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Surgical Technique and Difficult Situations for Crohn Disease from Adrian Greenstein
205
26
26.3 Duodenal Fistula
Most duodenal stulae originate in other areas
of diseased bowel, usually colon and occasionally
small bowel or ileocolonic anastamoses, but there
may be intrinsic duodenal Crohn’s disease as the
source of the stula. e symptoms of duodenal
stulae include diarrhea and weight loss, but they
may be asymptomatic and occasionally can only
be recognized upon surgical exploration [4, 5].
Duodenal stulae or strictures may be complicated by multiple jejunal or jejunoileal strictures
or other stulae. ese must all be dealt with
simultaneously. On occasion, a duodenal stula
may be complicated by a coloduodenocutaneous
component if it follows previous laparotomy. It is
important to appreciate that duodenal stulae may
originate in the small bowel or sigmoid colon in
proximity to the transverse colonic mesentery, as
the stulae may pass through the mesentery into
the duodenum. If the stula is not recognized and
repaired, postoperative intra-abdominal abscess
and/or duodenocutaneous stula may develop.
Surgery for duodenal stulae may be relatively
simple if there is only a pinpoint opening which
may be closed in two layers. Generally, however,
these stulae require advanced surgical technique,
and because of the proximity of the pancreaticoduodenal vessels, resection is not an option. Although
a laparoscopic approach is possible, duodenal stulae require advanced laparoscopic technique
with intracorporeal sewing. Because of the depth
of the duodenum and the diculty of dissection,
duodenal stulae should generally be done as open
procedures using lighted Britetrac retractors for
adequate exposure. To limit the length of the incision, the exures can be mobilized laparoscopically
if one has a coloduodenal stula. Aer appropriate
separation from the duodenum and then resection
of the diseased colon or small bowel, one can begin
to address the duodenum itself. As with duodenal
ulcer perforation, it is important when repairing a duodenal stula that the edges be freshened
back to well-vascularized pliable tissues. A limited
wedge excision in a transverse direction is sometimes possible without compromising the lumen.
Once this has been carried out, we always cover
the repair with a jejunal patch, sutured circumferentially with interrupted #3-0 silk. If the lumen is
narrowed, then a gastroenterostomy or Roux-en-Y
duodenojejunostomy may be required.
26.4 Sigmoid and Rectal Fistulae
Ileosigmoid and Ileorectal stulae are relatively
common, representing 8.9 % of all internal stulae. If large, they can result in an increase in the
frequency and volume of liquid stool. e patient
may have an appreciation of two forms of stool:
one liquid and of large volume aer having passed
directly through the stula; the second, relatively
formed, having passed through the entire colon
with concentration of the stool in the usual fashion with extraction of most of the liquid. It is not
uncommon to nd more than one ileosigmoid
stula. Management is dependent on the site of
origin which is usually the more proximal terminal ileum, but occasionally the sigmoid. On occasion, there is disease of both the terminal ileum
and sigmoid colon [6].
e extent of distal disease must be determined by preoperative colonoscopy. Aer stula
takedown, if both areas are diseased, the complex
mass should be resected “en bloc.” If the distal
component of the stula is nondiseased, it may be
closed with interrupted #3-0 transmural sutures
or in two layers– inner #3-0 Vicryl and outer #3-0
seromuscular silk. Although some surgeons staple
between the two loops with a thick load stapler,
the closure of the nondiseased side can be somewhat precarious due to friability of the tissues–
therefore, oversewing is advisable in these cases.
While simple ileosigmoid stulae can oen be
approached laparoscopically, stulae low in the
sigmoid colon or more distal in the region of the
rectouterine or rectovesical pouch should generally be approached in an open fashion. e pelvic
dissection is usually best done bluntly and needs
hand and nger assistance until the small bowel
and/or sigmoid has been elevated out of the deep
pelvis. Continuing down the rectum to an area
below the disease for anastomosis should be done
under direct vision, avoiding damage to the bladder in the absence of stula, autonomic nerves,
and iliac vessels and ureters. It is imperative that
the rectum be evaluated during the surgery with a
rigid or exible sigmoidoscope as well as through
palpation and/or visualization. A potential point
for transection of the rectum can be marked by
passing a needle through the rectal wall.
