Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 926 - файл
.pdf
10 Anastomotic Techniques for Crohn’s Surgery 265
https://t.me/med1917
Expertise and skill in minimally invasive surgery allows surgeons to explore
new possibilities in anastomosis creation in CD surgery. As mentioned earlier,
there are groups performing robotic intracorporeal Kono-S anastomosis. Additionally, a variation of stapled laparoscopic mesentery excluding intracorporeal
anastomosis has been reported [80].
Limits to the implementation of robotic surgery for CD may be the cost,
equipment implementation, training, and experience.
10.5 Restorative Techniques After Colectomy,
Proctocolectomy and Upper Gastrointestinal Surgery
CD is a panintestinal disorder that may necessitate the need for surgical resection of different parts of the gastrointestinal tract [2]. Segmental colectomy is an
accepted procedure for localized colonic disease. In the case of involved multiple
colonic segments, subtotal colectomy is the procedure of choice. Two segmental
colectomies could be considered when two isolated/distant segments are diseased
and when the patient has already undergone extensive small bowel surgery. Less
commonly, in selected cases of refractory pancolonic CD, in the absence of small
bowel and perianal active disease, restorative proctocolectomy can be offered to
patients, acknowledging a high risk of pouch failure [7].
The incidence of upper gastrointestinal Crohn’s disease have been increasing
in recent years. The incidence rate is above 10% at any time during follow-up
[81]. When persistent obstructive symptoms are refractory to medical therapy
and to endoscopic procedures, surgical intervention may be indicated. The next
paragraphs will describe the site-specific anastomosis.
10.5.1 Ileo-Rectal Anastomosis
Segmental colectomy and subtotal colectomy for CD may be indicated in the case
of colonic disease at multiple sites [7]. The two procedures have both been effective in the treatment of colonic CD [82]. Laparoscopic colectomy is generally
performed and ileorectal/ileosigmoid anastomosis is performed extracorporeally
[83, 84].
Contraindications to ileorectal anastomosis are a history of perianal CD and the
presence of dysplasia or rectal cancer that must be excluded prior to surgery.
No studies on the possible anastomotic configurations have been performed.
The preferred anastomotic technique of the surgeon/centre should be applied. A
common option is a side-to-end circular stapled ileorectal anastomosis that can be
performed intra- or extracorporeally. Unfortunately, the rate of clinical recurrence
is extremely high (up to 67% at the 10-year follow-up). This level of recurrence
needs to be comprehensively discussed with individual patients [85]. In addition
the rate of anastomotic leak and postoperative functional outcomes may discourage
patients [86].
266 A. Spinelli and E. Paoluzzi Tomada
https://t.me/med1917
10.5.2 Ileal Pouch-Anal Anastomosis and Coloanal
Anastomosis
In selected cases of pancolonic and rectal involvement restorative surgery can still
be considered [7]. History of perianal CD must be excluded, and there should
be no signs of small bowel disease. Since 1985, the Panis group has studied the
possibility of using ileal pouch-anal anastomosis (IPAA) in CD patients to offer
an alternative to coloproctectomy with end ileostomy [87]. Outcome after IPAA
was compared between CD and ulcerative colitis (UC) patients. No major differences were found in postoperative complications. A five-year permanent stoma
was necessary in 10% of CD patients, compared to 2% of UC patients. CD-related
complications at 10-year follow-up reached 30%. The functional outcomes and
risk of pouch failure are high for CD patients [88]. A large multicentre study confirmed that pouch failure was higher in CD patients than in UC and indeterminate
colitis patients [89].
In cases of severe long-standing fistulising and stenotic proctitis, another surgical option has been proposed for CD patients: intersphincteric sphincter-sparing
anterior rectal resection (IAR) [90]. Rectal mobilization up to the pelvic floor with
nerve-sparing mesorectal excision is performed. Then, transanally, intersphincteric
resection follows. After colorectal resection, a handsewn coloanal end-to-end anastomosis is created and a protective ileostomy formed. The total relapse rate was
54%. At the end of the study, 6 patients out of 11 had stoma closure.
