Description of new "bowel-sparing" techniques for long strictures of Crohn's disease

Prevalence and significance of mesentery thickening and lymph nodes enlargement in Crohn's disease

BACKGROUND

Mesentery thickening and enlarged lymphnodes are typical findings of Crohn's disease (CD), but their role is unknown. Aim of the present study was to evaluate their prevalence and significance on postoperative complications and long-term surgical recurrence after CD surgery.

METHODS

1272 consecutive, unselected patients were retrospectively reviewed, divided into 4 groups based on the presence or absence of a thickened mesentery and enlarged lymphnodes, and stratified for primary or recurrent surgical procedure. In all patients but those treated with strictureplasty the mesentery and lymphnodes were removed. Patients' characteristics, peri-operative findings, and long-term recurrence were compared by univariate and multivariate analysis.

RESULTS

Thickened mesentery and enlarged lymphnodes were not present in all cases, were typical of ileal location and penetrating behaviour, had a constant decrease over recurrences, were independent of either pre-operative medical therapy or surgical approach, did not increase the duration of surgery and complications, presented similar 20-years recurrence rate to normal mesentery and lymphnodes. Lymphopathy was associated to a worst nutritional status during disease recurrences. At multivariate analysis, age, location, and behaviour, but not mesenteric characteristics, were related to an increased risk of surgical recurrence.

CONCLUSIONS

This study provides new information on mesentery and lymphnodes in CD patients. Further studies are needed to clarify the appropriate surgical approach.

Strictureplasties performed by laparoscopic approach for complicated Crohn's disease. A prospective, observational, cohort study

BACKGROUND

Laparoscopy is considered the best surgical approach for Crohn's Disease (CD), and strictureplasty a reliable alternative to intestinal resection. Nevertheless, their association has never been evaluated.

AIM

To investigate feasibility and safety of conventional (SP) and non-conventional (NCSP) strictureplasties, using laparoscopy, for complicated CD.

METHODS

Starting January 2008, a prospective cohort study was performed, in consecutive, unselected patients, undergoing primary surgery for CD (Group-A). The residential database (CD-CARD) was used for the retrospective extraction of control patients (Group-B). Univariate and multi-variate analysis of pre-operative characteristics, intra-operative findings, morbidity, and intra-abdominal septic complications (IASCs) was performed.

RESULTS

Between January 2008 and December 2019, 331 patients received 162 SPs, 138 NCSPs, and 373 resections (Group-A). From the CD-CARD, 227 control patients received 159 SPs, 117 NCSPs, and 271 resections (Group-B) (ns). Preoperatively, Group-A presented batter nutritional status and received more biological therapies, Group-B more steroids. Group-A presented less abdominal abscesses, planned ostomies, minor complications, shorter operating time and hospitalization than Group-B, but similar major complications, IASCs and anastomotic leaks. IASCs were related to older age, elevated inflammatory indices, and preoperative treatment with high-risk drugs.

CONCLUSIONS

SP and NCSP are feasible by laparoscopy, with low morbidity rate, confirming the advantages of both minimally invasive and conservative surgery.

Sequential Approach for a Critical-View COlectomy (SACCO): A Laparoscopic Technique to Reduce Operative Time and Complications in IBD Acute Severe Colitis

Acute severe colitis is the major indication for surgery in inflammatory bowel diseases (IBD), and in particular, in ulcerative colitis (UC). A laparoscopic approach for abdominal colectomy is recommended, due to better perioperative and long-term outcomes. However, costs, time-spending, and outcomes are still a topic of improvement. We designed a standardized 10-steps, sequential approach to laparoscopic colectomy, based on the philosophy of the “critical view of safety”, with the aim to improve perioperative outcomes (operative duration, estimated blood loss, complications, readmissions, reoperations, and length of postoperative stay). We performed a retrospective cohort study using data from a prospectively maintained clinical database. We included all the consecutive, unselected patients undergoing laparoscopic subtotal colectomy (SCo) for IBD between 2008 and 2019 in a tertiary IBD Italian Centre. Starting from 2015, we regularly adopted the novel Sequential Approach for a Critical-View Colectomy (SACCo) technique. We included 59 (40.6%) patients treated with different laparoscopic approaches, and 86 patients (59.4%) operated on by the SACCo procedure. The mean operating time was significantly shorter for the SACCo group (144 vs. 224 min; p < 0.0001). The SACCo technique presented a trend to fewer major complications (6.8% vs. 8.3%), less readmissions (2.3% vs. 13.5%; p = 0.01), and shorter postoperative hospital stay (7.2 vs. 8.8 days; p = 0.003). Laparoscopic SACCo-technique is a safe and reproducible surgical approach for acute severe colitis and may improve the outcomes of this demanding procedure.

