Ten-year experience of strictureplasty for obstructive Crohn's disease

Short- and long-term outcomes of strictureplasty for obstructive Crohn's disease

AIM

To evaluate the frequency and outcome of strictureplasty in the era of biologicals and to compare patients operated on by strictureplasty alone, resection alone or a combination of both.

METHOD

A retrospective review of all patients undergoing strictureplasty for obstructing jejunoileal Crohn's disease (CD) in Oxford between 2004 and 2016 was conducted. For comparison, a cohort of CD patients with resection only during 2009 and 2010 was included.

RESULTS

In all, 225 strictureplasties were performed during 85 operations, 37 of them in isolation and 48 with simultaneous resection. Another 82 procedures involved resection only; these patients had shorter disease duration, fewer previous operations and longer bowel preoperatively. The frequency of strictureplasty procedures did not alter during the study period and was similar to that in the preceding 25 years. There was no postoperative mortality. One patient required re-laparotomy for a leak after strictureplasty. None developed cancer. The 5-year reoperation rate for recurrent obstruction was 22% (95% CI 12-39) for resection alone, 30% (17-52) for strictureplasty alone and 42% (27-61) for strictureplasty and resection (log rank P = 0.038). Young age was a risk factor for surgical recurrence (log rank P = 0.006).

CONCLUSION

The use of strictureplasty in CD has not changed significantly since the widespread introduction of biologicals. Surgical morbidity remains low. The risk of recurrent strictures is high and young age is a risk factor. In this study, strictureplasty alone was associated with a lower rate of reoperation compared with strictureplasty with resection.

Postoperative recurrent luminal Crohn's disease: a systematic review

Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.

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.

Prospective study of long-term results and prognostic factors after conservative surgery for small bowel Crohn's disease

BACKGROUND & AIMS

Several bowel-sparing techniques have been proposed for treating patients with CD, but there have been no prospective studies analyzing risk factors and long-term outcome. We prospectively evaluated safety and long-term efficacy of conservative surgery for patients with complicated CD.

METHODS

From 1993-2007, 393 of 502 consecutive patients underwent surgery for complicated CD of the small bowel. Those with colonic involvement were excluded. The Student t test, chi(2) test, Kaplan-Meier estimates, and Cox proportional hazard model were used to analyze postoperative complications and long-term outcome.

RESULTS

A total of 865 jejunoileal segments underwent 318 small bowel resections and 367 strictureplasties (either classic or nonconventional). There were no deaths; the complication rate was 5.6%, and the cumulative 10-year recurrence rate was 35%. None of the prognostic factors were correlated with postoperative complications. Younger age, an upper jejunoileal location, stricturing behavior, and small-bowel wall thickening 12 months after surgery showed hazard ratios of 2.4 (95% confidence interval [CI], 1-5.4; P = .03), 2.5 (95% CI, 1.3-4.7; P = .004), 2.2 (95% CI, 1.1-4.1; P = .01), and 4.5 (95% CI, 2.3-8.6; P = .000), respectively. Immunomodulator therapy failed to reduce long-term surgical recurrence.

CONCLUSIONS

Young patients with extended and stricturing disease are at high risk for disease recurrence after surgery. Bowel wall thickening was a reliable prognostic factor for these patients. Conservative surgery is safe and effective in treating patients with jejunoileal CD and should be considered as the first-line surgical treatment, preventing the risk of short bowel syndrome caused by repeated resections.

[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.

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.

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

BACKGROUND

Strictureplasty is an effective means of alleviating obstructive Crohn's disease while conserving bowel length. The aim of this study was to establish long-term outcomes of strictureplasty.

METHODS

Between 1978 and 2003, 479 strictureplasties were performed in 100 patients during 159 operations. Information on Crohn's disease, medical therapy, laboratory indices, surgical details, complication rates and outcomes was recorded. The primary endpoint was abdominal reoperation.

RESULTS

Mean follow-up was 85.1 (range 0.2-240.9) months. The overall morbidity rate was 22.6 per cent, with septic complications in 11.3 per cent, obstruction in 4.4 per cent and gastrointestinal haemorrhage in 3.8 per cent. The 30-day mortality rate was 0.6 per cent and the procedure-related series mortality rate 3.0 per cent. Perioperative parenteral nutrition was the only marker for morbidity (P < 0.001). Reoperation rates were 52 per cent at a mean of 40.2 (range 0.2-205.8) months after a first, 56 per cent at 26.1 (range 3.5-63.5) months after a second, 86 per cent at 27.4 (range 1.4-74.5) months after a third, and 62.5 per cent at 25.9 (range 7.3-70.5) months following a fourth strictureplasty procedure. The major risk factor for reoperation was young age (P < 0.001).