Aer dissecting below the site of disease, one can
consider anastomosing distally in the same way as
a low anterior resection is routinely done, although
26
206
A.J. Greenstein and A.J. Greenstein
this anastomosis in a friable pelvis is typically challenging. e rectum should be transected with a 45
or 60mm TA stapler, and the anastomosis should
be performed with a 28mm EEA stapler. In Crohn’s
disease, it is sometime dicult to pass a 33 mm
stapler through the rectum as it may be somewhat
narrowed at a more distal level. If the anastomosis cannot be done to normal rectum, which has
been “spared,” a diverting proximal loop ileostomy
should be carried out at the end of the case or an
abdominoperineal resection and permanent ileostomy may have to be performed. Postoperatively
the anastomosis should be reevaluated at 5–8 weeks
with a barium enema prior to closure of the diverting ileostomy if one has been done.
Two dicult types of primary sigmoid or rectal
stulae that we have encountered include extraperitoneal and mesenteric stulae. With an extraperitoneal stula, it can extend through the pelvic
peritoneal oor and enter the rectum below the
peritoneal reexion. It is sometimes dicult to
appreciate this type of stula, especially if there is
extreme friability of the tissues and multiple stulous openings. Mesenteric stulae can also be virtually impossible to detect preoperatively and remain
undetectable intraoperatively. Air passed through
the rectum may fail to pass through a serpiginous
stula and cannot be relied upon to rule out a stula. If one recognizes a diseased sigmoid or rectum
with concomitant abscess, one must assume there
to be a stula even it cannot be detected and resect
the diseased portion of bowel, with coloproctostomy to normal or relatively normal distal bowel.
26.5 Stricturing Disease
Strictures are a common problem that we encounter among our patients with Crohn’s disease. For
most short strictures, a Heineke-Mikulicz-type
strictureplasty suces. e stricture is incised
longitudinally through the strictured area onto
normal adjacent bowel when possible for at least
4–5cms. e closure should be done in 2 layers:
an inner continuous #3-0 Vicryl Connell suture
and an outer #3-0 silk seromuscular suture placed
either as a continuous or interrupted suture
depending on the length of the diseased and adjacent normal bowel and the longitudinal incision.
A Finney pyloroplasty should be reserved for long
strictures when preservation of bowel is critical;
otherwise, long strictures should be resected or
. Fig. 26.4 Stricture plasty with invagination of
mucose using continous connell suture
treated in selected cases by a Michelassi or Sasaki
strictureplasty [7, 8]. Double adjacent strictures
can be treated by a Fazio strictureplasty [9].
Of our patients with stricturing disease, the
most problematic are those with extensive continuous disease with intermittent strictured areas
and/or multiple stulae (. Fig. 26.4). We have
seen up to 30 strictures in at least two patients
and generally nd at least twice as many strictures during the operative period as can be seen
radiologically in the preoperative period. Clinical
judgment is essential in these complex patients,
and strictureplasty is oen carried out with concomitant small bowel or ileocolic resection. e
duration of surgery is usually very long but the
outcome gratifying, despite the high probability
of recurrence. e number of strictures and the
number of strictureplasties are associated with
Crohn’s disease recurrence and may be used as
prognostic indicators for Crohn’s disease [10].
Eventually if satisfactory conservative surgery
fails, an intestinal transplant is an option today.
We have seen the development of Crohn’s disease
in the transplanted bowel although this is rare.
26.6 Conclusion
Complex Crohn’s disease may occur with any of
the three groups, perforating, non-perforating,
and inammatory, but stulizing disease tends
to create the most dicult surgical problems.
Despite major advances in the medical therapy
of this disease, most patients require surgical
treatment at some time which has become more
favorable given the advantages conferred by
Surgical Technique and Difficult Situations for Crohn Disease from Adrian Greenstein
207
26
laparoscopic surgery. With careful monitoring
and appropriate treatment, patients with Crohn’s
disease can expect to live a relatively normal life
with good control of their symptoms.
References
1. Greenstein AJ, Janowitz HD, Sachar DB. The extraintestinal complications of Crohn’s disease and ulcerative colitis: a study of 700 patients. Medicine
(Baltimore). 1976;55:401–12.
2. Gilberts EC, Greenstein AJ, Katsel P, et al. Molecular
evidence for two forms of Crohn disease. Proc Natl
Acad Sci U S A. 1994;91:12721–4.
3. Greenstein AJ, Lachman P, Sachar DB, et al. Perforating
and non-perforating indications for repeated operations in Crohn’s disease: evidence for two clinical
forms. Gut. 1988;29:588–92.
4. Klein S, Greenstein AJ, Sachar DB. Duodenal fistulas in
Crohn’s disease. J Clin Gastroenterol. 1987;9:46–9.
5. Shapiro M, Greenstein AJ, Byrn J, et al. Surgical management and outcomes of patients with duodenal
Crohn’s disease. J Am Coll Surg. 2008;207:36–42.
