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How safe is strictureplasty in the management of Crohn's disease?
How Safe Is Strictureplasty in the Management of Crohn’s Disease? Gokhan Owner, MD, Victor W. Fazio, MD, Ian C. Lavery, MD, James M. Church, MD, Tracy L. Hull, MD, Cleveland, Ohio
BACKGROUND: Strictureplasty is a well-accepted technique in the management of selected patients with Crohn’s disease. To determine the safety and optimal clinical setting for performing strictureplasty, perioperative complications and long-term outcomes need to be analyzed. PAnENTsAND MATERIALS: We retrospectively reviewed the charts of 162 patients (67 men, 75 women) with Crohn’s disease who underwent strictureplasty between June 1964 and July 1994. Medical and surgical history, including medications and laboratory data, intraoperative findings, perioperative complications, and longterm follow-up data were recorded. RESULTS These patients underwent 696 strictureplasties (Heineke-Mikulicz procedures, 617; Finney procedures, 81). Median hospital stay was 8 days. Perioperative septic complications were noted in 8 patients (5%); however, reoperation for sepsis was needed only in 5 patients. Five percent of patients developed prolonged ileus after strictureplasty. Symptomatic improvement after strictureplasty was achieved in 98% of patients. Restricture or new stricture or perforative disease was seen in 5% and 17% of patients, respectively, during a 42-month median follow-up period. CONCLUSIONS: Our findings show that strictureplasty is a good surgical option for stenosing smatl-bowel Crohn’s disease, particularly in patients with multiple obstruction and in those vulnerable to short-bowel syndrome. Perioperative complications are few, and long-term results are gratifying. Am J Surg. 1996;171:57-61.
M
ost patients who suffer from Crohn’s disease eventually need surgical intervention and some require multiple bowel resection.1*4 This predisposes them to the development of short-bowel syndrome.3-6 In some patients, Crohn’s disease produces bowel perforation with resulting sepsis. In others, the disease causes bowel wall thick-
From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. Requests for reprints should be addressed to Victor W. Fazio, MD, Chairman, Department of Colorectal Surgery Al 11, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195. Presented at the 36th Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, California, May 14-17, 1995.
THE AMERICAN
ening and scarring, producing stenosis. In 1982, strictureplasty was first proposed as an alternative to intestinal resection in stenosing small-bowel Crohn’s disease by Lee and Papaioannou.5 Over the ensuing 14 years, strictureplasty has become accepted as a useful technique for achieving symptomatic relief with a minimum of bowel loss in small-bowel Crohn’s disease. There have been several reports on the safety and efficacy of this procedure.7-10 Most describe small series and the preferred clinical setting; the sequela, as well as the long-term reoperative rate after strictureplasty, still remain to be clarified. We present our experience with 162 patients who underwent 698 strictureplasties at the Cleveland Clinic Foundation.
PATIENTS AND METHODS A retrospective analysis was made of all patients who underwent strictureplasty between June 1984 and July 1994 for Crohn’s disease of the small bowel. Detailed information about prior medical or surgical therapy, initial symptoms, and results of physical examination were carefully recorded. Much of the information was recorded prospectively in many patients. Preoperative workup included basic blood tests and various radiologic and endoscopic studies as indicated by the patient’s presentation. A diagnosis of Crohn’s disease was confirmed in each case using clinical, radiologic, and histopathologic criteria,” Despite having obstructive symptoms, most patients had mechanical bowel preparation by using magnesium citrate, unless emesis occurred or the presenting obstruction was too severe (ie, visible peristalsis, gross distention of bowel loops). Prophylactic preoperative broad-spectrum antibiotics were given to all patients. The technique of strictureplasty has been described in detail in previous publications.7*12*‘3 Strictures ~10 cm are treated in a manner similar to a Heineke-Mikulicz pyloroplasty. A Finney-type strictureplasty is used for longer strictures. Identification of strictures during laparotomy is made by careful inspection and palpation of the intestine. During strictureplasty, ulcerated mucosa is biopsied. A metallic clip is attached to the mesentery adjacent to the strictureplasty site to facilitate identification of these sites in the future. The,number of strictureplasties performed, length of bowel remaining, and the need for concomitant bowel resection of active disease were abstracted from the operative report. Perioperative complications and their management were analyzed from the in-hospital chart. Long-term follow-up was conducted by clinical examination or questionnaires, via phone, or by personal interview. This provided information about recurrent symptoms, weight change, alteration in medical treatment, and any subsequent hospitalizations or surgical procedures after stricJOURNAL
