Emergency laparoscopic ileo-colic resection and primary intracorporeal anastomosis for Crohn’s acute ileitis with free perforation and faecal peritonitis: first ever reported laparoscopic treatment

Abstract

IntroductionLaparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn’s Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy.Case descriptionWe report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome.ConclusionsComplicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-1619-x) contains supplementary material, which is available to authorized users.

Intracorporeal anastomoses in emergency laparoscopic colorectal surgery from a series of 59 cases: where and how to do it – a technical note and video

“…Laparoscopic primary anastomosis is feasible either after a right or a left colectomy, with a three‐port standard approach or in single‐incision laparoscopic surgery (SILS) . Primary anastomoses can be safely performed in acute surgical patients with diffuse peritonitis but who are haemodynamically stable, and may be associated with good outcomes if performed by surgeons with significant expertise in minimally invasive and colorectal surgery, provided the anastomosis is well perfused and free of tension . Sigmoid resection with primary anastomosis after perforated acute diverticulitis and diffuse peritonitis has been demonstrated to be feasible and safe in selected patients , even in Hinchey IV patients if they are haemodynamically stable, without significant comorbidities and with onset of peritonitis < 12–24 h previously (and only when specific advanced laparoscopic colorectal expertise is available) .…”

Small bowel adenocarcinoma arising in longstanding fibrostenotic Crohn’s disease

“…The coexistence of pathological associations in emergency supports the need for a thorough intraoperative examination to address to all lesions (14). The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability and may be used successfully even in perforation associated with Crohn disease, ensuring a faster recovery and shorter hospital stay (15,16). In patients with associated malignancy, some authors recommend that the opportunity of primary anastomosis and bypass protection should be judged individually, upon the patient's clinical condition and past history of steroid use.…”

Facing Terminal Ileitis: Going Beyond Crohn’s Disease

“…The inflammation of the ileum is often caused by CD that manifests due to an idiopathic transmural inflammation affecting all the wall layers and may occur from mouth to anus but the most common affected site is the distal ileum. Skipped areas of inflammation can be found and this process leads to formation of ulcers that may produce penetrating (fistulizing), fibrostenotic (stricturing), or inflammatory pattern in the perianal region and abdominal wall [ 26-28 ].…”

“…UC “Crohn-like”, coming from a chronic pancreatic enzyme taking, has been also described in the literature [ 26 , 37 , 38 ].…”