Recurrence after strictureplasty or resection for Crohn's disease

Managing Stricturing Crohn's Disease: Resect? Strictureplasty? Dilate?

Crohn's disease (CD) is a pan-intestinal disease of the gastrointestinal tract characterized by inflammatory, penetrating, and fibrostenotic phenotypes. Fibrostenotic stricture formation, without inflammatory or penetrating disease, is a common complication in CD, primarily affecting the small intestine and leading to small bowel obstruction. Because there is no medical therapy that prevents or reverses stricturing disease, endoscopic and surgical treatments are the mainstays of treatment, indicated to palliate symptoms and treat the complications. Endoscopic approaches include dilation, stricturotomy, and endoscopic stenting. Surgical options include resection, intestinal bypass, and various strictureplasty techniques. In this article, we will focus on the treatment of stricturing CD: specifically, the considerations important in choosing between different treatment options and technical tips to deal with complicated disease.

Asia-Pacific consensus statements on Crohn's disease. Part 2: Management

The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology (APAGE) with the goal of developing best management practices, coordinating research and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis (UC) with specific relevance to the Asia-Pacific region. The present consensus statements were developed following a similar process to address the epidemiology, diagnosis and management of Crohn's disease (CD). The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses and treatment availability. It does not intend to be all-comprehensive and future revisions are likely to be required in this ever-changing field.

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

Resection leads to less recurrence than strictureplasty in a paediatric population with obstructive Crohn's disease

Introduction. Resection and strictureplasty are used to treat patients with obstructive Crohn's disease. Strictureplasty is preferable in adults as it retains bowel length. This study aims to identify differences in outcomes of children undergoing strictureplasty and resection for obstructive Crohn's disease. Method. Patients under 20 years undergoing surgery over a nine-year period were included. Data was collected on procedures for stenotic Crohn's disease. Patients were divided into 2 groups: Group 1 treated with strictureplasties and Group 2 resections. Postoperative complications and recurrence rates were recorded. Kaplan-Meier method was used to analyze the data. Results. Twenty-six patients and 40 operations were identified. Mean age was 15.6 years (7.2–19.4) with equal numbers of males and females. Mean follow-up was 45.9 months (0.1–149.9). 20/40 procedures involved the terminal ileum; 9/40, the ileocolic junction; 8/40, the upper GI tract; and 3/40, the colon. Group 1 consisted of 19 strictureplasties and Group 2 consisted of 13 resections and 8 combined procedures. Significantly more patients in Group 1 required further surgery (11/19 versus 3/21; P = 0.008). Conclusion. Allowing for variations in disease duration, severity, and previous medical management, these data suggest that resection is preferable to strictureplasty in treating obstructive Crohn's disease in children and adolescents.

The surgical options and management of intestinal Crohn's disease

Crohn's disease (CD) is a pan-gastrointestinal illness. It is notorious for recurrences which can develop in any segment of the gastrointestinal tract. There are many indications and surgical options for intestinal Crohn's disease . We discuss these options based on the current literature. It is important to note however, that operative treatment is based on the correct diagnosis, clinical presentation, sphincter function and patient motivation. Early and timely referral to a surgeon is paramount. The goals of continued medical therapy need to be clearly defined as do the criteria for referral to surgery.

Efficacy and safety of endoscopic balloon dilation of symptomatic intestinal Crohn's disease strictures

AIM

To evaluate prospectively the clinical efficacy and safety of endoscopic hydrostatic balloon dilation in a consecutive cohort of symptomatic intestinal Crohn's disease strictures.

METHODS

Between September 2003 and December 2008 we performed endoscopic balloon dilations in 37 Crohn's disease patients with 39 intestinal symptomatic strictures (4 naïve and 35 postoperative). Dilations were performed using a Rigiflex through-the-scope balloon. Clinical success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation, following technical success. Actuarial curves of clinical, endoscopic (redilation) and surgical recurrence were obtained by Kaplan-Meier method. Demographic and disease variables were related to the main outcomes.

RESULTS

After a mean follow-up of 26.3 months (range, 2-61 months), the long-term global benefit rate was 89% (33/37). The 1-2-3 years cumulative symptom-free rates were respectively: 76%, 55% and 46%. Four patients were operated upon. Technical success predicts a lower rate of surgery. There were no complications related to the endoscopic procedures.

CONCLUSIONS

Endoscopic balloon dilation of symptomatic Crohn's disease strictures may achieve clinical benefit in many patients and is a valid alternative to surgery in the management of the disease. Dilation may be repeated in recurrent intestinal obstructions and appears safe without morbidity.

Endoscopic balloon dilatation using double-balloon endoscopy is a useful and safe treatment for small intestinal strictures in Crohn's disease

BACKGROUND

Endoscopic balloon dilatation (EBD) is a therapeutic option for intestinal strictures of Crohn's disease (CD). Double-balloon endoscopy (DBE) enables EBD to be performed even for deep-situated strictures of the small intestine. The aim of this study was to clarify the efficacy and safety of EBD using DBE for small bowel strictures in patients with CD.