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tients. The median preoperative prednisone dose was 20 mg per day and ranged from 5 mg to 150 mg per day. Fifty-seven (35%) of the patients reported a mean weight loss of 15.2 f 162 rtient (n) 8.5 pounds during a mean duration of 4.1 + 3.5 months prior 1:1.2 ?x (M:F) to strictureplasty. Mean preoperative albumin level was 3.7 dal number of surgeries 191 (162)’ Jmber Of StriCtUreptaStieS 698 (612)’ + .7 g/dL and was recorded in 145 patients. Forty-four perHeinecke-Mikulicz 617 (541) cent of the patients undergoing strictureplasty had hypoalFinney 81 (71)’ buminemia (13 g/dL). The mean hemoglobin level was 12.3 adian duration of Crohn’s disease (y) (range) 13 (O-41) + 2.0 gJdL. This was documented in 156 patients, of whom sdian duration of symptoms (m) (range) 5 P-84) 88% had a hemoglobin level ~14 g/dL. arcotic dependency (%) 13 (8) A median prognostic nutritional index of 58% (range 3% lo&bowel syndrome (%) 7 (4.5) to 90%) was recorded in 25 patients who had been receiving evious bowel resection (%) 110 (68) or were started on total parenteral nutrition immediately prior )r Crohn’s disease to strictureplasty. A hand-sewn strictureplasty with interdicates primary strictureplasties. rupted absorbablesutures was performed in the vast majority of patients. Sixty-eight percent (110 patients) underwent syn chronous bowel resection at the time of strictureplasty. The ireplasty. No patient was excluded from our analysis. most common synchronous resection was of small bowel :urrently, all the above parameters are routinely recorded (19%) followed by ileocolic resection and neoileocolic anasi our prospective strictureplasty registry. tomosis (18%). The length of small bowel remaining after Comparisons of proportions of events were made with chistrictureplasty and resection wasrecorded in 108 patients. The iuare tests or Fisher’s exact tests when necessary.Statistical mean length was 264.3 + 01.1 cm. gnificance was set at P ~0.05. Descriptive statistics were The median hospital stay was 8 days (range 2 to 57). There
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the patients without any treatment. One patient required a relaparotomy due to postoperative m adhesions. Irma-abdominal vasopressin in1 fusion was used in 2 patients with poststrictureplasty-related hemorrhage. Including the patient with an injured ureter, a total of 7 patients underwent receliotomy. No difference in the perioperative complication rate was noted between patients treated with strictureplasty alone and those who had synchronous bowel resection. The median duration of followup was 42 months (range 1 to 120), during which time reoperative recurrence occurred in 22% 12 Months of the patients. Figure 1 demonstrates reoperation as a function Time of time calculated by the KaplanFigure 2. Decrease in prednisone dose of patients who had been on 220 mglday of predMeier method. Symptomatic renisone preoperatively. crudescence was treated in 6% of patients. Six months postoperatively, 98% of patients noted relief COMMENTS Crohn’s disease cannot be cured, and patients are likely to of obstructive symptoms. Marked to moderate improvements undergo one or more operations for their disease at some time in symptoms were reported in 159 patients. Two patients reduring their life. Additionally, no adjuvant medical treatment ported minimal to unchanged symptomatology, and 1 patient reported worsening of clinical status. The median dose has proved to be effective in preventing recurrence followof prednisone use at 6 months postoperatively was 10 mg ing surgery. Patients with jejunoileal Crohn’s are, therefore, (range 5 to 40) per day. The proportion of patients using at risk for losing significant amounts of bowel. Thus, stricsteroids was 18% at this time. Figure 2 demonstrates the detureplasty has been welcomed as a viable option in the mancrease in the prednisone dose of patients who had been on agement of stenosing Crohn’s disease. It is an alternative to 220 mg per day of prednisone preoperatively. An average repeat resections with the subsequent risk of development of weight gain of 4.9 f 6.0 pounds was documented in patients a short-bowel syndrome. Initially strictureplasty was criticized 6 months after strictureplasty. because diseased bowel is left in situ, and the anastomosis is constructed through macroscopically involved intestine.‘4a16 Thirty-six patients (22%) underwent reoperation for recrudescence of Crohn’s disease causing symptoms. Eight paHowever, several studies have demonstrated recurrence of tients (5%) were managed by repeat strictureplasty at preCrohn’s disease is independent of the presence of disease at the intestinal margin.17J8 Also, Crohn’s disease is potentially vious strictureplasty sites. Twenty-eight patients (17%) were noted to have disease at other sites distant from prepanintestinal, and the patient is always at risk of relapse. Surgery in Crohn’s disease should be regarded as a palliavious strictureplasty. A new strictureplasty was performed in 18 of these patients (ll%), and 10 patients (6%) untive procedure to improve both the health and symptoms of the patient while preserving as much intestine as possible.5 derwent resection. Five patients who underwent resectidn Strictureplasty can only be justified if the results prove the for new disease had a previous strictureplasty site resected procedhte to be safe, and if outcomes, including recurrence as well. rates and morbidity, are comparable with conventional exWe analyzed several parameters for association with comcisional surgery. plications. We could not demonstrate that any relationship Operative mortality rates for resection in Crohn’s disease between complications and the number of strictureplasties range from 0.3% to 3.2%.19-22To date, no operative morperformed, the preoperative steroid dose, or concomitant tality has been reported after strictureplasty.2~9~10~14 No morbowel resection. The only factor associated with an increased tality was observed in this series. incidence of complication was a preoperative albumin level Short-bowel syndrome during long-term follow-up after re~2.5 g/dL. Hypoalbuminemia was associated with a 30% section is seen in 1.5% to 12.6% of patients.3,6j23Septic commorbidity compared with an 11% morbidity when the alplications after conventional resection for Crohn’s disease are bumin level was 72.5. This difference was not statistically reported in a range of 3% to 49%.8J9 After strictureplasty, pesignificant (chi-square test). Similarly, no statistically sigrioperative septic complications vary from 5% to 14%?,9j10 nificant relationship could be demonstrated between recurThese results are at the lower end of the range of septic morrence requiring surgery and the number of strictureplasties bidity observed after conventional resective surgery. performed or synchronous bowel resection. l
