- Email: [email protected]
The Side-to-Side Isoperistaltic Strictureplasty
The Side-to-Side Isoperistaltic Strictureplasty Fabrizio Michelassi, MD
C
rohn’s disease is a chronic, recurrent, panintestinal disease characterized by the development of full-thickness histopathologic changes leading to ulcers, perforations, inflammatory masses, abscesses, fistulae, stenoses, and more infrequently hemorrhage and cancer. Although recent advances in the understanding of the etiology and pathogenesis of the disease promise to offer better, more specific and effective therapeutic options, Crohn’s disease cannot, at this point in time, be cured by medical or surgical interventions. Therefore, treatments are aimed at addressing its related complications. Most Crohn’s related complications require intestinal resections as part of the surgical procedure. Unfortunately, Crohn’s is a recurrent disease and the need for future additional intestinal resections may occur in any given patient. With each subsequent resection, the potential for intestinal insufficiency and short-gut syndrome increases. Therefore, nonresectional options such as strictureplasty have gained popularity as an alternative to lengthy resections in the treatment of stricturing Crohn’s disease of the small intestine. The first description of intestinal strictureplasties is attributed to Katariya,1 an Indian surgeon who applied strictureplasty techniques to terminal ileal strictures secondary to intestinal tuberculosis. In 1976, Emmanuel Lee2 working at the John Radcliffe Infirmary in Oxford, England, introduced the Heineke-Mikulicz strictureplasty for strictures up to 5 to 7 cm in length. This technique consists of a longitudinal antimesenteric enterotomy, which is then closed in a transverse way, creating a diamond-shape deformity with enlargement of the intestinal lumen. For longer strictures up to 15 cm in length, a Finney strictureplasty3 may be employed. With this technique, the affected bowel is folded onto itself in a U shape and the two limbs are sutured together. If the diseased bowel is too rigid to be folded without tension, the loop of normal bowel immediately proximal or distal to the diseased loop can be placed adjacent to the diseased loop in the U configuration. A longitudinal enterotomy is then made halfway between the mesenteric and antimesenteric borders, following the course of the U. Sutures are then placed on the
From the Department of Surgery, Weill Medical College of Cornell University, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, NY. Address reprint requests to Fabrizio Michelassi, MD, Weill Medical College of Cornell University, Department of Surgery, 525 East 68th Street, Box 129, New York, NY, 10021. E-mail: [email protected]
8
1524-153X/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2007.03.003
posterior wall of the enteroenterostomy, beginning at the apex of the strictureplasty. This suture line is continued anteriorly and is reinforced with an outer layer of interrupted nonabsorbable sutures. A combination of the Heineke-Mikulicz and Finney strictureplasties has been described independently by Sasaki4 and Fazio5 for two strictures located in close proximity of each other. With increased experience and confidence in these techniques, surgeons have used multiple strictureplasties in the same patient. Yet, these conventional strictureplasties lend themselves poorly to cases of extensive jejunoileitis with multiple short strictures located a small distance from each other over a long length of bowel or to cases of recurrent neoterminal ileitis with multiple short strictures. To address this challenge, the author first proposed the side-to-side isoperistaltic strictureplasty in 1996,6 now commonly known as the “Michelassi” strictureplasty.7
Surgical Technique After inspection of the affected bowel, the mesentery of the diseased loop is divided at its midpoint, and the small bowel is severed between atraumatic intestinal clamps. If necessary, the mid-portion of the diseased loop is resected if it contains a long continuous stricture with a thick, unyielding wall. The proximal intestinal loop is moved over the distal one in a side-to-side fashion (Fig 1). Care is taken to ensure that stenotic areas of one loop are placed adjacent to the dilated areas of the other loop. The two loops are then approximated by a layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures (Fig 2). A longitudinal enterotomy is performed on both loops and the intestinal ends are tapered to avoid blind stumps (Fig 3). Biopsies of suspicious areas of disease are obtained for frozen section to exclude occult malignancy. Hemostasis is obtained with suture ligatures or electrocautery. The outer suture line is reinforced with an internal row of running, full-thickness 3-0 absorbable sutures, continued anteriorly as a running Connell suture. This layer is reinforced by an outer layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures (Fig 4). A similar technique can be used when performing a side-to-side isoperistaltic strictureplasty between the neoterminal ileum with recurrent disease and the ascending colon (Fig 5).