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.

Modified Side-To-Side Isoperistaltic Strictureplasty over the Ileocaecal Valve: An Alternative to Ileocaecal Resection in Extensive Terminal Ileal Crohn's Disease

BACKGROUND

A modified Michelassi strictureplasty over the ileocaecal valve or ileocolic anastomosis could be an alternative to ileocaecal resection. This study assessed the outcome of the modified Michelassi strictureplasty in patients with extensive stenotic terminal ileal Crohn's disease [CD].

METHODS

This type of strictureplasty was proposed to all patients with an extensive strictured [neo-] terminal ileal segment [> 20 cm]. Short- and long-term outcome data were retrieved from a prospectively maintained database. Safety and medium-term efficacy were studied, using both postoperative magnetic resonance enterography [MRE] and ileocolonoscopy at 6 months.

RESULTS

Between June 2009 and September 2014, 29 CD patients had a modified strictureplasty [male 9/29, median age 38 [range: 16-64] years]. The median length of strictureplasty was 50 [27-110] cm. Twelve patients underwent a total of 30 additional procedures during surgery, mainly additional short strictureplasties, but also segmental resections. The majority had a laparoscopic-assisted procedure. Median length of hospital stay was 9 [6-17] days. Two patients had an early rescue procedure to oversew a small anastomotic leak. MRE and ileocolonoscopy at follow-up showed a remarkable regression of inflammation and bowel wall thickness. Clinical recurrence, necessitating initiation or modification of medical therapy, and surgical recurrence were reported in 11 and 1 patient after a median follow-up of 21 [1-54] months, respectively.

CONCLUSION

A modified long Michelassi strictureplasty appears to be safe in patients with extensive stricturing Crohn's ileitis. Significant mucosal and bowel wall healing is observed and suggests that clearance of microbial stasis may play a role in this process.

Surgery for luminal Crohn’s disease

Many patients with Crohn’s disease (CD) require surgery. Indications for surgery include failure of medical treatment, bowel obstruction, fistula or abscess formation. The most common surgical procedure is resection. In jejunoileal CD, strictureplasty is an accepted surgical technique that relieves the obstructive symptoms, while preserving intestinal length and avoiding the development of short bowel syndrome. However, the role of strictureplasty in duodenal and colonic diseases remains controversial. In extensive colitis, after total colectomy with ileorectal anastomosis (IRA), the recurrence rates and functional outcomes are reasonable. For patients with extensive colitis and rectal involvement, total colectomy and end-ileostomy is safe and effective; however, a few patients can have subsequent IRA, and half of the patients will require proctectomy later. Proctocolectomy is associated with a high incidence of delayed perineal wound healing, but it carries a low recurrence rate. Patients undergoing proctocolectomy with ileal pouch-anal anastomosis had poor functional outcomes and high failure rates. Laparoscopic surgery has been introduced as a minimal invasive procedure. Patients who undergo laparoscopic surgery have a more rapid recovery of bowel function and a shorter hospital stay. The morbidity also is lower, and the rate of disease recurrence is similar compared with open procedures.

How I do it: Side-to-side isoperistaltic strictureplasty for extensive Crohn's disease

INTRODUCTION

Bowel-sparing surgical techniques, such as the Heineke-Mikulicz and the Finney strictureplasty, have been proposed as an alternative to lengthy intestinal resection in the treatment of small bowel strictures in Crohn's disease. However, these conventional strictureplasty techniques lend themselves poorly to cases of multiple short strictures closely clustered over a lengthy small bowel segment.

DISCUSSION

In this article, we present the surgical technique of the side-to-side isoperistaltic strictureplasty, which is optimal in addressing these specific situations.

