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Strictureplasty: An alternative approach in long segment bowel stenosis Crohn's disease
Strictureplasty: An Alternative Approach in Long Segment Bowel Stenosis Crohn’s Disease By G. Federici di Abriola, P. De Angelis, L. Dall’Oglio, and M. Di Lorenzo Rome, Italy and Montreal, Quebec
Background/Purpose: Intestinal resection is the most frequent surgical procedure for bowel stenoses in Crohn’s disease (CD). Recurrence of strictures, particularly with ileocolonic disease, often requires resection of lengthy segments of bowel, potentially resulting in short bowel syndrome. Different techniques of strictureplasty, such as those described by Mikulicz, Finney and Michelassi, are used in adults. However, these procedures are uncommon in pediatric surgery. The authors report their experience with different techniques of strictureplasty and with their modified Michelassi technique for the surgical treatment of long intestinal strictures caused by CD. Methods: Five adolescents (2 boys; 3 girls; mean age, 16 age; range, 14 to 20 years) with severe ileocolonic stenoses and intestinal obstruction, not responsive to medical and nutri-
I
N THE MANAGEMENT of complex Crohn’s disease (CD) in young patients with intestinal strictures (duodenal, jejunal, ileal, and colonic), pharmacologic and nutritional therapies allow control of symptoms. However, in a very high percentage of cases, patients require surgery because of failure or complications of medical treatment, steroid dependence, partial intestinal obstruction, enteric fistula, reduction of weight gain, and growth failure.1,2 Management of bowel stenoses is challenging, because these lesions are very difficult to control with conservative therapy with approximately 50% of pediatric patients requiring intestinal resection in the first 5 years after the diagnosis of CD.3 Traditional surgical management of intestinal stenosis has been resection of the stenotic bowel loop and the reconstruction of intesFrom the Digestive Surgery and Endoscopic Unit, Department of Gastroenterology, Bambino Gesu` Children’s Hospital, Rome, Italy, and the Department of Surgery, University of Montre´al, Ste-Justine Hospital, Montreal, Quebec, Canada. Presented at the 34th Annual Meeting of the Canadian Association of Paediatric Surgeons, Vancouver, British Columbia, Canada, September 19-22, 2002. Address reprint requests to Giovanni Federici di Abriola, Digestive Surgery and Endoscopic Unit, Bambino Gesu` Children’s Hospital, P.zza S. Onofrio 4, 00165 Rome, Italy. © 2003 Elsevier Inc. All rights reserved. 0022-3468/03/3805-0037$30.00/0 10.1016/S0022-3468(03)00017-4 814
tional therapy, were treated with different strictureplasty techniques. In 3 of them the modified side-to-side Michelassi technique was used. Results: No postoperative complications occurred. After a mean follow-up of 20.5 months (range, 6 to 28 months), patients are free of symptoms with good nutritional status and off steroid therapy. Conclusions: Strictureplasty is a good and effective surgical option for sparing bowel length in CD patients with extensive intestinal strictures. J Pediatr Surg 38:814-818. © 2003 Elsevier Inc. All rights reserved. INDEX WORDS: Crohn’s disease, stricture, bowel stenoses, strictureplasty.