Side-to-side isoperistaltic strictureplasty
9
Figure 1 The mesentery of the diseased loop is divided at its midpoint and the small bowel is severed between atraumatic intestinal clamps. The proximal intestinal loop is moved over the distal one in a side-to-side fashion.
Figure 2 Care is taken to ensure that stenotic areas of one loop are placed adjacent to dilated areas of the other loop. The two loops are then approximated by a layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures.
10
F. Michelassi
Figure 3 A longitudinal enterotomy is performed on both loops and the intestinal ends are tapered to avoid blind stumps. Biopsies of suspicious areas of disease are obtained for frozen section to exclude occult malignancy. Hemostasis is obtained with suture ligatures or electrocautery.
Figure 4 The outer suture line is reinforced with an internal row of running, full-thickness 3-0 absorbable sutures. The inner suture line is continued anteriorly as a running Connell suture. This layer is reinforced by an outer layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures.
Side-to-side isoperistaltic strictureplasty
11
Figure 5 A similar technique can be used between the neo-terminal ileum and the ascending colon.
Indications and Contraindications A side-to-side isoperistaltic strictureplasty is indicated in the surgical treatment of jejunoileitis with multiple fibrotic strictures and of recurrent neo-terminal ileitis with multiple short strictures as to preserve intestinal absorptive capacity of the normal bowel located between strictures. It can be performed alone or in conjunction with a resection. Like any strictureplasty, the side-to-side isoperistaltic strictureplasty is contraindicated for segments with acute inflammation and phlegmon. It is also contraindicated in patients with generalized peritonitis or profound malnutrition. Additionally, long, high-grade strictures resulting from extremely thickened and rigid intestinal wall are often not amenable to strictureplasty and therefore require resection.
Results Accurate follow-up of the first 21 side-to-side isoperistaltic strictureplasties performed by the author8 demonstrated that the procedure was safe and that coordinated intestinal peristalsis was maintained in the stricturoplastied segment. Only
one patient experienced a gastrointestinal hemorrhage, presumably originating from the strictureplasty suture line. All patients were discharged on oral feedings after a mean of 8 days (range, 5-11). In all patients, the side-to-side isoperistaltic strictureplasty resulted in resolution of the occlusive symptoms, improved nutritional status, and improvement of the Crohn’s Disease Activity Index. No patient required total parenteral nutrition after discharge from the hospital. Additionally, at 3 months, there was endoscopic and histopathologic evidence of disease regression. Since then, many other centers have adopted the technique around the world. A recent publication9 has collected the initial experience of these centers and has demonstrated that the technique is reproducible with minor morbidity (3.4% dehiscence rate, 2% intestinal hemorrhage rate). Furthermore, only 14 of 184 total patients required surgery for recurrent disease at the strictureplasty site at an average time of 35 months.
Conclusions Crohn’s disease is a recurring disorder that cannot be cured with surgical resection. As such, surgery is intended to pro-
F. Michelassi
12 vide palliation. The surgeon must strive to alleviate symptoms as effectively as possible without exposing the patient to excessive morbidity. In this context, strictureplasty techniques have been proven to be safe bowel-preserving procedures and have become integral part of the technical armamentarium of the surgeon dealing with Crohn’s patients. Worldwide implementation of the side-to-side strictureplasty technique and its variations has occurred. This procedure is indicated in the surgical treatment of jejunoileitis with multiple fibrotic strictures and of recurrent neo-terminal ileitis with multiple short strictures as to preserve intestinal absorptive capacity of the normal bowel located between strictures. The procedure carries a very low mortality and morbidity rate, with acceptable recurrence rates. Epidemiologic studies have shown an increased risk for small bowel adenocarcinoma in Crohn’s disease patients. This risk is increased in patients with long-standing disease. It is not known if strictureplasty by virtue of its retention of diseased tissue increases this risk. At the time of the writing of this chapter there have been only two well-documented cases of an adenocarcinoma developing at a site of previous small bowel strictureplasty and it is thus believed that the risk of malignancy after strictureplasty is low.10,11 In view of this potentially devastating complication, epidemiologic studies need to be conducted to quantify the neoplastic risk associated with a strictureplasty; however, at the moment, the fear of neoplastic transformation is not sufficient to dissuade sur-
geons from performing bowel-sparing procedures when otherwise indicated.
