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19 Stricturing Crohn’s Disease: Strictureplasty
279
c
d
Fig. 19.9 Michelassi strictureplasty
longitudinal enterotomy is made on both overlapping segments, and a side-to-side
enteroenterostomy is then performed in the usual manner. The use of proximal, nondiseased bowel offers better laxity of the mesentery and better suture line integrity.
However, it should be cautioned that this technique is challenging to perform and
carries the inherent risk of a potential two-fold bowel loss should the repair fail or a
complication arise (Fig.19.10).
Allthough the initial diameter of the small bowel is larger in the Poggioli stricutreplasty the main disadvantage is the risk of extensive bowel loss shall the stricutreplasty need to be resected.
Sasaki etal. [49] describe a variant of Michelassi’s technique in which Heineke–
Mikulicz strictureplasty is added to both ends of the strictureplasty (Figs.19.11
and 19.12).
280
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G. Bislenghi and A. D’Hoore
Fig. 19.10 The Poggioli isoperistaltic stricutreplasty
Fig. 19.11 Sasaki
modication at the in- and
outlet of the isoperistaltic
stricutreplasty to avoid any
early stenosis at the inlet
19 Stricturing Crohn’s Disease: Strictureplasty
Fig. 19.12 Peroperative
view an a long
isoperistaltic strictureplasty
with a Sasaki modication
at the inlet of the
strictureplasty
281
19.4.2.6 Results
Short-Term Results
The safety and feasibility of strictureplasty for Crohn’s disease has been well validated. In a meta-analysis by Yamamoto etal. [40], 1112 patients who underwent
3259 strictureplasties were studied. The overall morbidity rate was 13% and the
mortality rate was nil. Only 4% of patients developed a septic complication, such as
anastomotic leak, abscess formation, and stula. Less than half of these patients
required a laparotomy for sepsis. The strictureplasty site was commonly associated
with sepsis (78% of patients). The postoperative hemorrhage rate was 3%. In a more
recent systematic review and meta-analysis more than 1600 patients who had over
4500 stricturoplasties were described [43]. The reported overall complication rate
was low, ranging from 5% to 20% and mortality rate was nil. Long-term recurrence
rates ranged from 25% to 70%. Interestingly, half of the patients included had strictureplasties as the rst surgical procedure.
The most common complications after strictureplasty were small bowel obstruction (2.6%), intra-abdominal septic complications and suture leakages (4.2%), and
intra-luminal and intra-abdominal bleeding (3.2%), with a cumulative re-operation
rate of 2.8%. The main risk factors claimed to inuence post-operative complications were malnutrition, hypoalbuminemia, unscheduled surgery, peritonitis, intraabdominal septic complication with peritoneal contamination, anemia, and older
age. In contrast, steroid use, synchronous bowel resection, and number, site, or
lengths of strictureplasties were not signicant risk factors. Only 5 cases of adenocarcinoma of the small bowel arising at a strictureplasty site have been reported
(0.3%.) Therefore, routine biopsy with frozen section before performing a strictureplasty is not advised [40, 42, 43, 50, 51].
Strictureplasty is safe and does not confer increased morbidity when compared
with small resections and anastomosis. In a meta-analysis by Reese etal. [52] 662
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G. Bislenghi and A. D’Hoore
patients, who underwent strictureplasty or bowel resection were examined. The
overall early postoperative complication rate of strictureplasty was 12.7% compared to 19.1% in the resection group, septic complications occurred in 8.1% of
strictureplasties, and 11.2% of intestinal resections, and postoperative hemorrhage
rates in 3.0% vs. 6.7%, respectively. None of these differences was statistically
signicant.
A word of caution about the actual role of strictureplasty in small bowel Crohn’s
disease: the indications of strictureplasty has been expanded over the last years
probably because many authors reported the procedure as safe. If strictureplasty is
an alternative treatment to resection for brotic strictures under all circumstances
remains unclear. Several studies have compared the outcomes of the two techniques.
However, in those studies strictureplasty was mainly used for short brotic strictures and resection was used for phlegmonous disease, long strictures, abscess and
stula. The inclusion of a wide variety of disease presentations obscures their comparison. Therefore, there is no clear direction for surgeons in choosing one or the
other procedure. Well-designed prospective studies are necessary to compare the
outcomes of strictureplasty and resection.