10.5.3 Surgical Management of the Upper Gastrointestinal
Crohn’s Disease Manifestations
Upper gastrointestinal CD presentations have increased in recent years [81]. One
of the main sites of disease manifestation is the duodenum, with symptoms of
upper bowel obstruction. At this site, either a resectional approach or a bowel sparing approach can be used [91]. Distal gastrectomy can be considered a resective
approach in the case of duodenal bulb involvement. Bypass procedures (gastrojejunostomy, duodenojejunostomy, Roux-en-Y bypass) allow for diversion away
from the obstructed duodenum. The advantage of these procedures is that the duodenum can be affected at any site. On the other hand, stricturoplasty, generally the
Heinecke-Mickulicz type, can be an optimal management procedure for obstruction at the duodenal level when duodenal mobilization is feasible. Few studies
have focused on these procedures, comparing the two strategies. Conflicting results
regarding peri-operative complications have been reported [92, 93]. Therefore, the
decision on the type of procedure to apply is at the discretion of each surgeon/
centre.
10 Anastomotic Techniques for Crohn’s Surgery 267
https://t.me/med1917
10.6 Bowel-Sparing Surgery: Stricturoplasties
The fibrotic and fibroinflammatory patterns of CD are a common type of presentation, less common at the first manifestation of disease and more frequent during
the course of the disease, causing a persistent narrowing of the bowel lumen that
can be defined clinically, endoscopically, and radiologically. Stricturoplasty can
be used to treat these areas of stenosis. This non-resective technique is a bowel
preserving procedure and aims to widen the narrowed areas. Many variations have
been used in surgical practice, and approximately 15 have been described in the
literature [13].
Stricturoplasty is indicated in cases of multiple short (<10 cm) strictures, presence of long strictures that would prevent a bowel sparing resectional approach,
previous resection of long bowel segments with the risk of SBS development,
recurrent stenosis at prior anastomotic site, and formation of early strictures i.e.
within 1 year after surgery [3, 7]. It has been demonstrated using various methods
that at stricturoplasty sites the bowel mucosa has a normal noninflamed appearance
and function [94, 95]. Stricturoplasties are contraindicated in the case of associated
perforation, peritonitis, abscesses, suspected presence of carcinoma or large bowel
strictures. Stricturoplasties can be adapted to different bowel segments, depending
on the mobility of the diseased segment and the length of stricture. Stricturoplasty
techniques have evolved since the first description of pyloroplasty by Heinecke
and Mickulicz in the 1880s. Surgeons have a handful of different procedures to
apply according to the specific disease presentation [11, 13, 96, 97]. A recent
classification has been proposed dividing the procedures into Heinecke-Mikuliczlike procedures, intermediate procedures, and enteroenterostomies (Michelassi
modifications) [13]. The most relevant techniques are summarized in Table 10.2.
10.6.1 Heinecke-Mikulicz-Like Stricturoplasties
The following types of stricturoplasties are intended for short and medium-length
strictures.
Heinecke-Mikulicz (H-M) stricturoplasty is indicated for short strictures (<7–10
cm), which are the most common and is the main conventional stricturoplasty. The
technique consists of a longitudinal incision with cutting diathermy from normal
bowel to normal bowel on the antimesenteric side, covering the entire stricture and
a subsequent transverse suture. Stay sutures can be positioned to provide traction in
the correct transverse direction. Then, a continuous suture completes the closure.
The choice to use a single layer or a double layer suture line depends on the
final luminal bowel diameter [98]. This technique is not used for longer strictures
because an increased tension would develop on the transverse suture line.
Judd stricturoplasty is a modification of H-M that is especially useful when
there is a fistula at the site of a short/medium length stricture. A longitudinal
incision is performed as in the case of an H-M procedure, and the fistula is excised
268 A. Spinelli and E. Paoluzzi Tomada
https://t.me/med1917
Table 10.2 Stricturoplasties: Heinecke-Mickulicz-like procedures, intermediate procedures,
enteroentero-anastomosis
Class Stricturoplasty Features
Heinecke-Mickulicz like Heinecke-Mickulicz • Most commonly used
Judd • HM- modification
Intermediate Finney • Conventional
Jaboulay • U-shaped entero-entero
Combination of HM and
Finney
Entero-entero anastomosis Michelassi • Side-to-side isoperistaltic
Poggioli • Side-to-side isoperistaltic
Sasaki • Side-to-side isoperistaltic
Modified Michelassi • Disease-to-disease free
• Conventional
• Transversal suture
• 7–10 cm strictures
• Fistula excision
• Transversal suture
• 7–10 cm strictures
• U-shaped anastomosis at the
stricture site
• Risk of faecal stasis
• Upto15cmstrictures
anastomosis on normal bowel on
the sides of a stricture
• Upto20cmstrictures
• Interrupted midpoint Finney
sutures and HM closures
• Multiple short strictures
anastomosis of strictured loops
• Reduced recurrence
• Long strictures up to 100 cm
disease-to-disease-free
anastomosis
• Strictures > 20 cm or multiple
segments
• Double HM
• Up to 100 cm strictures
side-to-side isoperistaltic
ileocolic anastomosis
• Over ileocaecal valve
• Distal ileal loop stricture
• Primary or secondary disease
• Stricture > 10 cm
10 Anastomotic Techniques for Crohn’s Surgery 269
https://t.me/med1917
via an elliptical incision. Then, a transversal closure of the enterotomy follows
[96].