References 1. Katariya RN, Sood S, Rao PG, et al: Stricture-plasty for tubercular strictures of the gastro-intestinal tract. Br J Surg 64:496-498, 1977 2. Lee EC, Papaioannou N: Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl 64:229-233, 1982 3. Hurst RD, Michelassi F: Strictureplasty for Crohn’s disease: Techniques and long-term results. World J Surg 22:359-363, 1998 4. Sasaki I, Funayama Y, Naito H, et al: Extended strictureplasty or multiple short skipped strictures of Crohn’s disease. Dis Colon Rectum 39:342-344, 1996 5. Fazio VW, Tjandra JJ: Strictureplasty for Crohn’s disease with multiple long strictures. Dis Colon Rectum 36:71-72, 1993 6. Michelassi F: Side-to-side isoperistaltic strictureplasty for multiple Crohn’s strictures. Dis Colon Rectum 39:345-349, 1996 7. Yamamoto T, Fazio VW, Tekkis PP: Safety and efficacy of strictureplasty for Crohn’s disease: A systematic review and meta-analysis. Dis Colon Rectum (accepted for publication) 8. Michelassi F, Hurst RD, Melis M, et al: Side-to-side isoperistaltic strictureplasty in extensive Crohn’s disease: A prospective longitudinal study. Ann Surg 232:401-408, 2000 9. Michelassi F, Taschieri A, Tonelli F, et al: An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn’s disease. Dis Colon Rectum 50:277-284, 2006 10. Marchetti F, Fazio VW, Ozuner G: Adenocarcinoma arising from a strictureplasty site in Crohn’s disease. Report of a case. Dis Colon Rectum 39:1315-1321, 1996 11. Jaskowiak NT, Michelassi F: Adenocarcinoma at a strictureplasty site in Crohn’s disease: Report of a case. Dis Colon Rectum 44:284-287, 2001
C
rohn’s disease is a chronic, recurrent, panintestinal disease characterized by the development of full-thickness histopathologic changes leading to ulcers, perforations, inflammatory masses, abscesses, fistulae, stenoses, and more infrequently hemorrhage and cancer. Although recent advances in the understanding of the etiology and pathogenesis of the disease promise to offer better, more specific and effective therapeutic options, Crohn’s disease cannot, at this point in time, be cured by medical or surgical interventions. Therefore, treatments are aimed at addressing its related complications. Most Crohn’s related complications require intestinal resections as part of the surgical procedure. Unfortunately, Crohn’s is a recurrent disease and the need for future additional intestinal resections may occur in any given patient. With each subsequent resection, the potential for intestinal insufficiency and short-gut syndrome increases. Therefore, nonresectional options such as strictureplasty have gained popularity as an alternative to lengthy resections in the treatment of stricturing Crohn’s disease of the small intestine. The first description of intestinal strictureplasties is attributed to Katariya,1 an Indian surgeon who applied strictureplasty techniques to terminal ileal strictures secondary to intestinal tuberculosis. In 1976, Emmanuel Lee2 working at the John Radcliffe Infirmary in Oxford, England, introduced the Heineke-Mikulicz strictureplasty for strictures up to 5 to 7 cm in length. This technique consists of a longitudinal antimesenteric enterotomy, which is then closed in a transverse way, creating a diamond-shape deformity with enlargement of the intestinal lumen. For longer strictures up to 15 cm in length, a Finney strictureplasty3 may be employed. With this technique, the affected bowel is folded onto itself in a U shape and the two limbs are sutured together. If the diseased bowel is too rigid to be folded without tension, the loop of normal bowel immediately proximal or distal to the diseased loop can be placed adjacent to the diseased loop in the U configuration. A longitudinal enterotomy is then made halfway between the mesenteric and antimesenteric borders, following the course of the U. Sutures are then placed on the
From the Department of Surgery, Weill Medical College of Cornell University, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, NY. Address reprint requests to Fabrizio Michelassi, MD, Weill Medical College of Cornell University, Department of Surgery, 525 East 68th Street, Box 129, New York, NY, 10021. E-mail: [email protected]
8
1524-153X/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2007.03.003