PATIENTS AND METHODS

The subjects comprised 25 patients with CD who underwent EBD using DBE for small intestinal strictures for which a colonoscope or gastrointestinal scope could not be inserted. All subjects had obstructive symptoms due to strictures that were confirmed using small intestinal enteroclysis. They were observed for at least 6 months after the initial EBD. The short-term success rate of EBD using DBE, the complication rate and the long-term outcome were investigated.

RESULTS

This procedure was successful with regard to short-term dilatation in 18 of the 25 CD patients (72%). Long strictures measuring more than 3 cm were seen in six out of seven (85.7%) of the unsuccessful EBD cases, compared with two out of 18 (11.1%) of the successful EBD cases (P=0.001). Complications were encountered in two of the 25 patients (8%). The cumulative surgery-free rate for all the subjects was 83% and 72% at 6 and 12 months, respectively.

CONCLUSION

EBD using DBE is a useful and safe procedure for small intestinal short strictures in CD patients. We conclude that this procedure is a therapeutic option that should be attempted before resorting to surgical therapy.

[Crohn's disease small bowel strictureplasties: early and late results]

BACKGROUND

Strictureplasty is an alternative surgical procedure for Crohn's disease, particulary in patients with previous resections or many intestinal stenosis.

AIM

To analyze surgical complications and clinical follow-up in patients submitted to strictureplasty secondary to Crohn's disease.

METHODS

Twenty-eight patients (57.1% male, mean age 33.3 years, range 16-54 years) with Crohn's disease and intestinal stenosis (small bowel, ileocecal region and ileocolic anastomosis) were submitted to strictureplasty, at one institution, between September 1991 and May 2004. Thirteen patients had previous intestinal resections. The mean follow-up was 58.1 months. A total of 116 strictureplasties were done (94 Heineke-Mikulicz--81%, 15 Finney--13%, seven side-to-side ileocolic strictureplasty--6%). Three patients were submitted to strictureplasty at two different surgical procedures and two in three procedures.

RESULTS

Regarding to strictureplasty, postoperative complication rate was 25% and mortality was 3.6%. Early local complication rate was 57.1%, with three suture leaks (10.7%) and late complication was present in two patients, both with incisional hernial and enterocutaneous fistulas (28.6%). Patients remained hospitalized during a medium time of 12.4 days. Clinical and surgical recurrence rates were 63% and 41%, respectively. Among the patients submitted to another surgery, two patients had two more operations and one had three. Recurrence rate at strictureplasty site was observed in 3.5%, being Finney technique the commonest one. Presently, 19 patients had been asymptomatic with the majority of them under medical therapy.

CONCLUSION

Strictureplasties have low complication rates, in spite of having been done at compromised site, with long term pain relief. Considering the clinical course of Crohn's disease, with many patients being submitted to intestinal resections, strictureplasties should be considered as an effective surgical treatment to spare long intestinal resections.

Strictureplasty

Strictureplasty in patients with Crohn's disease is an option in the colorectal surgeon's armamentarium for fibrostenotic obstructive disease. Common types include the Heineke-Mikulicz strictureplasty, Finney strictureplasty, and the side-to-side isoperistaltic strictureplasty. The procedure has potential for significant morbidity; therefore, it should be chosen for the patient carefully. Strictureplasty complements bowel resection in Crohn's disease; it is an excellent procedure to reduce the risk of developing short-bowel syndrome and its associated complications.

Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis

PURPOSE

This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.

METHODS

A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.

RESULTS

A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.

CONCLUSIONS

Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.

Jejunal Crohn's disease is associated with a higher postoperative recurrence rate than ileocaecal Crohn's disease

OBJECTIVE

Crohn's disease is a chronic inflammatory, panintestinal disease of uncertain aetiology. The recurrence rate of Crohn's disease, often taken as the time when further surgical procedure is undertaken, has been reported to be as high as 76% in 10 years. The site of the disease has not yet been associated with the recurrence rate of Crohn's disease. The aim of the study was to compare the outcome of patients who were surgically treated for jejunal Crohn's disease to those whose diseases was confined to the ileocaecal region.

METHOD

The information was tracked from our database of 724 surgically treated Crohn's disease patients between 1943 and 2002. Twenty-eight patients with jejunal Crohn's disease at their first operation (12 jejunum alone, 16 also involving other sites) were identified. For each of these patients, 3 patients with ileocaecal Crohn's, matched for age, sex, and smoking habits (n = 84) were identified as controls.

RESULTS

The median age in both groups was 21 years (range 16-52 years) with a median follow-up period of 19 years. The 3, 5 and 10 years re-operation rate for the groups with jejunal disease were 43%, 50% and 61% compared to 22%, 30% and 51% with ileocaecal disease, respectively.

