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Medical Therapy of Fistulizing Crohn’s Disease 175
Cyclosporine A
Ten uncontrolled studies, some published only in
abstract form and comprising altogether only 64
patients, examined the effect of intravenous CyA for
the treatment of fistulizing CD with an overall initial
response of 83% [35–44].
Present and Lichtiger [38] treated 16 patients with
Crohn’s fistulae (10 perirectal, 4 enterocutaneous, 2
rectovaginal) with cyclosporine A, starting with a
continuous intravenous infusion (4 mg/kg/day),
switched to the oral route (6–8 mg/kg/day). Fourteen
responded to parenteral CyA (7 complete closure, 7
moderate improvement) and discontinued the
steroids, with a mean time for response of 7.4 days.
When switched to the oral route, 64% remained in
remission, 36% relapsed.
These results have been supplemented by a review
of literature including 39 patients with fistulizing
Crohn’s disease who have been treated with CyA
[43]. Within this group, 90% responded to intra-
venous cyclosporine, but 82% relapsed with CyA sus-
pension.
A modest reduction in fistula recurrence has been
produced with combined use of CyA, AZA and a
tapering schedule of prednisolone over 3 months
before cessation of CyA therapy [45]. All nine
patients responded to intravenous cyclosporine with
no recurrences after its discontinuation. CyA was
terminated after 3 months, while AZA and low-dose
prednisolone were continued: four patients did not
deteriorate, three deteriorated slightly and two had a
recurrence.
Adverse events of high dose CyA include paresthe-
sias, hypertrichosis, hypertension, tremor, renal
insufficiency, hepatotoxicity, headache, opportunis-
tic infections, gingival hyperplasia and seizures [46].
On the base of these studies, it is reasonable to use
CyA in fistulizing Crohn’s disease in the acute phase;
as it will not achieve long-term response, all patients
should be treated with concurrent AZA/6-mercap-
topurine for maintenance or, if the patient is aller-
gic/intolerant to AZA/6-MP, with parenteral MTX.
Tacrolimus
Tacrolimus is a potent immunosuppressant agent
that inhibits the transcription of IL-2 in T-helper
cells, used mainly for the prevention of allograft
rejection. Uncontrolled retrospective series suggest
its efficacy for treatment of fistulizing CD [47–49]. In
the only randomized, double-blind, placebo-con-
trolled trial, Sandborn et al. [50] randomized 48
patients with actively draining Crohn’s fistulae to
placebo or oral tacrolimus (initial dosage of
0.20 mg/kg/day for 10 weeks). A clinical response
(closure of at least 50% of fistulae maintained for at
least 4 weeks) occurred in 43% of tacrolimus-treated
patients and 8% of placebo (p=0.004). However,
there was no difference in the complete closure of fis-
tulae, (10% of tacrolimus vs. 8% placebo). Adverse
events observed in patients treated with tacrolimus
include renal insufficiency, tremor, headaches,
paresthesias, leg cramps and tremor.
In a subsequent study, ten patients with fistulae
refractory to medical therapy (including infliximab)
and on long-term steroids or immunosuppressors,
were treated with oral tacrolimus (0.05 mg/kg every
12 hours) with 6–24 months follow-up. Four
achieved a complete response and five achieved a
partial response and could discontinue or reduce
steroids and immunosuppressors with no serious
side effect [51].
Mycophenolate mofetil
Mycophenolate mofetil (MFF) is a potent immuno-
suppressant that inhibits lymphocyte proliferation
through a blockade of guanosine nucleotide synthe-
sis. In a study comparing the efficacy of AZA plus
steroids vs. MMF plus steroids, MMF produced a
more rapid improvement in the activity index in
cases with severe activity and a similar response in
cases with moderate activity [52].
Uncontrolled case series have suggested the effica-
cy of mycophenolate in long-term maintenance of
remission [53–56]. Wenzl et al. [56] observed that
almost 55% of patients with complicated CD
responded, but 64% of the initial responders relapsed
within 18 months. Well-designed placebo-controlled
trials are necessary to establish the role of this drug.
Anti-Tumor Necrosis Factor-Alfa Therapy
Infliximab
Cytokines including TNF-α are critical in the inflam-
matory processes that characterize CD. Mucosal
biopsy specimens and mononuclear cells isolated
from the lamina propria of a patient with CD express
high levels of TNF-α. Infliximab is a chimeric mono-
clonal antibody that binds to and neutralizes human
TNF-α. Its infusion results in a significant reduction
in inflammation, as confirmed in many randomized
placebo-controlled trials.
