(a, b) Examples of colocutaneous fistula in patients with inflammatory bowel disease
CT scan of patient with colovesical fistula . Note air in the bladder
Fistula between healthy small bowel and diseased segment of colon
Luminal view of enteric fistula in setting of active inflammatory Crohn’s disease
(a, b) Laparoscopic views of fistulizing Crohn’s disease
(a–c) Crohn’s ileosigmoid fistula . After confirming that the sigmoid is not primarily involved with active inflammatory Crohn’s disease, the endoscopic stapler is used to transect across the fistula followed by resection of the disease terminal ileum and preservation of the sigmoid colon. (All: Courtesy of Daniel Popowich, MD)
Indications and Contraindications
A laparoscopic approach is indicated in almost all patients. Inability to tolerate pneumoperitoneum and steep Trendelenburg position because of medical comorbidity or massive obesity are rare in this population. The primary contraindication is a prior history of multiple surgeries with obliterative adhesions. Anatomical considerations that may complicate laparoscopy include large hernias, dense adhesions from prior surgery, or enterocutaneous fistulas that require resection of the abdominal wall. Patients who are hemodynamically unstable generally cannot tolerate laparoscopy, as the positioning is typically more exaggerated, the operative times may be longer, and the pneumoperitoneum causes a decrease in cardiac preload. Patients must be able to tolerate the physiologic changes associated with laparoscopy in order to undergo this approach. This includes patients with severe pulmonary disease as well. In the vast majority of cases, however, laparoscopy can be attempted and if the patient does not tolerate a trial at positioning, or adhesions are too severe, conversion to an open procedure may be indicated. Other contraindications include lack of surgeon experience or lack of appropriate equipment.
There are some situations in which a large fistula is present that may require assistance from other subspecialty surgeons, such as a low bladder fistula or rare ureteric fistula . In such cases, it is necessary to coordinate preoperative planning with the assisting surgeons. Especially for the sigmoid colon, if it is possible to do the majority of the procedure laparoscopically and a portion of the procedure through a small Pfannenstiel incision, many of the benefits of laparoscopy may be provided to the patient by minimizing the size of the definitive incision. Careful preoperative planning in a team-based approach and clear communication with the operating room staff is necessary in these situations.
Segmental colon resection in the setting of CD remains somewhat controversial [5–10]. Although a full discussion of this topic is outside the confines of this chapter, a total colectomy is usually indicated for CD-related dysplasia or pancolitis, considering ileorectal anastomosis for those with rectal sparing and good continence [11]. Segmental colectomy, with or without a temporary diverting ileostomy, can be considered for those with short segment disease in whom the rectum, anus, and proximal colon appear salvageable.
Principles and Quality Benchmarks
The first principle of treating IBD associated with fistula and abscess is to ensure that the source of sepsis has been controlled, and the patient has been stabilized hemodynamically. These patients rarely present acutely. When possible, treatment with antibiotics and utilization of radiologic drainage as a bridge to surgery is advocated to clear sepsis and allow the patient to recover from systemic sepsis and allow for preoperative optimization. Nutritional optimization may need to be considered as well, and we primarily base assessment on weight loss, using prealbumin in those otherwise suspected to be malnourished. Patients are frequently evaluated by dieticians on the multidisciplinary team. If patients can tolerate enteral diets, they are educated on dietary choices and supplements that optimize their protein and calorie needs. If patients cannot tolerate oral intake, they are evaluated and followed carefully by members of a multidisciplinary nutritional support team to manage enteral or total parenteral nutrition. Ideally patients will demonstrate weight gain or stabilization of weight loss and normal serum markers of nutrition including albumin and prealbumin. There are instances where the disease severity is so great that surgical resection is necessary prior to improvement in nutritional status. For that reason, we generally are more concerned about getting 7–10 days of adequate nutrition, rather than waiting for laboratory values to normalize.
When proceeding with the operation, it is important to remember to evaluate the entire bowel for active disease, even if the indication for operation is colonic disease. The extent of disease is not always accurately identified preoperatively. Typically, preoperative evaluation includes colonoscopy and one or more means of small bowel assessment, such as CT or MR enterography. If no recent endoscopic assessment is available, preoperative colonoscopy should be performed to assess for the extent of colitis or proctitis and for any underlying malignancy, as it allows more accurate surgical planning and a better discussion with the patient. If patients are very symptomatic and/or preoperative colonoscopy cannot be completed, this can be performed intraoperatively. Even so, it is important to visually inspect the entire intestine for active disease and in our practice, we generally exteriorize and “run” or sequentially palpate the entire small intestine. At a minimum this can be done laparoscopically with a hand-over-hand technique of running the small bowel, with care taken to avoid injuring the bowel, although generally the small bowel can be exteriorized and palpated when a specimen is being removed.