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No patient with strictureplasty-related hemorrhage required operative intervention. Such bleeding usually can be managed by transfusion of packed red blood cells. Only 2 of our patients required active (nonoperative) treatment.13 These results testify to the safety of strictureplasty. Ninetyeight percent of patients reported significant improvement of obstructive symptoms, and most patients were less dependent on medical treatment postoperatively. Fifty percent of patients were completely weaned from steroid treatment. The mean duration of follow-up was 42 months (range 1 to 120), during which time recurrence needing reoperation was seen in 22% of patients. Medically managed recurrence was observed in 6% of patients, thus giving a total combined recurrence rate of 28%. Cumulative 5-year incidence of reoperative recurrence was calculated to be 28% by the KaplanMeier method. These results compare favorably with, reoperative recurrence rates after conventional resective surgery, which vary from 30% to 53% at 10 years.*,4It is of note that restricture at a previous strictureplasty site was only seen in 5% of patients. Most reoperations were performed for new sites of disease.Strictureplasty is not recommended for active disease,nor should it be performed in the vicinity of inflammatory phlegmon, enteric fistula, overt perforation, or intra-abdominal abscess.Sixty-eight percent of our patient population had synchronous resection for active Crohn’s disease.No difference in reoperative recurrence rate was noted in such patients. Our results support the effectiveness of strictureplasty in small-bowel Crohn’s disease.Favorable morbidity and long term recurrence rates observed in our patient population testify to strictureplasty asbeing a useful adjunct to existing surgical options in the treatment of Crohn’s disease.
REFERENCES 1. Farmer RG, Whelan G, Fazio VW. Long-term follow-up of patients with Crohn’s disease. Gastmenterology. 1985;88:1818-1825. 2. de Dombal FT, Burton I, Goligher JC. The early and late results of surgical treatment for Crohn’s disease. Br J Surg. 1971;58:805-816. 3. Hellers G. Crohn’s disease in Stockholm County 1955-1974. A study of epidemiology, results of surgical treatment and long-term prognosis. Acta Chir Scat& 1979;49O(suppl490):31-69. 4. Chardovoyne R, Flint GW, Pollack S, Wise L. Factors affecting recurrence following resection for Crohn’s disease. Dis Colon Rectum. 1986;29:495-502. 5. Lee ECG, Papaioarmou N. Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R CoU Surg EngI. 1982;64:229-233. 6. Thompson JS. Strategies for preserving intestinal length in the short-bowel syndrome. Dis Colon Rectum. 1987;30:208-213. 7. Fazio VW, Tjandra JJ, Lavery IC, et al. Long-term follow up of strictureplasty in Crohn’s disease. Dis Colon Rectum. 1993;36:355-361. 8. Alexander-Williams J, Haynes IG. Up-to-date management of small bowel Crohn’s disease. A& Surg. 1987;20:245-264. 9. Spencer MP, Nelson H, Wolff BG, Dozios RR. Strictureplasty for obstructive Crohn’s disease: the Mayo experience. Mayo Clin Pmt. 1994;69:33-36. 10. Alexander-Williams J. Surgical management of small intestinal Crohn’s disease: resection or strictureplasty. Semin Colon Rectal Surg. 1994;5:193-198. 11. Farmer RG, Hawk WA, Tumbull RB. Clinical patterns in Crohn’s disease: a statistical study of 615 cases. Gasnoenrerology. 1975;86: 627-635. 12. Fazio VW. Conservative surgery for Crohn’s disease of the small 60
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bowel. The role of strictureplasty. Med CIin North Am. 1990;74: 169-181. 13. Ozuner G, Fazio VW. Management of gastrointestinal bleeding after strictureplasty for Crohn’s disease. Dis CoIon Recmm. 1995;38: 297-300 14. Fazio VW, Galandiuk S, Jagelman DG, Lavery IC. Strictureplasty in Crohn’s disease. Ann Surg. 1989;210:621-625. 15. Wolff BG, Beart RW Jr, Frydenberg HB, et al. The importance of disease free margins in resections for Crohn’s disease. Dis Colon Rectum. 1983;36:239-243. 16. Dehn TCB, Kettlewell MGW, Mortensen NJ, et al. Ten-year experience of strictureplasty for obstructive Crohn’s disease. Br J Surg. 1989;76:339-341. 17. Pennington L, Hamilton SR, Bayless TM, et al. Surgical management of Crohn’s disease: influence of disease at margin of resection. Ann Surg. 1980;192:311-318. 18. Heuman R, Boeryd B, Balin T, et al. The influence of disease at the margin of resection on the outcome of Crohn’s disease. Br J Surg. 1983;70:519-521. 19. Hulten L. Surgical treatment of Crohn’s disease of the small bowel or ileocecum. World J Surg. 1988;12:180-185. 20. Alexander-Williams J, Haynes IG. Conservative operations for Crohn’s disease of the small bowel. World J Surg. 1985;9:945-95 1. 21. Barber K, Waugh J, Beahrs 0, et al. Indications for and results of surgical treatment of regional ileitis. Ann Surg. 1962;156:472-482. 22. Michelassi F, Balestracci T, Chappell R, Block GE. Primary and recurrent Crohn’s disease. Experience with 1379 patients. Ann Surg. 1991;214:23@-240. 23. Cooke WT, Mallas E, Prior P, Allan RN. Crohn’s disease: course, treatment and long-term prognosis. Q J Med. 1980;49:363-384.