Present et al. [57] demonstrated the efficacy of
infliximab in the treatment of fistulizing CD in a
placebo-controlled multicentered study in which 94
176 L. Benini, F. De Iorio, N. Tacchella, Italo Vantini
patients with active abdominal or perianal fistulae
received either infliximab 5 mg/kg, infliximab
10 mg/kg, or placebo. Treatments were administrat-
ed at weeks 0, 2 and 6. The primary goal was a reduc-
tion of 50% or more in the number of draining fistu-
lae observed at two or more consecutive visits; a sec-
ondary goal was fistula-closure. Sixty-eight percent
of patients on infliximab 5 mg/kg and 56% on inflix-
imab 10 mg/kg achieved the primary goal compared
to 26% on placebo. Much more notably, complete fis-
tula healing was obtained in 55% of patients on
infliximab 5 mg/kg and in 38% 10 mg/kg. The major-
ity of fistulae closed before the third infusion and the
median duration of remission was 3 months. No dif-
ferences were noted with regards to duration, extent
of disease, prior surgery, number of fistulae or con-
comitant medications.
Infliximab has also proved to maintain its efficacy
in the long term. In a randomized controlled trial of
573 patients with active Crohn’s disease (CDAI score
of at least 220), responders to a 5 mg/kg i.v. of inflix-
imab (335 patients) were randomly assigned to
repeat infusions of placebo at weeks 2 and 6 and then
every 8 weeks until week 46 (group I), or 5 mg/kg
infliximab at the same timepoints (group II), or
5 mg/kg infliximab at weeks 2 and 6 followed by
infliximab 10 mg/kg (group III). At week 30, 21% of
the patients of group I were in remission, compared
to 39% of group II and 45% of group III [58].
Sands et al. performed a multicenter randomized
double-blind placebo-controlled trial to evaluate the
efficacy of infliximab maintenance therapy in 306 CD
patients and one or more fistulae. Initially patients
received 5 mg/kg infliximab i.v. at week 0, 2 and 6. A
total of 195 patients who responded at week 14
were
randomized to receive infliximab or placebo. The
remaining 87 patients who didn’t achieve an initial
response were also randomly assigned to placebo or
infliximab maintenance therapy. Among the respon-
ders, those assigned to maintenance infliximab had a
longer time to the loss of response than those on
placebo (median 40 vs. 14 weeks). At week 54, 36% of
the infliximab group had a complete absence of
draining fistulae, compared with 19% in the placebo
group. There was no difference in response between
infliximab and placebo among initial non-respon-
ders [59].
No consensus has been reached on the best inflix-
imab regimen for the long-term treatment of CD
between short-term courses and retreatment of
relapses vs. maintenance therapy. Some authors sus-
tain that infliximab should be used as a bridge thera-
py while awaiting the onset of effects of conventional
immunosuppressive therapy [60].
In a recent analysis of Crohn’s disease, patients
treated with infliximab in ACCENT I, episodic and
scheduled treatment strategies were compared under
conditions that simulate clinical practice. Patients
treated with scheduled infliximab, particularly in the
10 mg/kg group, had better symptomatic responses
than those treated on demand. Both scheduled
groups had fewer hospitalizations, higher rates of
mucosal healing, and lower rates of antibody positiv-
ity, with no increase in side effects, than those treat-
ed on demand [61].
The main argument in favour of long-term sched-
uled infliximab is represented by the reduced preva-
lence of anti-infliximab antibodies during scheduled
therapy rather than during episodic therapy, and by
the association of these antibodies with decreased
serum infliximab concentrations, decreased clinical
responsiveness, and increased risk of allergic reac-
tions [62].
The long-term use of infliximab for fistulizing CD
is still under investigation in terms both of a limited
efficacy and cost-effectiveness. As for the first prob-
lem, Poritz et al found that, if clinical improvement
was obtained in 18 out of 26 patients with fistulizing
CD, with complete fistula closure in 6, surgery was
ultimately required in 14 patients and 6 continued to
have draining fistulae [63]. The problem of the cost-
effectiveness of infliximab therapy has been raised by
a recent cost-utility analysis [64] in which infliximab
proved to be more effective then either metronida-
zole or AZA, but also far more expensive. However,
these results are outweighed by the consideration
that patients with fistulizing Crohn’s disease in the
ACCENT II study who received maintenance inflix-
imab had significantly fewer days of hospitalization,
number of hospitalizations, surgical procedures in
total, and fewer major surgical procedures compared
to those who received placebo [65].