CONCLUSIONS

The presence of jejunal Crohn's disease is associated with a higher rate of early disease recurrence compared to ileocaecal disease but long-term recurrences rate do not differ significantly.

Long strictureplasty is as safe and effective as short strictureplasty in small-bowel Crohn's disease

BACKGROUND

For the past 20 years it has been shown that intestinal strictureplasty is safe and effective in the management of short strictureplasty. Long strictureplasty (> 20 cm) may be an alternative to resection in some patients, especially in diffuse disease or after previous extensive resections. We reviewed the outcome of long strictureplasty for Crohn's Disease, to examine safety and recurrence rates, compared with conventional short strictureplasty.

METHODS

Sixty-two patients have undergone single strictureplasty for jejunoileal Crohn's disease since 1974. Median follow-up was 121 (range 7-253) months. Twenty-one operations involved a single long strictureplasty, and 41 operations had a single short strictureplasty.

RESULTS

No significant differences were identified between the groups. The postoperative complications in long strictureplasty included 2 abscesses only and after short strictureplasty there was one anastomotic leak and one postoperative abscess. The median hospital stay was 10 days after long strictureplasty and 9 days after short strictureplasty. Three-, 5- and 10-year disease-free rates for long and short strictureplasty, respectively, were 3-year 80.4% and 62.1%; 5-year 55.2% and 49.8% and 10-year 49.1% and 33.5% (NS).

CONCLUSIONS

These data indicate that long strictureplasty is safe and produces equivalent results to conventional (short) strictureplasty.

Indications and results of side-to-side isoperistaltic strictureplasty in Crohn's disease

PURPOSE

Strictureplasty has commonly been used for short stenotic tracts, but it has rarely been applied to stenoses longer than 10 cm. Michelassi proposed a side-to-side isoperistaltic strictureplasty for single or multiple strictures that affected long bowel tracts. The experience and results obtained to date with this type of strictureplasty are limited. We therefore decided to review the cases in which we performed this procedure.

METHODS

Thirty-one patients, aged 21 to 66 years, underwent this operation between August 1996 and October 2002. Indications for surgery included subocclusion in 22 patients, malnutrition in 9 patients, and fistula or abscess in 6 patients. Two side-to-side isoperistaltic strictureplasties have been performed in jejunum, 6 in jejunum-ileum, 16 in the proximal ileum, 1 in terminal ileum, and 6 in the ileo-cecal tract.

RESULTS

The average length of side-to-side isoperistaltic strictureplasty as 32.1 cm (range, 10-54 cm). Sixteen patients also underwent concomitant bowel resection and 17 patients have received additional strictureplasty. There was no perioperative mortality, nor were there any postoperative complications requiring reoperation. In all patients intestinal occlusion and malnutrition were resolved. Decrease of activity indices was observed in 62.3 percent of patients within 6 months after surgery. At an average follow-up of 26.4 months, six patients required reoperation, but in only one of them did the recurrence involve a previous strictureplasty site. In that case the side-to-side isoperistaltic strictureplasty was soft and was without signs of inflammation or stenosis.

CONCLUSIONS

Side-to-side isoperistaltic strictureplasty seems to provide a technical solution leading to improvement when long intestinal inflamed tract are treated. Longer follow-up and larger experience is needed to validate this observation.

Therapeutic options in the management of strictures in Crohn's disease

Intestinal strictures are a commonly encountered problem in patients with Crohn's disease. Endoscopic management with hydrostatic balloon dilation is an effective alternative to surgery in patients with endoscopically accessible lesions that are shorter than 7-8 cm. Endoscopic balloon dilation is the preferred initial modality in anastomotic strictures. The presence of inflammation near the stricture should not be considered a contraindication to dilation, and intralesional steroid injection should be considered in these patients with inflammation present in the area of the stricture. Further technological developments in endoscopes and balloon dilators may allow for broader application of these techniques.

[Surgical treatment for Crohn's disease]

Surgery is mandatory in most patients with Crohn's disease. Crohn's disease refractory to medical treatment represents the main indication for surgery. After intestinal resection, the patient remains exposed to a high risk of recurrence on the remnant bowel. It is the reason why, firstly, intestinal resection for Crohn's disease should be performed without extended resections margins, secondly, it must be restricted to symptomatic lesions, and thirdly, prophylactic therapy should be given postoperatively. The laparoscopic approach is to date more an more proposed in patients with Crohn's disease. It could be the procedure of choice for elective ileocaecal resection. Its use in emergency situations and for more large resections, such as total colectomy followed by ileorectal anastomosis is still under evaluation.

