INTRODUCTION
Inflammatory bowel diseases (IBDs), such as Crohn’s disease (CD), mainly affect the small and large intestines, and they are marked by intestinal fibrosis and inflammation, which extend through the entire thickness of the intestinal wall[1]. Surgical interventions, such as ileostomy creation and subsequent reversal, are often required in patients with CD[2]. The function of an ileostomy is to reroute the fecal matter of a newly constructed pelvic anastomosis away from the colon[3]. However, the emergence of laparoscopic intracorporeal anastomosis (LIA) offers an alternative to open anastomosis (OA), in line with the principles of minimally invasive surgery, and it has promising potential advantages for postoperative outcomes and recovery[4]. This editorial paper highlights the lessons learned from clinical experience and outcomes[5], providing a roadmap for improving surgical care for CD.
KEY COMPARISONS: BENEFITS AND OUTCOMES OF LIA VS OA
LIA requires longer operative times than OA[6], mainly because of its technical complexity. Nevertheless, LIA has demonstrated significant advantages in terms of recovery. Patients undergoing LIA experience a faster return of gastrointestinal function and shorter hospitalization[7]. Guo et al[7] also demonstrated that patients undergoing intracorporeal anastomosis experienced less pain after surgery and less opioid analgesic use. In comparison, OA often involves extracorporeal handling, which can lead to delayed recovery and, in some cases, larger incision lengths, heightened bowel handling, and a greater risk of mesenteric tears or bleeding[6]. Compared to extracorporeal anastomosis, LIA is associated with fewer postoperative disease complications such as surgical site infections (SSIs)[8]. Some previous studies have also demonstrated that this surgical technique offers major benefits, especially in obese patients, with a study by Kotze et al[9] demonstrating reduced SSIs in obese CD patients.
CHALLENGES IN ADOPTING LIA: SURGICAL SKILLS & PATIENT SELECTION
The adoption of LIA is associated with certain challenges, the greatest being the time and effort needed to learn and master its techniques. Whereas laparoscopic surgery has become more widespread, an experimental study by Xia et al[10] mentioned that the LIA procedure involves a steep learning curve because of the need for advanced laparoscopic skills, specialized equipment, and strict adherence to specific techniques. The risk of anastomotic leakage and occasional mechanical failure can arise from improper stapler application during intestinal anastomosis[10]. Moreover, consistent pre- and post-surgical care is lacking for patients undergoing ileostomy reversal, as mentioned in studies by Kisielewski et al[3]. This deficiency can lead to higher chances of complications after surgery, such as extended hospital stays and a tendency to rely more heavily on traditional surgical methods[3]. Furthermore, patient selection is critical for determining the appropriate surgical approach. Unique surgical challenges and complications arise with the increasing prevalence of visceral obesity (VO), largely due to anatomical differences such as shorter and heavier mesenteries[7].
ROLE OF EXCLUSIVE ENTERAL NUTRITION IN CD SURGERY
Exclusive enteral nutrition (EEN) helps improve mucosal healing, stabilizes nutritional deficiencies, and decreases disease activity, often outperforming total parenteral nutrition (TPN) to reduce postoperative complications and improve outcomes, especially in patients with IBD[11]. Studies by Geesala et al[1] have shown that EEN polymeric formulae and nutrients, such as glutamine, help repair and strengthen the intestinal barrier. EEN may also reduce inflammation in children with CD by boosting TGF-β activity, promoting regulatory T cells (Tregs), and lowering the levels of pro-inflammatory Th1 cells[1]. Advanced sequencing techniques have illustrated that EEN can help restore gut bacterial balance in children with CD by decreasing harmful gram-negative bacteria, enhancing beneficial gram-positive bacteria, improving overall bacterial diversity, and addressing dysbiosis, including low bacterial diversity and shifts in bacterial populations[1]. EEN was less tolerated than other nutritional interventions, which were further stratified by disease phenotype or age[12], with participants experiencing challenges such as low energy, mood issues, and difficulties complying with a rigid dietary plan[11]. Mental health struggles, including the emotional burden of dietary restrictions, are associated with withdrawal from EEN[13]. Despite its limitations, EEN is preferred over TPN because of its ability to minimize the risks associated with catheter infections, as well as complications that are common with TPN after surgery[11].
TECHNOLOGICAL ADVANCEMENTS SUPPORTING LIA ADOPTION
The adoption of LIA has been significantly enhanced by technological advancements that address its inherent challenges. Innovative tools like reusable 3D-printed models have proven efficient and streamlined in facilitating continuous training, enabling surgeons to gain proficiency in controlled environments[6,10,14]. Coincidentally, this can reduce healthcare costs and improve the quality of surgery[9]. The 3D model offers remarkable advantages in terms of cost-effectiveness and sustainability by reducing both material expenditure and material loss[10]. This ensures consistent results through the use of pre-prepared anastomosis components of a fixed size, which enables fair and standardized skill assessments. The model improves training by allowing repeated procedures, such as suturing, to be performed with remarkable fidelity. It is also ethical to avoid the use of animals or cadaveric specimens[10]. The advanced stapling device has proven effective in lowering general hospital expenses, likely because it can shorten operation times. However, its higher price compared with the traditional hand-sewing technique for surgical sutures should be carefully considered[3]. The use of robot-assisted techniques has made LIA more accessible and practical by simplifying the technical challenges and expanding their feasibility for surgeons[6,15].
LESSONS LEARNED: INSIGHTS FOR FUTURE PRACTICE
This study highlights several key findings. First, LIA offers significant benefits in terms of enhanced recovery and reduced postoperative pain when performed by experienced surgical teams[4]. The faster return of bowel function and shortened inpatient stays underline its potential as a preferred option for ileostomy reversal[4,7]. Second, by providing surgeons with risk-free settings, simulation-based surgical training allows them to develop and refine their skills, receive valuable feedback, and apply these abilities in the operating room, leading to better teamwork and surgical outcomes[10]. This could not only bridge the gap between theoretical knowledge and practical expertise but also ensure better surgical outcomes. Furthermore, Kisielewski et al[3] reported that a standardized and optimized protocol could be explored for patients undergoing ileostomy reversal surgery; more positively, however, consistent adherence to antibiotic prophylaxis is well-established and should be sustained[3]. Lastly, future research should prioritize high-risk subgroups, such as patients with VO or complex CD, and explore the integration of robotic platforms to further optimize the safety, precision, and accessibility of LIA.
CONCLUSION
LIA offers significant advantages for ileostomy reversal in patients with CD, including faster recovery and fewer complications. However, the successful performance of this technique demands that technical challenges and logistic hurdles be surmounted, which can be achieved through extensive surgical training and strong institutional support. The established benefits of minimally invasive surgical techniques for intracorporeal cases are obvious, and they make the development of training programs an essential guide for preparing surgeons to successfully perform these complex procedures. Assuming that further research will define the optimal approach needed when employing the anastomotic technique, LIA holds great promise to advance the quality of surgical care and secure improved outcomes for this unique population, who often present with complex conditions.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: Malaysia
Peer-review report’s classification
Scientific Quality: Grade A, Grade B, Grade B
Novelty: Grade A, Grade B, Grade B
Creativity or Innovation: Grade A, Grade B, Grade B
Scientific Significance: Grade A, Grade B, Grade B
P-Reviewer: Chand A; Shukla A; Yu X S-Editor: Lin C L-Editor: A P-Editor: Xu ZH