CONCLUSION

Long-term follow-up has confirmed the safety of strictureplasty in Crohn's disease. Morbidity is appreciable, although the surgical mortality rate is low. Reoperation rates are comparable following first and repeat strictureplasty procedures.

Factors affecting recurrence after surgery for Crohn’s disease

Although in Crohn’s disease post-operative recurrence is common, the determinants of disease recurrence remain speculative. The aim of this study was to examine factors affecting post-operative recurrence of Crohn’s disease. A Medline-based literature review was carried out. The following factors were investigated: age at onset of disease, sex, family history of Crohn’s disease, smoking, duration of Crohn’s disease before surgery, prophylactic medical treatment (corticosteroids, 5-amino salicylic acid [5-ASA] and immunosuppressants), anatomical site of involvement, indication for surgery (perforating or non-perforating disease), length of resected bowel, anast-omotic technique, presence of granuloma in the specimen, involvement of disease at the resection margin, blood transfusions and post-operative complications. Smoking significantly increases the risk of recurrence (risk is approximately twice as high), especially in women and heavy smokers. Quitting smoking reduces the post-operative recurrence rate. A number of studies have shown a higher risk when the duration of the disease before surgery was short. There were, however, different definitions of ‘short’ among the studies. Prophylactic cortic-osteroids therapy is not effective in reducing the post-operative recurrence. A number of randomized controlled trials offered evidence of the efficacy of 5-ASA (mesalazine) in reducing post-operative recurrence. Recently, the thera-peutic efficacy of immunosuppressive drugs (azathioprine and 6-mercaptopurine) in the prevention of post-operative recurrence has been investigated and several studies have reported that these drugs might help prevent the recurrence. Further clinical trials would be necessary to evaluate the prophylactic efficacy of immunosuppressants. Several studies showed a higher recurrence rate in patients with perforating disease than in those with non-perforating disease. However, evidence for differing recurrence rates in perforating and non-perforating diseases is inconclusive. A number of retrospective studies reported that a stapled functional end-to-end anastomosis was associated with a lower recurrence rate compared with other types of anastomosis. However, prospective randomized studies would be necessary to draw a definite conclusion. Many studies found no difference in the recurrence rates between patients with radical resection and non-radical resection. Therefore, minimal surgery including strictureplasty has been justified in the management of Crohn’s disease. In this review, the following factors do not seem to be predictive of post-operative recurrence: age at onset of disease, sex, family history of Crohn’s disease, anatomical site of disease, length of resected bowel, presence of granuloma in the specimen, blood transfusions and post-operative complications. The most significant factor affecting post-operative recurrence of Crohn’s disease is smoking. Smoking significantly increases the risk of recurrence. A short disease duration before surgery seems, albeit to a very minor degree, to be associated with a higher recurrence rate. 5-ASA has been shown with some degree of confidence to lead to a lower recurrence rate. The prophylactic efficacy of immunosuppressive drugs should be assessed in future. A wider anastomotic technique after resection may reduce the post-operative recurrence rate, though this should be investigated with prospective randomized controlled trials.

Postoperative change of mucosal inflammation at strictureplasty segment in Crohn's disease: cytokine production and endoscopic and histologic findings

PURPOSE

This study was designed to examine postoperative change of mucosal inflammation at strictureplasty segment in Crohn's disease mainly by cytokine measurements.

METHODS

Patients who underwent strictureplasty for Crohn's disease in the terminal ileum were investigated. Mucosal samples at the strictureplasty site were obtained during operation. At 3, 6, and 12 months after operation, biopsy specimens were taken from the strictureplasty site and macroscopically normal ileum at endoscopy. Mucosal cytokine concentrations were measured by enzyme-linked immunosorbent assay.