DISCUSSION Harry Oberhelman, MD (Palo Alto, California): Although the observed absence of mortality and the low septic morbidity rate of 5% is quite commendable, I was concerned by the number of patients that required perioperative transfusion. I wonder how many of those patients bled postoperatively. A reoperation rate of 22% for recurrent diseaseat a mean of 42 months compares favorably with the usual resective surgery, but what will it be at 5 years?What will it be in 10 years? Gokhan Ozuner, MD: First, I’d like to addressthe issue of perioperative transfusion. A number of the patients that I described started the procedure off with a low hemoglobin concentration. Among the 25 patients who did require perioperative blood transfusion, 18 patients were thought to have strictureplasty-related hemorrhage. Any time the patients become symptomatic or drop their hematocrit significantly, a nasogastric tube is passed,coagulation studies obtained, and transfusion of blood is given. Excessive cautery to the strictureplasty wound risks late perforation and sepsis. Undercauterization risks excessive bleeding. Of the 25 patients, 18 were thought to have strictureplastyrelated hemorrhage. Only 2 patients required intra-arterial pitressin infusion and none required reoperation for bleeding from a strictureplasty site. Now, what will be the long-term recurrence? It’s very difficult to answer the question at this time. Reoperation is likely in most, if not all, given the extensive nature of the disease. To date, reoperation rate is similar to patients having resectional treatment of single segment disease.Prospective studies and registry utilization will help provide the answer.
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Alan G. Thorson, MD (Omaha, Nebraska): One thing when we’ve been doing strictureplasties, and particularly the longer ones, we sometimes seem to end up with quite a saccular dilatation or diverticulum. This always raises the question as whether this is going to be subject to stasis or a blindloop type problem. Have you seen any type of problem along those lines with the longer strictures you have done? Recently, a new technique that is an isoperistaltic side-toside strictureplasty has been described. Since reviewing these patients, have you had an opportunity to use that technique, and if so, do you have any comments about its utilization and effectiveness? Dr. Ozuner: Patients who undergo strictureplasty feel very well. The physiologic effect of the saccular dilatation or diverticulum is unknown, although no apparent adverse effect of the Finney-type strictureplasty has emerged. Yet we recognize the potential for bacterial overgrowth and malabsorption and thus have some recent experience with the combination and isoperistaltic strictureplasty, both of which avoid this sacculation effect. No long-term studies of these latter procedures have been published to date. Fabrizio Michelassi, MD (Chicago, Illinois): You have studied 162 patients over a lo-year period. I’d like to know what percentage of the entire group of patients operated on for Crohn’s disease complications do they represent at the Cleveland Clinic. In the presence of a duodenal stricture, when do you suggest a strictureplasty, and when do you suggest that we do a conventional gastrojejunostomy? I would like to ask you whether some of the strictureplasties have been prophylactic. Do you have any data to sug
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gest that prophylactic strictureplasties may indeed lower the rate of reoperations in Crohn’s patients? Dr. Ozuner: Prophylactic as a term applied to strictureplasty is hard to define. Certainly treated strictures could be left alone for a time, but further narrowing to whaterver is a critical level may lead to early reoperation. Most of our reoperations are for new strictures or untreated “asymptomatic” strictures rather than recurrent strictures, by a 5:l margin. Only 3 duodenal strictureplasties have been done by us, these seem best reserved for short segment’strictures of the 2nd and 3rd part of the duodenum. James M. Becker, MD (Boston, Massachusetts): The big concern with strictureplasty is a long-term one, and that is in regards to whether or not we are creating a whole population of people who in 2 or 3 decades will develop malig nancies in the small or the large intestine. Have you identified any patients with long-term follow-up that have had malignancy? Do you have some prospective way of endoscopically or radiographically assessing the mucosa at the strictureplasty site for premalignant changes? And do you have any speculation about this possibility? Dr. Ozuner: We have 1 patient, a 62-year-old woman with adult celiac disease who developed adenocarcinoma of the ileum 8 years after a strictureplasty. This will remain a risk for sites treated by stnctureplasty, possibly of a similar order of magnitude as patients with jejunoileitis who do not undergo surgery. We know of no good method of assessing malignant potential. In our case cited above, sticture biopsy showed in flammation changes only at the time of strictureplasty.