Colonoscopic hydrostatic balloon dilatation of Crohn's strictures

Recurrent strictures cause considerable morbidity among many patients with Crohn's disease. We present a retrospective review of the outcome of patients who underwent endoscopic hydrostatic balloon dilatation of Crohn's strictures in our hospital over the past 7 years. All patients were under observation at Addenbrooke's Hospital, Cambridge. An initial assessment of all strictures was made radiologically, and any patient with active disease was treated before consideration of endoscopic dilatation. Dilatation was carried out with Microvasive Rigiflex balloons. Outcome after dilatation was assessed by review at subsequent clinic visits. Sixteen of 22 patients had resolution of their obstructive symptoms after dilatation, although one third of patients required more than two dilatations over the follow-up period. Six of 22 patients had persisting symptoms after endoscopic treatment, requiring surgery. There were no complications noted after any of the 71 dilatations that were performed. We conclude that hydrostatic balloon dilatation is a safe and effective alternative to surgery in the management of Crohn's strictures within the reach of the colonoscope.

Long-term outcome of surgical management for diffuse jejunoileal Crohn's disease

BACKGROUND

In diffuse jejunoileal Crohn's disease, resectional surgery may lead to short-bowel syndrome. Since 1980 strictureplasty has been used for jejunoileal strictures. This study reviews the long-term outcome of surgical treatment for diffuse jejunoileal Crohn's disease.

METHODS

The cases of 46 patients who required surgery for diffuse jejunoileal Crohn's disease between 1980 and 1997 were reviewed.

RESULTS

Strictureplasty was used for short strictures without perforating disease (perforation, abscess, fistula). Long strictures (<20 cm) or perforating disease was treated with resection. During an initial operation, strictureplasty was used on 63 strictures in 18 patients (39%). After a median follow-up of 15 years, there were 3 deaths: 1 from postoperative sepsis, 1 from small-bowel carcinoma, and 1 from bronchogenic carcinoma. Thirty-nine patients required 113 reoperations for jejunoileal recurrence. During 75 of the 113 reoperations (66%), strictureplasty was used on 315 strictures. Only 2 patients experienced the development of short-bowel syndrome and required home parenteral nutrition. At present, 4 patients are symptomatic and require medical treatment. All other patients are asymptomatic and require neither medical treatment nor nutritional support.

CONCLUSIONS

Most patients with diffuse jejunoileal Crohn's disease can be restored to good health with minimal symptoms by surgical treatment that includes strictureplasty.

Advances in inflammatory bowel disease

Optimal management of patients with IBD requires a multidisciplinary approach involving primary care physicians, gastroenterologists, surgeons, radiologists, and nutritionists. The rapidly evolving medical armamentarium promises better quality of life for patients afflicted with these complex, chronic diseases. It is expected that future development of biologic agents will add to the therapeutic options, although it may complicate treatment algorithms. Surgical advancements, particularly in ileoanal anastomosis and bowel preservation by strictureplasty, have improved outcome dramatically. The focus on development of new therapies and refinement of older ones demands a constant attention to the latest peer-reviewed literature and that the clinician keep abreast of the various advancements that have been summarized here.

Strictureplasty in Crohn's disease: surgical option

PURPOSE

The objective of this study was to review early and late results of our personal experience with strictureplasty for patients affected by Crohn's disease.

METHOD

During a 16-year period, 44 of 383 patients underwent strictureplasty. Of the 269 strictures present at surgery, 174 were treated by performing strictureplasties (156 were closed transversely according to the Heineke-Mikulicz technique, 16 were done side-to-side in the Finney manner, and 2 were done according to Jaboulay technique), and 88 were treated with a synchronous resection. An individualized technique was used for seven other strictures, with side-to-side ileocolic (5 strictures in 3 patients) or ileoileal anastomosis (2 strictures in one patient).

RESULTS

No operative mortality was recorded, nor were septic complications caused by anastomotic leakage observed. The mean follow-up period was 47.8 +/- 42.4 (range, 3-132) months. After a median follow-up period of 50 (range, 18-89) months, a second operation for symptomatic recurrence was performed on ten patients, and two of them developed new symptomatic strictures after 3 and 36 months, requiring a third operation. Symptomatic restrictures of previous strictureplasty sites requiring surgery occurred in 8.8 percent of cases. Furthermore, no statistically significant difference (Kaplan-Meier) was observed in the reoperation rate among the patients with skip lesions or closed strictures or among patients treated by strictureplasty alone or with associated resection.

CONCLUSION

We conclude that strictureplasty is a valuable adjunct or alternative to resection in the treatment of Crohn's strictures.

Obstruction in Crohn's Disease: Strictureplasty Versus Resection

Although the long-term outcome of patients undergoing strictureplasty is still to be determined, safety and effectiveness of this technique have been widely demonstrated in several reports during the past decade, with follow-up up to 10 years. However, since contraindications exist, careful selection of patients is needed. Thus, strictureplasty does not replace resection, but must be considered as a valid adjunct to conventional excisions surgery for obstructive small bowel Crohn's disease, expecially when the patient is vulnerable to short bowel syndrome. Further studies with longer follow-up are needed to determine whether or not nonresective techniques should be used with the view of sparing bowel length, in cases where resection can be done without an actual risk of short bowel syndrome (eg, terminal ileitis, where resection of terminal ileum and cecum has always been considered the "gold standard").

Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn's disease using "bowel-sparing" techniques

BACKGROUND

Conservative surgery has become accepted as a useful option for the surgical treatment of complicated Crohn's disease (CD).

METHODS

One hundred thirty-eight consecutive patients treated with strictureplasty or miniresections for complicated CD have been observed prospectively. The possible influence of a number of variables on the risk of recurrence was investigated using the Cox proportional hazard model, and a time-to-event analysis was made using the Kaplan-Meier function.

RESULTS

There was no perioperative mortality; the morbidity rate was 5.7%. A close correlation was found between the risk of recurrence and the time between diagnosis and first surgery. The overall 5-year recurrence rate was 24%, being 36% in the patients requiring surgery within 1 year of diagnosis and 14% in those operated on more than 1 year after diagnosis.

CONCLUSIONS

Risk factor analysis highlighted a group of patients at high risk of surgical recurrence. Given that our results are similar to those reported in other series, we consider strictureplasty and miniresections safe and effective procedures for the treatment of complicated CD.

Surgical therapy for ulcerative colitis and Crohn's disease

Over the past 2 decades there has been considerable progress in the surgical management of inflammatory bowel disease. Crohn's disease is a chronic, nonspecific inflammatory disease of the gastrointestinal tract of unknown cause. It involves mainly the ileum, colon, and rectum, most often producing symptoms of obstruction or localized perforation with fistula. Although surgical treatment is palliative, operative excision in combination with strictureplasty, where appropriate, provides effective symptomatic relief and reasonable long-term benefit. Chronic ulcerative colitis is a diffuse inflammatory disease of the mucosal lining of the colon and rectum. Total removal of the colon and rectum provides a complete cure. Newer surgical alternatives, developed over the last 2 decades, have eliminated the need for a permanent ileostomy following definitive resection of the involved colon and rectum.

An audit of strictureplasty for small-bowel Crohn's disease

PURPOSE

The aim of this study was to review the long-term outcome of strictureplasty for small-bowel Crohn's disease.

METHODS

We reviewed 111 patients who underwent 285 primary strictureplasties (Heineke-Mikulicz, 236; Finney, 49) between 1980 and 1997.

RESULTS

Eighty-seven patients (78 percent) had had previous bowel resections. Forty-six patients (41 percent) required synchronous resection for perforating disease (abscess or fistula) or long strictures (>20 cm). The mean number of strictureplasties was three (range, 1-11). There were no operative deaths. Septic complications (fistula or intra-abdominal abscess) related to strictureplasty developed in eight patients (7 percent), of whom two required a proximal ileostomy. Abdominal symptoms were relieved in 95 percent of patients. The majority (95 percent) of patients with preoperative weight loss gained weight (median gain, +2 kg; range, -6 to +22.3 kg). After a median follow-up of 107 months, symptomatic recurrence occurred in 60 patients (54 percent). In 11 patients symptomatic recurrence was successfully managed by medical treatment. Forty-nine patients (44 percent) required reoperation for recurrence: strictureplasty alone in 22 patients, resection alone in 19 patients, strictureplasty and resection in 6 patients, and ileostomy alone in 2 patients. Eighteen patients (16 percent) required a third operation. One patient died from a small-bowel carcinoma which developed in the vicinity of a previous strictureplasty. Two of 19 patients with diffuse jejunoileal disease developed short-bowel syndrome, and were receiving longterm parenteral nutrition. Two other patients were taking corticosteroids for recurrent symptoms. All other patients were asymptomatic, receiving neither medical treatment nor nutritional support.

CONCLUSIONS

Strictureplasty is a safe and efficacious procedure for small-bowel Crohn's disease in the long-term.

Outcome of strictureplasty for duodenal Crohn's disease

BACKGROUND

The outcome of strictureplasty for duodenal Crohn's disease has not been critically documented. The aim of this study was to assess the outcome of strictureplasty for duodenal Crohn's disease.

METHODS

A retrospective review was undertaken of 13 patients who underwent strictureplasty (including four pyloroplasties) for obstructive duodenal Crohn's disease between 1974 and 1997.

RESULTS

Ten patients underwent strictureplasty as the primary procedure, and in three strictureplasty was used as a revision procedure after previous bypass surgery. Two patients developed anastomotic breakdown and were treated either by Roux-en-Y duodenojejunostomy or partial gastrectomy. Symptoms of obstruction persisted in four patients after strictureplasty; three eventually resolved after prolonged nasogastric aspiration, but the other required gastrojejunostomy. In the long term, six patients developed restricture at the previous strictureplasty site. Five required repeat strictureplasty and the other patient underwent duodenojejunostomy. One patient who had repeat strictureplasty required a further strictureplasty because of restricture at the previous strictureplasty site. Overall nine of 13 patients required further surgery because of early postoperative complications or restricture at the strictureplasty site.