Data for procedure-specic recurrence rates are available only for a few strictureplasty techniques.
Campbell’s meta-analysis has compared the efcacy and safety of conventional
strictureplasty techniques (Heineke-Mikulicz, Finney) to nonconventional strictureplasty techniques (modied Finney, combined Heineke-Mikulicz and Finney, modied Heineke-Mikulicz, Michelassi, and others). The Heineke-Mikulicz technique
was the most commonly (>90%) used conventional strictureplasty. The Michelassi
technique was the most commonly used non-conventional strictureplasty (>80%).
Nonconventional strictureplasty had the same, if not lower rates, of complications
compared with the more conventional techniques. Specically, long-term (recurrent
stricture, small bowel obstruction, reoperation, carcinoma, and deaths) and shortterm (small bowel obstruction, sepsis, postoperative bleed, other infections) complications were analyzed. Early complication rates were 15% for conventional
strictureplasty versus 8% for nonconventional strictureplasty, while late complications were 29% for conventional strictureplasty versus 17% for nonconventional
strictureplasty. Non-conventional, advanced strictureplasty techniques do not confer
a higher postoperative morbidity risk than conventional, simpler strictureplasty
techniques [43].
The Michelassi side-to-side isoperistaltic strictureplasty should be discussed
separately. This type of strictureplasty has been validated as feasible and safe in
several smaller studies. An international multicenter observational study of 184
patients with Crohn’s disease who underwent a side-to-side isoperistaltic strictureplasty determined that the overall morbidity rate was low, ranging from 5.7 to
20.8%. In this series, the length of diseased bowel selected for strictureplasty ranged
from 20.8±9.9cm to 64.3±29.3cm and synchronous strictureplasties were performed in 41.9–83.3% of cases [51].
19 Stricturing Crohn’s Disease: Strictureplasty
283
Long-Term Results
Strictureplasty sites are not immune from disease recurrences. Reese et al. [52]
found no difference in terms of recurrence or need of surgical treatment between
strictureplasty and resections (37.8% vs 31.0%). Patients undergoing strictureplasty
were 8% more likely to experience surgical recurrence than patients undergoing
resection (p=0.01). The site of the recurrence was not specied. Similarly, Bellolio
etal. reported a reoperation rate after strictureplasty of 45.7% at a median follow-up
of 63months. The surgery free-survival after 5 and 10years was 70.7% and 26.6%
respectively. Again, the site of recurrence was not reported [53]. In the series with
the longest mean follow-up (107months), 54% of patients had developed a symptomatic recurrence and 44% required surgery at 10years [54]. Dietz etal. [55] in a
retrospective review of 314 patients who underwent 1124 strictureplasty procedures
reported an operative recurrence rate of 34% within a 7.5years of follow-up period.
Yamamoto analyzing more than 3200 strictureplasties found a 5-year site-specic
recurrence rate of only 3% [40]. Fichera etal. published data about 78 patients with
134 sites requiring operative intervention (85 requiring resection and 49 amenable
to strictureplasty). Signicantly fewer recurrences at strictureplasty sites compared
to resection sites (45% vs. 70%; P<0.05) were observed.
Data for procedure-specic recurrence rates are available only for a few strictureplasty techniques. Campbell etal. reported recurrent structuring disease in 32% of
patients with conventional strictureplasties and 17.8% of patients with unconventional
strictureplasties over a mean follow-up of 50months. In the series of Tichansky etal.
[56] recurrence rates ranged from 23% for the Finney strictureplasty to 32% for the
Heineke-Mikulicz strictureplasty. Interestingly, only 8% of recurrences occurred on a
previous strictureplasty site, most of the recurrences occurring away from it. Similarly,
Yamamoto analyzes data from 3259 strictureplasties and assesses an overall symptomatic recurrence rate of 39% for jejunoileal strictures (161 out of 411 patients) and
36% for ileocolonic strictures (9 out of 25 patients). Strikingly, only 3% or 20%,
respectively, of strictures were found at the previous site of strictureplasty [42].