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BACKGROUND: Strictureplasty is a well-accepted technique in the management of selected patients with Crohn’s disease. To determine the safety and optimal clinical setting for performing strictureplasty, perioperative complications and long-term outcomes need to be analyzed. PAnENTsAND MATERIALS: We retrospectively reviewed the charts of 162 patients (67 men, 75 women) with Crohn’s disease who underwent strictureplasty between June 1964 and July 1994. Medical and surgical history, including medications and laboratory data, intraoperative findings, perioperative complications, and longterm follow-up data were recorded. RESULTS These patients underwent 696 strictureplasties (Heineke-Mikulicz procedures, 617; Finney procedures, 81). Median hospital stay was 8 days. Perioperative septic complications were noted in 8 patients (5%); however, reoperation for sepsis was needed only in 5 patients. Five percent of patients developed prolonged ileus after strictureplasty. Symptomatic improvement after strictureplasty was achieved in 98% of patients. Restricture or new stricture or perforative disease was seen in 5% and 17% of patients, respectively, during a 42-month median follow-up period. CONCLUSIONS: Our findings show that strictureplasty is a good surgical option for stenosing smatl-bowel Crohn’s disease, particularly in patients with multiple obstruction and in those vulnerable to short-bowel syndrome. Perioperative complications are few, and long-term results are gratifying. Am J Surg. 1996;171:57-61.
M
ost patients who suffer from Crohn’s disease eventually need surgical intervention and some require multiple bowel resection.1*4 This predisposes them to the development of short-bowel syndrome.3-6 In some patients, Crohn’s disease produces bowel perforation with resulting sepsis. In others, the disease causes bowel wall thick-
From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. Requests for reprints should be addressed to Victor W. Fazio, MD, Chairman, Department of Colorectal Surgery Al 11, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195. Presented at the 36th Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, California, May 14-17, 1995.
THE AMERICAN
ening and scarring, producing stenosis. In 1982, strictureplasty was first proposed as an alternative to intestinal resection in stenosing small-bowel Crohn’s disease by Lee and Papaioannou.5 Over the ensuing 14 years, strictureplasty has become accepted as a useful technique for achieving symptomatic relief with a minimum of bowel loss in small-bowel Crohn’s disease. There have been several reports on the safety and efficacy of this procedure.7-10 Most describe small series and the preferred clinical setting; the sequela, as well as the long-term reoperative rate after strictureplasty, still remain to be clarified. We present our experience with 162 patients who underwent 698 strictureplasties at the Cleveland Clinic Foundation.
PATIENTS AND METHODS A retrospective analysis was made of all patients who underwent strictureplasty between June 1984 and July 1994 for Crohn’s disease of the small bowel. Detailed information about prior medical or surgical therapy, initial symptoms, and results of physical examination were carefully recorded. Much of the information was recorded prospectively in many patients. Preoperative workup included basic blood tests and various radiologic and endoscopic studies as indicated by the patient’s presentation. A diagnosis of Crohn’s disease was confirmed in each case using clinical, radiologic, and histopathologic criteria,” Despite having obstructive symptoms, most patients had mechanical bowel preparation by using magnesium citrate, unless emesis occurred or the presenting obstruction was too severe (ie, visible peristalsis, gross distention of bowel loops). Prophylactic preoperative broad-spectrum antibiotics were given to all patients. The technique of strictureplasty has been described in detail in previous publications.7*12*‘3 Strictures ~10 cm are treated in a manner similar to a Heineke-Mikulicz pyloroplasty. A Finney-type strictureplasty is used for longer strictures. Identification of strictures during laparotomy is made by careful inspection and palpation of the intestine. During strictureplasty, ulcerated mucosa is biopsied. A metallic clip is attached to the mesentery adjacent to the strictureplasty site to facilitate identification of these sites in the future. The,number of strictureplasties performed, length of bowel remaining, and the need for concomitant bowel resection of active disease were abstracted from the operative report. Perioperative complications and their management were analyzed from the in-hospital chart. Long-term follow-up was conducted by clinical examination or questionnaires, via phone, or by personal interview. This provided information about recurrent symptoms, weight change, alteration in medical treatment, and any subsequent hospitalizations or surgical procedures after stricJOURNAL
