Strictureplasty for ileocolic 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.

Endoscopic stricturotomy versus ileocolonic resection in the treatment of ileocolonic anastomotic strictures in Crohn's disease

BACKGROUND AND AIMS

Endoscopic stricturotomy (ESt) is a novel technique in the treatment of anastomotic strictures in Crohn's disease (CD). The aim of this study was to compare the outcome of patients with ileocolonic anastomotic stricture treated with ESt versus ileocolonic resection (ICR).

METHODS

This historical cohort study included consecutive CD patients with ileocolonic anastomotic stricture treated with ESt or ICR from 2010 to 2017. The primary outcomes were surgery-free survival and postprocedural adverse events.

RESULTS

Thirty-five patients treated with ESt and 147 patients treated with ICR were analyzed. Median follow-up was .8 years (interquartile range [IQR], .2-1.7) and 2.2 years (IQR, 1.2-4.4) in the ESt and ICR groups, respectively (P < .001). Subsequent stricture-related surgery was needed in 4 patients (11.3%) receiving ESt and in 15 patients (10.2%) receiving ICR (P = .83). Kaplan-Meier analysis also showed no statistical difference regarding surgery-free survival between the 2 groups (P = .24). Procedure-related major adverse events were documented in 5 of 49 patients (10.2% per procedure) undergoing ESt and 47 patients (31.9%) undergoing ICR (P = .003). Risk factors for decreased surgery-free survival on multivariate analysis included preprocedural corticosteroids (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.0-8.1), multiple strictures (HR, 4.9; 95% CI, 1.7-14.2), and increased disease-related hospitalizations (HR, 4.0; 95% CI, 1.2-13.0).

CONCLUSIONS

With the limitation of a shorter follow-up, ESt achieved comparable surgery-free survival with a decreased morbidity when compared with ICR.

Strictureplasty in Complex Crohn's Disease: Beyond the Basics

The strictureplasty operation was originally adopted for use in selected patients with Crohn's disease to allow for bowel conservation. The procedure and its usage have evolved over time as experience and confidence with the technique has grown. The short- and long-term outcomes of strictureplasty compared with resection attest to its safety and durable efficacy.

Endoscopic Stricturotomy Versus Balloon Dilation in the Treatment of Anastomotic Strictures in Crohn's Disease

BACKGROUND

Current treatment modalities for anastomotic stricture in Crohn's disease (CD) include endoscopic balloon dilation (EBD) and surgery. We recently published a case series of inflammatory bowel disease patients treated with the novel endoscopic stricturotomy (ES). The aim of this case-control study was to compare the efficacy and safety of ES versus conventional EBD in the treatment of anastomotic strictures in CD patients.

METHODS

All eligible patients with CD anastomotic stricture who were treated with ES or EBD were included. The primary outcomes were surgery-free survival and post-procedural complications.

RESULTS

A total of 185 patients were studied, including 21 treated with ES since 2009, and 164 treated with EBD since 1998. The immediate technical success after therapy was achieved in 100% of patients treated with ES and 89.5% of patients with EBD. Symptomatic and endoscopic improvement rates were higher in those treated with ES than EBD. Subsequent surgery was needed in 2 (9.5%) patients with ES and 55 (33.5%) with EBD (P = 0.03), during a median of 0.8 (interquartile range [IQR]:0.1-1.6) year and 4.0 (IQR: 0.8-6.9) years, respectively. Five procedure-associated perforation (1.1% per procedure) occurred in the EBD group and none in the ES group. In contrast, 4 procedure-associated, transfusion-required bleeding (8.8% per procedure) occurred in the ES group and none in the EBD group.

CONCLUSIONS

ES appears to be more effective in treating CD patients with anastomotic stricture than EBD. Although ES may have a lower risk for perforation, the procedure needs to be perfected to reduce its bleeding risk.

Endoscopic Stricturotomy with Needle Knife in the Treatment of Strictures from Inflammatory Bowel Disease

BACKGROUND

Fibrotic strictures in patients with inflammatory bowel disease (IBD) are often not amenable to medical therapy. Therapy with endoscopic balloon dilation usually requires frequent repeat treatments. Therefore, we developed the novel needle knife stricturotomy (NKSt) for the treatment of strictures in the patients with IBD. The aim of this study was to evaluate the efficacy and safety of NKSt.

METHODS

Data of patients with strictures treated with NKSt in our Interventional IBD Unit at the Cleveland Clinic were extracted from the registry. The primary and secondary outcomes were surgery-free survival and procedure-related complications.