Adverse events observed in patients treated with
infliximab include infusion reactions such as delayed
hypersensitivity, formation of anti-chimeric antibod-
ies and anti-dsDNA autoantibodies and, in rare
cases, onset of drug-induced lupus. Approximately
3% of patients in the ACCENT I trial developed
delayed hypersensitivity reactions manifested by
serum-sickness-like symptoms. This may be due to
the fact that a proportion of the molecule is still of
murine origin and therefore potentially immuno-
genic. Attempts are therefore being made to produce
less immunogenic biologic agents, thereby increasing
their “human” proportion (Fig. 4).
The efficacy of a humanized chimeric antibody
(CDP-571) against human TNF-α in fistula closure
has been assessed in a randomized placebo-controlled
trial on 37 patients with actively draining fistulae [66].
Closure of at least 50% of fistulae was obtained in 12
of 24 patients on CDP-571 and in 2 of 23 on placebo.
Other agents that inhibit TNF-α activity such as pen-
Medical Therapy of Fistulizing Crohn’s Disease 177
toxifylline and etanercept failed to demonstrate their
efficacy in CD. Moreover, some of these agents are
only active in a subset of patients with highly active
disease, as identified by elevated C-reactive protein.
Possible explanations for the different activity of bio-
logical drugs sharing the same target may be found in
their different biological actions (binding to soluble
or to membrane-bound TNF, capacity to produce T-
cell apoptosis, fixation of complement, induction of
antibody-dependent cytotoxicity).
Two open-label studies of thalidomide, a potent
inhibitor of TNF alfa, have shown some degree of
efficacy in fistulizing CD [67, 68]. Together, these
studies support a strategy of TNF-α inhibition as a
basis for healing fistulizing CD. In addition to its
well-known teratogenic effects, thalidomide has been
complicated by marked somnolence and peripheral
neuropathy.
Novel Therapies
A number of novel therapies have been suggested for
the treatment of fistulizing CD. The use of fibrin glue
and plasma factor XIII concentrates have been
advanced as adjunctive therapies in the management
of perianal fistulae. Hyperbaric oxygen has also been
suggested as an adjunctive therapy in healing fis-
tulizing CD. Although case reports have documented
successful healing during therapy, no randomized
placebo-controlled studies have been performed to
confirm these findings. Further studies are necessary
to assess the role of these therapies in the manage-
ment of fistulizing CD [69].
Elemental Diet, Bowel Rest and Parenteral Nutrition
Only anecdotal experience exists on the use of ele-
mental diets and total parenteral nutrition in fistuliz-
ing CD. Calam et al. [69] reported on six patients in
whom an elemental diet was used specifically to treat
perianal fistulae in Crohn’s disease. Four improved
with an elemental diet, but fistulae only healed com-
pletely in one patient. No studies specifically exam-
ined total parenteral nutrition in perianal CD. The
use of elemental diets or total parenteral nutrition for
fistulizing CD is therefore not recommended.
Conclusion
Treatment of CD fistulizing Crohn’s disease requires
a close collaboration between the gastroenterologist
and the surgeon. Antibiotics and immunomodula-
tors such as azathioprine/6-mercaptopurine or metho-
trexate, if the patient is AZA-6MP intolerant/resist-
ant, should be given early in the disease. In the case
of resistance to immunomodulators, infliximab is the
treatment of choice. Short-term cyclosporine A or
tacrolimus may be tried in patients who fail to
respond to infliximab. Abscesses should always be
drained by an expert surgeon.
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molecules. In black, com-
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Introduction
In his landmark article titled “Regional Ileitis: A
Pathologic and Clinical Entity” [1], Crohn wrote:
“Medical treatment is purely palliative and support-
ive. . . . THE PROPER APPROACH TO A COMPLETE
CURE IS BY SURGICAL RESECTION of the diseased
segment of the small intestine and of the ileocecal
valve with its contiguous cecum”.