Comparison of conventional and nonconventional strictureplasties in Crohn's disease: a systematic review and meta-analysis

BACKGROUND

The Heineke-Mikulicz and Finney techniques are conventional strictureplasties that have been used to manage short (<10 cm) and medium-length (>10 cm and <20 cm) strictures from Crohn's disease. Nonconventional strictureplasty techniques have emerged to facilitate bowel conservation for atypical strictures. These techniques include the modified Finney, combined Heineke-Mikulicz and Finney, modified Heineke-Mikuliczs, Michelassi, and modifications of it and others.

OBJECTIVE

The aim of this study is to compare conventional vs nonconventional strictureplasties with respect to short-term complications and long-term results.

DATA SOURCES AND STUDY SELECTION

A MEDLINE search was performed using "Crohn's disease", "surgical therapy", "strictureplasty", "complications", "reoperation", and "recurrence" as medical subject headings. Studies conducted between 1975 and June 31, 2010 were found via PubMed, Ovid, Embase, and Cochrane databases and categorized into 3 groups. These groups consist of centers performing conventional strictureplasties, nonconventional strictureplasties, or both. Studies with at least 3 patients were reviewed.

INTERVENTIONS

A mixed-effects meta-analysis for each outcome was performed by use of Supermix software by SSI Scientific Software International.

MAIN OUTCOME MEASURES

We focused on immediate and long-term complication rates among the groups. The 6 immediate complications include small-bowel obstructions, sepsis, other infections, reoperations, early postoperative GI bleeds, and other early complications. The 5 long-term complications include recurrent strictures, small-bowel obstructions, reoperations, carcinoma, and deaths.

RESULTS

We reviewed 32 studies with 1616 patients who underwent 4538 strictureplasties. One thousand one hundred fifty-seven patients underwent conventional strictureplasties with an early complication rate of 15%; 459 patients underwent nonconventional strictureplasties with an early complication rate of 8%. A late complication rate of 29% for the conventional strictureplasty group and 17% for the nonconventional strictureplasty group was noted.

LIMITATIONS

We are limited by the data published with the inherent risk of finding and analyzing mostly articles with positive results.

CONCLUSION

The nonconventional strictureplasty techniques were noninferior to the conventional strictureplasty procedures with respect to all prespecified outcomes.

[Endoscopic management of luminal stenosis in inflammatory bowel disease]

Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection.

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 transanal approach with laparoscopy or laparotomy for the treatment of rectal strictures in Crohn's disease

INTRODUCTION

Rectal strictures in patients with Crohn's colitis are common and options described for their treatment include direct steroid injection, injection of tumor necrosis factor (TNF) inhibitors, endoscopic balloon dilatation, use of Hegar dilators, stricturoplasty, and proctectomy. Adequate treatment is a challenge, especially with respect to the prevention of stricture recurrence. We present an option for the surgical treatment of these strictures using a transanal resection of the rectum with the addition of laparoscopy or laparotomy.

METHODS

Three patients who had medically refractory or chronic Crohn's colitis with rectal strictures were referred to us after failed medical management, rectal dilation, and balloon dilation of the strictures. In each case, we performed a transanal sphincter preserving dissection in the prone position and used the lithotomy position for intraabdominal mobilization, completion of the rectosigmoid resection, pull-through of the left colon, and coloanal anastomosis.

RESULTS

We resected the rectal strictures transanally in all three cases. One case provided the opportunity to perform a laparoscopy-assisted procedure, whereas the other 2 patients had laparotomy-assisted rectosigmoid resections. We did a coloanal anastomosis in 2 patients with healthy left colon. In the third case, the anal canal was preserved, but the patient was left with a stoma.

CONCLUSIONS

Transanal resection is feasible in the surgical treatment of rectal strictures in patients with Crohn's colitis. It preserves the anal sphincteric mechanism and may help in avoiding a permanent stoma in a subgroup of patients. We found the prone position very helpful in performing the transanal rectal dissection.

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.