RESULTS

The mucosal concentrations of proinflammatory cytokines (interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha) and anti-inflammatory mediator (interleukin-1 receptor antagonist) at the strictureplasty segment greatly increased at the time of operation. Interleukin-1beta, interleukin-1 receptor antagonist, interleukin-6, interleukin-8, and tumor necrosis factor-alpha concentrations at the strictureplasty segment decreased during a 12-month period after operation. Twelve months after operation there was no significant difference in each cytokine concentration between the strictureplasty and macroscopically normal segments. The mucosal interleukin-1 receptor antagonist/interleukin-1beta ratio at the strictureplasty segment increased during a 12-month period after operation. Twelve months after operation there was no significant difference in the ratio between the strictureplasty and macroscopically normal segments. The endoscopic and histologic severities of mucosal inflammation at the strictureplasty site also decreased; however, their findings were not normalized during the study.

CONCLUSIONS

During one year after strictureplasty for Crohn's disease, cytokine production at the strictureplasty segment was decreased to the level of the macroscopically normal ileum and an imbalance between proinflammatory and antiinflammatory cytokines was corrected.

A prospective, longitudinal study of nonconventional strictureplasty in Crohn’s disease1 1No competing interests declared

BACKGROUND

Bowel-sparing techniques have been proposed to avoid extended or repeated resections in patients with Crohn'rsquo;s disease (CD), but without precise indications, prospective evaluation, and with a technically limited repertoire.

STUDY DESIGN

A prospective longitudinal study of new nonconventional strictureplasties (NCSP) in order to evaluate the safety, type and site of recurrence, and longterm clinical and surgical efficacy.

RESULTS

Between January 1993 and December 2002, 102 among 305 consecutive patients underwent at least one NCSP for complicated CD. Patients were treated following precise indications and then included in a prospective database with scheduled followup. Factors claimed to influence postoperative and longterm outcomes and type and site of recurrence were analyzed. We performed 48 ileoileal side-to-side isoperistaltic strictureplasty (SP), 41 widening ileocolic SP, 32 ileocolic side-to-side isoperistaltic SP, associated with Heineke-Mikulicz SP (in 80 procedures) or with minimal bowel resections or both (in 47 procedures). Postoperative mortality was nil; complication rate was 5.7%. Ten years clinical and surgical recurrence rates were 43% and 27%, respectively. Recurrence rate on an NCSP site was 0.8%. No specific factor was identified as related to postoperative or longterm outcomes.

CONCLUSIONS

Perioperative and longterm results of NCSP are comparable to or even better than both conservative and resective surgery as reported in the literature, with a low recurrence rate on the NCSP site. Considering the unpredictability of the clinical course of CD and the lifetime need for surgical procedures, NCSP, together with minimal resection and classic SP repertoire, should be considered first-line treatment in complicated CD.

[The role of strictureplasty in the treatment of Crohn's disease]

Crohn's disease is pandigestive disease of unknown aethiology, with tendency to reccurrences. Until now it is impossible to heal this disease either by medical or surgical treatment. All unfavourable consequences of this disease are result of inadequate treatment of complications which are leading to systemic weakening, with further progression of morbid process. Therefore, the principle of timely and minimal invasive surgical procedure has been generally adopted. Introduced in eighties, strictureplasty is a procedure of such characteristics. During the period 1980-2001 this method was used in 1/3 of 126 patients with Crohn's disease. There were 79 strictureplaties performed, 9 long and 70 short. Out of these 42, 12(28.6%) were postoperative recurrences, and there was one case of duodenal strictureplatsty. Postoperative small bowel fistulae were not observed, and there was no mortality in this group. During the follow up period of at least 5 years, in only two cases (4.76%) some functional disturbances of digestive functions were observed, without indications for reoperation. In this article indications and details of operative technique are discussed.

Defining small bowel strictures

BACKGROUND

Strictures of the intestine can be difficult to detect despite current radiological techniques.

AIM

To review our experience with a new Foley catheter technique.

METHOD

Three cases are reviewed in which a Foley catheter was used to identify a fibrous stricture.

RESULTS

A Foley catheter with an inflated 10ml balloon inserted through an enterotomy successfully identified the site of stricture in three cases of fibrous stricture obstruction.

CONCLUSION

A Foley catheter inserted through an enterotomy is a useful method of identifying fibrous strictures.

Mechanisms of intestinal failure in Crohn's disease

PURPOSE

The purpose of this study was to determine the mechanisms by which patients with Crohn's disease develop intestinal failure and, in particular, to assess the relative importance of severe primary disease, repeated uncomplicated elective small intestine resection, and resection performed as a consequence of intra-abdominal septic surgical complications.