6. Heimann T, Greenstein AJ, Aufses Jr AH. Surgical management of ileosigmoid fistula in Crohn’s disease. Am
J Gastroenterol. 1979;72:21–4.
7. Sasaki I, Funayama Y, Naito H, et al. Extended strictureplasty for multiple short skipped strictures of Crohn’s
disease. Dis Colon Rectum. 1996;39:342–4.
8. Michelassi F. Side-to-side isoperistaltic strictureplasty
for multiple Crohn’s strictures. Dis Colon Rectum.
1996;39:345–9.
9. Fazio VW, Tjandra JJ. Strictureplasty for Crohn’s disease
with multiple long strictures. Dis Colon Rectum.
1993;36:71–2.
10. Greenstein AJ, Zhang LP, Miller AT, et al. Relationship
of the number of Crohn’s strictures and strictureplasties to postoperative recurrence. J Am Coll Surg.
2009;208:1065–70.
209
Surgical Technique and
Dicult Situations from
Karl-Heinz Vestweber
Karl-HeinzVestweber
27.1 Crohn’s Disease – 210
27.1.1 Technical Aspects oftheIntestinal Anastomosis – 211
27.1.2 Suturing Technique oftheAnastomosis – 212
27.1.3 Intestinal Stenosis: Strictureplasties – 212
27.1.4 Abdominal Fistulae – 214
27.2 Cancer andUlcerative Colitis# – 220
27
27.3 Conclusions – 220
27.4 Abdominal Drains AfterOperations
Because ofCrohn’s Disease
ofUlcerative Colitis – 220
27.5 Dicult Situations – 221
References – 225
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_27
210
K.-H. Vestweber
27
27.1 Crohn’s Disease
Surgical interventions especially for chronic
inammatory bowel disease were recognised at
the end of the nineteenth century. e name
Crohn’s disease was created aer B.B. Crohn has
described the regional ileitis in 1932.
LESNIOWSKI from Poland describes already
1904 changes of the bowel wall corresponding
to “Crohn’s lesions”. In 1913 the Scottish surgeon Dalziel operates on stenosis of the ileum
which hedescribes as inamed and sti like “an
eel in rigour mortis”, obviously “ileitis terminalis
Crohn”.
Without doubt Crohn’s disease is a domain of
conservative treatment, and the indications for
surgical interventions are either complications
such as stulas, abscesses, ileus or perforations or
sometimes symptomatic resistable inammations, which cannot be successfully treated by
adequate medications.
It is remarkable that even aer the introduction of highly eective drugs such as the antiTNF- alpha drugs (iniximab), the number of
surgical procedures has not changed substantially [1].
According to the surgical incisions, I do not
think that paramedian or pararectal accesses are
appropriate approaches for Crohn’s disease patients.
Especially young patients oen need several operations during their lives – possibly in dierent
abdominal quadrants, which results sometimes in a
further dierent incision. Sometimes an ostomy is
necessary and the previous scares interfere with the
position of the intended ostomy site.
Since the mid-1990s, laparoscopic approaches
became available routinely.
Additionally to the trocar incisions, usually a
separate incision becomes necessary to take out
the specimen from the abdomen. To nd the best
location for this is also crucial (f.i., Pfannenstiel
incision).
Recently natural orice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) became available and
proved to be very helpful especially for inammatory bowel diseases.
Single-port incisions take place directly at the
umbilicus or a later stoma location. It is possible
to plug in all three working ports and at the end to
take out the specimen aer removing the SILS
port ([2],
. Fig.27.1a–f).
a
d
. Fig. 27.1 Single-port operation through the umbilicus.
a Umbilical incision with the wound protector (Alexis) in
position. b Introduction of the exible SILS port with trocars. c Extrusion of the SILS port together with the closed
e
b
c
f
end of the bowel. d The large bowel exteriorized through
the umbilical incision. e Closure of the umbilical wound.
f Remaining a little incision with a small plaster
Surgical Technique and Dicult Situations from Karl-Heinz Vestweber
27.1.1 Technical Aspects of the
Intestinal Anastomosis
For decades, we used an end-to-end anastomosis
aer ileocoecal resection. e lumen of the bowel
endings was equalised by using an oblique to
straight technique from the small bowel to the
large bowel (. Fig.27.2).
Some new data show that at least the old sideto- side anastomosis is suitable again. Nowadays
we use the side-to-side construction in most cases
([3, 4], . Figs.27.3 and 27.4).