posterior wall of the enteroenterostomy, beginning at the apex of the strictureplasty. This suture line is continued anteriorly and is reinforced with an outer layer of interrupted nonabsorbable sutures. A combination of the Heineke-Mikulicz and Finney strictureplasties has been described independently by Sasaki4 and Fazio5 for two strictures located in close proximity of each other. With increased experience and confidence in these techniques, surgeons have used multiple strictureplasties in the same patient. Yet, these conventional strictureplasties lend themselves poorly to cases of extensive jejunoileitis with multiple short strictures located a small distance from each other over a long length of bowel or to cases of recurrent neoterminal ileitis with multiple short strictures. To address this challenge, the author first proposed the side-to-side isoperistaltic strictureplasty in 1996,6 now commonly known as the “Michelassi” strictureplasty.7
Surgical Technique After inspection of the affected bowel, the mesentery of the diseased loop is divided at its midpoint, and the small bowel is severed between atraumatic intestinal clamps. If necessary, the mid-portion of the diseased loop is resected if it contains a long continuous stricture with a thick, unyielding wall. The proximal intestinal loop is moved over the distal one in a side-to-side fashion (Fig 1). Care is taken to ensure that stenotic areas of one loop are placed adjacent to the dilated areas of the other loop. The two loops are then approximated by a layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures (Fig 2). A longitudinal enterotomy is performed on both loops and the intestinal ends are tapered to avoid blind stumps (Fig 3). Biopsies of suspicious areas of disease are obtained for frozen section to exclude occult malignancy. Hemostasis is obtained with suture ligatures or electrocautery. The outer suture line is reinforced with an internal row of running, full-thickness 3-0 absorbable sutures, continued anteriorly as a running Connell suture. This layer is reinforced by an outer layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures (Fig 4). A similar technique can be used when performing a side-to-side isoperistaltic strictureplasty between the neoterminal ileum with recurrent disease and the ascending colon (Fig 5).
Side-to-side isoperistaltic strictureplasty
9
Figure 1 The mesentery of the diseased loop is divided at its midpoint and the small bowel is severed between atraumatic intestinal clamps. The proximal intestinal loop is moved over the distal one in a side-to-side fashion.
Figure 2 Care is taken to ensure that stenotic areas of one loop are placed adjacent to dilated areas of the other loop. The two loops are then approximated by a layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures.
10
F. Michelassi
Figure 3 A longitudinal enterotomy is performed on both loops and the intestinal ends are tapered to avoid blind stumps. Biopsies of suspicious areas of disease are obtained for frozen section to exclude occult malignancy. Hemostasis is obtained with suture ligatures or electrocautery.
Figure 4 The outer suture line is reinforced with an internal row of running, full-thickness 3-0 absorbable sutures. The inner suture line is continued anteriorly as a running Connell suture. This layer is reinforced by an outer layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 sutures.
Side-to-side isoperistaltic strictureplasty
11
Figure 5 A similar technique can be used between the neo-terminal ileum and the ascending colon.
Indications and Contraindications A side-to-side isoperistaltic strictureplasty is indicated in the surgical treatment of jejunoileitis with multiple fibrotic strictures and of recurrent neo-terminal ileitis with multiple short strictures as to preserve intestinal absorptive capacity of the normal bowel located between strictures. It can be performed alone or in conjunction with a resection. Like any strictureplasty, the side-to-side isoperistaltic strictureplasty is contraindicated for segments with acute inflammation and phlegmon. It is also contraindicated in patients with generalized peritonitis or profound malnutrition. Additionally, long, high-grade strictures resulting from extremely thickened and rigid intestinal wall are often not amenable to strictureplasty and therefore require resection.