tinal continuity with different anastomotic techniques. To reduce the frequency of recurrences, previous experiences advocate limited bowel resections with distal ligation of vessels without lymphadenectomy, and endto-end anastomosis, avoiding the use of drains.4,5 To spare intestinal length and because of a higher incidence of recurrence of disease in patients undergoing extensive intestinal resection, such resection must be limited to the stenotic bowel.6 Unlike bowel resection and anastomosis, different surgical techniques of strictureplasty have been proposed over the years. The aim was to preserve as much functional intestine as possible thus avoiding the short gut syndrome. These new techniques currently are used for patients with a shorter clinical history who have a higher incidence of rapidly occurring stenoses, which may increase the risk of short gut syndrome.7,8 In 1996, Michelassi9 proposed his own technique for healing long segment bowel stenosis. In this procedure, the stenotic intestine is sectioned transversally at the midpoint of the stenosis, the mesentery is divided, and the proximal intestinal loop is advanced over the distal one, a longitudinal enterotomy is made on both loops, and a side-to-side seromuscular anastomosis is performed. This produces a shorter, but nonstenotic, intestinal loop. Because this technique is not suitable in cases of severe stricture caused by intestinal wall thickening, we modified the original technique. Journal of Pediatric Surgery, Vol 38, No 5 (May), 2003: pp 814-818
STRICTUREPLASTY FOR CROHN’S DISEASE
815
Fig 1. (A) Intestinal loop is divided proximal to the stricture. (B) The loop, proximal to the section, is approximated side to side to the stricture, and both ends are opened on the antimesenteric side. The posterior side to side anastomosis is completed. (C) Schematic transverse section of the bowel after strictureplasty. (D) Side to side anastomosis. Both intestinal ends are spatulated to avoid blind stumps.
Regarding the incidence and rapidity of onset of complications and recurrences, the results of strictureplasty are better or, at least, comparable with those of bowel resection.1,4,5,6,7 Moreover, the frequency of recurrence after strictureplasty has been shown to decrease in operated bowel loops.10 Conservative surgery allows for the discontinuation of steroid medication, promotes weight gain, and improves gastrointestinal symptoms and quality of life. The aim of this article is to report our experience with different techniques of strictureplasty and, in particular, with our modification of the Michelassi technique for long stenoses with thickening of the intestinal wall. MATERIALS AND METHODS The charts of 5 pediatric patients with a diagnosis of CD, 2 boys and 3 girls, mean age, 16 years (range, 14 to 20 years), were reviewed retrospectively. PCDAI (Paediatric Crohn’s Disease Activity Index) was evaluated before surgery.11 In all 5 patients, strictureplasty was carried out because of partial bowel obstruction not responsive to medical therapy including enteral nutrition. All patients were steroid dependent. Evaluation of stenotic bowel was by barium enema and ultrasound scan. Exclusion criteria were abdominal abscesses or fistulas in patients with a Body Mass Index (BMI) less than fifth percentile; surgery was performed after a period of parenteral or enteral nutrition.
Surgical Technique The abdominal cavity was explored, and the gastrointestinal tract inspected to measure the length and numbers of stenoses and the thickness of the bowel wall. This was done to adopt the most appropriate surgical strategy. For short stenoses, the techniques of Heineke-Mikulicz and Finney were used. In patients with long and severe reduction of the intestinal lumen, the thickening of the bowel wall did not permit the use of the classic Michelassi technique. In these cases we used our modified technique of advancing the nonstenotic loop (Fig 1A) proximal to the stricture over the intestinal stenosis followed by a side-to-side anastomosis. A longitudinal enterotomy is performed on the antimesenteric side over the entire length of the stenotic and nonstenotic loops (Fig 1B). A side-to-side isoperistaltic anastomosis then is performed with absorbable running seromuscular suture and reinforced with interrupted serosal stitches (Fig 1C). Both intestinal ends are spatulated to avoid blind stumps (Fig 1D). No abdominal drains are used.
Case Summaries Case 1 was a patient with a 5-cm distal ileal stenosis involving the ileocecal valve treated with Heineke-Mikulicz strictureplasty. Case 2 was a patient with 10-cm distal ileal stenosis and contiguous colonic stenosis, for a cumulative intestinal length of 20 cm treated with Finney strictureplasty. In the other 3 patients with severe ileocolonic stenosis 25, 30, and 35 cm in length (Fig 2A), respectively and a thickened ileal wall of more than one cm, the Michelassi strictureplasty was not
816
DI ABRIOLA ET AL
fifth percentile. No intestinal strictures other than the surgically treated ones were seen at laparotomy. The only previous surgical procedure for CD consisted of seton drainage of perianal abscess and fistula. Mean length of stay was 9 days (range, 7 to 15 days). No early or late complications were recorded. Postoperative barium enema at 6 months showed no evidence of stenosis in the operated bowel with good passage of the contrast medium (Fig 2B). The mean duration of follow-up was 22 months (range, 6 to 30 months). All patients were weaned from steroid medication; none showed any further signs or symptoms of partial bowel obstruction. The mean PCDAI before surgery was 51.12 (range, 60 to 34); this was reduced to 8.62 (range, 13.5 to 5) 6 months after surgery. DISCUSSION
Fig 2. (A) Barium contrast study with the narrow stricture of the distal ileum. (B) X ray normal transit at 6 months postoperatively.