METHODS

This was a retrospective analysis of 41 patients with Crohn's disease referred to a specialized intestinal failure unit between January 1987 and September 1998 for permanent home parenteral nutrition. To compare the surgical activity in patient groups, a resection index was calculated by dividing the number of intestinal resections by the interval in years between the first resection for Crohn's disease and referral for management of intestinal failure.

RESULTS

Extensive primary Crohn's disease was responsible for intestinal failure in 7 cases (17 percent). The remainder (n = 34, 83 percent) developed intestinal failure after intestinal resection. Nine of the "surgical" Crohn's patients developed intestinal failure after uncomplicated sequential resection, (median small-bowel length 65 (range, 60-120) cm) after a median of 3 (range, 2-8) operations over a median of 17 (range, 3-27) years. By contrast, the other 25 surgical Crohn's patients developed intestinal failure after multiple unplanned laparotomies for intra-abdominal sepsis (median small-bowel length 70 (range, 60-200) cm), with a median of 4 (range, 2-7) laparotomies performed over a median of 0.5 (range, 0.1 to 1.5) years (P < 0.001). The resection index for the 25 Crohn's patients undergoing laparotomies for intra-abdominal sepsis was significantly greater than that of the 9 patients who had planned sequential resections (2.1 (0.27-25) vs. 0.23 (0.1-1.0); P < 0.002, Mann-Whitney U test).

CONCLUSION

Intestinal failure develops in Crohn's disease primarily as a result of complications of surgical treatment. The largest group of patients at risk consists of those who are undergoing multiple unplanned laparotomies to control intra-abdominal sepsis.

Simple technique for the intraoperative detection of Crohn's strictures with a calibration sphere

Several methods have been used to detect and evaluate small-bowel strictures in Crohn's disease. We describe a simple technique for the calibration of strictures using a 2.5-cm medical plastic sphere. This method provides an aseptic, safe, and effective calibration of the entire small bowel.

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").

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.

Strictureplasty is an effective option in the operative management of duodenal Crohn's disease

INTRODUCTION

Duodenal Crohn's disease requiring surgery has traditionally been managed with a bypass procedure. We compared our experience with duodenal strictureplasty with this traditional approach.

METHODS

Records of patients operated on for duodenal Crohn's disease since 1980 were retrospectively reviewed. Patients having strictureplasty or bypass were compared with regard to demographics, indications, complications, and outcome.

RESULTS

Since 1980, 34 patients were operated on for duodenal Crohn's disease. Mean age was 38.9 (range, 16-68) years, and 20 of 34 patients were females, with no significant differences between operative groups. Obstruction was the presenting symptom in 33 of 34 patients, and all had strictures. The basis for diagnosis of duodenal Crohn's disease was macroscopic appearance and the presence of Crohn's elsewhere in 29 of 34 patients, with only 5 of 34 having either duodenal or contiguous antral granulomas. Thirty-seven strictures were present in the 34 patients; 24 were in the proximal duodenum (8 strictureplasty, 16 bypass), 9 were in the midduodenum (4 strictureplasty, 5 bypass), and 4 were in the distal duodenum (3 strictureplasty, 1 bypass). Bypass was performed in 21 patients, with two operative complications, and at a mean follow-up of 8 years, 1 of 21 patients required reoperation for recurrent disease. Strictureplasty was performed in 13 patients, with two operative complication, and at a mean follow-up of 3.6 years, 1 patient required reoperation for recurrence also. Vagotomy was performed in 16 of 21 bypasses and 7 of 13 strictureplasties.

CONCLUSIONS

Although follow-up is shorter, strictureplasty is a safe and effective operation for duodenal Crohn's disease and should be considered when feasible.

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.

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.

Laparoscopically assisted ileocecal resection for Crohn's disease associated with intestinal stenosis and ileovesical fistula

We describe a 22-year-old man with Crohn's ileocolitis accompanied by intestinal stenosis and ileovesical fistula in whom laparoscopically-assisted surgery was successfully performed after thorough nutritional therapy. Laparoscopic procedures are characterized by minimal access and minimal invasion, features which can contribute to the early recovery of patients who undergo surgery. It is suggested that laparoscopic (or laparoscopically-assisted) surgery after strict nutritional therapy can be effective in the treatment of patients with Crohn's disease who have intestinal complications.

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.

How safe is strictureplasty in the management of Crohn's disease?

BACKGROUND

Strictureplasty is a well-accepted technique in the management of selected patients with Crohn's disease. To determine the safety and optimal clinical setting for performing strictureplasty, perioperative complications and long-term outcomes need to be analyzed.