There are a number of additional HM-like procedures described in the literature, including double-HM, Moskel–Walske–Neumayer stricturoplasty—a Yshaped enterotomy over a stricture that is then closed in a transverse fashion, and
ileocolic HM widening.
10.6.2 Intermediate Stricturoplasty Procedures
Subsequent types of stricturoplasties are indicated for longer strictures and multiple strictures along a bowel segment. The overall length of the affected bowel
should not exceed 25 cm.
Finney stricturoplasty is used for medium-length strictures (7–15 cm). Finney
stricturoplasty is a conventional procedure. This type of stricturoplasty requires
a longitudinal incision on the antimesenteric side of the bowel loop affected by
an intermediate length stricture including 1–2 cm of normal bowel on both sides
of the stricture [99]. The portion of the bowel affected by the stricture is folded
onto itself in a U-shaped conformation. The posterior layer is closed first in a
continuous layer. Then, the anterior layer is sutured in an interrupted fashion. The
disadvantage of this procedure is the creation of a lateral diverticulum entailing the
risk of faecal stasis, bacterial overgrowth, and blind loop syndrome. The results
after Finney stricturoplasty are not consistent in terms of recurrence rate [96, 100].
Jaboulay stricturoplasty is a U-shaped entero-enterostomy at the level of the
normal bowel on the sides of a stricture. Two longitudinal incisions are performed
on the non-diseased areas so that the strictured portion is excluded from the newly
created route [101].
Combination of Heinecke-Mikulicz and Finney stricturoplasty [102] is indicated
for multiple strictures longer than 8–10 cm with short “skip” segments. This stricturoplasty is fashioned in a way that combines the two conventional types of
stricturoplasty. The bowel is incised with electrocautery in a longitudinal direction on the antimesenteric side of the strictures, the “skip” segment and 3 cm
of normal bowel. Separate sutures are placed at the midpoint and in the middle
of the strictures to balance the tension of the suture lines. The posterior layer is
sutured, and then the anterior layer is closed with interrupted seromuscular bites
with absorbable sutures.
Additional modifications of the Finney techniques have been described [13].
10.6.3 Enteroenterostomies
The following procedures are indicated for long fibrotic segments (up to 90 cm),
complex stenotic presentations, or atypical sites such as target bowel segments
with fistulas.
270 A. Spinelli and E. Paoluzzi Tomada
https://t.me/med1917
Side-to-side isoperistaltic stricturoplasty (Michelassi) [103]: this anastomotic
stricturoplasty was developed for long strictures of up to 80–100 cm) or multiple
strictures [7]. This procedure was created to overcome the limits of conventional
stricturoplasties, in particular the risk of an unyielding bowel segment and creating
tension on suture lines. The mesentery of the involved loop is sectioned, and the
bowel is severed with atraumatic clamps. The proximal loop is positioned over
the distal loop in a side-to-side alignment. Interrupted seromuscular sutures are
used to approximate the loops. Next, a longitudinal incision is performed on both
loops on the antimesenteric side. The stumps are fashioned to avoid blind ends
with spatulation. The outer suture line is performed with interrupted or running
full-thickness sutures, and the inner suture line is continued with a running fullthickness suture. Clips can be applied on the edges to allow imaging detection
of the anastomotic site. The Michelassi technique has proven to be safe, with an
acceptable recurrence rate of approximately 20% and low morbidity and mortality
[104].
