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

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

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.

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.

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.

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.

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.

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 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.