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3.2 狹窄型克羅恩病的手術技巧

因克羅恩病的不可治愈性和以去除癥狀為目的原則,克羅恩病的外科治療理念從廣泛病變切除的“巨創”逐步演變為盡量保留腸管的“微創”。外科醫師已逐漸開始摒棄克羅恩病因系膜肥厚、組織脆、腹腔連、手術難度大等陳舊思想,不斷嘗試腹腔鏡克羅恩病手術[10]。近年來亦有手助腹腔鏡、單孔腹腔鏡、機器人輔助治療克羅恩病的相關報道[11-13]。克羅恩病腹腔鏡手術優勢明顯,同樣具有美觀、創傷小、恢復快等優點[14]。部分術后復發患者依然可以選擇腹腔鏡手術[15]。Bergamaschi等[16]對92例克羅恩病患者分別行腹腔鏡和開腹回結腸切除術,其研究結果顯示:腹腔鏡手術組患者術后5年小腸梗阻發生率為11.1%,較開腹手術的35.4%明顯降低,差異有統計學意義。但克羅恩病腹腔鏡手術中轉開腹率高是不爭的事實,嚴格篩選手術適應證患者是避免中轉開腹的關鍵。本研究中腹腔鏡手術率低,中轉開腹率高,這主要與筆者團隊對腹腔鏡腸道炎性疾病手術認識以及術前評估不夠有關,部分復發再次手術患者術中腹腔粘連并沒有術前預估的嚴重,可以通過腹腔鏡完成手術。

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3.2 Surgical techniques in stricturing Crohn’s disease (CD)

Due to the incurable nature of CD and the alleviation of symptoms as the principle of treatment, the concept of surgical treatment of CD has been evolved from massive ablation of diseased area to minimally invasive surgery that reserves as much intestinal tract as possible. Surgeons have gradually abandoned the outdated concept that surgery on CD is difficult due to mesenteric hypertrophy, tissue fragility and abdominal adhesion, and continuously tried laparoscopic surgery on CD (10). Hand-assisted laparoscopy, single site laparoscopy, and robot-assisted surgery on treating CD have also been reported in recent years (11-13). The advantages of using laparoscopic surgery on CD are evident, with the same ones like pleasing appearance, small incision, and fast-recovery (14). Some patients with postoperative recurrence can still choose laparoscopic surgery (15). Bergamaschi et al. (16) compared 39 patients who underwent laparoscopic ileocolic resection with 53 patients who had open ileocolic resection, and found out that five-year small-bowel obstruction rates were 11.1 and 35.4%, respectively, in laparoscopic ileocolic resection and open ileocolic resection patients, and the difference was statistically significant. Nevertheless, the rate of switching to open abdomen surgery during laparoscopic surgery remains high. The key of prevention is strict screening of patients who are suitable for the procedure. In this study, the rate of laparoscopic surgery was low and that of switching to open abdomen surgery during laparoscopic surgery was high. This is mainly due to the fact that the author’s team did not have either a complete understanding of laparoscopic surgery on inflammatory bowel disease, or an adequate pre-surgery evaluation. In some patients with postoperative recurrence, the abdominal adhesion was less severe than pre-surgery evaluation, and they can still choose laparoscopic surgery.

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3.2 Surgical techniques in stricturing Crohn’s disease (CD)

Due to the incurable nature of CD and the alleviation of symptoms being the aim of treatment, the concept of surgical treatment for CD has evolved from massive ablation of the diseased area to minimally invasive surgery that reserves as much of the intestinal tract as possible. Surgeons have gradually abandoned the outdated concept that surgery for CD is difficult due to mesenteric hypertrophy, tissue fragility, and abdominal adhesion and have continuously attempted performing laparoscopic surgery for CD (10). The use of hand-assisted laparoscopy, single site laparoscopy, and robot-assisted surgery for treating CD has also been reported in recent years (11-13). The advantages of using laparoscopic surgery for CD are evident, and it also has benefits of pleasing appearance, small incision, and fast recovery (14). Some patients with postoperative recurrence can still choose to undergo laparoscopic surgery (15). Bergamaschi et al. (16) compared 39 patients who had undergone laparoscopic ileocolic resection with 53 patients who had undergone open ileocolic resection and found that five-year small bowel obstruction rates were 11.1 and 35.4% in patients who had undergone laparoscopic ileocolic resection and those who had undergone open ileocolic resection, respectively. This difference was statistically significant. Nevertheless, the rate of switching to open abdominal surgery during laparoscopic surgery remains high. The key to prevent this is the strict screening of patients who are suitable to undergo the procedure. In this study, the rate of laparoscopic surgery was low and that of switching to open abdominal surgery during laparoscopic surgery was high. This is mainly due to the fact that the author’s team did not have a complete understanding of laparoscopic surgery for inflammatory bowel disease or perform an adequate preoperative assessment. In some patients with postoperative recurrence, abdominal adhesion was less severe than that suggested by preoperative assessment, and the patients were able to choose laparoscopic surgery.

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