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tients. The median preoperative prednisone dose was 20 mg per day and ranged from 5 mg to 150 mg per day. Fifty-seven (35%) of the patients reported a mean weight loss of 15.2 f 162 rtient (n) 8.5 pounds during a mean duration of 4.1 + 3.5 months prior 1:1.2 ?x (M:F) to strictureplasty. Mean preoperative albumin level was 3.7 dal number of surgeries 191 (162)’ Jmber Of StriCtUreptaStieS 698 (612)’ + .7 g/dL and was recorded in 145 patients. Forty-four perHeinecke-Mikulicz 617 (541) cent of the patients undergoing strictureplasty had hypoalFinney 81 (71)’ buminemia (13 g/dL). The mean hemoglobin level was 12.3 adian duration of Crohn’s disease (y) (range) 13 (O-41) + 2.0 gJdL. This was documented in 156 patients, of whom sdian duration of symptoms (m) (range) 5 P-84) 88% had a hemoglobin level ~14 g/dL. arcotic dependency (%) 13 (8) A median prognostic nutritional index of 58% (range 3% lo&bowel syndrome (%) 7 (4.5) to 90%) was recorded in 25 patients who had been receiving evious bowel resection (%) 110 (68) or were started on total parenteral nutrition immediately prior )r Crohn’s disease to strictureplasty. A hand-sewn strictureplasty with interdicates primary strictureplasties. rupted absorbablesutures was performed in the vast majority of patients. Sixty-eight percent (110 patients) underwent syn chronous bowel resection at the time of strictureplasty. The ireplasty. No patient was excluded from our analysis. most common synchronous resection was of small bowel :urrently, all the above parameters are routinely recorded (19%) followed by ileocolic resection and neoileocolic anasi our prospective strictureplasty registry. tomosis (18%). The length of small bowel remaining after Comparisons of proportions of events were made with chistrictureplasty and resection wasrecorded in 108 patients. The iuare tests or Fisher’s exact tests when necessary.Statistical mean length was 264.3 + 01.1 cm. gnificance was set at P ~0.05. Descriptive statistics were The median hospital stay was 8 days (range 2 to 57). There
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the patients without any treatment. One patient required a relaparotomy due to postoperative m adhesions. Irma-abdominal vasopressin in1 fusion was used in 2 patients with poststrictureplasty-related hemorrhage. Including the patient with an injured ureter, a total of 7 patients underwent receliotomy. No difference in the perioperative complication rate was noted between patients treated with strictureplasty alone and those who had synchronous bowel resection. The median duration of followup was 42 months (range 1 to 120), during which time reoperative recurrence occurred in 22% 12 Months of the patients. Figure 1 demonstrates reoperation as a function Time of time calculated by the KaplanFigure 2. Decrease in prednisone dose of patients who had been on 220 mglday of predMeier method. Symptomatic renisone preoperatively. crudescence was treated in 6% of patients. Six months postoperatively, 98% of patients noted relief COMMENTS Crohn’s disease cannot be cured, and patients are likely to of obstructive symptoms. Marked to moderate improvements undergo one or more operations for their disease at some time in symptoms were reported in 159 patients. Two patients reduring their life. Additionally, no adjuvant medical treatment ported minimal to unchanged symptomatology, and 1 patient reported worsening of clinical status. The median dose has proved to be effective in preventing recurrence followof prednisone use at 6 months postoperatively was 10 mg ing surgery. Patients with jejunoileal Crohn’s are, therefore, (range 5 to 40) per day. The proportion of patients using at risk for losing significant amounts of bowel. Thus, stricsteroids was 18% at this time. Figure 2 demonstrates the detureplasty has been welcomed as a viable option in the mancrease in the prednisone dose of patients who had been on agement of stenosing Crohn’s disease. It is an alternative to 220 mg per day of prednisone preoperatively. An average repeat resections with the subsequent risk of development of weight gain of 4.9 f 6.0 pounds was documented in patients a short-bowel syndrome. Initially strictureplasty was criticized 6 months after strictureplasty. because diseased bowel is left in situ, and the anastomosis is constructed through macroscopically involved intestine.‘4a16 Thirty-six patients (22%) underwent reoperation for recrudescence of Crohn’s disease causing symptoms. Eight paHowever, several studies have demonstrated recurrence of tients (5%) were managed by repeat strictureplasty at preCrohn’s disease is independent of the presence of disease at the intestinal margin.17J8 Also, Crohn’s disease is potentially vious strictureplasty sites. Twenty-eight patients (17%) were noted to have disease at other sites distant from prepanintestinal, and the patient is always at risk of relapse. Surgery in Crohn’s disease should be regarded as a palliavious strictureplasty. A new strictureplasty was performed in 18 of these patients (ll%), and 10 patients (6%) untive procedure to improve both the health and symptoms of the patient while preserving as much intestine as possible.5 derwent resection. Five patients who underwent resectidn Strictureplasty can only be justified if the results prove the for new disease had a previous strictureplasty site resected procedhte to be safe, and if outcomes, including recurrence as well. rates and morbidity, are comparable with conventional exWe analyzed several parameters for association with comcisional surgery. plications. We could not demonstrate that any relationship Operative mortality rates for resection in Crohn’s disease between complications and the number of strictureplasties range from 0.3% to 3.2%.19-22To date, no operative morperformed, the preoperative steroid dose, or concomitant tality has been reported after strictureplasty.2~9~10~14 No morbowel resection. The only factor associated with an increased tality was observed in this series. incidence of complication was a preoperative albumin level Short-bowel syndrome during long-term follow-up after re~2.5 g/dL. Hypoalbuminemia was associated with a 30% section is seen in 1.5% to 12.6% of patients.3,6j23Septic commorbidity compared with an 11% morbidity when the alplications after conventional resection for Crohn’s disease are bumin level was 72.5. This difference was not statistically reported in a range of 3% to 49%.8J9 After strictureplasty, pesignificant (chi-square test). Similarly, no statistically sigrioperative septic complications vary from 5% to 14%?,9j10 nificant relationship could be demonstrated between recurThese results are at the lower end of the range of septic morrence requiring surgery and the number of strictureplasties bidity observed after conventional resective surgery. performed or synchronous bowel resection. l