technically feasible. In these cases, our Michelassi modification technique was used. Metronidazole, Cefoxitine and Amikacine were administered intravenously for 5 days postoperatively. Liquid and semisolid feeding was started gradually. Pentasa (mesalazine preparation) was given exclusively as maintenance. Follow-up consisted of a barium enema and PCDAI evaluation at 6 months postoperatively.
RESULTS
Strictureplasty and our modification of Michelassi’s technique allowed for successful treatment of all the patients with intestinal stenosis. All the patients were on artificial enteral nutrition and had a BMI more than the
There is general agreement that surgery in CD has to be limited to patients unresponsive to the medical therapy. Thus, surgical treatment currently is reserved for the treatment of complications, such as bowel stenosis, in view of the well-known risk of disease recurrence and of restenoses.6,8 Technical refinements are needed in traditional surgery to reduce the risk of complications and recurrences. Thus, many investigators advocate a conservative surgery.6 In adult CD patients, Caprilli et al5 have observed a more frequent and more rapid bowel stricture relapse rate of 15 versus 36 months when comparing extensive intestinal resection with a more limited one. Strictureplasty represents the most conservative surgical technique for treatment of intestinal strictures in CD. When compared with intestinal resection, strictureplasty offers a valid option for sparing bowel length. Moreover, results are superior, regarding both the incidence and delay of onset of recurrences and postoperative complications.12,13 Although there are no controlled published studies regarding these techniques, recent reports show very interesting results in adults. Dietz et al14 confirm that strictureplasty is a safe and viable alternative to resection. Borley et al15 report significantly better results with strictureplasty than with resection, especially in the follow-up period. The type of strictureplasty usually depends on the length of intestinal stenosis. For short stenoses, the technique of Heineke-Mikulicz, Finney, or Jabouley are usually satisfactory, associated in some special cases with bowel resection. The Fazio technique can be used for multiple short stenoses separated by segments of normal intestine2,10 as it consist in a longitudinal enterotomy performed through the strictures and the adjacent normal bowel, followed by a transverse closure. As previously mentioned, the Michelassi technique9 is
STRICTUREPLASTY FOR CROHN’S DISEASE
817
Fig 3. Both loops are opened, and the posterior side of the anastomosis is completed. The narrow stenotic loop, with thickened wall, is on top. The nonstenotic but affected loop is below. The ulcer is evident. (B) Completed strictureplasty.
an excellent alternative for surgical management of long segment stenosis. However, to apply it to those patients with severe reduction of the intestinal lumen and thickened intestinal wall, we modified the original technique. The proximal loop of nonstenotic intestine was advanced over the stenosis to perform a side-to-side anastomosis (Fig 3A). This modification enabled us to successfully treat patients who had very long and severe intestinal
stenosis. Our strictureplasty technique proved feasible in all instances (Fig 3B). Without this technical modification, all our patients would have been treated with bowel resection. These patients benefited by sparing of intestinal length, reduction of frequency, and increased delay of onset of recurrence.5 According to our selection criteria, none of our patients had evidence of intestinal fistula. Before surgical treatment, nutritional status had been improved (BMI ⬎5th percentile) using enteral nutrition.4 PCDAI at follow-up was reduced dramatically with no evidence of recurrences of stenosis. All patients currently are off steroid medications. To date, there is no randomized, controlled study comparing adult patients undergoing resection with those with strictureplasty. This is not surprising because such a study would be severely biased by the fact that patients requiring intestinal resection are usually the ones with the most severe disease. In this regard, further randomized studies are necessary to provide more accurate guidelines. We believe that in CD pediatric patients with failed medical treatment and steroid dependence, strictureplasty is a good surgical option compared with bowel resection. 11,13 Our modification of the original technique makes the Michelassi strictureplasty feasible also in those patients requiring bowel resection. This procedure may spare intestinal length, better the quality of life, and decrease the risk of recurrent bowel stenosis.12,16 Furthermore, strictureplasty also can improve gastrointestinal symptoms, promoting weight gain and allowing discontinuation of steroid drugs.17-20 ACKNOWLEDGMENTS The authors thank Dr F. Ferro for drawings and Drs Cucchiara, Malandrino, and Sferlazzas for clinical cooperation.
