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Pre-Operative Radiographic Findings Predictive of Laparoscopic Conversion to Open Procedures in Crohn's Disease
Jeffrey Mino*1, Jon Vogel3, Lucca Stocchi2, Mark E. Baker4, Namita S. Gandhi4, Xiaobo Liu5, Rosebel Monteiro1
1General Surgery, Cleveland Clinic, Cleveland, OH; 2Colorectal Surgery, Cleveland Clinic, Cleveland, OH; 3Colorectal Surgery, University of Colorado, Denver, CO; 4Radiology, Cleveland Clinic, Cleveland, OH; 5Quantitative Health, Cleveland Clinic, Cleveland, OH
Laparoscopy is accepted as a standard surgical approach for Crohn's disease. However, the rate of conversion is high, ranging from 15-70% depending on the population. There are also concerns that conversion results in worsened outcomes versus an initial open procedure. This study evaluated pre-operative radiographic findings to determine who is at increased risk of conversion and may therefore benefit from an initial open approach.
A case-matched study included patients from 2004-2013 with pre-operative CTE/MRE who underwent laparoscopic surgery converted to an open approach, and compared them to laparoscopically completed controls with similar age , same surgeon, and number of previous abdominal operations. Studies were reviewed by two blinded radiologists. Variables included abdominal AP diameter , amount of subcutaneous fat, peritoneal vs. pelvic location of disease (true or false hemipelvis or abdomen), intestinal location of disease (colon, TI, ileum, jejunum), and presence, length, and location of strictures, simple or complex fistula, phlegmon, or abscess. Pearson's chi-square or Fisher's exact tests assessed associations between conversion and categorical measures. Two-sample T-test evaluated relationships for continuous measures.
Twenty-seven patients meeting study criteria were compared with 81 controls. A negative association between conversion and disease in the left true pelvis was found (p=.019) and neared significance for left abdomen (p=.08). Positive correlations were found with pelvic fistulas (p=.003), complex fistulas (p=.017), and pelvic abscesses (p=.009), and neared significance for Baker classification (p=.058).
Preoperative imaging may help avoid unnecessary conversions and the risks associated with them. Patients with complex fistulas and pelvic disease may benefit from an open procedure.
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