Results Accurate follow-up of the first 21 side-to-side isoperistaltic strictureplasties performed by the author8 demonstrated that the procedure was safe and that coordinated intestinal peristalsis was maintained in the stricturoplastied segment. Only
one patient experienced a gastrointestinal hemorrhage, presumably originating from the strictureplasty suture line. All patients were discharged on oral feedings after a mean of 8 days (range, 5-11). In all patients, the side-to-side isoperistaltic strictureplasty resulted in resolution of the occlusive symptoms, improved nutritional status, and improvement of the Crohn’s Disease Activity Index. No patient required total parenteral nutrition after discharge from the hospital. Additionally, at 3 months, there was endoscopic and histopathologic evidence of disease regression. Since then, many other centers have adopted the technique around the world. A recent publication9 has collected the initial experience of these centers and has demonstrated that the technique is reproducible with minor morbidity (3.4% dehiscence rate, 2% intestinal hemorrhage rate). Furthermore, only 14 of 184 total patients required surgery for recurrent disease at the strictureplasty site at an average time of 35 months.
Conclusions Crohn’s disease is a recurring disorder that cannot be cured with surgical resection. As such, surgery is intended to pro-
F. Michelassi
12 vide palliation. The surgeon must strive to alleviate symptoms as effectively as possible without exposing the patient to excessive morbidity. In this context, strictureplasty techniques have been proven to be safe bowel-preserving procedures and have become integral part of the technical armamentarium of the surgeon dealing with Crohn’s patients. Worldwide implementation of the side-to-side strictureplasty technique and its variations has occurred. This procedure is indicated in the surgical treatment of jejunoileitis with multiple fibrotic strictures and of recurrent neo-terminal ileitis with multiple short strictures as to preserve intestinal absorptive capacity of the normal bowel located between strictures. The procedure carries a very low mortality and morbidity rate, with acceptable recurrence rates. Epidemiologic studies have shown an increased risk for small bowel adenocarcinoma in Crohn’s disease patients. This risk is increased in patients with long-standing disease. It is not known if strictureplasty by virtue of its retention of diseased tissue increases this risk. At the time of the writing of this chapter there have been only two well-documented cases of an adenocarcinoma developing at a site of previous small bowel strictureplasty and it is thus believed that the risk of malignancy after strictureplasty is low.10,11 In view of this potentially devastating complication, epidemiologic studies need to be conducted to quantify the neoplastic risk associated with a strictureplasty; however, at the moment, the fear of neoplastic transformation is not sufficient to dissuade sur-
geons from performing bowel-sparing procedures when otherwise indicated.
References 1. Katariya RN, Sood S, Rao PG, et al: Stricture-plasty for tubercular strictures of the gastro-intestinal tract. Br J Surg 64:496-498, 1977 2. Lee EC, Papaioannou N: Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl 64:229-233, 1982 3. Hurst RD, Michelassi F: Strictureplasty for Crohn’s disease: Techniques and long-term results. World J Surg 22:359-363, 1998 4. Sasaki I, Funayama Y, Naito H, et al: Extended strictureplasty or multiple short skipped strictures of Crohn’s disease. Dis Colon Rectum 39:342-344, 1996 5. Fazio VW, Tjandra JJ: Strictureplasty for Crohn’s disease with multiple long strictures. Dis Colon Rectum 36:71-72, 1993 6. Michelassi F: Side-to-side isoperistaltic strictureplasty for multiple Crohn’s strictures. Dis Colon Rectum 39:345-349, 1996 7. Yamamoto T, Fazio VW, Tekkis PP: Safety and efficacy of strictureplasty for Crohn’s disease: A systematic review and meta-analysis. Dis Colon Rectum (accepted for publication) 8. Michelassi F, Hurst RD, Melis M, et al: Side-to-side isoperistaltic strictureplasty in extensive Crohn’s disease: A prospective longitudinal study. Ann Surg 232:401-408, 2000 9. Michelassi F, Taschieri A, Tonelli F, et al: An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn’s disease. Dis Colon Rectum 50:277-284, 2006 10. Marchetti F, Fazio VW, Ozuner G: Adenocarcinoma arising from a strictureplasty site in Crohn’s disease. Report of a case. Dis Colon Rectum 39:1315-1321, 1996 11. Jaskowiak NT, Michelassi F: Adenocarcinoma at a strictureplasty site in Crohn’s disease: Report of a case. Dis Colon Rectum 44:284-287, 2001