Over the years ambiguous long-term results have been reported when the Finneylike strictureplasties have been compared to the Heineke-Mikulicz. In some papers
this technique has been reported to have a higher recurrence rate, probably due to
the creation of a large, lateral diverticulum with faecal stasis and bacterial overgrowth [55]. Experience with recurrences and need of surgery is accumulating
slowly after performance of a side-to-side isoperistaltic strictureplasty. One observational study [51] reported recurrence rates of 7.6% after a mean follow-up of
35months, with most recurrences sited at the inlet and outlet of the side-to-side
strictureplasty. As consequence of this observation, some authors began to advocate
performance of a Heineke-Mikulicz strictureplasty at the inlet and outlet, respectively. Recently, Tonelli etal. published long-term results about 91 patients undergoing side-to-side strictureplasty. This is one of the series with the longest follow-up.
Fourty-four percent of patients developed a recurrence at a median follow up of
284
G. Bislenghi and A. D’Hoore
55months. The recurrence involved the strictureplasty site in 24 patients (28.9%)
after a median follow up of 48months, being surgical in 15 patients. The surgical
recurrence affected the SISS body in 8 patients, the inlet in 4 patients and the outlet
in 3 patients. Age at diagnosis, family history and smoking habit were found to be
independent factors of relapse. The S-S plasty lead to a resolution of symptoms in
more than 90% of cases. Even after long-term follow-up data suggest encouraging
results for this type of strictureplasty [57].
19.5 Future Perspectives
There is an ongoing quest to avoid classical ileocaecal resection and to encorporate
strictureplasties over the ileocecal valve. This idea is not new but was limited to the
length that could be treated with the classical sitructreplasty (Fig.19.13).
However, there was a recent interest to adapt the isoperistaltic stricutreplasties as
an alternative for resection. As the ultimate bowel sparing techniques, a modied
side-to-side isoperistaltic strictureplasty over the ileocaecal valve for the treatment
of terminal ileal Crohn’s disease has recently been proposed [58, 59]. Several surgeons have used a side-to-side isoperistaltic strictureplasty to treat terminal ileal
Fig. 19.13 Finney and HM over the valve for short terminal and valve strictures. These techniques
are merely reserved for short anastomotic strictures
19 Stricturing Crohn’s Disease: Strictureplasty
285
Crohn’s disease (CD) and some have performed a side-to-side isoperistaltic ileocolic strictureplasty (SSIS), incorporating the ascending colon into the strictureplasty.
Others have combined a segmental resection with an SSIS. Our preference is not to
incorporate the terminal ileum into the strictureplasty unless it is diseased. This
avoids the loss of healthy bowel when a resection of the strictureplasty might be
necessary because of leakage or surgical recurrence. When performed the strictureplasty is extended through the ileocaecal valve, which is often affected by disease.
After laparoscopic mobilization of the right colon, the terminal ileum and proximal
part of the ascending colon are exteriorized through an umbilical incision. The
length of the diseased segment is measured. A suitable point to divide the bowel and
mesentery is selected in the middle of the loop. A short healthy area of bowel avoiding excessive brosis or inammation is preferred to avoid too much traction on the
strictureplasty. The bowel and part of the mesentery are divided to enable mobilization of the proximal part through the ileocaecal valve. The most proximal loop is
opened longitudinally by monopolar cautery and the strictureplasty is started at the
outlet, using interrupted Vicryl 20 sutures (Johnson & Johnson (New Brunswick,
New Jersey, USA); Vicryl suture 2-0, V323H) for the posterior suture line. The more
distal loop is then opened longitudinally to include the ileocaecal valve and the
anterior suture line is inserted. Additional separate stitches are used as required for
haemostasis. An appendectomy is routinely performed in all cases. The strictureplasty ends at the inlet, giving the opportunity to perform the Sasaki modication,
which incorporates enlargement at the inlet by an HM strictureplasty (Fig.19.14).
Fig. 19.14 MR
enterography
demonstrating a long
diseased terminal and
preterminal ileum.
Classical surgery would
indicate ileocaecal
resection
286
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G. Bislenghi and A. D’Hoore
To allow bowel sparing in this case a long stricutreplasty isoperistaltic can be
performed (Fig.19.15).
The same technique is very useful if multiple sequential strictures are present in
the ileal region adjacent to the valve. Performing sequential HM or Finny will lead
to stasis and recurrence (Fig.19.16).