Dilation of colonic strictures by intralesional injection of infliximab in patients with Crohn's colitis

BACKGROUND

Intestinal stenosis is a frequent complication of Crohn's disease, often leading to repeated bowel obstruction and surgery. The prevalence of small bowel stenosis has ranged from 20% to 40% and from 7% to 15% in patients with colonic disease. Although balloon dilation is the initial preferred approach, many patients eventually restenose and require surgical resection or stricturoplasty. Infliximab, a chimeric IgG1 kappa monoclonal antibody against TNF-alpha, has been effective in the treatment of enteric as well as fistulous complications of Crohn's disease. Repeated systemic administration has been successful for active inflammatory disease yet has been reported to be ineffective in the treatment of strictures. Although the TREAT registry has shown systemic infliximab to be safe in the long term, there is concern regarding infectious as well as neoplastic complications.

METHODS

This report describes 3 patients refractory to all medical therapy including systemic infliximab.

RESULTS

In all 3 patients, dilation of a colonic stricture was accomplished by injection of infliximab, via the sclerotherapy technique, into the distal and medial portions of the stricture.

CONCLUSIONS

Infliximab was shown to be effective in the treatment of strictures in 3 patients.

[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.

Sequential stenotic strictures of the small bowel leading to obstruction

Small bowel obstructions (SBOs) are primarily caused by adhesions, hernias, neoplasms, or inflammatory strictures. Intraluminal strictures are an uncommon cause of SBO. This report describes our findings in a unique case of sequential, stenotic intraluminal strictures of the small intestine, discusses the differential diagnosis of intraluminal intestinal strictures, and reviews the literature regarding intraluminal pathology.

A novel technique to relieve a closed-loop obstruction secondary to a competent ileocecal valve and an unresectable mid-colon tumor

A competent ileocecal valve complicates the surgical treatment of an unresectable obstructing mid-colon tumor. Specifically, it may not be feasible to bypass with a colocolotomy, especially when the sigmoid colon has limited mobility or if the ascending colon is severely distended and edematous. A technique is described in which the closed loop obstruction is relieved at its proximal extent by an ileocecal valvuloplasty. A circular stapling device is fired across the ileocecal valve. Once the ileocecal valve is rendered competent, a loop ileostomy or a colocolotomy can be constructed, providing effective palliation for this difficult situation.

Surgical management of intestinal failure

Surgery plays a key role in the management of both acute and, less frequently, chronic intestinal failure. Acute intestinal failure frequently requires surgical treatment when it arises as a consequence of intestinal fistulation or obstruction. In specialised clinical practice approximately 50% of acute intestinal failure is associated with intestinal fistulas and in approximately 50% of patients, this condition arises as part of the natural history or complicating treatment for Crohn's disease. A considerable proportion of such patients have abdominal infection and present complex nutritional and metabolic problems. The most important aspect of the surgical management of patients with acute intestinal failure associated with intra-abdominal infection is management of sepsis, since recovery is unlikely in the presence of active infection. Moreover, effective nutritional support and restoration of body composition is not possible if sepsis remains unresolved. Surgical strategies to deal with intra-abdominal infection may involve percutaneous drainage, laparotomy and resection of fistulating segments of intestine and, when infection is persistent and contamination extensive, laparostomy (a technique in which the abdomen is left open and allowed to heal by secondary intention). Surgical treatment should not only be timely and effective, but also aimed at preventing secondary damage to the small intestine, in order to minimise the risk of short bowel syndrome. In some cases a proximal defunctioning stoma may be required, with prolonged nutritional support, using either home total parenteral nutrition or feeding via the defunctioned distal gut (fistuloclysis), pending restoration of intestinal continuity. The role of surgical treatment for patients with short bowel syndrome is less clear. While surgery is frequently required for the management of complications of short bowel syndrome (including gallstones and possibly peptic ulcer disease), the role of intestinal lengthening and tapering procedures (to increase functional intestinal length), and artificial valves, reversed segments and colonic interposition (to reduce intestinal transit) remains controversial. For some patients with short bowel syndrome and, in particular, those with combined intestinal and hepatic failure, intestinal transplantation may become the treatment of choice as long-term results continue to improve.

An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn's disease

PURPOSE

The side-to-side strictureplasty is a bowel-sparing alternative to resection in the treatment of stricturing Crohn's disease. This study was initiated to review the adoption of the side-to-side strictureplasty as a new surgical technique and the relative outcomes a decade after its description.

METHODS

A total of 184 unique patients from six centers in the United States, Italy, and Japan served as the basis for this study. A questionnaire instrument was used to assemble prospectively acquired preoperative, intraoperative, perioperative, and postoperative data from each center into a computer-generated database.