PATIENTS AND MATERIALS

We retrospectively reviewed the charts of 162 patients (87 men, 75 women) with Crohn's disease who underwent strictureplasty between June 1984 and July 1994. Medical and surgical history, including medications and laboratory data, intraoperative findings, perioperative complications, and long-term follow-up data were recorded.

RESULTS

These patients underwent 698 strictureplasties (Heineke-Mikulicz procedures, 617; Finney procedures, 81). Median hospital stay was 8 days. Perioperative septic complications were noted in 8 patients (5%); however, reoperation for sepsis was needed only in 5 patients. Five percent of patients developed prolonged ileus after strictureplasty. Symptomatic improvement after strictureplasty was achieved in 98% of patients. Restricture or new stricture or perforative disease was seen in 5% and 17% of patients, respectively, during a 42-month median follow-up period.

CONCLUSIONS

Our findings show that strictureplasty is a good surgical option for stenosing small-bowel Crohn's disease, particularly in patients with multiple obstruction and in those vulnerable to short-bowel syndrome. Perioperative complications are few, and long-term results are gratifying.

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.

Endoscopic balloon dilatation of duodenal strictures in Crohn's disease

Endoscopic balloon dilatation of oesophageal and colonic strictures is now widely performed. Duodenal strictures due to Crohn's disease represent a difficult clinical problem as surgical intervention is a major undertaking and recurrences are common. We describe endoscopic balloon dilatation in three patients with obstructive symptoms from duodenal strictures due to Crohn's disease. The procedure appeared safe, was well tolerated and resulted in an excellent symptomatic response. This method is particularly suitable for short duodenal strictures and avoids the need for surgical intervention in this difficult group of patients.

Management of gastrointestinal bleeding after strictureplasty for Crohn's disease

PURPOSE

To determine the incidence, clinical features, and optimal management of poststrictureplasty hemorrhage in Crohn's disease.

METHODS

Retrospective analysis of 139 patients with Crohn's disease seen at the Cleveland Clinic who underwent a total of 523 strictureplasties between June 1984 and June 1992.

RESULTS

Poststrictureplasty hemorrhage occurred in 13 patients (9.3 percent). Average drop in hemoglobin and hematocrit in these patients was 5.8 g/dl and 0.174, respectively. All patients were managed nonoperatively. Mean follow-up was 29.6 (range, 7-62) months.

CONCLUSION

Strictureplasty in Crohn's disease is a safe procedure in selected patients. Poststrictureplasty hemorrhage is uncommon; however it can be managed nonoperatively in most cases. An algorithm for management of such patients is presented.

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.

Strictureplasty for obstructive Crohn's disease: the Mayo experience

BACKGROUND

Strictureplasty for obstructive Crohn's disease of the small bowel continues to gain favor throughout the world. Although the potential advantages of preserving intestinal length are obvious, the optimal clinical setting for performing strictureplasty remains to be determined.

PATIENTS

Of 244 patients who underwent abdominal exploration for complications of Crohn's disease between Jan. 1, 1985, and Jan. 1, 1991, at the Mayo Clinic, 35 had a total of 71 strictureplasties. Concomitant resection of bowel with active disease was performed in 67% of the procedures.

RESULTS

In this series, no perioperative deaths occurred, and no anastomotic leaks, enteric fistulas, or intra-abdominal abscesses were noted during a 3-year follow-up. The overall perioperative complication rate was 14%. Postoperatively, 33 of the 35 patients were able to resume enteral nutrition and discontinue medical treatments. The symptomatic recurrence rate at 3 years was 20%; six patients have required reoperation.

CONCLUSION

These findings support the use of strictureplasty for isolated, quiescent, stenotic bowel lesions associated with Crohn's disease.

Strictureplasty for ileocolic anastomotic strictures in Crohn's disease

PURPOSE

Because of the limited experience, the use of strictureplasty for a strictured ileocolic anastomosis associated with Crohn's disease was reviewed.

METHODS

We reviewed 22 patients who had a strictureplasty to treat symptomatic ileocolic anastomotic strictures related to Crohn's disease. The median interval between a previous ileocolic anastomosis and strictureplasty was 2 years (range, 1 to 26 years). The median age was 39 years and there were 15 males and 7 females. The median follow-up was 2 years.