When performing a resection for CD, it is important to preserve as much bowel as possible, though this is less directly relevant for colonic disease. Surgical margins should be grossly negative for active disease for 2 cm, as defined by the normal appearing bowel with absence of mesenteric inflammation . It is not necessary to have frozen section assessment of surgical margins. An anastomosis should not be created if there is active purulence in proximity to the anastomosis, such as a large pelvic abscess with resultant thickening and secondary inflammation of the distal rectum. A proximal diverting loop ileostomy should be considered if there are concerns about the quality of the remaining intestine for anastomosis, patient nutrition, or immunosuppression.
Preoperative Planning, Patient Workup, and Optimization
Except in the relatively rare situations of bleeding or acute perforation, preoperative optimization is essential for patients with IBD. Abscesses that can be drained are dealt with using image-guided techniques , including retroperitoneal abscesses , unless small. Smaller abscesses and some intramesenteric abscesses may be best left undrained and treated with antibiotics. Holding any immunosuppressive agents, such as biologic agents, is also recommended. Steroids are tapered if possible but can rarely be stopped in patients with these types of symptoms. There are no set guidelines for the duration of time of biologic agents to be held, though we generally wait 6–8 weeks prior to proceeding with an operation. The nutritional status of the patient should be assessed to determine the safety of proceeding with an operation and the likelihood of successful healing postoperatively. Evaluation of serum levels of albumin, prealbumin, and transferrin is useful. In patients who are malnourished, preoperative supplemental nutrition may be necessary. This can be done orally with high-protein supplements but may require enteral or parenteral nutrition, particularly in those who are chronically partially obstructed with their disease, or who have high-output or symptomatic fistulas which preclude intestinal feeding. Postoperative supplemental enteral or parenteral nutrition is generally unnecessary. Many patients are also routinely seen by our enterostomal team and given a temporary mark for a stoma. In cases requiring intraoperative decision-making, both left and right-sided marks are placed, taking care to be away from old scars and skinfolds.
Once surgery is scheduled, standard enhanced recovery protocols are applied [12]. Patients should be encouraged to stop smoking and limit alcohol intake, as these have been shown to have improved postoperative outcomes when done for greater than 4 weeks prior to operation. Patient education and setting clear postoperative expectations are paramount in preparation for surgery. This discussion includes expected goals regarding pain control , postoperative diet advancement , patient participation in recovery , and discharge criteria and planning .
In preparation for the operation, all patients who are not obstructed should undergo mechanical bowel preparation. Bowel preparation is commonly utilized as it provides several benefits in the laparoscopic setting. The decompressed bowel after mechanical bowel preparation allows for easier manipulation and specimen extraction. Particularly important is that the addition of oral neomycin and metronidazole with the mechanical bowel appears to be associated with a significant decrease in rate of postoperative surgical site infection.
Preoperative diet remains controversial, as patients traditionally fast from midnight the night prior to surgery. In our practice, consistent with anesthesia guidelines, patients are allowed to continue to consume clear liquids up until 2 hours prior to surgery. Some enhanced recovery protocols also provide patients with carbohydrate loading fluids to drink the morning of surgery. Patients with chronic obstructive disease who will not tolerate a bowel preparation are kept on a liquid diet for 48 hours and given two bottles of magnesium citrate, a milder preparation that is usually tolerated reasonably well. For more details on preoperative preparations, please refer to the chapters on enhanced recovery protocols in colorectal surgery (Chaps. 7 and 8).
Standard venous thromboembolism prophylaxis and preoperative intravenous antibiotics should be administered in accordance with SCIP (Surgical Care Improvement Project) guidelines [12]. This has been shown to minimize the risk of surgical site infection. Enhanced recovery programs also call for antinausea prophylaxis to be administered [12]. Currently, alvimopan is not indicated for laparoscopic surgery, as it has not been clearly shown to improve postoperative outcomes; however, we will give a single dose to patients at high risk of conversion, and this will continue postoperatively if the patient is converted to open surgery. For more details on enhanced recovery recommendations, please refer to the chapter on enhanced recovery protocols in colorectal surgery (Chaps. 7 and 8).
