If there’s one thing I’ve learned on my internal medicine rotation, it’s that the differential for “abdominal pain” is about a mile long. It helps when the pain can be localized to one of the abdominal quadrants, but when it’s a diffuse, constant discomfort… yeah… lots of possibilities.
Surgery always tends to be a last resort (if possible), and in over half the cases of Crohn’s, it becomes necessary after pharmacotherapy and nutrition alterations fail. The question is what kind of surgery should the patient undergo.
At first, one would think that laparoscopic surgery is the obvious choice. It’s far less invasive, typically has fewer post-op complications, more “advanced”, and becoming more and more prevalent in the world of gastroenteric surgery. However, there’s a tactile component in traditional open surgery which is better suited for assessing fistulas and abscesses – two common complications of inflammatory bowel diseases like Crohn’s.
This very question was explored using randomized controlled trials. 1
The trial’s participants came from two different sources: Maartense et al and Milson et al. Please reference the link at the bottom of this post to see the differences between the two in terms of randomizing patients. The following table combines the data for the sake of a quick overview.
|Reoperation within 30 days||1||2|
|Recurrence requiring surgery||10||11|
|Reoperation for non-disease complications||3||7|
Subsequent data analysis showed no statistically significant difference in the outcomes of laparoscopic surgery versus open surgery for Crohn’s.
In fact, several interesting points in the study go against the mentality that laparoscopy is a far superior technique. For example, because of the highly vascular bowel associated with Crohn’s, intra-operative blood loss may actually be lower in the open surgery. At the same time, open surgery takes less time to perform and has comparable analgesic usage post-op. Hmmm, so much for laparoscopic techniques being the “in” thing. 😉 There’s obviously still a place for open surgery, since no reliable benefits for laparoscopic surgery have been made in the context of Crohn’s.
1. Dasari BVM, McKay D, Gardiner K. Laparoscopic versus Open surgery for small bowel Crohn’s disease. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD006956. DOI: 10.1002/14651858.CD006956.pub2