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No patient with strictureplasty-related hemorrhage required operative intervention. Such bleeding usually can be managed by transfusion of packed red blood cells. Only 2 of our patients required active (nonoperative) treatment.13 These results testify to the safety of strictureplasty. Ninetyeight percent of patients reported significant improvement of obstructive symptoms, and most patients were less dependent on medical treatment postoperatively. Fifty percent of patients were completely weaned from steroid treatment. The mean duration of follow-up was 42 months (range 1 to 120), during which time recurrence needing reoperation was seen in 22% of patients. Medically managed recurrence was observed in 6% of patients, thus giving a total combined recurrence rate of 28%. Cumulative 5-year incidence of reoperative recurrence was calculated to be 28% by the KaplanMeier method. These results compare favorably with, reoperative recurrence rates after conventional resective surgery, which vary from 30% to 53% at 10 years.*,4It is of note that restricture at a previous strictureplasty site was only seen in 5% of patients. Most reoperations were performed for new sites of disease.Strictureplasty is not recommended for active disease,nor should it be performed in the vicinity of inflammatory phlegmon, enteric fistula, overt perforation, or intra-abdominal abscess.Sixty-eight percent of our patient population had synchronous resection for active Crohn’s disease.No difference in reoperative recurrence rate was noted in such patients. Our results support the effectiveness of strictureplasty in small-bowel Crohn’s disease.Favorable morbidity and long term recurrence rates observed in our patient population testify to strictureplasty asbeing a useful adjunct to existing surgical options in the treatment of Crohn’s disease.
REFERENCES 1. Farmer RG, Whelan G, Fazio VW. Long-term follow-up of patients with Crohn’s disease. Gastmenterology. 1985;88:1818-1825. 2. de Dombal FT, Burton I, Goligher JC. The early and late results of surgical treatment for Crohn’s disease. Br J Surg. 1971;58:805-816. 3. Hellers G. Crohn’s disease in Stockholm County 1955-1974. A study of epidemiology, results of surgical treatment and long-term prognosis. Acta Chir Scat& 1979;49O(suppl490):31-69. 4. Chardovoyne R, Flint GW, Pollack S, Wise L. Factors affecting recurrence following resection for Crohn’s disease. Dis Colon Rectum. 1986;29:495-502. 5. Lee ECG, Papaioarmou N. Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R CoU Surg EngI. 1982;64:229-233. 6. Thompson JS. Strategies for preserving intestinal length in the short-bowel syndrome. Dis Colon Rectum. 1987;30:208-213. 7. Fazio VW, Tjandra JJ, Lavery IC, et al. Long-term follow up of strictureplasty in Crohn’s disease. Dis Colon Rectum. 1993;36:355-361. 8. Alexander-Williams J, Haynes IG. Up-to-date management of small bowel Crohn’s disease. A& Surg. 1987;20:245-264. 9. Spencer MP, Nelson H, Wolff BG, Dozios RR. Strictureplasty for obstructive Crohn’s disease: the Mayo experience. Mayo Clin Pmt. 1994;69:33-36. 10. Alexander-Williams J. Surgical management of small intestinal Crohn’s disease: resection or strictureplasty. Semin Colon Rectal Surg. 1994;5:193-198. 11. Farmer RG, Hawk WA, Tumbull RB. Clinical patterns in Crohn’s disease: a statistical study of 615 cases. Gasnoenrerology. 1975;86: 627-635. 12. Fazio VW. Conservative surgery for Crohn’s disease of the small 60
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bowel. The role of strictureplasty. Med CIin North Am. 1990;74: 169-181. 13. Ozuner G, Fazio VW. Management of gastrointestinal bleeding after strictureplasty for Crohn’s disease. Dis CoIon Recmm. 1995;38: 297-300 14. Fazio VW, Galandiuk S, Jagelman DG, Lavery IC. Strictureplasty in Crohn’s disease. Ann Surg. 1989;210:621-625. 15. Wolff BG, Beart RW Jr, Frydenberg HB, et al. The importance of disease free margins in resections for Crohn’s disease. Dis Colon Rectum. 1983;36:239-243. 16. Dehn TCB, Kettlewell MGW, Mortensen NJ, et al. Ten-year experience of strictureplasty for obstructive Crohn’s disease. Br J Surg. 1989;76:339-341. 17. Pennington L, Hamilton SR, Bayless TM, et al. Surgical management of Crohn’s disease: influence of disease at margin of resection. Ann Surg. 1980;192:311-318. 18. Heuman R, Boeryd B, Balin T, et al. The influence of disease at the margin of resection on the outcome of Crohn’s disease. Br J Surg. 1983;70:519-521. 19. Hulten L. Surgical treatment of Crohn’s disease of the small bowel or ileocecum. World J Surg. 1988;12:180-185. 20. Alexander-Williams J, Haynes IG. Conservative operations for Crohn’s disease of the small bowel. World J Surg. 1985;9:945-95 1. 21. Barber K, Waugh J, Beahrs 0, et al. Indications for and results of surgical treatment of regional ileitis. Ann Surg. 1962;156:472-482. 22. Michelassi F, Balestracci T, Chappell R, Block GE. Primary and recurrent Crohn’s disease. Experience with 1379 patients. Ann Surg. 1991;214:23@-240. 23. Cooke WT, Mallas E, Prior P, Allan RN. Crohn’s disease: course, treatment and long-term prognosis. Q J Med. 1980;49:363-384.