Operative Setup
Patients are placed in a modified lithotomy position, ensuring that the legs and arms are positioned appropriately to avoid nerve injury. The patient’s arms should both be tucked by their sides, with the use of sleds if needed for larger patients. In order to overcome the steep Trendelenburg positioning, a bean bag may be placed underneath the patient, the chest may be taped to the table, or anti-sliding padding can be used. The lithotomy position is important so access to the anus is maintained.
Operative Technique: Surgical Steps
The basics steps of laparoscopic colectomy for CD follow similar principles to those described in the chapters on laparoscopic left and sigmoid colectomy for benign (Chap. 3) and malignant disease (Chap. 17). In cases of abscess and fistula with inflammatory bowel disease, and similar to some complex diverticular disease, there are several operative steps that are helpful.
Laparoscopic Access
Many of these cases are re-operative in nature. Even so, we start with a sub-umbilical cutdown to insert a Hasson balloon port. This commonly is quite straightforward. If there are adhesions or concerns of adherent intestine, a lateral 5 mm visual port is inserted, away from the area of the pathology. This guides placement of a second port which allows adhesiolysis and insertion of additional ports as required.
Definition of Anatomy and Pathology and Abscess Management
The procedure starts with a review of the area of pathology. Multiple small bowel loops may be involved and there may be extensive adhesions. The operation then starts with lysis of adhesions, separating each loop individually off the phlegmon. In these cases, the entire small bowel will be examined extracorporeally, but if there are areas of particular concern, they are marked with a laparoscopic 3-0 polyglycolic acid suture. Loops of small bowel that contain fistulas are controlled by an endoloop suture, to minimize intraabdominal leakage and contamination . Generally, each adherent loop of bowel is separated so that they can be removed through a small incision for resection or examination.
Once the small bowel loops have been separated, the colon can be evaluated. The decision of whether the mesentery or bowel is mobilized first really depends on what step will facilitate dissection of the diseased segment most safely and effectively. Oftentimes, the best strategy is to start by mobilizing the bowel proximal to the pathology in order to define the correct anatomical planes. This will help identify anatomic landmarks and guide the dissection safely toward the diseased segments and associated phlegmons, abscess cavities, and/or fistulas. This dissection will lead next to taking down colovesical, colovaginal fistulas , or even left lower quadrant cutaneous fistulas. These are transected with a combination of sharp dissection with scissors and blunt dissection using a Maryland or bowel grasper. For those who like energy devices for dissection, these are particularly unsuitable in fistula and abscess cases, as the tissues are often so thickened that the energy devices cannot be closed effectively. When a pericolonic abscess cavity is unroofed, a suction device is immediately positioned into the cavity to aspirate out all pus before it contaminates the abdomen. The goal at this stage is simply to control and minimize spillage of purulence. The use of monopolar cautery should be minimized in order to avoid inadvertent burn injury to the bowel. Sponges can be very helpful to achieve hemostasis as well as to provide effective bowel retraction. Frequently ovaries, fallopian tubes, or the appendix may be adherent to the inflammatory phlegmon or abscess and must be carefully separated. If the appendix is involved, it is removed as per routine. Once the pathology and anatomy have been fully defined, the entire small bowel should be examined for disease, as described above.
Another important consideration is identification of the ureter . Frequently the ureter may be more medial than expected due to distorted anatomy from the inflammatory process. Consider ureteral stents, although these are generally not required except for cases with a psoas abscess, prior pelvic surgery, or some colovaginal fistulae with a phlegmon involving the pelvic sidewall.
Mobilization and Division of Mesentery
For the left colon, a low ligation of the inferior mesenteric vessels is adequate unless there is dysplasia or a concern for cancer. Our preferred approach in cancer is a medial to lateral approach to the mesentery . This frequently also works well in cases with inflammatory disease. Usually the easiest first step is to grasp the rectosigmoid mesentery and elevate it from the retroperitoneum and incise with scissors or cautery parallel to the inferior mesenteric vessels over the sacral promontory. This allows CO2 to distend the presacral space, and the mesentery is mobilized as per routine. If there is too much tethering on the mesentery because of a vesical fistula , this is taken down first. The left colic vessels may need to be divided to achieve adequate length for tension-free colorectal anastomosis.
