Background
Ileocecal resection is the surgical removal of the cecum along with the most distal portion of the small bowel—specifically, the terminal ileum (TI). This is the most common operation performed for Crohn disease, though other indications also exist (see below).
Ileoceal resection may be accomplished via either an open or a laparoscopic approach (see Technique). [1, 2, 3, 4, 5] Laparoscopic ileocecal resection appears to be an acceptably safe alternative to the equivalent open procedure, [6, 7] provided that sufficient laparoscopic expertise is available.
Indications
Ileocecal resection is indicated for the following:
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Crohn disease complicated by stricture of the TI after failed medical therapy
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Cecal perforation
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High-risk premalignant polyps of the cecum that are not amenable to endoscopic polypectomy
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High-risk benign polyps that are not amenable to endoscopic polypectomy (eg, large tubulovillous adenoma)
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Lower gastrointestinal (GI) hemorrhage localized to the cecum
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Noniatrogenic injury (eg, gunshot wound with cecal perforation)
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Iatrogenic injury (eg, perforation or hemorrhage after colonoscopy or polypectomy)
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Palliation in specific cases (eg, cecal cancer with metastasis with complications such as bleeding or obstruction)
Contraindications
Ileocecectomy, along with other major operations, is contraindicated in patients with severe medical comorbidities who are critically ill and unable to survive a laparotomy or general anesthesia.
Formal right hemicolectomy, rather than just ileocecal resection, is the treatment of choice for cecal volvulus (with or without ischemia) and right-side colon cancers for which surgery is appropriate (eg, colonic adenocarcinoma, appendiceal malignancy, or a T1 polyp of the cecum that is endoscopically unresectable).
Technical Considerations
Anatomy
As in all surgery, understanding the anatomy is key for safe and successful ileocecal resection. [8] The TI empties into the saclike cecum through the ileocecal valve, a mucosal invagination. The appendix originates from the cecum on the posteromedial surface at the convergence of the taeniae coli. The cecum is suspended by a short mesocecum and generally has limited mobility.
The vascular supply of the TI and the cecum is derived from the ileocolic artery, which is a branch of the superior mesenteric artery (SMA). If the right colic artery is present, it can branch off the ileocolic artery. Communication with adjacent vessels in the colon exists via the marginal artery of Drummond. The venous drainage follows the arterial supply and drains into the superior mesenteric vein (SMV), which joins with the splenic vein to form the portal system.
The lymphatic drainage, also following the arterial anatomy, goes to the superior mesenteric lymph nodes. Sympathetic innervation and parasympathetic innervation of the right colon originate from the lower thoracic spinal cord and the right vagus nerve, respectively.
During mobilization of the cecum and right colon, the surgeon must be mindful of the duodenum, kidney, and ureter deep to the colon. (See the image below.)
Arterial blood supply to colon.
Outcomes
de Buck van Overstraeten et al reported on safety and clinical and surgical recurrence rates, including predictors of recurrence, in consecutive patients who underwent ileocecal resection for Crohn disease (N = 538; median follow-up, 6 y). [9] The incidence of anastomotic leakage was 3.0%. Clinical recurrence rates were 17.6% at 1 year, 45.4% at 5 years, and 55.0% at 10 years; corresponding rates of requirement for further surgery were 0.6%, 6.5%, and 19.1%, respectively. Smoking and microscopic resection margin positivity were independent risk factors for clinical recurrence; the latter was also a risk factor for further surgery.
Yzet et al performed a systematic review and meta-analysis (30 studies) to evaluate the impact of residual miscroscopic disease on the risk of postoperative recurrence after ileocecal resection for Crohn disease. [10] Inflammatory margins (a focus of 23 studies) were associated with a higher rate of clinical and surgical recurrences; myenteric plexitis (a focus of 7 studies) was associated with higher rates of clinical and endoscopic recurrence; submucosal plexitis (a focus of 6 studies) was not associated with an increased risk of endoscopic recurrence.
In patients who have undergone ileocecal resection for Crohn disease after initial failure of anti–tumor necrosis factor (TNF) therapy and experience postoperative recurrence of the disease, retreatment with an anti-TNF agent may be useful, especially in combination with an immunomodulator. [11]
Zhu et al prospectively evaluated the feasibility, safety, and short-term outcomes of laparoscopic ileocecal resection combined with an enhanced recovery after surgery (ERAS) perioperative care program in patients with Crohn disease. [12] The primary outcome was total postoperative hospital stay; secondary outcomes were time to first flatus and stool, pain score, morbidity, reoperation rate, readmission rate, and in-hospital costs. Patients in the ERAS group had shorter postoperative hospital stays (5.19 ± 1.28 vs 9.94 ± 3.33 d) and lower in-hospital costs, but no significant differences in other parameters were noted.
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Arterial blood supply to colon.