RESULTS

Average age at surgery for patients selected for a side-to-side strictureplasty varied significantly between centers (minimum, 31.0 years; maximum, 39.5 years, P < 0.006). Use of the side-to-side strictureplasty technique for primary Crohn's disease vs. surgically recurrent disease also varied significantly by center (primary minimum, 16.7 percent; maximum, 68.6 percent, P < 0.03). Furthermore, length of diseased bowel selected for construction of a side-to-side strictureplasty was significantly different among centers (minimum, 20.8 +/- 9.9 cm; maximum, 64.3 +/- 29.3 cm, P < 0.001). Use of synchronous bowel resection away from the site of the side-to-side strictureplasty was relatively common (minimum, 21.1 percent; maximum, 66.7 percent) as it was with the use of additional synchronous strictureplasties (minimum, 41.9 percent; maximum, 83.3 percent). The six centers experienced a low number of complications (minimum, 5.7 percent; maximum, 20.8 percent). Forty-one of 184 total patients required surgery for recurrent disease, with an average time to recurrence of 35 months. The difference of reoperation-free five-year survival experienced by the patients in the six centers was not statistically significant, with a cumulative reoperation-free five-year survival of 77 percent across all centers.

CONCLUSIONS

Worldwide implementation of the side-to-side strictureplasty technique and its variations has occurred. This procedure carries a very low mortality and morbidity rate, with acceptable recurrence rates.

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.

Azathioprine and mesalamine for prevention of relapse after conservative surgery for Crohn's disease

BACKGROUND & AIMS

Because the reoperation rate for Crohn's disease is high after resective surgery, use of conservative surgery has increased. Mesalamine was investigated for the prevention of postoperative relapse, with disappointing results. The role of azathioprine in the postoperative setting is unknown. We aimed to compare the efficacy and safety of azathioprine and mesalamine in the prevention of clinical and surgical relapse in patients who have undergone conservative surgery for Crohn's disease.

METHODS

In a prospective, open-label, randomized study, 142 patients received azathioprine (2 mg. kg -1. day -1 ) or mesalamine (3 g/day) for 24 months. Clinical relapse was defined as the presence of symptoms with a Crohn's Disease Activity Index score >200 and surgical relapse as the presence of symptoms refractory to medical treatment or complications requiring surgery.

RESULTS

After 24 months, the risk of clinical relapse was comparable in the azathioprine and mesalamine groups, both on intention-to-treat (odds ratio [OR], 2.04; 95% confidence interval [CI], 0.89-4.67) and per-protocol analyses (OR, 1.79; 95% CI, 0.80-3.97). No difference was observed with respect to surgical relapse at 24 months between the 2 groups. In a subgroup analysis, azathioprine was more effective than mesalamine in preventing clinical relapse in patients with previous intestinal resections (OR, 4.83; 95% CI, 1.47-15.8). More patients receiving azathioprine withdrew from treatment due to adverse events than those receiving mesalamine (22% vs. 8%; P = 0.04).

CONCLUSIONS

While no difference was observed in the efficacy of azathioprine and mesalamine in preventing clinical and surgical relapses after conservative surgery, azathioprine is more effective in those patients who have undergone previous intestinal resection.

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.

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.

Small bowel stenosis in Crohn's disease: clinical, biochemical and ultrasonographic evaluation of histological features

AIM

To establish whether intestinal ultrasound, clinical or biochemical indices of activity can assess histological features of ileal stenosis in Crohn's disease.

METHODS

In 43 patients undergoing surgery for a single ileal stenosis, clinical and biochemical parameters, as well as intestinal ultrasound, were assessed prior to surgery. The echo pattern of thickened bowel segments at the site of stenosis was classified as hypoechoic, stratified or mixed (segments with/without stratification). During surgery, stenoses were identified, resected and then histologically examined using standardized criteria.

RESULTS

Clinical and biochemical indices of activity showed an overall weak positive correlation with histological inflammatory parameters and a negative correlation with fibrosis. The intestinal ultrasound echo pattern at the stenosis site was stratified in 25 patients, hypoechoic in 14 and mixed in four. Stenoses characterized by a stratified echo pattern showed a significantly higher degree of fibrosis, those characterized by hypoechoic echo pattern showed a higher degree of inflammation, while stenoses with a mixed echo pattern showed high degrees of both fibrosis and inflammation.