RESULTS

A total of 85 patients were included in this study. Multiple strictures were noticed in 30 (35.3%) patients at inception, giving a total of 127 strictures treated. The median length of the treated strictures was 1.5 cm (interquartile range: 1.0-2.0) and 52 (41.6%) were endoscopically nontraversable. The immediate success with passage of the scope through the stricture after NKSt therapy was achieved in all patients. During the median follow-up of 0.9 years (interquartile range: 0.3-1.8) and a median of 2.0 treatment (interquartile range: 1.0-3.0), 13 (15.3%) patients required stricture-related surgery. There were 77 (60.6%) patients who required additional NKSt, endoscopic balloon dilation, or both after the inception of NKSt. In a total of 272 NKSt procedures performed, 10 (3.7%) adverse events occurred, including 9 with delayed bleeding and one hospitalization due to perforation.

CONCLUSIONS

Endoscopic NKSt is effective and safe for treating the primary and secondary IBD-related strictures, which may provide an alternative for endoscopic balloon dilation and surgical intervention.

A comprehensive review of strictureplasty techniques in Crohn's disease: types, indications, comparisons, and safety

INTRODUCTION

Crohn's disease is one of the chronic inflammatory diseases of the gastrointestinal tract that is often complicated by stricture formation with resulting obstructive symptoms. The technical repertoire of strictureplasty procedures has increased over the years in an effort to manage the diverse presentations of this condition while limiting the need for bowel resection. In this comprehensive review, we describe, compare, categorize, and appraise the strengths and weaknesses of 15 unique strictureplasty techniques.

METHODS

To identify all unique strictureplasty procedures, a Medline search utilizing "Crohn's disease," "surgical therapy," "strictureplasty," "enteroenterostomy," "Heineke-Mikulicz," and "side-to-side isoperistaltic" strictureplasty as medical subject headings was completed. PubMed, Ovid, Embase, and Cochrane database searches were conducted. Relevant articles between 1980 to December 2010 were reviewed. We initially selected 58 articles, but only 18 introduced novel surgical procedures related to 15 types of strictureplasty in Crohn's disease.

RESULTS

We identified 15 types of strictureplasty techniques. These were categorized into three main groups. The revised nomenclature will facilitate the reader to understand the differences and utility of each technique. These groups include the Heineke-Mikulicz-like strictureplasties, the intermediate procedures, and the enteroenterostomies. Heineke-Mikulicz strictureplasty was the most frequently used technique.

CONCLUSION

Various techniques of strictureplasty have been reported in the published literature. Strictureplasty has been shown to be a safe and efficacious technique that is comparable to bowel resection for stricturing Crohn's disease. This technique spares bowel length and puts the Crohn's disease patient at a lower risk of developing short bowel syndrome with repeated resections.

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.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

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.

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.

Operative management of small bowel Crohn's disease

Despite advances in medical treatment, most patients who have Crohn's disease of the small intestine need surgery at some point during the course of their disease. Surgery is currently indicated for intractable disease and complications of the disease (strictures, abscesses, fistulas, hemorrhage). There is increasing interest in nonsurgical and minimal access strategies of dealing with complicated disease, however. These new approaches may enable postponement of surgery to a more favorable time, or conversion of a two-stage procedure involving a stoma to a one-stage resection with anastomosis. A continuing challenge is prevention of disease recurrence postoperatively.

Endoscopic balloon dilatation of intestinal strictures in Crohn's disease: safe alternative to surgery

BACKGROUND AND AIM

Endoscopic balloon dilatation (EBD), a non-surgical treatment option for intestinal strictures in Crohn's disease, appears to be applied infrequently, possibly due to the perceived risk of perforation and early recurrence. This study aimed to determine the outcomes of EBD by a single endoscopist using a defined technique.

METHODS

The records of all patients with Crohn's disease in whom EBD was attempted over a 12-year period were examined to determine the rate of technical success, complications and outcome. A stricture was defined as that which prevented passage of the 14 mm diameter colonoscope. Technical success was defined as the ability to traverse the stricture postdilatation. Patients were selected on the colonoscopic appearance of the stricture and dilatation was performed using through-the-endoscope balloons. Antibiotics were given during and for 7 days postdilatation.

RESULTS

EBD was attempted on 83 strictures (31 anastomotic and 52 primary) in 37 patients (15 males) and was successful in 75 (90%) of 31 patients. A single dilatation only was required in 21 patients who had a median follow-up of 20 months (range 6-122 months). Recurrent symptomatic stricture requiring dilatation (eight patients) or surgery (two patients) occurred 8 (1-112) months after the initial dilatation. The only complication occurred in one patient where an intra-abdominal fistula and abscess were probably related to the dilatation.

CONCLUSION

EBD of intestinal strictures associated with Crohn's disease has a low complication rate and leads to prolonged clinical benefit. It should be considered as a real alternative to surgery.

Intervention-free Interval following Strictureplasty for Crohn’s Disease

INTRODUCTION

Strictureplasty is now well established as a bowel-sparing alternative for surgical treatment of complicated Crohn's disease. Limited resection is still preferred in patients with uncomplicated disease, as subsequent reoperation rates are low.