REFERENCES 1. Michelassi F, Balestracci T, Chappell R, et al: Primary and recurrent Crohn’s disease. Experience with 1379 patients. Ann Surg 214:230-238, 1991 2. Oliva L, Wyllie R, Alexander F, et al: The results of strictureplasty in pediatric patients with multifocal Crohn’s disease. J Pediatr Gastroenterol Nutr 18:306-310, 1994 3. Sedwick DM, Barton JR, et al: Population based study of surgery in juvenile onset Crohn’s disease. Br J Surg 78:171-175 , 1991 4. Kroesen AJ, Buhr HJ: New aspects of surgical therapy of recurrent Crohn’s disease. Yonsei Med J 41:1-7, 2000 5. Caprilli R, Corrao G, Taddei G, et al: Prognostic factors for postoperative recurrence of Crohn’s disease. Dis Colon Rectum 39: 335-341, 1996 6. Fazio VW, Aufses AH: Evolution of surgery for Crohn’s disease. Dis Colon Rectum 42:979-988, 1999 7. Dietz DW, Laureti S, Strong SA, et al: Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn’s disease. J Am Coll Surg 192:330-337, 2001
8. Sachar DB, Wolfson DM, Greenstein AJ, et al: Risk factors for postoperative recurrence of Crohn’s disease. Gastroenterology 85:917921, 1983 9. Michelassi F: Side-to side isoperistaltic strictureplasty for multiple Crohn’s strictures. Dis Colon Rectum 39:345-349, 1996 10. Hurst RD, Michelassi F: Strictureplasty for Crohn’s disease: Techniques and long-term results. World J Surg 22:359-363, 1998 11. Hyams JS, Treem VR, Carey DE, et al: Development and validation of a Pediatric Crohn’s Disease Activity Index. J Pediatr Gastroenterol Nutr 12:439-447, 1991 12. Fazio VW, Tiandra JJ: Strictureplasty for Crohn’s disease with multiple long strictures. Dis Colon Rectum 36:71-72, 1993 13. Tonelli F, Ficari F: Strictureplasty in Crohn’s disease: Surgical option. Dis Colon Rectum 43:920-926, 2000 14. Dietz DW, Fazio VW, Laureti S, et al: Strictureplasty in diffuse Crohn’s jejunoileitis: Safe and durable. Dis Colon Rectum 45:764-770, 2002 15. Borley NR, Mortensen NJ, Chaudry MA, et al: Recurrence after
818
abdominal surgery for Crohn’s disease. Relationship to disease site and surgical procedure. Dis Colon Rectum 45:377-383, 2002 16. Worsey MJ, Hull T, Ryland L, et al: Strictureplasty is an effective option in the operative management of duodenal Crohn’s disease. Dis Colon Rectum 45:596-600, 1999 17. Broering DC, Eisenberger CF, Koch A, et al: Quality of life after surgical therapy of small bowel stenosis in Crohn’s disease. Dig Surg 18:124-130, 2001
DI ABRIOLA ET AL
18. Akobeng AK, Suresh-Babu MV, Firth D, et al: Quality of life in children with Crohn’s disease: A pilot study. J Pediatr Gastroenterol Nutr 28:S37-39, 1999 19. Yamamoto T, Keighley MR: Long-term results of strictureplasty for ileocolonic anastomotic recurrence in Crohn’s disease. J Gastrointest Surg 3:555-560, 1999 20. Markowitz JF: Strictureplasty in pediatric Crohn’s disease. J Pediatr Gastroenterol Nutr 18:266-268, 1994
Background/Purpose: Intestinal resection is the most frequent surgical procedure for bowel stenoses in Crohn’s disease (CD). Recurrence of strictures, particularly with ileocolonic disease, often requires resection of lengthy segments of bowel, potentially resulting in short bowel syndrome. Different techniques of strictureplasty, such as those described by Mikulicz, Finney and Michelassi, are used in adults. However, these procedures are uncommon in pediatric surgery. The authors report their experience with different techniques of strictureplasty and with their modified Michelassi technique for the surgical treatment of long intestinal strictures caused by CD. Methods: Five adolescents (2 boys; 3 girls; mean age, 16 age; range, 14 to 20 years) with severe ileocolonic stenoses and intestinal obstruction, not responsive to medical and nutri-
I