Side-to-side Diseased to Disease-Free Anastomosis (Poggioli) [105] is indicated
for a long stenosis or runs of multiple short strictures. The bowel is opened at
the beginning of the stenotic area, and the mesentery is sectioned with vessel
ligation. The proximal disease free and, most often, dilated loop is brought below
the diseased segment. A longitudinal incision is performed on both segments on
the antimesenteric aspect. A running suture is performed with absorbable sutures.
Reinforcing stitches can be applied with caution to prevent knot tension on the
disease-free loop.
Modified side-to-side isoperistaltic anastomosis with double Heinecke-Mikulicz
procedure after intestinal resection (Sasaki) [106] is a variation of the strictur-
oplasty described by Michelassi, it modifies the closure of the two ends of the
anastomosis. The aim was to reduce the recurrence rate because of the increased
risk of recurrence at anastomotic ends. After intestinal resection, the bowel loops
are approximated in an isoperistaltic direction for a length of 8 cm. A longitudinal antimesenteric incision is performed on both sides. The ends are not
spatulated in this case. Heineke-Mikulicz transverse closure is performed at both
ends after opening the ends along stapling lines. This allows for enlargements at
the anastomotic inlet and outlet.
Modifications of stricturoplasties include the application of stricturoplasty over
the ileocaecal valve.
Modified side-to-side isoperistaltic stricturoplasty over the ileocaecal valve (modified Michelassi) [107] is a modification of the Michelassi stricturoplasty that
appears to be safe in patients with a long fibro-stenotic segment at the level of
the terminal ileum. This enteroenterostomy has been used both on the ileocaecal
valve in primary disease or on the ileocolonic anastomotic site of disease recurrence in secondary disease. The thickened bowel should be resected at a central
point of the strictured segment at a site of decreased wall stiffness to reduce the
risk of tension and the development of anastomotic leakage. The proximal bowel
end is then paired on top of the distal ileal side and opposed to the caecum. A
longitudinal incision is made on the antimesenteric side of the segment, starting
10 Anastomotic Techniques for Crohn’s Surgery 271
https://t.me/med1917
from the proximal end. The posterior layer of the anastomosis is started in a distalto-proximal direction. Then, the distal segment is longitudinally incised. Then, the
final anterior layer of the enteroenterostomy is performed. When needed, mucosal
haemostasis is achieved with interrupted Monocryl 3/0 stitches. One of the most
commonly reported complications is prolonged postoperative ileus, likely due to
prolonged intraoperative bowel manipulation. Endoscopic and radiological recurrence and the need for medical therapy after surgery were low in this case series.
Further comparative studies are needed.
10.7 Complications in Crohn’s Disease Surgery
The incidence of complications after surgery for CD is increased compared to
surgery for other benign and malignant conditions [108]. It appears that the preoperative status of patients with CD is poor and unfavourable to face the surgical
stress. Malnutrition, low body mass index, hypoalbuminaemia, anaemia, smoking,
and the long-term use of immunosuppressive drugs are all factors that can have
a negative impact on subsequent surgical outcome. Preoperative acute conditions
and intrabdominal sepsis should be treated prior to surgery where possible. In
general, it has been shown that surgery for acute conditions in CD patients results
in more extensive bowel resections and, in turn, higher postoperative complications [109]. A complete preoperative assessment is mandatory so that patients are
optimized. Nutritional status should be assessed, and enteral and parenteral nutrition considered when indicated [110]. Active disease should be clearly defined
with cross-sectional magnetic resonance imaging [15], to identify and eventually treat intra-abdominal nonsurgical complications. Additionally, preoperative
colonoscopy helps in defining the extent of disease. Anaemic patients should be
supplemented as low iron levels are associated with an increased complication rate,
specifically anastomotic leak. Smoking cessation programs should be offered to all
smoker CD patients. Smoking at the population level is one of the main predisposing factors for complications and for disease recurrence [111, 112]. Research
has focused on the use of immune targeting therapies and surgical safety, postoperative complication rate, and optimal timing. The impact of treatment with
anti-TNF agents, including infliximab, and newer drugs—vedolizumab and ustekinumab—on minimally invasive ileocaecal resections has been studied [113, 114].
No difference was found in postoperative complications between patients on or off
treatment. Guidelines do not recommend the termination of therapy of anti-TNF
agents perioperatively [7]. In contrast, corticosteroids should be stopped prior to
surgery as continuous use of steroid agents such as prednisolone 20 mg/daily has
been shown to increase postoperative complications [7].