CONCLUSION

Strictureplasty for duodenal Crohn's disease is associated with a high incidence of postoperative complications and restricture.

Controversies in Crohn's disease

Despite recent advances in the medical therapy of Crohn's disease, surgery continues to play a central role in the treatment of the disease. The strategy for surgical management of Crohn's disease continues to evolve. This chapter reviews many of the controversies surrounding surgical palliation of complications of Crohn's disease. Included is a discussion of indications for strictureplasty in treatment of intractable intestinal obstruction. Factors influencing long-term outcome with sphincter-saving resection in the treatment of Crohn's colitis are reviewed. Experience with definitive treatment of anal Crohn's disease and repair of rectovaginal fistulas is examined. Finally, recent experience supporting ileocolic resection when acute Crohn's ileitis is identified during laparotomy for right lower quadrant pain is critically evaluated. These controversial aspects of the surgical treatment of Crohn's disease reflect an improved understanding of the natural history of the disease as well as refinement in surgical techniques and better definition of criteria for surgical intervention.

Reoperative rates for Crohn's disease following strictureplasty. Long-term analysis

BACKGROUND

In Crohn's disease, ten-year reoperative recurrence rates after resection range from 30 to 53 percent. To determine the effect of strictureplasty on reoperative "recurrence" rates, experience at a single tertiary care institution was reviewed.

PATIENTS AND MATERIALS

Records of all patients who underwent strictureplasty for Crohn's disease from June 1984 to July 1994 at a tertiary care institution were reviewed. Data collected included duration of disease, medical and surgical history related to Crohn's disease, indications for strictureplasty, and longterm outcome.

RESULTS

One hundred sixty-two patients (87 male) underwent 191 operations for a total of 698 strictureplasties (Heineke-Mikulicz, 617; Finney's, 81). Mean number of strictureplasties was three, and mean patient age was 36 years. No mortality occurred. Cumulative five-year incidence of reoperative recurrence was 28 percent (95 percent confidence interval, 18.8-37.2 percent), with a median follow-up of 42 (range, 1-120) months. Obstructive symptoms were relieved in 98 percent of patients. To determine whether any difference in reoperative rates exists between patients who have strictureplasty alone and those who have strictureplasty with bowel resection, we divided patients in two groups, those receiving strictureplasty alone and those undergoing stricutreplasty plus resection. For patients treated by strictureplasty alone (Group A, n = 52; 32 percent), cumulative reoperative rate at five years was 31 +/- 9.6 (+/-standard error) and for patients with concomitant bowel resection (Group B, n = 110; 68 percent), it was 27.2 +/- 5.4 (+/-standard error). No statistical difference was present between these two groups. Of patients undergoing strictureplasty alone (Group A), operative recurrence was managed by new stricutreplasty in seven, by restricutreplasty in two, and by bowel resection in one. Among patients in Group B (strictureplasty and concomitant bowel resection), new strictureplasty was performed in 11, restrictureplasty in 6, and bowel resection in 9.

CONCLUSION

Strictureplasty is a safe and effective procedure for Crohn's disease in selected patients. Reoperative rates are comparable with resective surgery, and most recurrences occur at new sites.

Adenocarcinoma arising from a strictureplasty site in Crohn's disease. Report of a case

The occurrence of small-bowel cancer in Crohn's disease (CD) is a rare event. The risk seems to be greatest in patients with long-standing disease. Strictureplasty has proved to be a valuable alternative in the management of Crohn's strictures of the small-bowel. Critics and proponents of strictureplasty for selected patients with small-bowel Crohn's disease have voiced their concerns about cancer risk in the strictured or strictureplasty site. To date, there has been no clear or detailed report of such an occurrence. The authors report the first case of small-bowel adenocarcinoma arising at the site of a previous strictureplasty. In this patient, biopsies of the strictures at the original operation confirmed CD and excluded both cancer and dysplasia. Malignancy occurred seven years later at a strictureplasty site. The main clinical sign associated with the adenocarcinoma was severe, persistent anemia. The authors conclude that the risk of adenocarcinoma developing at the site of a previous strictureplasty for CD, although small, is real.

Factors influencing recurrence in Crohn's disease. An analysis of a consecutive series of 353 patients treated with primary surgery

PURPOSE

This study was undertaken to investigate the factors that influenced the risk of symptomatic recurrence in patients with Crohn's disease who were treated with primary resective surgery.

METHODS

Data regarding age, gender, time from diagnosis to surgery, medication, preoperative infectious complications, laboratory values, emergency/elective surgery, location and extent of disease, and resection margins were analyzed in relation to recurrence in 353 patients who were undergoing a "curative" resection in 1969 to 1986.