Results of over 40 patients have been published with an acceptable low rate of
early postoperative complications (2 anastomotic leakage). One patient had to be
reoperated on owing to the formation of stenosis at the inlet and a new short strictureplasty (HM) was performed. Another patient underwent adhesiolysis for adhesion obstruction. To date, no resection of the strictureplasty has been required. After
a median follow-up of 33months 27 patients (68%) are free of symptoms. Of them
9 patients (22.5%) remained in remission without any adjuvant medical treatment.
Thirty-one patients (77.5%) needed postoperative medical treatment. Thirteen
(32%) fail to reach clinical remission (Figs.19.17 and 19.18).
Fig. 19.15 Modied over the valve side-to-side isoperistaltic strictureplasty as further developed
in our department to avoid resection of the terminal and perterminal ileum
Results mucosal healing month 6
19 Stricturing Crohn’s Disease: Strictureplasty
287
Fig. 19.16 Multiple strictures are treated using one long side-to side stricutreplasty over the valve
Fig. 19.17 Long-term
results of the modied
side-to-side isoperistaltic
strictureplasty over the
ileocaecal valve
12 responders
40 patients
underwent SSIS
30 no immediate
medical treatment
9 remained in
remission
21 relapsed and got
biologic therapy
27 responders (68%) 13 failures (32%)
10 immediate
medical treatment
6 brought into
remission
4 failures
9 failures
Fig. 19.18 Endoscopic results 6months after stricutreplasty over the valve. Not always a complete healing has been observed but there is a remarkable reduced inammation
288
G. Bislenghi and A. D’Hoore
The most intriguing observation of stricturoplasty is the normalization of the
bowel wall and a low site-specic recurrence rate, which has been reported between
2% and 5% at 10years. The surgical intervention seems to have the potential to stop
progressing or even to reverse intestinal brosis. Based on Cleveland Clinic data,
following strictureplasty operations, patients have been encouraged to undergo follow- up small bowel series after an interval of at least 6months. Of the 44 asymptomatic patients who complied, recurrence at the strictureplasty sites with narrowing
of the caliber of the bowel was noted in only 11% of patients after a median interval
of 2years [60]. Maconi etal. performed serial ultrasound examinations in patients
after strictureplasty and found a reduced thickness of the intestinal wall, suggesting
a possible mechanism and further fueling the promise of reversibility of intestinal
strictures [61].
Repetitive surgery for recurrences typically shows macroscopically normal
bowel segments previously treated by stricturoplasty from 6months after surgery
[58, 59, 62–64]. Although healing was not complete in every patient, important
improvement was however clearly visible. Endoscopic improvement appeared to be
the consequence of surgery, since most patients did not receive any Crohn’s medication postoperatively. It could be speculated that the alleviation of faecal stasis may
play a key role in postoperative mucosal healing, modifying the microbial-mucosal
interaction. Functional recovery of strictureplasty has never been investigated
because of the difcult accessibility of the treated segment for investigational
purposes. Performing a strictureplasty over the ileocaecal valve or ileocolic anastomosis gave the opportunity for exible endoscopic monitoring, offering a good
clinical model for research on the healing process and functional recovery of the
treated segment. It remains however unclear whether the diseased bowel segment
returns to normal function after stricturoplasty. Further research should therefore
focus on the mechanisms of healing and on the assessment of functional recovery,
in terms of motility and absorptive function, of the operated segment. Indeed, should
clear functional recovery be observed, it would make sense to save a short strictured
segment, whereas saving a bowel segment without any functional recovery would
be unnecessary. Research on the mechanisms of healing and functional recovery
will help surgeons to decide in which cases performing strictureplasty in order to
conserve bowel length would be most appropriate.
In view of the above the notion of the irreversibility of intestinal brosis has to
be challenged. Up to now bowel brosis has been considered a progressive and
irreversible process that leads irremediably to stricture formation. The chronic progressive nature of stricturing CD lead to the common belief that brosis is a oneway street from brosis to stricture formation with intestinal obstruction followed
by the eventual need for surgical resection.
The concept of reversibility of intestinal brosis is in concordance with various
observations from other organs such as the improvement of skin scarring [61] and
reduced skin thickening in systemic sclerosis, [65] decreased proteinuria in patients
with renal interstitial brosis, [66] the improvement of vital capacity in idiopathic
pulmonary brosis [60, 67] the successful therapeutic reduction of myocardial collagen content in hypertensive patients [68] and reversibility of myocardial brosis