. Fig. 27.2 End-to-end anastomosis after ileocoecal
resection. The lumen is brought into line by oblique cut in
the small bowel and a right angle cut in the large bowel
211
27
a
c
e
b
d
. Fig. 27.3 a Side-to-side anastomosis. First row single
sutures with closed bowel lumen. b Bowel lumen opened
after nishing the back wall of the anastomosis. c Second
back wall row– continuous monolament suture. d Continuous Connell suture of the anterior wall. e Additional sutures
(single stitch) nishing the anastomosis
27
212
K.-H. Vestweber
. Fig. 27.4 Side-to-side anastomosis using a GIA stapler
27.1.2 Suturing Technique of the
Anastomosis
In the 1970s, we constructed the intestinal anastomosis by using the classical seromuscular single
stitch method with extramucosal sutures. Prof.
Goligher suggested to use a double-row variation
in the 1980s, which was accepted by my chief
Prof. Troidl.
5 Both ends of the bowel (usually closed by sta-
ples or clamps) are brought together.
5 First row with single stitches of absorbable
sutures.
5 Aer opening of the bowel lumen on both
sides, an absorbable running suture nishes
the posterior wall.
5 e anterior wall is closed by an inverting
running “Connell suture”.
5 Outside-inside/inside-outside.
5 Contralateral: outside-inside/inside-outside
5 Aer slightly dragging the usually monola-
ment running suture, the bowel wall inverts.
Care must be taken not to take too much tissue as there is the certain risk of stricture formation. e stitches are therefore best
performed, close to the cutting line.
5 A second row of interrupted sutures com-
pletes the continuous suture. It is important
to make sure that only little additional tissue
is inverted– again to be sure not to create
stenosis. Technically best is to keep the anastomosis with the le hand on the thumbindex nger and then put in the individual
stitches. Some of my colleagues put the second row of sutures also continuously using
monolament material– that makes obviously no dierence.
5 Of course the side-to-side anastomosis can be
performed in stapling technology (GIA suturing device).
I personally oversew the staple line of the anastomosis with some ne single sutures, especially
in the tip of the anastomosis (at the end of the
stapling device). Leaks of the anastomosis were
localised most oen at this site and occasionally
also at the closing site of the introduction holes
for the stapler branches. My personal preference is the closure of this suture device insertion openings also by double-row technique
(Connell suture and ne interrupted stitches
additionally).
Small bowel anastomoses can also be performed using the side-to-side or end-to-end technique. For side-to-side anastomosis, we make
sure that no big “CECA” arise.
27.1.3 Intestinal Stenosis:
Strictureplasties
Whenever a resection can be avoided, it should be
avoided. It is the aim to preserve as much bowel as
achievable. One possibility is strictureplasties,
which correct scarred stenosis by plastic methods
without resecting bowel.
At the beginning of the 1980s, strictureplasties
were introduced in the surgery of Crohn’s disease
by the surgical research group of Sir John
Alexander Williams in Birmingham [5].
e original technique of the HeinekeMikulicz pyloroplasty was used in stomach ulcer
surgery to correct strictures in the pyloroduodenal area.
is technique is particular suitable for short
segment stenosis. In this case, just like pyloroplasty, the bowel is opened between two stay
sutures (one on each side of the stricture). e
incision is longitudinal with an adequate length.
en the longitudinal incision is pulled apart into
a transverse direction. e result is the desired
widening of the stenosis. A double-row suture is
then carried across accordingly (. Fig.27.5).
For long strictures, which should not be
resected (f.i., already short bowel), another
Surgical Technique and Dicult Situations from Karl-Heinz Vestweber
213
27
a
. Fig. 27.5 a A short stricture in the small bowel wall because of long-lasting Crohn’s disease. b Strictureplasty suture
(Heineke-Mikulicz technique), rst row continuous Connell suture
b
. Fig. 27.6 More than ten strictureplasties with vari-
ous techniques to treat many stenoses in a patient with
relatively short bowel (around 2m)
technique originating from stomach surgery can
be used. e Finney pyloroplasty allows a wide
side- to- side anastomoses [6].
In very dicult cases with extraordinary long
strictures, a very long side-to-side anastomosis
can be used, especially in those cases which would
result in short bowel syndromes aer loosing
bowel length further [7].
Recent data show new dierent constructions
of strictureplasties. e aim is always to preserve
bowel length as much as possible [8].
If the bowel is already critically short, we do
not hesitate to use many strictureplasties in a single case instead of resection (
. Fig.27.6).