The enthusiasm aroused by considering surgical
therapy as a decisive treatment for Crohn’s disease
(CD) faded away. Knowledge acquired over time
revealed the peculiar inclination of this disease to
affect the entire intestine tract ubiquitously and to be
connected with frequent extra-intestinal manifesta-
tions. Medical treatment has then become the main-
stay of therapy for patients with CD. Introduction of
new classes of drugs, such as immunosuppressants/
immunomodulators, led by recognition of the role of
the immune system in the disease pathogenesis,
increased the success both in controlling the disease
in its acute phase and in maintaining the quiescent
phase. Regardless, approximately 70–80% of patients
suffering from CD requires surgical treatment during
the course of the disease; this percentage has been
constant over the last 40 years according to data
given by the literature [2, 3]. While intestinal perfo-
ration, sepsis, intestinal obstruction, continuous
bleeding, fistulae and abscesses are clear and unam-
biguous conditions indicating the need of surgical
treatment, on the contrary, there is a considerable
percentage of patients falling into a “grey area” that,
in clinical practice, foments the age-old argument
between gastroenterologists and surgeons regarding
timing of the surgical operation [4]. It is therefore
clear that the therapeutical trend is to try to identify
patients with a higher risk of complications to be
then surgically treated [5] in order to delay surgical
treatment as long as possible through more and more
aggressive medical therapies [6, 7] or mini-invasive
therapeutical approaches, such as percutaneous
draining of abscesses or, more rarely, dilation of
stenoses or haemolysation in the case of haemor-
rhagic events [8]. However, the risk connected with
too conservative an approach is leading compro-
mised patients towards surgical treatment with the
resulting complications.
As Delaney recently pointed out [9], the absence
of complications leads to a fast improvement of
patients’ quality of life after surgical treatment (in his
study quality of life was assessed both preoperatively
and 30 days postoperatively). Patients not only
judged surgical therapy positively, but they even sug-
gested applying it earlier and proposing it as a pri-
mary option in the case of disease relapse.
Application of the principle stated by the Birming-
ham group (as recurrence is almost inevitable, the
main aim being to save as much intestinal tissue as
possible [10]), certainly made surgical treatment
increasingly conservative, emphasising the impor-
tance of attempting to avoid intestinal resection or at
least reduce the width used in the past
From all this, we now understand that an appropri-
ate multidisciplinary approach is essential when treat-
ing CD, a disease that, despite much enthusiasm and
new therapeutical options, seems to have a clinical his-
tory that has changed very little over the last 40 years
if , as Wolters concluded in a recent systematic review
of the literature [11]: “structured literature review pro-
vides no hard evidence for change in disease outcome
in Crohn’s disease during the last four decades”.
The aim of this chapter is to analyse the state of the
art of surgical options in the treatment of CD,
attempting to especially emphasise correct indica-
tions, surgical techniques and correct surgical timing.
Surgical Indications in Crohn’s Disease and
Preoperative Preparation
Table 1 summarises indications for surgical treat-
ment in Crohn’s disease [4, 12, 13]. Surgery may be
either scheduled or urgent. The subdivision into
absolute and relative indications is partly arbitrary.
Regardless of CD, intestinal perforation is considered
to require urgent surgical treatment, but determining
Surgical Options in Small-Bowel Disease
Gian Gaetano Delaini, Gianluca Colucci, Filippo Nifosì
182 G.G. Delaini, G. Colucci, F. Nifosì
where the therapy failed is sometimes very difficult.
Many cases also require careful consideration by the
gastroenterologist. A recurring event in clinical prac-
tice that is a common experience for many individu-
als treating this type of patients is to define, in some
cases, clear definition between a pattern of subocclu-
sion due to inflammatory oedema (that can respond
to therapy) or to fibrosis (that cannot respond to
therapy but to surgery only). Some preoperative care
and attention, if permitted by the clinical situation,
should always be used.
The patient should be operated only after a thor-
ough study [14]. The single-contrast gastrointestinal
(GI) series with small-bowel follow-through repre-
sents, presently, an examination with a good
cost/benefit ratio and that, in many important cases,
gives information regarding intestinal transit and the
presence of stenosis [15]. On many occasions, in
urgent cases especially, enteroclysis with computed
tomography (CT] and double-contrast evaluation
provides information on the presence of peritoneal
abscesses or on fistulae. Ultrasonography with or
without Doppler as well as magnetic resonance imag-
ing (MRI) [16] can be used for monitoring disease
activity and response to therapy or when the use of
ionising radiation is contraindicated (e.g. pregnancy
or childhood). Even if surgical exploration allows
visualisation of the intra-abdominal state, the possi-
bility of planning the surgical approach is essential
and supportive in the search for any fistulous tracts,
which are often difficult to find.