METHODS

A retrospective review of 26 patients who underwent surgery for small bowel Crohn's disease between 1996 and 2004 was undertaken. A total of 96 small bowel strictureplasties had been performed; 19 patients had strictureplasties performed in isolation, and the remaining 7 patients underwent strictureplasty with concomitant limited resection.

RESULTS

There was no operative mortality. The median follow-up was 41 months. Four patients developed complications that required further surgery. At 41 months, 73.3% of patients undergoing strictureplasty alone and 79.7% undergoing strictureplasty with concomitant resection were intervention-free. If followed up to 70 months or more, the same proportion of patients would remain intervention-free. Four patients developed further recrudescent disease and required surgery: strictureplasty, limited resection, or both. Of these patients, 25% were intervention-free at 41 months.

CONCLUSIONS

Our results show that strictureplasty alone or with concomitant resection can confer intervention-free periods of 41 months or more in 73.3% of patients, suggesting that strictureplasty can be utilized as an alternative to limited resection in uncomplicated Crohn's disease.

Strictureplasty

BACKGROUND

Advances in the use of bowel-sparing surgery for Crohn's disease have led to the development of strictureplasty as an important technique to conserve small bowel length and reduce morbidity associated with malabsorption.

METHODS

A literature review of long-term studies on strictureplasty was undertaken, and evidence of its safety and efficacy was evaluated.

RESULTS

The safety and efficacy of strictureplasty is confirmed in retrospective studies carried out over a period of 5-10 years, particularly when employed in patients at risk of short bowel syndrome, but certain questions regarding bowel function and disease activity after surgery remain unanswered. There is also concern that diseased tissue is left in situ after strictureplasty; this tissue has the potential for malignant transformation in the long term.

CONCLUSION

Strictureplasty has been used in surgery for Crohn's disease for the past 25 years. Studies have proven its efficacy in the treatment of carefully selected patients at risk of malabsorption owing to short bowel syndrome.

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.

Hydrostatic balloon dilatation of Crohn's strictures

AIM

To evaluate the safety and long-term efficacy of per-endoscopic hydrostatic balloon dilatation in a retrospective series of patients with Crohn's disease.

METHODS

Thirty-eight patients had balloon dilatation for intestinal symptomatic strictures which were located as follows: ileo-colonic (26) or colocolic (2) anastomosis, colon (4), ileum (3), proximal jejunum (1) and ileo-caecal valve (5); three patients had two strictures accessible to dilatation. The mean length of the strictures was 2.1 cm (s.d., 0.3 cm).

RESULTS

Thirty-two of the 38 patients were successfully dilated and followed for a median of 22.8 months (0.2-103 months) until surgery or last news. The probabilities of obstructive symptom recurrence were 36% at 1 year and 60% at 5 years. Twelve patients had a second dilatation, and three a third. The probabilities of surgery for stricture were 26% at 1 year and 43% at 5 years. Results were not influenced by age, sex, activity of the disease, passage of the stricture by the colonoscope or concomitant medical therapies. Complications occurred in 9.4% of the 53 dilatation sessions, with only one perforation.

CONCLUSIONS

Hydrostatic balloon dilatation is effective for Crohn's symptomatic strictures, and can avoid or postpone surgery, with an acceptable rate of complications.

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.

Side-to-side isoperistaltic strictureplasty in extensive Crohn's disease: a prospective longitudinal study

OBJECTIVE

To report on the results of a prospective longitudinal study of a new bowel-sparing procedure (side-to-side isoperistaltic strictureplasty [SSIS]) in patients with extensive Crohn's disease.

METHODS

Between January 1992 and April 1999, the authors operated on 469 consecutive patients for Crohn's disease of the small bowel. Seventy-one patients (15.1%) underwent at least one strictureplasty; of these, 21 (4.5%; 12 men, 9 women; mean age 39) underwent an SSIS. The long-term changes occurring in the SSIS were studied radiographically, endoscopically, and histopathologically.

RESULTS

The indication for surgical intervention was symptomatic partial intestinal obstruction in each of the 21 patients. Fourteen SSISs were constructed in the jejunum, four in the ileum, and three with ileum overlapping colon. The average length of the SSIS was 24 cm. Performance of an SSIS instead of a resection resulted in preservation of an average of 17% of small bowel length. One patient suffered a postoperative gastrointestinal hemorrhage. All patients were discharged on oral feedings after a mean of 8 days. In all cases, SSIS resulted in resolution of the preoperative symptoms. With follow-up extending to 7.5 years in 20 patients (one patient died of unrelated causes), radiographic, endoscopic, and histopathologic examination of the SSIS suggests regression of previously active Crohn's disease.

CONCLUSIONS

SSIS is a safe and effective procedure in patients with extensive Crohn's disease. The authors' results provide radiographic, endoscopic, and histopathologic evidence that active Crohn's disease regresses at the site of the SSIS.

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.

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.