RESULTS

Univariate analyses showed a higher risk of recurrence in women with ileal and ileocolonic disease than in men (P < 0.05), in patients with ileocolonic disease compared with those with isolated ileal disease (P < 0.05), and in ileal disease patients with an increased disease extent (P < 0.05). In a multivariate analysis performed on patients with ileal disease, increased disease extent, limited resection on the colonic side, and referral from other hospitals were three independent variables that indicated an increased risk of recurrence (P < 0.05). Length of disease-free resection margins did not influence the risk of recurrence either in univariate or in multivariate analysis (P > 0.05).

CONCLUSIONS

Disease extent has prognostic value regarding the risk of symptomatic recurrence in Crohn's disease, whereas the length of resection margins does not influence the risk of relapse. These results favor a conservative approach, particularly in patients with extensive disease.

The impact of disease pattern, surgical management, and individual surgeons on the risk for relaparotomy for recurrent Crohn's disease

OBJECTIVE

The authors provide a multivariate analysis of a large single-center experience with limited surgery for Crohn's disease.

SUMMARY BACKGROUND DATA

During the past decade, the aim of surgery for Crohn's disease has shifted from radical operation, achieving inflammation-free margins of resection, to "minimal surgery," intended to remove just grossly inflamed tissue or performing strictureplasties.

METHODS

Seven hundred ninety-three cases of resection and/or strictureplasty in 689 individuals with histologically verified Crohn's disease were followed for a mean period of 50 months (range, 5-166 months). Two different end points were analyzed: 1) any relaparotomy for recurrent (or persistent) Crohn's disease and 2) relaparotomy for site-specific recurrence. More than 30 variables of patient/disease characteristics and surgical management were included in a proportional hazard model.

RESULTS

Five parameters were associated independently with the risk for relaparotomy: increased risk coincided with young age at onset of disease, involvement of jejunum, enterocutaneous fistula, or performed strictureplasty, and decreased risk followed ileocecal resection. Site-specific risks of reoperation were calculated on the basis of 1260 intestinal resections or anastomoses performed in these patients. Young age at onset, duodenal and jejunal involvement, presence of enterocutaneous or perianal fistula, and a single surgeon (of 23) were associated significantly with increased risk of regional recurrence but not strictureplasty or inflammation at margins of resection.

CONCLUSIONS

Limited surgery for Crohn's disease is not associated with increased risk of regional recurrence requiring reoperation. However, patients with juvenile onset, proximal small bowel disease, and some types of fistulae are at a considerable risk of experiencing early surgical recurrence.

Extended strictureplasty for multiple short skipped strictures of Crohn's disease

PURPOSE

We will describe a new procedure for treatment of multiple short strictures involving a short segment of Crohn's disease.

METHODS

This procedure involves the following: 1) stay sutures at the mid portion of the two strictures; 2) an antimesenteric longitudinal enterotomy of 12 cm or more; 3) two or three interrupted transmural sutures in the four lateral portions of the two stenoses; 4) a transverse running suture, according to Heineke-Mikulicz-type strictureplasty; and 5) interrupted seromuscular sutures.

RESULTS

We performed four such "double Heineke-Mikulicz"-type strictureplasties in three patients with Crohn's disease without postoperative complications.

CONCLUSION

This type of double Heineke-Mikulicz-type strictureplasty is suitable for multiple short skipped strictures of Crohn's disease in selected patients.

Recurrence and reoperation after strictureplasty for obstructive Crohn's disease: long-term results [corrected]

Strictureplasty extends the surgical options for the treatment of obstructive Crohn's disease. Over 15 years, 52 patients had 241 strictureplasties at 76 operations with no operative mortality and with septic complications in only two patients (4 percent). Median (range) follow-up was 49.5 (1-182) months. Nineteen patients (36 percent) required a second operation for Crohn's disease between 1 and 57 months after first strictureplasty. Most symptomatic recurrence was caused by new segments of stricturing or perforating disease, and recurrence of Crohn's disease was noted at only nine strictureplasty sites (3.7 percent) in four patients. Seven patients (13 percent) required a third operation for Crohn's disease. Patients undergoing strictureplasty alone were no more likely to require reoperation than those who had a concomitant resection at the first procedure (X2 = 0.619, P > 0.2). The reoperation rates after first and second operations were similar (X2 = 0.021, P > 0.2). Minimal surgery does not appear to lead to an accelerated or additional need for subsequent operation. Strictureplasty provides a safe, effective and rapid procedure to restore patients to good health while preserving the intestine and may be recommended for carefully selected strictures as an adjunct to conventional excisional surgical treatment.

Surgical treatment of inflammatory bowel disease

Surgery continues to play an important role in the overall treatment strategy for patients with Crohn's disease and ulcerative colitis. Innovative techniques have greatly facilitated the operative approach in patients with both disorders.

