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Short-Term Outcomes of Laparoscopy Combined with Enhanced Recovery Pathway after Ileocecal Resection for Crohn’s Disease: a Case-Matched Analysis

  • 2012 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Laparoscopy combined with an enhanced recovery pathway (ERP) is widely considered to be the first-choice option for patients with colorectal cancer. However, no previous reports have focused on patients with Crohn’s disease (CD) treated by laparoscopy and ERP.

Methods

Twenty patients with CD underwent laparoscopic ileocecal resection with an ERP at two institutions. The ERP protocol included no bowel preparation nor fasting, no nasogastric tube, no abdominal drains, early removal of urinary catheter, early solid dietary intake and mobilization, opioid-sparing analgesia and restrictive fluid management. This group was compared with a matched historical control group of 70 CD patients who underwent laparoscopic ileocecal resection treated with conventional care.

Results

Compliance with the ERP was high (≥80 %) for all items except no drain placement. A significantly earlier return of bowel function (time to first flatus and stool) was observed in the ERP group. Mean postoperative and total length of stay were significantly shorter in the ERP group. Postoperative complications were similar in both groups.

Conclusions

This is the first reported experience of laparoscopy with ERP in CD patients and suggests that optimized perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.

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Conflict of Interest

None.

Author information

Authors and Affiliations

  1. Department and Chair of General Surgery, Istituto Clinico Humanitas-IRCCS, University of Milan, Via Alessandro Manzoni 56, 20089, Rozzano (Milan), Italy

    Antonino Spinelli, Piero Bazzi, Matteo Sacchi & Marco Montorsi

  2. IBD Unit, Department of Gastroenterology, Istituto Clinico Humanitas-IRCCS, Via Alessandro Manzoni 56, 20089, Rozzano (Milan), Italy

    Silvio Danese & Gionata Fiorino

  3. Department and Chair of Gastroenterology, Istituto Clinico Humanitas-IRCCS, University of Milan, Via Alessandro Manzoni 56, 20089, Rozzano (Milan), Italy

    Alberto Malesci

  4. General Surgery Unit, Policlinico S. Orsola Malpighi, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy

    Lorenzo Gentilini & Gilberto Poggioli

Authors
  1. Antonino Spinelli
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  2. Piero Bazzi
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  3. Matteo Sacchi
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Corresponding author

Correspondence to Antonino Spinelli.

Additional information

Discussant

Dr. Bridget N. Fahy (Houston, TX): I would like to congratulate Dr. Spinelli and colleagues on this interesting study which is the first of its kind to examine the combined benefit of laparoscopy and an enhanced recovery pathway after ileocecal resection for Crohn’s disease. Although the study sample was small, with just 20 patients in the laparoscopy + ERP and 70 historical controls in the conventional care group, the authors were able to demonstrate a high rate of compliance in their ERP group and some benefits in terms of reduced time to return of bowel function and earlier hospital discharge.

I have several questions for Dr. Spinelli:

1. Managing patient and family expectations regarding postoperative recovery is an important component of prompt postoperative discharge. You indicated that patients in the ERP group received multidisciplinary patient information vs. standard patient information. Can you describe how the preoperative patient information varied between the ERP and conventional groups?

2. Can you describe the opioid-sparing pain regimen used both intra- and postoperatively? The percentage of patients with VAS pain scores of >3 postoperatively was almost twice as high in the ERP group, so I am wondering how this may impact patient satisfaction with this pain management approach.

3. There were three postoperative hemorrhages in the ERP group (15 %) and seven in the conventional group (10 %). These rates are higher than I would expect for this procedure. Can you describe how the mesentery was divided and speculate on the cause of this high rate of postoperative hemorrhages?

Thank you for your presentation and for allowing me to review this interesting work.

Closing Discussant

Dr. Antonino Spinelli: I would like to thank Dr. Fahy for her comments.

1. ERP patients received a multidisciplinary preoperative education by a team of surgeon, anesthesiologist, gastroenterologist, and dedicated IBD nurse. The information provided in the ERP group was not only limited to the surgical procedure but also included other important and practical aspects as preparation for surgery, timing and type of diet intake, pain management modalities, and mobilization. We dedicated a long time (often more than 1 h) to this education in ERP patients, emphasizing patient motivation to be actively involved in his own recovery. We had the feeling that this helped greatly in reducing anxiety.

2. In the ERP group, remifentanil, an ultrashort-acting opioid, was intraoperatively used, while postoperative analgesic regimen was based on the use of paracetamol and ketorolac initially and paracetamol and ibuprofen at a later stage. Patients with a VAS of >3 were 40 % in ERP group and 27 % in conventional care group on postoperative day 1, dropping to 10 and 5.7 %, respectively, on postoperative day 2. These results probably reflect the opioid-free postoperative regimen in the ERP group, as well as the earlier and prolonged mobilization requested to ERP patients compared to conventional care patients. We had enthusiastic feedbacks from our patients, but we did not specifically assess patient satisfaction in the present study.

3. In the present study, we actually report two abdominal bleedings (10 %) in the ERP group and four in the conventional care group (5.7 %). The data you mentioned include four cases of self-limiting anastomotic intraluminal bleedings, which did not require any treatment (one in the ERP group and three in the conventional care group). Thickened mesenteries were divided between stitches and sutures. Intraluminal bleedings, commonly not requiring any treatment, can occur when stapled anastomoses are performed; we decided to mention this type of complication, rarely reported. About the intraperitoneal bleedings (overall 6/90, 6.6 %), they occurred in patients with extremely thickened mesenteries and in 4/6 cases with associated coagulation impairment.

Conference Presentation

These data have been presented at the European Crohn’s and Colitis Organisation (ECCO) 2012 Congress, February 16–18, 2012, Barcelona, Spain (poster presentation) and the Digestive Disease Week (DDW) 2012 Congress, May 19–22, 2012, San Diego, CA, USA (oral presentation).

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Spinelli, A., Bazzi, P., Sacchi, M. et al. Short-Term Outcomes of Laparoscopy Combined with Enhanced Recovery Pathway after Ileocecal Resection for Crohn’s Disease: a Case-Matched Analysis. J Gastrointest Surg 17, 126–132 (2013). https://doi.org/10.1007/s11605-012-2012-5

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