Laparoscopic versus Open surgery for small bowel Crohn's disease

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Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that most commonly involves the terminal ileum and colon (55 percent). Surgical treatment is required in approximately 70 percent of patients. Multiple procedures and repeat operations are required in 30 - 70 percent of all patients (Duepree 2002) but the disease remains incurable. Laparoscopy has gained wide acceptance in gastrointestinal surgery with potential advantages of faster return to normal activity and diet, reduced hospital stay, reduced postoperative pain, better cosmesis (Duepree 2002, Dunker 1998, Milsom 2001, Reissman 1996), improved social and sexual interaction (Albaz 2000) and its use is accepted in benign and malignant colorectal diseases. Laparoscopic surgery offers additional advantage of smaller abdominal fascial wounds, low incidence of hernias, and decreased rate of adhesive small-bowel obstruction (Albaz 2000) compared with conventional surgery reducing the need for non-disease-related surgical procedures in CD population. There are concerns about missing occult segments of disease and critical proximal strictures due to limited tactile ability, earlier recurrence due to possible reduced immune response induced by laparoscopy, technical difficulty due to fragile inflamed bowel and mesentery and the existence of adhesions, fistulas, and abscesses (Uchikoshi 2004). It is therefore important to evaluate the potential benefits and risks of laparoscopic surgery versus open surgery in patients with small bowel CD (Lowney 2005). To determine if there is a difference in the perioperative outcomes and re-operation rates for disease recurrence following laparoscopic surgery compared to open surgery in small bowel CD. Published and unpublished randomised controlled trials were searched for in the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) 2010 issue 2 The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects (DARE) 2010 issue 2 The Cochrane Colorectal Cancer Group Controlled Trials Register Ovid MEDLINE (1990 to 2010) EMBASE (1990 to 2010) Health Technology Assessment (HTA) Database (1990 to 2010) Randomised controlled trials (RCT) comparing laparoscopic and open surgery for small bowel CD were included. Two reviewers independently assessed the studies and extracted data. RevMan 5.0 was used for statistical analysis. Two RCTs comparing laparoscopic and open surgery for small bowel CD were identified. Long term outcomes of the patients in both the trials were published separately and these were included in the review. Laparoscopic surgery appeared to be associated with reduced number of wound infections (1/61 vs 9/59), reoperation rates for non disease related complications (3/57 vs 7/54 ) but the difference was not statistically significant [p values were 0.23 and 0.19 respectively]. There was no statistically significant difference between any of the compared outcomes between laparoscopic and open surgery in the management of small bowel CD. Laparoscopic surgery for small bowel CD may be as safe as the open operation. There was no significant difference in the perioperative outcomes and the long term reoperation rates for disease-related or non-disease related complications of CD. Laparoscopia versus cirugía abierta para la enfermedad de Crohn del intestino delgado La enfermedad de Crohn (EC) es una enfermedad intestinal inflamatoria crónica que compromete más frecuentemente el íleon terminal y el colon (55%). Se requiere tratamiento quirúrgico en aproximadamente el 70% de los pacientes. Se necesitan múltiples procedimientos y operaciones repetidas en un 30% a un 70% de los pacientes (Duepree 2002), pero la enfermedad sigue siendo incurable. La laparoscopia ha ganado una amplia aceptación en la cirugía gastrointestinal con ventajas potenciales de: normalización más rápida de la actividad y del régimen dietético, menor estancia hospitalaria, dolor posoperatorio reducido, mejores resultados estéticos (Duepree 2002, Dunker 1998, Milsom 2001, Reissman 1996), mejor interacción social y sexual (Albaz 2000) y su uso se acepta en las enfermedades colorrectales benignas y malignas. La cirugía laparoscópica ofrece ventajas adicionales como heridas fasciales abdominales más pequeñas, baja incidencia de hernias y una tasa reducida de obstrucción adhesiva del intestino delgado (Albaz 2000) comparada con la cirugía convencional, que reduce la necesidad de procedimientos quirúrgicos no relacionados con la enfermedad en la población con EC. Hay inquietudes sobre la omisión de los segmentos ocultos de la enfermedad y estenosis proximales críticas debido a la capacidad táctil limitada, la recurrencia anterior debida a una respuesta inmunitaria reducida inducida por laparoscopia, la dificultad técnica debida a un intestino y mesenterio frágiles e inflamados y la existencia de adherencias, fístulas y abscesos (Uchikoshi 2004). Por lo tanto, es importante evaluar los beneficios y los riesgos potenciales de la cirugía laparoscópica versus cirugía abierta en los pacientes con EC del intestino delgado (Lowney 2005). Determinar si hay una diferencia en los resultados perioperatorios y las tasas de reoperación para la recurrencia de la EC del intestino delgado después de la cirugía laparoscópica comparada con la cirugía abierta. Se realizaron búsquedas de ensayos controlados aleatorios, publicados y no publicados, en las siguientes bases de datos electrónicas: Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials (CENTRAL) 2010, número 2 La Base de Datos Cochrane de Revisiones Sistemáticas (Cochrane Database of Systematic Reviews) y la Database of Abstracts of Reviews of Effects (DARE) 2010, número 2...