In cases where the abscess is medial, however, a medial approach is fraught with difficulty, and there is frequently too much inflammation to visualize any plane. Rather than transecting the mesentery blindly, we will switch to a lateral to medial approach. The planes there are often more manageable, even allowing mobilization as far medial as the ureter and presacral space. If that is not the case, move proximally on the descending colon, and a plane can usually be found. The last option is a high medial approach, coming between the duodenojejunal flexure and the inferior mesenteric vein, which generally allows entry to a clean anatomical plane.
If there is any doubt about an anatomical plane, stay inside the mesenteric fascia. While this causes a little more bleeding, it is much safer. It is important not to dissect blindly, particularly with an energy device, as these can so effectively stop bleeding that one may stray outside the correct plane and cause injury to surrounding urinary, vascular, or nerve structures.
Many of these abscesses and fistulas involve the left pelvic sidewall. In these cases, one must carefully combine blunt and sharp dissection techniques , and frequently switch from medial to lateral views, to progress gradually to completely dissect the mesentery off the abscess wall or pelvic sidewall. The goal is to have adequately mobilized the left colon, so that the diseased segment can be removed, with an adequate margin of normal tissue and adequate length for a tension-free anastomosis. Splenic flexure mobilization is almost routinely required in these cases but division of the inferior mesenteric vein again at the tail of the pancreas is rarely required. Please refer to specific laparoscopic techniques in Chap. 4 on laparoscopic splenic flexure release.
Colon Transection
Proximal colonic division is generally extracorporeal. The distal transection margin is critical and may be complex. The most frequent consideration is whether one is distal to the inflammation. Our goal is always to mobilize enough rectum and mesorectum so that we reach visibly and palpably normal tissue. Sometimes a loop of sigmoid is stuck in the pelvis, and this must be completely mobilized. Sometimes the upper rectal wall is thickened because of an adjacent abscess, and we generally mobilize more distally, sometimes below the peritoneal reflection until normal bowel can be identified. If the rectum does not look healthy enough for an anastomosis, it is transected as a Hartmann’s stump and an end colostomy is brought out, which may subsequently be closed depending on a variety of factors such as pathology, patient status, etc. Indeed, the quality of the distal rectum is usually a predominant determinant of whether an anastomosis will be performed, or a Hartmann’s stump left for safety. Additional considerations for anastomosis include the extent and severity of any residual proctitis in the rectal stump. For details on steps to take during Hartman’s procedures , please refer to the chapter on Key steps to facilitate minimally invasive Hartmann’s reversal (Chap. 20).
Specimen Extraction
In simple cases requiring a sigmoid or left colon resection , a left lower quadrant muscle splitting incision is made. This is technically straightforward with a low complication rate. If a diverting stoma is required, the specimen is removed through that opening, if necessary making a “key-hole” incision to enlarge the opening.
For patients with an enterocolic fistula that required dissection of tethered small bowel loops from an abscess or phlegmon, or with concurrent ileocolic and left colon disease, a short periumbilical midline incision is used. A wound protector is critical to prevent contamination by the abscess or fistula. This permits sequential exteriorization of the entire length of the small bowel, which can be examined, resected, or repaired as appropriate.
Anastomosis
Small bowel anastomoses are performed most frequently using a stapled side-side functional end-end approach. Left-sided anastomoses are stapled transanally. We use a 28 mm circular stapler to minimize anal stretching and to facilitate reaching the apex of the rectal stump. Sizers are not usually required for these cases, although they are sometimes used to gently stretch the rectum. In rare cases, a hand-sewn colorectal anastomosis may be performed, and this can be performed through a short Pfannenstiel incision.
Fistula Repair
The enteric and colon sides of fistulas are generally both resected as segmental resections (Fig. 5.3). In the setting of Crohn’s disease, it is necessary to first evaluate both for active inflammation. If the tissues are actively inflamed, then a fistula repair is not advisable, and formal resection should be carried out (Figs. 5.4 and 5.5a, b). If there is no surrounding inflammation, a tiny fistula in small bowel may be managed with a wedge resection and hand-sewn closure of the enterotomy. While some surgeons advocate selective use of stapling across fistulas when only one of the bowel segments is involved with Crohn’s disease, we do not routinely staple across fistula tracts, as we feel this is by definition abnormal tissue and at higher risk for recurrence. We tend to reserve this for patients with multiple prior Crohn’s resections and less residual small bowel (Fig. 5.6a–c). For more discussions on laparoscopic management of complex Crohn’s ileocolic disease, please refer to the chapter on advanced laparoscopic right colectomy techniques (Chap. 16).