N THE MANAGEMENT of complex Crohn’s disease (CD) in young patients with intestinal strictures (duodenal, jejunal, ileal, and colonic), pharmacologic and nutritional therapies allow control of symptoms. However, in a very high percentage of cases, patients require surgery because of failure or complications of medical treatment, steroid dependence, partial intestinal obstruction, enteric fistula, reduction of weight gain, and growth failure.1,2 Management of bowel stenoses is challenging, because these lesions are very difficult to control with conservative therapy with approximately 50% of pediatric patients requiring intestinal resection in the first 5 years after the diagnosis of CD.3 Traditional surgical management of intestinal stenosis has been resection of the stenotic bowel loop and the reconstruction of intesFrom the Digestive Surgery and Endoscopic Unit, Department of Gastroenterology, Bambino Gesu` Children’s Hospital, Rome, Italy, and the Department of Surgery, University of Montre´al, Ste-Justine Hospital, Montreal, Quebec, Canada. Presented at the 34th Annual Meeting of the Canadian Association of Paediatric Surgeons, Vancouver, British Columbia, Canada, September 19-22, 2002. Address reprint requests to Giovanni Federici di Abriola, Digestive Surgery and Endoscopic Unit, Bambino Gesu` Children’s Hospital, P.zza S. Onofrio 4, 00165 Rome, Italy. © 2003 Elsevier Inc. All rights reserved. 0022-3468/03/3805-0037$30.00/0 10.1016/S0022-3468(03)00017-4 814
tional therapy, were treated with different strictureplasty techniques. In 3 of them the modified side-to-side Michelassi technique was used. Results: No postoperative complications occurred. After a mean follow-up of 20.5 months (range, 6 to 28 months), patients are free of symptoms with good nutritional status and off steroid therapy. Conclusions: Strictureplasty is a good and effective surgical option for sparing bowel length in CD patients with extensive intestinal strictures. J Pediatr Surg 38:814-818. © 2003 Elsevier Inc. All rights reserved. INDEX WORDS: Crohn’s disease, stricture, bowel stenoses, strictureplasty.
tinal continuity with different anastomotic techniques. To reduce the frequency of recurrences, previous experiences advocate limited bowel resections with distal ligation of vessels without lymphadenectomy, and endto-end anastomosis, avoiding the use of drains.4,5 To spare intestinal length and because of a higher incidence of recurrence of disease in patients undergoing extensive intestinal resection, such resection must be limited to the stenotic bowel.6 Unlike bowel resection and anastomosis, different surgical techniques of strictureplasty have been proposed over the years. The aim was to preserve as much functional intestine as possible thus avoiding the short gut syndrome. These new techniques currently are used for patients with a shorter clinical history who have a higher incidence of rapidly occurring stenoses, which may increase the risk of short gut syndrome.7,8 In 1996, Michelassi9 proposed his own technique for healing long segment bowel stenosis. In this procedure, the stenotic intestine is sectioned transversally at the midpoint of the stenosis, the mesentery is divided, and the proximal intestinal loop is advanced over the distal one, a longitudinal enterotomy is made on both loops, and a side-to-side seromuscular anastomosis is performed. This produces a shorter, but nonstenotic, intestinal loop. Because this technique is not suitable in cases of severe stricture caused by intestinal wall thickening, we modified the original technique. Journal of Pediatric Surgery, Vol 38, No 5 (May), 2003: pp 814-818
STRICTUREPLASTY FOR CROHN’S DISEASE
815
Fig 1. (A) Intestinal loop is divided proximal to the stricture. (B) The loop, proximal to the section, is approximated side to side to the stricture, and both ends are opened on the antimesenteric side. The posterior side to side anastomosis is completed. (C) Schematic transverse section of the bowel after strictureplasty. (D) Side to side anastomosis. Both intestinal ends are spatulated to avoid blind stumps.