Our own data represent 57 patients with 130
strictureplasties. Main indications for the procedures were subileus because of enteric stenosis
. Fig. 27.7 Heineke-Mikulicz strictureplasty more than
2 years after the primary construction. No restenosis happened. The “thumb-index nger test” is easily possible
and stulation and sometimes even conglomerate
masses.
Relatively rare are restenoses at the former site
of strictureplasty [9].
. Figure27.7 shows an old
strictureplasty at a reoperation more than 2 years
aer primary surgery.
During surgery for Crohn’s disease, it makes
sense to explore the small intestine for stenosis
and measure the length of small bowel to retain it
in the operating report. Also during laparoscopic
surgery, the intestine can be checked for lesions
with atraumatic endoscopic instruments.
Preoperatively, we ask for a hydro-MRI to check
especially the small bowel; this of course can be
done without radiation and gives helpful hints on
pathologic ndings.
214
K.-H. Vestweber
27
a
c
. Fig. 27.8 a A young female patient with Crohn’s
disease coming into the emergency department with
septic shock. The inner side of the thigh showing a sharply
marked blue-violet demarcation at the skin level. b After
incision ischemic tissue could be seen. c Exploration into
b
d
deep spaces shows signs of necrotizing fasciitis and myositis. d The reason for this infection: a stula from Crohn’s
involved large bowel to the retroperitoneum. The infection
descended through the pelvic structures into the thigh. The
inner stula in the pelvic wall can be seen at the picture
27.1.4 Abdominal Fistulae
Fistulae are commonly associated with Crohn’s
disease. ey can penetrate into dierent structures. In enterocutaneous tracts, bowel content
reaches the skin, enteroenteric channels lead to
short circuits, and enterovesical and retroperitoneal can cause severe infectious complications. In my opinion, all those types of stulae
have to be treated immediately or at least aer a
short period of conservative approaches –
surgically.
In particular, I have experienced dangerous
entero-retroperitoneal stulae which spread into
the retroperitoneal space and cause very severe
descending infections into the pelvis and the
thigh with septic shock (. Fig.27.8a–d).
Enterocutaneous stulae can interfere with
the quality of life of the patients massively, so they
should be treated to resolve the very distressing
symptoms. Sometimes they can be corrected quite
easily during operations, f.i., if one stula from
the small bowel loop to the skin exists. Aer
. Fig. 27.9 Enterocutaneous stulae in the suprapubic
abdomen. The stulation comes from a singular small
bowel stula
correcting the defect, the quite unpleasant symptoms resolve quickly (
. Fig.27.9).
If enteroenteric stulae, for example, from the
upper jejunum to the large bowel exist, this can
cause massive malnutrition. Long-lasting conservative attempts are useless; a careful preoperative
nutritional therapy is necessary; most oen parenteral nutrition is required [10].
Surgical Technique and Dicult Situations from Karl-Heinz Vestweber
a b
c
215
27
. Fig. 27.10 a A barium contrast follow through shows
an early passage from the upper jejunum into the transverse
colon. The patient suered from severe malnutrition. b
Schematic sketch of the intraoperatively found situation.
An example of an enteroenteric stula with
short circuit from the upper jejunum to the transverse colon is shown in . Fig.27.10a–c. e orally
given contrast agent shows in the upper jejunum a
direct access to the transverse colon.
e operation demonstrates a complex system
of several stulae before and within a jejunal stenosis draining directly into the colon. e small
bowel below the stenosis was suciently long and
was without further lesions. Aer resection of a
short segment of the jejunum and colon including
the stula tracts, the patient recovered quickly
with major improvement in nutritional status and
quality of life.
Personal Conclusion forSurgical
Treatment ofCrohn’s Patients
As long as possible, a conservative approach for
Crohn’s disease is justied. Early interdisciplinary
consultations between gastroenterologists and
Behind the stula from the jejunum to large bowel, quite
long healthy small bowel is present. c The operative specimen shows the short resected parts of small and large
bowel, stulae are marked
visceral surgeons are important. Special oce
hours for those patients are required. Experienced
consultants are necessary for best treatment of
those patients with oen dicult courses of the
diseases.
If bowel stenosis occurs or conservative treatment is not successful or has too many side eects,
surgery has to be considered. Resections are carried out with preserving as much as bowel as possible. In the moment, side-to-side anastomosis is
preferred for restoration of continuity; we use a
two-layer anastomotic technique.
Strictureplasties in many technical variations
and correction of enteric stulae should be used
freely according to necessity.
Ulcerative Colitis
Ulcerative colitis is a disease with particularly
bloody diarrhoea. is disease has been recognised
very early in history. However, surgical approaches