Small colovesical fistulas are tested by distending the bladder with very dilute methylene blue. If there is no leak, they are not sutured. Larger fistulas are repaired with laparoscopic suturing. An omental pedicle graft should be placed next to the bladder, and a drain should be placed and monitored in case of a urine leak. A contrast study is done at 48 hours for small fistulas. Larger (sutured) fistulas are imaged at 2 weeks by cystography before removing the Foley catheter. Vaginal fistulas are left open unless they are large in which case they are sutured with absorbable sutures. An omental pedicle graft is placed over the defect when possible.
Other Steps
A segment of omentum is brought down as an omental pedicle graft between any remaining wall of a fistula or abscess cavity if reach permits. Drains are placed into residual contained abscess cavities, although not if the abscess cavity has not been mostly excised. Surgical wounds are closed in a standard fashion, and a wound protector is used in all cases. Vacuum-assisted (VAC) dressings are not used. In rare cases of extreme purulence or wound contamination, the wound is partially closed and a betadine wick is inserted and removed on POD3 for delayed primary closure. If there is a colocutaneous fistula that requires excision of the abdominal wall and skin (Fig. 5.1a, b), these defects are typically managed with wet to dry dressing changes, which can be switched to negative pressure dressing changes once healthy granulation tissue is visible. The utilization of laparoscopy helps reduce the rates of surgical site infection when compared to open operations. Standard enhanced recovery protocols and intraoperative surgical site infection measures are implemented.
Pitfalls and Troubleshooting
The level of difficulty can range from straightforward to highly complex depending on the degree of severity of the inflammation. The learning curve in general for laparoscopic left colectomy is upward of 50 cases and may not necessarily include the challenges specific to safely managing penetrating CD [13]. Common challenges include the ability to separate the colon from adjacent structures, identifying and protecting the left ureter, managing the difficult Crohn’s mesentery, and closure of the fistula on the organ remaining in situ (typically bladder or vagina). When separating the colon from adjacent structures, if standard techniques are not successful, some surgeons favor conversion to hand-assist to optimize blunt dissection while minimizing the size of the incision to maintain the benefits of a laparoscopic approach.
Identifying the ureter can be difficult in the setting of severe inflammation . Keep in mind that the ureter may be more medial than normal. Ureteral stents may be placed preoperatively or intraoperatively if necessary [14]. We tend to favor selective intraoperative placement since a previous study we performed showed that this made surgery faster and was just as manageable for urology [14]. Typically, ureteral stents may help identify but not prevent ureteral injuries, and their presence should not supplant safe dissection and knowledge of the anatomy.
The mesentery in CD can be challenging as it is frequently thickened, friable, woody, and tends to bleed easily. Even when taking segments of mesentery with small vascular branches, blood loss can be quite significant. When using an energy device, it may be necessary to take the mesentery in layers and cauterize/seal the vessel in multiple locations prior to ligation. Endoloop® (Ethicon, Somerville, NJ, USA) and endoscopic clip appliers may be helpful when taking named vessels and should be available.
The predominant overarching theme in completing these cases laparoscopically should be safety. Safe and quality surgical technique should not be compromised for the sole purpose of completing the case in a minimally invasive fashion. Specifically, in cases where there is difficulty in managing a bleeding mesentery or a question of integrity of bowel, bladder, or vaginal repair; conversion is indicated. Conversion is also indicated for several technical reasons such as inability to establish or maintain pneumoperitoneum, inability to maintain adequate visualization, or inability to clear gross fecal contamination.
Outcomes
Recurrence rates after segment resection for Crohn’s colitis
Related posts:
Preparation in Colorectal Surgery: Impact on SSIs and Enhanced Recovery Protocols
Techniques for Specimen Extraction During Laparoscopic Colorectal Surgery
Colorectal Anastomotic Leaks: Best Practices to Assess the Integrity and Perfusion of Left-Sided Anastomoses
Program Colorectal Pathway: Laparoscopic Splenic Flexure Release (Tips and Tricks)
Challenge of the Transverse Colon Tumor: Laparoscopic Techniques and Strategies
Low Anterior Resection: Unique Considerations and Optimal Setup
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