RESULTS

Strictureplasty on a strictured ileocolic anastomosis was either a Heineke-Mikulicz (n = 15) or a Finney (n = 7) strictureplasty. Fifteen (68 percent) patients needed 47 additional strictureplasties in other sites of the small bowel and 5 (23 percent) patients had synchronous small bowel resection mainly for separate areas of phlegmonous disease. Only five (23 percent) patients did not have a synchronous procedure on the small bowel. There was no mortality or major septic complications. After surgery, relief of obstructive symptoms was noted in all patients. The median weight gain at six months after surgery was 3 kg (range, -5 to +10 kg) and 75 percent of the patients were weaned off steroids. Symptomatic "recurrence" occurred in two (9 percent) patients from new strictures at sites unrelated to previous strictureplasties; only one needed reoperation for recurrence. Patency of the strictureplasty on ileocolic anastomosis in asymptomatic patients was confirmed by small bowel contrast study (n = 12) and colonoscopy (n = 4).

CONCLUSIONS

Strictureplasty preserves small bowel length and may be a viable alternative to repeat ileocolic resection in suitable cases.

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.

Pseudotumoral appearance of small bowel strictureplasty for Crohn's disease

In two patients with Crohn's disease, strictureplasties had been marked operatively by a metal clip, so that definitive location on subsequent small bowel examination was possible. Each strictureplasty presented radiologically as a short annular constriction with apparently shouldered edges and parallel lumen. Similar radiological features were found in five other patients with strictureplasties, suggesting that a pseudotumoral appearance is characteristic of strictureplasty. Attention is drawn to this finding to avoid confusion with malignancy.

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.

Results of multiple strictureplasties in diffuse Crohn's disease of the small bowel

With extensive small bowel strictures due to Crohn's disease, resectional surgery may lead to short bowel syndrome. Strictureplasty (SP) has emerged as a useful alternative for selected strictures. This study reviews the results of 42 patients with diffuse obstructive Crohn's disease of the small bowel in whom at least four SP were performed in each patient (median: 7; range: 4-15; total SP: 315). Twenty-three patients (55%) had had 1-5 previous small bowel resections. Co-existing perforative disease was present in four patients (10%). Synchronous resection of a separate segment of small bowel was performed in 22 patients (52%). There was no operative mortality. Enterocutaneous fistula and/or intra-abdominal abscess developed in three patients (7%) and only one of these needed operative intervention. The median follow-up was 3 years (range: 10 months to 7 years). After SP, all patients experienced relief from obstructive symptoms. The median weight gain was 3 kg (range: -1-21 kg) and more than half the patients were weaned off steroids. Symptomatic recurrence occurred in 10 patients (24%) and was due to strictures (N = 9) and/or perforative disease (N = 2) at new site(s) unrelated to previous SP. Rate of symptomatic restricture of the SP site was 1.6% and was associated with new strictures elsewhere in all cases. Thus, in selected cases, SP is a safe and effective treatment for diffuse Crohn's strictures.

Strictureplasty for ileo-colic anastomotic strictures in Crohn's disease

We report an audit of outcome on 24 patients (16 females) who had a strictureplasty to treat ileo-colic anastomotic strictures. All except one patient had their original resection for Crohn's disease, and required reoperation because of symptoms of recurrent intestinal obstruction for a mean 9.3 months (range 1-36); the remaining patient was discovered to have ileo-colic anastomotic stricture before he underwent laparotomy for closure of loop ileostomy. At operation, four patients needed additional small bowel strictureplasties, two of whom also underwent small bowel resection for separate areas of phlegmonous disease. There was no post-operative mortality, three patients developed wound infection and one had a pelvic abscess, which settled on antibiotic therapy. Two patients have since died of unrelated disease. Five patients have since needed reoperation for recurrence; only one had a stricture at the site of previous strictureplasty. Over a mean follow-up of 70.8 months (range 18-393) all 22 living patients now have complete relief of symptoms.

Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures resulting from Crohn's disease

Endoscopic balloon dilatation was undertaken in seven patients who presented with obstructive symptoms resulting from Crohn's disease. Five patients had strictures from recurrent disease at the site of an ileotransverse anastomosis, one had duodenal stenosis and one a colonic stricture. The procedures were performed under intravenous sedation on one to four occasions (median 2) and were uncomplicated. Sustained improvement over an 18-24-month follow-up period was achieved in five patients, but dilatation was unsuccessful in two cases. Endoscopic balloon dilatation is a safe and effective option in selected patients with intestinal strictures resulting from Crohn's disease and may overcome the need for surgery.