Strictureplasty without concomitant resection for small bowel obstruction in Crohn's disease

The efficacy of strictureplasty in the treatment of Crohn's disease is often attributed in part to concomitant resection of strictured small bowel segments. Fifty-four patients with obstructive Crohn's disease who underwent 215 strictureplasty procedures (Heineke-Mikulicz, 179; Finney, 36) without concomitant resection of small bowel were reviewed. The median age was 38 (range 18-66) years and the median follow-up 3 (range 1-7) years. The mean number of strictureplasties per patient was 4 (range 1-13). Twenty-four patients had undergone at least one previous small bowel resection. There was no operative death. Intra-abdominal abscess and enterocutaneous fistula occurred in two patients each and reoperation for sepsis was needed in one. At 1 year after surgery the median weight gain was 4 kg; all but two patients had relief of obstructive symptoms and 26 of 37 were weaned off steroids. Symptomatic recurrence occurred in 14 patients and seven required reoperation. Rates of recurrent stricture and of new stricture or perforative disease were 2.3 per cent of strictureplasty sites and 26 per cent of patients respectively.

Diffuse jejunoileitis of Crohn's disease

Diffuse jejunoileitis is an uncommon, but important manifestation of Crohn's disease because of the associated high morbidity and challenges in medical management. Despite this there have been no studies of prognosis or management of diffuse jejunoileitis for nearly 20 years. This study analysed the outcome among 34 patients (20 women and 14 men) with diffuse jejunoileitis diagnosed between 1960 and 1991 including clinical features, medical and surgical management, death rates, current status, and prognosis. Diffuse jejunoileitis presents in younger patients (mean age at diagnosis 26.4 years) than those with distal ileal Crohn's disease (mean age at diagnosis 33.3 years). Nearly all presented with clear cut abdominal symptoms including a combination of colicky abdominal pain (91%), weight loss (62%), and diarrhoea (53%). Most patients had severe symptoms reflected by the fact that 77% had been treated with corticosteroids for periods of more than six months at some stage during their follow up. The mean follow up from diagnosis was 16 years. Twenty eight patients (82%) had at least one operation for diffuse jejunoileitis and two thirds of the patients (n = 21) required two or more operations. The frequency of surgical intervention was particularly high in the younger patients (r = 0.71, p < 0.001). The proportion of patients requiring surgery was highest in the first year after diagnosis. The annual operative rate was 15% for the first 10 years and then it fell to 5.2% in years 11-15, and 2.6% in years 16-20. The data suggest that the disease does burn itself out over time. The increasing use of strictureplasty for short strictures and the minimal use of resection has eliminated problems associated with the short small bowel syndrome. The longterm prognosis of this patients is good. Only two patients died (one of perforation of the jejunum and another of an unrelated bronchogenic carcinoma). After a mean interval from diagnosis of 16 year, 24 of 32 living patients are well and symptom free. Only eight have abdominal symptoms of whom three are receiving corticosteroid treatment and one azathioprine. The combination of anti-inflammatory drugs with the relief of recurrent obstructive symptoms by strictureplasty can together produce a good longterm prognosis in most patients with diffuse jejunoileitis.

Long-term follow-up of strictureplasty in Crohn's disease

Because Crohn's disease of the small bowel is often diffuse, strictureplasty has been advocated as an alternative or adjunct to resection(s) of strictured segments. We reviewed 116 patients with obstructive Crohn's disease undergoing 452 primary strictureplasties (Heineke-Mikulicz, 405; Finney, 47). The median age was 34 years (range, 13-72 years); the male-to-female ratio 1.4:1; and the median follow-up was three years (range, six months to seven years). Seventy-six patients (66 percent) had at least one previous small bowel resection. Perforative disease was present in 18 patients (15 percent), and synchronous resections were performed in 71 patients (61 percent). The median number of strictureplasties was three (range, 1-15). There was no mortality. Septic complications (intra-abdominal abscess/fistula) occurred in seven patients (6 percent), and reoperation for sepsis was needed in two patients. Relief of obstructive symptoms was achieved in 99 percent of the patients. After surgery, the median weight gain was 4 kg, and two-thirds of the patients were weaned off steroids. Symptomatic recurrence occurred in 28 patients (24 percent), and 17 patients (15 percent) needed reoperation. Rates of restricture and new stricture/perforative disease were 2.8 percent and 24 percent, respectively.

Stapled strictureplasty for Crohn's disease

Stapled strictureplasty has been performed on 26 occasions in 22 patients. In contrast with sutured strictureplasty, there were no major postoperative complications. The use of staples provides a method of identifying whether recurrence is at the strictureplasty site. Stapled strictureplasty avoids an enterotomy through recurrent disease and may have advantages over conventional sutured strictureplasty.