CONCLUSION

Ultrasound and, to a lesser degree, clinical and laboratory indices discriminate between inflammatory and fibrotic ileal stenoses complicating Crohn's disease, thus allowing appropriate medical and/or surgical treatment to be defined.

Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn's disease: a prospective comparative study

OBJECTIVE

Accurate assessment of intestinal complications of Crohn's disease (CD) is extremely important, both in clinical practice and in trials. The accuracy of radiographic and ultrasonographic diagnosis of internal fistulae and abscesses complicating CD is still debated and requires further investigation. We compared ultrasonography (US) and contrast radiography in detecting intestinal fistulae and abscesses complicating CD.

METHODS

A prospective study was carried out on 625 consecutive CD patients who underwent complete evaluation of the intestinal tract by means of colonoscopy and double contrast barium enema, small bowel enteroclysis, and abdominal ultrasound (US). Computed tomography (CT) was also carried out in cases of severe CD with clinical suspicion of septic complications. The accuracy of US, barium radiology, and CT in detecting internal fistulae and abscesses was assessed by comparing results with intraoperative findings in 128 consecutive patients who underwent operation immediately after diagnostic workup.

RESULTS

Internal fistulae and intra-abdominal abscesses were identified intraoperatively in 56 (43.7%) and 26 (20.3%) patients, respectively. Diagnostic accuracy of US and x-ray studies in detecting internal fistulae was comparable (85.2% vs 84.8%), with sensitivity of 71.4% for US and 69.6% for x-ray studies, and specificity of 95.8% for both. Combination of radiographic techniques and US significantly improved diagnostic accuracy in detection of internal fistulae. In severe cases of CD with clinical suspicion of septic complications such as abdominal mass or fever, the accuracy of US, barium studies, and CT was 88.5%, 80.3%, and 77%, respectively (p = ns). The presence of abscesses was correctly detected in 90.9% of cases by means of US and in 86.4% by CT (p = ns), although accuracy was higher for CT (91.8%) than for US (86.9%) because of false positive results in US studies.

CONCLUSIONS

Despite the fact that barium radiology is widely considered the method of choice in detection of internal fistulae, accuracy is not entirely satisfactory. Comparable accuracy was found for US and CT. The combination of barium and US studies, or the sole use of US in more CD patients with more severe disease, can reliably detect most internal fistulae and abscesses.

Oxidative stress, vitamin A and vitamin E behaviour in patients submitted to conservative surgery for complicated Crohn's disease

AIMS

To assess whether plasma peroxidation and plasma levels of antioxidant compounds are correlated with clinical and biochemical activity in complicated Crohn's disease patients, and to evaluate whether the relief of obstructive complication by conservative surgery has any effect on the oxidative stress.

PATIENTS AND METHODS

From May 1998 to May 2000, 20 Crohn's disease patients were studied. Basal peroxidative state (basal thiobarbituric acid reactive substances), peroxidative state after stimulation with copper sulfate (stimulated thiobarbituric acid reactive substances], lag time of plasma peroxidation susceptibility, plasma levels of vitamin E and A, C reactive protein, erythrocyte sedimentation rate and Crohn's disease activity index, were determined, before surgery, then 2 months and 1 year after surgery. A group of 134 healthy volunteers were used as controls. All patients were treated by conservative surgical procedures (i.e., strictureplasty and/or minimal resections). Student t test for paired and unpaired data and Spearman R correlation coefficient were calculated.

RESULTS

Peroxidative plasma levels, as well as inflammatory indices, are significantly reduced 2 months and 1 year after surgery (p < 0.005), but basal levels of peroxidation and antioxidant scavengers seem to be disregulated in Crohn's disease patients compared to those in controls (p < 0.005). A correlation was found between basal thiobarbituric acid reactive substances, lag-time and erythrocyte sedimentation rate (R:0.51; p < 0.05. R:0.56; p < 0.05) and C reactive protein (R:0. 6; p < 0.005. R:0. 65; p < 0.005).