The main postoperative complications after CD surgery are intra-abdominal
sepsis, including anastomotic leak, peritonitis, or intra-abdominal abscesses.
The anastomotic configuration has a marginal role in reduction of postoperative complications; as already discussed above, with the side-to-side stapled
configuration having a lower leak rate.
272 A. Spinelli and E. Paoluzzi Tomada
https://t.me/med1917
With regard to stricturoplasties, the rate of postoperative complications vary
from 0 to 57% [11, 13], with a reoperation rate of up to 50%. The main complications are anastomotic leak, fistula, and abscess formation. In general, HM
stricturoplasties are considered to have a reduced morbidity compared to Finney
stricturoplasties.
Frequent abdominal surgery with multiple resections are a major risk for CD
patient with the potential clinical nightmare of the development of SBS. This
results in a reduced absorptive surface area and a short bowel transit time. SBS is
defined as a malabsorptive condition for fluids, electrolytes, and nutrients necessitating permanent and continuous parenteral nutrition for 1 year after surgery
in stable patients despite medical and nutritional treatments. Remaining bowel
length < 200 cm (measured at the mesenteric side), undergoing total colectomy
and ostomy creation, and frequent surgery (≥ 3 times) are predictive factors for
the development of SBS in CD patients [31].
Unfortunately, postoperative complications in CD surgery are common and
can be very detrimental. Thus, careful preoperative disease and patient condition
assessment and proper surgical timing are crucial elements in CD surgery.
10.8 Considerations on Disease Recurrence
The rate of postoperative recurrence is up to 30% at 5 years, and one in 3 people
who had a resection will have a second within 10-years [33, 115]. A major focus of
research has been to find predictive factors for recurrence and potentially protective
factors. The earliest recurrence after surgical resection and anastomosis is evident
endoscopically as early as 1 week after surgery. Endoscopic recurrence is graded
according to the Rutgeerts score and its modifications [12, 116]. The relevance
of adapting the Rutgeerts score to the anatomic locations created by new surgical techniques has recently been defined [116]. A randomized controlled trial is
currently studying endoscopic recurrence and endoscopic findings that could predict postoperative recurrence, the Post-Operative Crohn’s Endoscopic Recurrence
(POCER) study [117](NCT00989560). The difficulty of correctly identifying
endoscopic disease recurrence has long been noted [52]. This is particularly so
for stapled anastomosis. Inverted and everted stapled lines, as described above,
heal differently, and ulcerations are common at inverted stapled lines as part of an
inflammatory healing process which is evident at 6-months at endoscopic followup [53]. The risk is to overscore recurrence at ileocolic anastomosis and re-initiate
medical therapy when it is not really needed.
Clinical recurrence is defined by the return of symptoms.
A variety of factors have been identified which may predict postoperative recurrence, including active smoking, perianal disease, penetrating disease phenotype,
prior surgery, and extensive small bowel resection. Active smoking has long been
established as a negative factor for all types of CD recurrence after surgical
resection [10, 111, 112].
10 Anastomotic Techniques for Crohn’s Surgery 273
https://t.me/med1917
Nutrition is another crucial element in CD surgery. Studies have been designed
to detect the role of enteral nutrition after ileal or ileocaecal resection, and show
positive impact with decreased postoperative recurrence [118, 119].
With the expansion of knowledge on the microbiota and the gut-immune axis,
the role of the gastrointestinal microbiome in postoperative CD patients has been
studied. A reduction in postoperative recurrence has been found to be associated
with specific species inhabiting the gut microbiota [120, 121].
Perianal disease and the penetrating disease phenotype are associated with a
more aggressive disease phenotype, and postoperative recurrence is higher.
The role of resection margins in CD resectional surgery has long been considered a possible factor predictive of recurrence. Initial evidence showed no difference in recurrence if transection was performed at a 2 cm distance or 12 cm from
macroscopic diseased margins [122]. Currently, a randomised clinical trial is being
undertaken, the Crohn’s Extension and Resection Trial—CERT—(NCT01876264).
