 7 days; range: 3–30 days). Most patients were able to eat and they were either discharged from the hospital by day 5 or transferred to the gastroenterology service for ongoing medication management, which accounted for some of the long hospital stays. The patients were followed up for a maximum of 80.7 months (average: 14.7 months; median: 9.7 months). Despite 8 patients having unscheduled readmissions postoperatively, only 3 patients had complications. The mean time until complications was 20 days (range: 13–25 days). Two patients developed a postoperative abscess, and both of them were taking 20 mg of prednisone daily. One patient developed a small bowel obstruction due to a second Crohn's stricture that manifested itself after the more severe downstream obstruction was relieved with ileocecectomy. There were no anastomotic leaks or wound infections.

At the time of latest follow-up, the mean number of bowel movements per day was 2.9, with a range of 1–11 per day (median: 2).

Discussion

It has been demonstrated that surgery for Crohn's disease is amenable to laparoscopic options in the adult population, ameliorating the need for a major laparotomy.^1,2 Initially, the use of laparoscopy was employed primarily to ensure a diagnosis. ³ Extending beyond the utility of laparoscopy for the initial diagnosis, the advantages of the laparoscopic management of Crohn's disease in children are remarkable for several reasons. Laparoscopy allows for visualization of the inflammatory mass, initial laparoscopic assessment of the remaining bowel, and simple mobilization of the hepatic flexure. The extracorporeal anastomosis through the umbilicus offers the advantage of the open vascular division and anastomosis. Some authors have demonstrated that patients with complications from Crohn's disease have better outcomes with laparoscopic management compared with traditional open approaches for enteric resection, such as decreased blood loss, improved length of stay, earlier return of bowel function, and improved functional recovery indices.^1,3–6 One study reported that patients who underwent a laparoscopy-assisted resection were discharged home on average 2.2 days earlier than those who underwent an open resection. ⁷ Overall, the conversion rates from laparoscopic to open ileocecectomy have been reported to occur in 2.5%–39% in retrospective and prospective series.^1,2,7 Commonly, the main reasons for conversion were due to adhesions, extensive inflammation of disease, or the size of the inflammatory mass. However, some other authors dispute this notion stating that a laparoscopic approach for ileocolic resection is possible in the face of pancolitis refractory to medical treatment. ²

Crohn's disease occurs less frequently in children than adults. Naturally, the chronicity of disease in children is limited compared with adults and most surgical encounters for pediatric Crohn's disease will be the first resection. Pediatric surgeons, therefore, face a less complexity in the spectrum of disease as most patients have isolated involvement of the terminal ileum making ileocecectomy the most common procedure performed for pediatric Crohn's disease. This makes the translation of the adult experience toward children more favorable as we often face more favorable disease.

As many patients with Crohn's disease will undergo more than one bowel resection during their lifetime, laparoscopic surgery will likely decrease potential postoperative adhesions. ⁸ High-dose steroids or other immunosuppressive therapies influence wound healing and scarring, which would be optimized by having smaller scars resulting from minimally invasive surgery, therefore being advantageous for improved cosmetic outcome.

Conservative treatment frequently includes bowel rest and TPN. In our series, TPN was found to not alter results in Crohn's patients who undergo laparoscopic ileocecectomy. Overall, our series demonstrated low anastomotic leaks, wound infection, and postoperative abscesses. Treatment with immunosuppression, TPN, or other medical therapy in hopes of preventing surgical intervention did not alter postoperative outcomes.

The surgical outcomes of this series of patients yielded expected outcomes with laparoscopic success and also minimal complications. This series demonstrates that laparoscopic ileocecectomy, both via single-site and standard laparoscopy, is safe and effective in the setting of medically refractory segmental Crohn's disease in pediatric patients.