DISCUSSION Harry Oberhelman, MD (Palo Alto, California): Although the observed absence of mortality and the low septic morbidity rate of 5% is quite commendable, I was concerned by the number of patients that required perioperative transfusion. I wonder how many of those patients bled postoperatively. A reoperation rate of 22% for recurrent diseaseat a mean of 42 months compares favorably with the usual resective surgery, but what will it be at 5 years?What will it be in 10 years? Gokhan Ozuner, MD: First, I’d like to addressthe issue of perioperative transfusion. A number of the patients that I described started the procedure off with a low hemoglobin concentration. Among the 25 patients who did require perioperative blood transfusion, 18 patients were thought to have strictureplasty-related hemorrhage. Any time the patients become symptomatic or drop their hematocrit significantly, a nasogastric tube is passed,coagulation studies obtained, and transfusion of blood is given. Excessive cautery to the strictureplasty wound risks late perforation and sepsis. Undercauterization risks excessive bleeding. Of the 25 patients, 18 were thought to have strictureplastyrelated hemorrhage. Only 2 patients required intra-arterial pitressin infusion and none required reoperation for bleeding from a strictureplasty site. Now, what will be the long-term recurrence? It’s very difficult to answer the question at this time. Reoperation is likely in most, if not all, given the extensive nature of the disease. To date, reoperation rate is similar to patients having resectional treatment of single segment disease.Prospective studies and registry utilization will help provide the answer.
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Alan G. Thorson, MD (Omaha, Nebraska): One thing when we’ve been doing strictureplasties, and particularly the longer ones, we sometimes seem to end up with quite a saccular dilatation or diverticulum. This always raises the question as whether this is going to be subject to stasis or a blindloop type problem. Have you seen any type of problem along those lines with the longer strictures you have done? Recently, a new technique that is an isoperistaltic side-toside strictureplasty has been described. Since reviewing these patients, have you had an opportunity to use that technique, and if so, do you have any comments about its utilization and effectiveness? Dr. Ozuner: Patients who undergo strictureplasty feel very well. The physiologic effect of the saccular dilatation or diverticulum is unknown, although no apparent adverse effect of the Finney-type strictureplasty has emerged. Yet we recognize the potential for bacterial overgrowth and malabsorption and thus have some recent experience with the combination and isoperistaltic strictureplasty, both of which avoid this sacculation effect. No long-term studies of these latter procedures have been published to date. Fabrizio Michelassi, MD (Chicago, Illinois): You have studied 162 patients over a lo-year period. I’d like to know what percentage of the entire group of patients operated on for Crohn’s disease complications do they represent at the Cleveland Clinic. In the presence of a duodenal stricture, when do you suggest a strictureplasty, and when do you suggest that we do a conventional gastrojejunostomy? I would like to ask you whether some of the strictureplasties have been prophylactic. Do you have any data to sug
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gest that prophylactic strictureplasties may indeed lower the rate of reoperations in Crohn’s patients? Dr. Ozuner: Prophylactic as a term applied to strictureplasty is hard to define. Certainly treated strictures could be left alone for a time, but further narrowing to whaterver is a critical level may lead to early reoperation. Most of our reoperations are for new strictures or untreated “asymptomatic” strictures rather than recurrent strictures, by a 5:l margin. Only 3 duodenal strictureplasties have been done by us, these seem best reserved for short segment’strictures of the 2nd and 3rd part of the duodenum. James M. Becker, MD (Boston, Massachusetts): The big concern with strictureplasty is a long-term one, and that is in regards to whether or not we are creating a whole population of people who in 2 or 3 decades will develop malig nancies in the small or the large intestine. Have you identified any patients with long-term follow-up that have had malignancy? Do you have some prospective way of endoscopically or radiographically assessing the mucosa at the strictureplasty site for premalignant changes? And do you have any speculation about this possibility? Dr. Ozuner: We have 1 patient, a 62-year-old woman with adult celiac disease who developed adenocarcinoma of the ileum 8 years after a strictureplasty. This will remain a risk for sites treated by stnctureplasty, possibly of a similar order of magnitude as patients with jejunoileitis who do not undergo surgery. We know of no good method of assessing malignant potential. In our case cited above, sticture biopsy showed in flammation changes only at the time of strictureplasty.
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