Regarding the incidence and rapidity of onset of complications and recurrences, the results of strictureplasty are better or, at least, comparable with those of bowel resection.1,4,5,6,7 Moreover, the frequency of recurrence after strictureplasty has been shown to decrease in operated bowel loops.10 Conservative surgery allows for the discontinuation of steroid medication, promotes weight gain, and improves gastrointestinal symptoms and quality of life. The aim of this article is to report our experience with different techniques of strictureplasty and, in particular, with our modification of the Michelassi technique for long stenoses with thickening of the intestinal wall. MATERIALS AND METHODS The charts of 5 pediatric patients with a diagnosis of CD, 2 boys and 3 girls, mean age, 16 years (range, 14 to 20 years), were reviewed retrospectively. PCDAI (Paediatric Crohn’s Disease Activity Index) was evaluated before surgery.11 In all 5 patients, strictureplasty was carried out because of partial bowel obstruction not responsive to medical therapy including enteral nutrition. All patients were steroid dependent. Evaluation of stenotic bowel was by barium enema and ultrasound scan. Exclusion criteria were abdominal abscesses or fistulas in patients with a Body Mass Index (BMI) less than fifth percentile; surgery was performed after a period of parenteral or enteral nutrition.
Surgical Technique The abdominal cavity was explored, and the gastrointestinal tract inspected to measure the length and numbers of stenoses and the thickness of the bowel wall. This was done to adopt the most appropriate surgical strategy. For short stenoses, the techniques of Heineke-Mikulicz and Finney were used. In patients with long and severe reduction of the intestinal lumen, the thickening of the bowel wall did not permit the use of the classic Michelassi technique. In these cases we used our modified technique of advancing the nonstenotic loop (Fig 1A) proximal to the stricture over the intestinal stenosis followed by a side-to-side anastomosis. A longitudinal enterotomy is performed on the antimesenteric side over the entire length of the stenotic and nonstenotic loops (Fig 1B). A side-to-side isoperistaltic anastomosis then is performed with absorbable running seromuscular suture and reinforced with interrupted serosal stitches (Fig 1C). Both intestinal ends are spatulated to avoid blind stumps (Fig 1D). No abdominal drains are used.
Case Summaries Case 1 was a patient with a 5-cm distal ileal stenosis involving the ileocecal valve treated with Heineke-Mikulicz strictureplasty. Case 2 was a patient with 10-cm distal ileal stenosis and contiguous colonic stenosis, for a cumulative intestinal length of 20 cm treated with Finney strictureplasty. In the other 3 patients with severe ileocolonic stenosis 25, 30, and 35 cm in length (Fig 2A), respectively and a thickened ileal wall of more than one cm, the Michelassi strictureplasty was not
816
DI ABRIOLA ET AL
fifth percentile. No intestinal strictures other than the surgically treated ones were seen at laparotomy. The only previous surgical procedure for CD consisted of seton drainage of perianal abscess and fistula. Mean length of stay was 9 days (range, 7 to 15 days). No early or late complications were recorded. Postoperative barium enema at 6 months showed no evidence of stenosis in the operated bowel with good passage of the contrast medium (Fig 2B). The mean duration of follow-up was 22 months (range, 6 to 30 months). All patients were weaned from steroid medication; none showed any further signs or symptoms of partial bowel obstruction. The mean PCDAI before surgery was 51.12 (range, 60 to 34); this was reduced to 8.62 (range, 13.5 to 5) 6 months after surgery. DISCUSSION
Fig 2. (A) Barium contrast study with the narrow stricture of the distal ileum. (B) X ray normal transit at 6 months postoperatively.