The importance of the mesentery is increasingly being considered. The extent
of mesenterial excision during ileocaecal resection, is being investigated in a clinical trial aiming to confront central mesenteric resection with mesenteric sparing
approaches during the procedure in terms of 6 month endoscopic recurrence, the
Mesenteric SParIng Versus Central mesenterectomY in Ileocolic Resection for Terminal Ileitis in Crohn’s Disease trial—SPICY (NCT04538638). Another trial is
aiming to establish a role of wide mesenteric excision [123]. Conflicting ideas
dominate the discussion regarding the role of the mesentery, on one side as an
element fostering inflammation and disease, hence the idea of wide mesenteric
excision, on the other side as an essential anatomical part for anastomosis support
as in the Kono-S anastomosis [124].
We have considered in this chapter the specific anastomotic technique and configuration after ileocaecal resection and their potential role in the development of
recurrence. This belief mainly derives from the fact that, after ileocaecal resection,
most recurrences arise at the level of the anastomosis. However, no difference
has been found in terms of recurrence between side-to-side and end-to-end anastomosis [50, 124]. As described, promising results are becoming apparent from
studies on the Kono-S anastomosis. This technique demonstrates reduced endoscopic, clinical, and surgical recurrence. Interestingly, there is a wide variation in
anastomotic recurrence rate in terms of site of primary disease and anastomotic
creation [10, 34].
It is important to highlight that no matter how standardized an anastomotic technique is, the technical variability of a specific surgeon, can influence the outcome
and therefore probably also recurrence.
Laparoscopic versus open approaches do not seem to have differences in terms
of recurrence rate.
The role of medical therapies in reducing postoperative recurrence is under
study. Thiopurines, nitroimidazolic antibiotics, mesalamine and infliximab showed
a potential benefit in terms of postoperative recurrence [60].
Emerging data regarding CD recurrence underline the importance of specialised
CD professionals who can employ knowledge and experience in defining the risk
274 A. Spinelli and E. Paoluzzi Tomada
https://t.me/med1917
profile of each patient and are skilled in the techniques that are required for CD
surgery.
10.9 Conclusions and Future Perspectives
In CD surgery, there is a persistent search for surgical procedures that reduce the
rate of postoperative complications and, above all, decrease the risk of recurrence.
With this in mind, many different anastomotic techniques have been studied [34].
Nevertheless, anastomotic site-specific postoperative morbidity and recurrence are
relevant. No main differences were demonstrated among the different anastomotic
types for restoration of bowel continuity after ileocaecal resection with respect
to these two major outcomes. Stapled or handsewn, side-to-side or end-to-end,
and isoperistaltic or anisoperistaltic, are only some of the possible options for the
configuration of the anastomosis. The most commonly performed anastomosis is
the stapled side-to-side isoperistaltic ileocaecal anastomosis. Regarding postoperative complications, in an initial large meta-analysis, end-to-end anastomosis was
shown to have a higher anastomotic leak rate than other techniques, including the
stapled SSA [55]. In the same study, no difference in the main long-term outcome
of recurrence was observed. Another meta-analysis further reinforced the potential
advantage of stapled SSA over handsewn EEA, specifically in terms of a reduced
anastomotic leak rate [8]. As far as long-term outcomes are concerned, postoperative recurrence was found to be comparable between the two studies. Therefore,
there appears benefit in SSA, but the available evidence is not conclusive.
A significant change in CD surgery in recent years was brought about by the
introduction of the antimesenteric functional end-to-end handsewn anastomosis,
the Kono-S anastomosis [9]. The novelty and encouraging results that have been
forthcoming by the implementation of this type of anastomosis are unique. In the
first multicentre study, the 5-year cumulative surgical recurrence rate was 1.7%
[63]. Nevertheless, the Kono-S anastomosis requires high technical skill and experience. New variations to improve its reproducibility are being developed in order
to reduce the anastomotic recurrence rate. A deeper understanding of the healing
processes associated with each anastomotic type (i.e., stapled versus handsewn)
will hopefully shed light on potential advantages of a specific anastomosis over
another.
The important criteria that guide CD surgery are those of bowel sparing and
minimal invasiveness. Bowel sparing renders CD surgery particularly challenging
and encourages surgeons to explore possible non-resectional procedures. Stricturoplasty techniques are increasingly being used and adapted to complex anastomoses
to include thickened fibrotic bowel loops [103, 107]. The major stimulation is the
increasing knowledge on mucosal healing and possible reversal of fibrostenotic
conditions [3].
Postoperative disease recurrence, postoperative complications and patients’
expectations and desires are all significant factors promoting surgical approaches
designed to reduce the possible negative impact of surgical stress. For this reason,
Соседние файлы в папке @xirurgi_2025