CONCLUSIONS

An imbalance between pro- and antioxidant mechanisms, due to chronic gut inflammation, is present in complicated Crohn's disease, and an excess of lipid peroxidation is probably an important pathogenetic factor Conservative surgery can reduce the oxidative stress avoiding repeated or extended resections that could lead to intestinal malabsorption and short bowel syndrome.

Review article: indication and type of surgery in Crohn's disease

The large majority of patients affected by Crohn's disease require surgery during their clinical history. Radical resection originally advocated for Crohn's disease does not decrease the recurrence rate, and repeated resections predispose patients to the development of short-bowel syndrome. Over the last few years, conservative surgery has become accepted by many authors as a safe means of treating obstructive Crohn's disease. In this review article we analyse the efficacy and safety of conservative techniques, in comparison with resective surgery. Indications, advantages and technical aspects of resective and conservative surgery are reported. The experience with 489 patients treated for complicated or treatment refractory Crohn's disease in our Institution suggests that strictureplasty is a safe and effective procedure in many cases, as reported by other authors. The risk of cancer in areas of active disease as in stenosis treated with strictureplasty seems to be negligible. Resective surgery still represents the 'gold standard' in patients with perforating Crohn's disease; however, conservative surgery, usually contraindicated in perforating Crohn's disease, can be advocated in patients with localized perforating disease presenting an actual risk of short bowel syndrome.

Preoperative characteristics and postoperative behavior of bowel wall on risk of recurrence after conservative surgery in Crohn's disease: a prospective study

OBJECTIVE

To evaluate in patients with Crohn's disease, using transabdominal ultrasound, the morphologic characteristics of the diseased bowel wall before and after conservative surgery and to assess whether these characteristics and their behavior in the postoperative follow-up are useful and reliable prognostic factors of clinical and surgical recurrence.

SUMMARY BACKGROUND DATA

Ultrasound is effective for evaluating the thickness of bowel wall, the most typical and constant finding of Crohn's disease. No data are currently available concerning the behavior of the diseased intestinal wall after conservative surgery and whether the preoperative characteristics of bowel wall or its behavior after conservative surgery may predict recurrence.

METHODS

In 85 consecutive patients treated with strictureplasty and miniresections for Crohn's disease, clinical and ultrasonographic evaluations were performed before and 6 months after surgery. Assessed before surgery were the maximum bowel wall thickness, the length of bowel wall thickening, the bowel wall echo pattern (homogeneous, stratified, and mixed), and the postoperative bowel wall behavior, classified as normalized, improved, unchanged, or worsened.

RESULTS

A significant correlation was found between a long preoperative bowel wall thickening and surgical recurrence. Bowel wall thickness after surgery was unchanged or worsened in 43.3% of patients; in these patients, there was a high frequency of previous surgery. Patients with unchanged or worsened bowel wall thickness had a higher risk of clinical and surgical recurrence compared with those with normalized or improved bowel wall thickness.

CONCLUSION

With the use of abdominal ultrasound, the authors found that the thickening of diseased bowel wall may unexpectedly improve after conservative surgery, and this is associated with a favorable outcome in terms of clinical and surgical recurrence. In addition to its diagnostic usefulness, ultrasound also provides reliable prognostic information concerning clinical and surgical recurrence in patients with Crohn's disease in the postoperative follow-up.

Palliative care in inflammatory bowel disease: an evidence-based approach

The management of the patient with inflammatory bowel disease (IBD) is challenging for both the physician and the patient. IBD imposes both a physical and emotional burden on patients' lives. Palliative care is important for IBD patients because it focuses on improving quality of life. While palliative care does not change the natural history of the disease, it provides relief from pain and other distressing symptoms. This article focuses on various aspects of care for IBD patients including pain control, management of oral and skin ulcerations, stomal problems in IBD patients, control of nausea and vomiting, management of chronic diarrhea and pruritus ani, evaluation of anemia, treatment of steroid-related bone disease, and treatment of psychological problems associated with IBD. Each of these areas is reviewed using an evidence-based approach. Evidence in category A refers to evidence from clinical trials that are randomized and well controlled. Category B Evidence refers to evidence from cohort or case-controlled studies. Category C is evidence from case reports or flawed clinical trials. Evidence from category D is limited to the clinical experience of the authors. Evidence labelled as category E refers to situations where there is insufficient evidence available to form an opinion. Algorithms for management of pain and nausea in IBD patients are presented.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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