technically feasible. In these cases, our Michelassi modification technique was used. Metronidazole, Cefoxitine and Amikacine were administered intravenously for 5 days postoperatively. Liquid and semisolid feeding was started gradually. Pentasa (mesalazine preparation) was given exclusively as maintenance. Follow-up consisted of a barium enema and PCDAI evaluation at 6 months postoperatively.
RESULTS
Strictureplasty and our modification of Michelassi’s technique allowed for successful treatment of all the patients with intestinal stenosis. All the patients were on artificial enteral nutrition and had a BMI more than the
There is general agreement that surgery in CD has to be limited to patients unresponsive to the medical therapy. Thus, surgical treatment currently is reserved for the treatment of complications, such as bowel stenosis, in view of the well-known risk of disease recurrence and of restenoses.6,8 Technical refinements are needed in traditional surgery to reduce the risk of complications and recurrences. Thus, many investigators advocate a conservative surgery.6 In adult CD patients, Caprilli et al5 have observed a more frequent and more rapid bowel stricture relapse rate of 15 versus 36 months when comparing extensive intestinal resection with a more limited one. Strictureplasty represents the most conservative surgical technique for treatment of intestinal strictures in CD. When compared with intestinal resection, strictureplasty offers a valid option for sparing bowel length. Moreover, results are superior, regarding both the incidence and delay of onset of recurrences and postoperative complications.12,13 Although there are no controlled published studies regarding these techniques, recent reports show very interesting results in adults. Dietz et al14 confirm that strictureplasty is a safe and viable alternative to resection. Borley et al15 report significantly better results with strictureplasty than with resection, especially in the follow-up period. The type of strictureplasty usually depends on the length of intestinal stenosis. For short stenoses, the technique of Heineke-Mikulicz, Finney, or Jabouley are usually satisfactory, associated in some special cases with bowel resection. The Fazio technique can be used for multiple short stenoses separated by segments of normal intestine2,10 as it consist in a longitudinal enterotomy performed through the strictures and the adjacent normal bowel, followed by a transverse closure. As previously mentioned, the Michelassi technique9 is
STRICTUREPLASTY FOR CROHN’S DISEASE
817
Fig 3. Both loops are opened, and the posterior side of the anastomosis is completed. The narrow stenotic loop, with thickened wall, is on top. The nonstenotic but affected loop is below. The ulcer is evident. (B) Completed strictureplasty.
an excellent alternative for surgical management of long segment stenosis. However, to apply it to those patients with severe reduction of the intestinal lumen and thickened intestinal wall, we modified the original technique. The proximal loop of nonstenotic intestine was advanced over the stenosis to perform a side-to-side anastomosis (Fig 3A). This modification enabled us to successfully treat patients who had very long and severe intestinal
stenosis. Our strictureplasty technique proved feasible in all instances (Fig 3B). Without this technical modification, all our patients would have been treated with bowel resection. These patients benefited by sparing of intestinal length, reduction of frequency, and increased delay of onset of recurrence.5 According to our selection criteria, none of our patients had evidence of intestinal fistula. Before surgical treatment, nutritional status had been improved (BMI ⬎5th percentile) using enteral nutrition.4 PCDAI at follow-up was reduced dramatically with no evidence of recurrences of stenosis. All patients currently are off steroid medications. To date, there is no randomized, controlled study comparing adult patients undergoing resection with those with strictureplasty. This is not surprising because such a study would be severely biased by the fact that patients requiring intestinal resection are usually the ones with the most severe disease. In this regard, further randomized studies are necessary to provide more accurate guidelines. We believe that in CD pediatric patients with failed medical treatment and steroid dependence, strictureplasty is a good surgical option compared with bowel resection. 11,13 Our modification of the original technique makes the Michelassi strictureplasty feasible also in those patients requiring bowel resection. This procedure may spare intestinal length, better the quality of life, and decrease the risk of recurrent bowel stenosis.12,16 Furthermore, strictureplasty also can improve gastrointestinal symptoms, promoting weight gain and allowing discontinuation of steroid drugs.17-20 ACKNOWLEDGMENTS The authors thank Dr F. Ferro for drawings and Drs Cucchiara, Malandrino, and Sferlazzas for clinical cooperation.
