The safety and feasibility of laparoscopic redo surgery for recurrent Crohn’s disease: A comparative clinical study of over 100 consecutive patients

Abstract Background Despite advances in medical treatments, most patients with Crohn's disease (CD) will still require surgery, with 20%‐50% needing redo surgery within 10 years after the primary procedure. There is no consensus on the application of laparoscopic redo surgery for recurrent CD. Methods This study included 107 patients with CD who underwent surgery from 2012 to 2020 at Osaka University Hospital. All procedures were laparoscopic. Patients were grouped based on whether the surgery was redo or primary for evaluation of the safety and feasibility of laparoscopic redo surgery. Results The study included 40 patients undergoing redo surgery and 67 having primary surgery. The median age at the time of the procedure was higher for those undergoing redo surgery (43 years vs 34 years, P < 0.0031), as were the duration of CD (16.5 years vs 8.3 years, P < 0.0012) and number of operating minutes (231.0 min vs 169.0 min, P < 0.0001). The remnant bowel length was shorter in the redo surgery group (270.0 cm vs 410.0 cm, P < 0.0001). Rates of open conversion were comparable between the two groups (10.0% vs 3.0%, P = 0.127), as were postoperative complications (32.5% vs 20.9%, P = 0.1812). Conclusions These results suggest that laparoscopic redo surgery is safe and feasible, with comparable conversion rates and postoperative complications in experienced institutions.

Hand-assisted laparoscopic surgery (HALS) was selected when extensive colectomy was required. HALS was indicated for patients with extensive colonic lesions, whereas SILS was indicated for patients with ileocolic lesions, ileocolic anastomotic lesions, or small intestinal lesions. Open conversion was considered depending on the intraoperative situation. The skin incisions used for each approach are shown in Figure S1.
From January 2012 to December 2020, a total of 131 consecutive patients who underwent surgery for CD intestinal lesions in Osaka University Hospital were included in this study. Patients with surgical indications for perianal diseases or cancer were excluded ( Figure 1). The patients were grouped by surgery type (primary or redo), and laparoscopic surgery outcomes were evaluated between the two groups.
Indications for the surgeries were determined in inflammatory bowel disease (IBD) treatment team conferences attended by gastroenterologists, colorectal surgeons, radiologists, nutritionists, and nurses. All surgeries were performed by two qualified and boardcertified colorectal surgeons with established endoscopic surgical skills.

| Surgical technique for redo surgery
All surgery was performed under general anesthesia, with the patient placed in the lithotomy position. An initial laparotomy (3-4 cm) was made in the umbilicus, and adhesions around the previous wound were dissected. For the redo surgeries, most of the surgical sites were located in the ileocolic anastomosis. In these cases, a SILS device with one camera port and two manipulation ports was fitted for performing intra-abdominal procedures, as previously described. 11 After pneumoperitoneum was established, another port was added at the right lower site (planned site of drainage tube) if necessary.

| Data collection
Data were retrospectively collected for the comparison between CD patients with redo surgery and those with primary surgery. Patient

| Statistical analysis
All statistical analyses were conducted using GraphPad Prism software, version 5.0 b. The chi-square test and Fisher's exact test were used to compare and analyze categorical variables. All analyses were two-tailed with P < 0.05 considered significant.

| Ethics statement
The protocol for this study was approved by the institutional review board of Osaka University Graduate School of Medicine (#15028).
The procedures conformed to the provisions of the Declaration of Helsinki. Written informed consent was obtained from all patients for use of their clinical data.

| Patient characteristics
In our institution, all intestinal surgeries for CD were started using a laparoscopic approach. A total of 131 consecutive patients underwent intestinal surgery for CD during the study period. We excluded 24 patients with surgical indication for cancer or perianal disease, so that data for 107 patients were analyzed in this study ( Figure 1

| Surgery-related factors
The proportions of the different laparoscopic surgical approaches were comparable between the two groups (P = 0.5895

| Short-term outcomes
Short-term outcomes are shown in Table 3.

| DISCUSS ION
Laparoscopic colorectal cancer surgery has become widespread and has been rapidly accepted. 14 In IBD, a laparoscopic approach has already been accepted for simple CD cases, with fewer complications and improved early postoperative outcomes. 9 The present study has several limitations. Its design was retrospective, and it was conducted in a single institution specializing in IBD and laparoscopic surgery. Most surgeries were performed by two board-certified surgeons, so the findings cannot be generalized to inexperienced centers and surgeons. Perioperative medication and diet, which would affect CD surgery, were selected largely according to clinician discretion and patient condition. This study also identified postoperative hospital stays as long as 20 days or more, whereas most previous results involve hospital stays of less than 1 week, whether for primary or redo surgery. 7,16,20,23,26 Finally, patients were allowed to have an elementary diet after negative CRP in accordance with institutional therapeutic guidelines based on previous results that postoperative inflammation is involved in CD recurrence. 12,25,29 With the increase in CD patients, laparoscopic redo surgery for recurrent CD will become a common procedure in the near future. Our results suggest that laparoscopic redo surgery is safe and feasible in experienced institutions. Although the quantification of adhesion severity is quite difficult, we have found that the adhe-