REFERENCES 1. Michelassi F, Balestracci T, Chappell R, et al: Primary and recurrent Crohn’s disease. Experience with 1379 patients. Ann Surg 214:230-238, 1991 2. Oliva L, Wyllie R, Alexander F, et al: The results of strictureplasty in pediatric patients with multifocal Crohn’s disease. J Pediatr Gastroenterol Nutr 18:306-310, 1994 3. Sedwick DM, Barton JR, et al: Population based study of surgery in juvenile onset Crohn’s disease. Br J Surg 78:171-175 , 1991 4. Kroesen AJ, Buhr HJ: New aspects of surgical therapy of recurrent Crohn’s disease. Yonsei Med J 41:1-7, 2000 5. Caprilli R, Corrao G, Taddei G, et al: Prognostic factors for postoperative recurrence of Crohn’s disease. Dis Colon Rectum 39: 335-341, 1996 6. Fazio VW, Aufses AH: Evolution of surgery for Crohn’s disease. Dis Colon Rectum 42:979-988, 1999 7. Dietz DW, Laureti S, Strong SA, et al: Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn’s disease. J Am Coll Surg 192:330-337, 2001
8. Sachar DB, Wolfson DM, Greenstein AJ, et al: Risk factors for postoperative recurrence of Crohn’s disease. Gastroenterology 85:917921, 1983 9. Michelassi F: Side-to side isoperistaltic strictureplasty for multiple Crohn’s strictures. Dis Colon Rectum 39:345-349, 1996 10. Hurst RD, Michelassi F: Strictureplasty for Crohn’s disease: Techniques and long-term results. World J Surg 22:359-363, 1998 11. Hyams JS, Treem VR, Carey DE, et al: Development and validation of a Pediatric Crohn’s Disease Activity Index. J Pediatr Gastroenterol Nutr 12:439-447, 1991 12. Fazio VW, Tiandra JJ: Strictureplasty for Crohn’s disease with multiple long strictures. Dis Colon Rectum 36:71-72, 1993 13. Tonelli F, Ficari F: Strictureplasty in Crohn’s disease: Surgical option. Dis Colon Rectum 43:920-926, 2000 14. Dietz DW, Fazio VW, Laureti S, et al: Strictureplasty in diffuse Crohn’s jejunoileitis: Safe and durable. Dis Colon Rectum 45:764-770, 2002 15. Borley NR, Mortensen NJ, Chaudry MA, et al: Recurrence after
818
abdominal surgery for Crohn’s disease. Relationship to disease site and surgical procedure. Dis Colon Rectum 45:377-383, 2002 16. Worsey MJ, Hull T, Ryland L, et al: Strictureplasty is an effective option in the operative management of duodenal Crohn’s disease. Dis Colon Rectum 45:596-600, 1999 17. Broering DC, Eisenberger CF, Koch A, et al: Quality of life after surgical therapy of small bowel stenosis in Crohn’s disease. Dig Surg 18:124-130, 2001
DI ABRIOLA ET AL
18. Akobeng AK, Suresh-Babu MV, Firth D, et al: Quality of life in children with Crohn’s disease: A pilot study. J Pediatr Gastroenterol Nutr 28:S37-39, 1999 19. Yamamoto T, Keighley MR: Long-term results of strictureplasty for ileocolonic anastomotic recurrence in Crohn’s disease. J Gastrointest Surg 3:555-560, 1999 20. Markowitz JF: Strictureplasty in pediatric Crohn’s disease. J Pediatr Gastroenterol Nutr 18:266-268, 1994