An essential aspect, which is often overlooked, is
preoperative marking the stoma. Creation of a tempo-
rary stoma takes place frequently, especially during
urgent surgery. The most frequent indications are
postoperative dehiscences, presence of major perianal
fistulae, intra-abdominal sepsis (which makes cre-
ation of the anastomosis unsafe) or a serious colonic
disease. Proper positioning of the stoma allows
patients to not only manage it easily but to accept it
[17]. It must remembered, moreover, that, as Post [18]
wrote, approximately 20% of “temporary” stomas
become definitive if the indication is postoperative
complications; this percentage increases up to 60% if
the indication is rectal stenosis or perianal fistulae.
Appropriate treatment during the postoperative
period must include an antithrombotic prophylaxis
and antibiotic administration. The latter will need to
be broad spectrum for some days in the case of
abscesses, fistulae or perforations, or just a single
dose given within 30 min of skin incision (repeated if
the operation lasts longer than 3 h) in the case of
noncontaminated operations (the so-called short-
term prophylaxis).
Another important aspect is nutritional support.
A state of malnutrition is rather frequent in these
patients, and it may be worsened by poor control of
the disease or by the presence of infection or fistulae.
Restoring electrolyte balance is essential. Caloric
support may be achieved through a total parenteral
nutrition or, if possible and the patient tolerates it,
through enteral nutrition, which has lower costs and
complications.
From Extended to Minor Resections: Evolution in
the Approach to CD
In the past, CD surgery entailed resection of all dis-
eased segments and the creation of anastomosis on
Table 1. Indication for surgical therapy
Absolute indication
Fulminant form of the disease
Intestinal obstruction (especially terminal ileum)
Intestinal perforation
Complication of the disease process Intestinal bleeding
Recalcitrant sepsis
Fistulae (?)
Abscess (?)
Failure of medical therapy
Complications of steroids or other medical therapy Growth failure
Controversial indications
Series of subileus
Recurrences subsiding after conservative treatment
Surgical Options in Small-Bowel Disease 183
the healthy tissue. Major intestinal resections were
then carried out, all with a radical intent. At the
beginning of the 1980s, Krause, reporting results
achieved in a retrospective study with a long follow-
up in which he compared minor and extended resec-
tions [19], stated that it was necessary to extend
resection margins up to 10–20 cm from the margins
of the diseased segment. In time, though, it became
obvious that this principle was not only wrong,
because the rate of CD relapses was not at all influ-
enced by extension of the resection, but it exposed
patients to a high risk of malabsorption comparable
with short-bowel syndrome.
The first data proving how inappropriate wide
resections were came from a study showing that the
presence of disease at the resection margins
(macroscopically healthy) did not affect the rate of
relapse [20]. Another study proved that the use of
intraoperative frozen section did not allow reduc-
tion of resection extension [21]. In 1996, Fazio pub-
lished a prospective randomised study with a good
sample where he compared patients operated with
resection performed 2 or 12 cm from the apparent-
ly healthy margin [22]. In this study, the main out-
come was defined as the need to perform surgery
again. The results (median follow-up 56 months)
showed a rate of relapse not statistically significant
between the two groups (25% in the group with a 2-
cm margin, 18% in the group with a 12-cm margin).
This work definitively proved how the approach
toward minor resections, with margins a few cen-
timetres from the diseased segment, is the appro-
priate one.
What are the indications for resective surgery?
Using Wien’s classification [23], Poggioli [24] sug-
gests that, schematically, penetrating manifestations
are likely to undergo resective surgery whereas
fibrostenotic manifestations (with the exception of
that involving the terminal ileum) are an indication
for stricturoplasty only in the case of a non-active
disease. This division, even if partly overcome by
Poggioli himself (as we will see when addressing
stricturoplasty), is a good starting point. Fistulous
tracts certainly are a high risk for non-resective sur-
gery. Resections in this case must be minor. It must
be remembered that resective surgery and stricturo-
plasty can and must integrate with each other. The
presence of localised areas of peritonitis away from
other injuries susceptible of stricturoplasty seems to
be not an absolute contraindication even if there is
still an agreement yet. They certainly are difficult sit-
uations, however, in which there is no consensus as
yet and the surgeon’s expertise is essential. Other
rather difficult cases are active and diffused diseases,
which are always difficult to approach. From the sur-
geon’s point of view, wide resections give greater
safety in comparison with stricturoplasty on inflam-
matory tissues; however, we must take into account
the problems connected with absorption. In these
patients, considering the inflammatory processes,
absorption ability is not exclusively connected with
the length of intestine left but also with the structur-
al and functional features.
“Classic” CD, terminal ileitis, has always repre-
sented the most common indication for a resection,
especially in the case of initial manifestation of the
disease. This operation can be mostly performed
with laparoscopy.
In literature, there are several studies comparing
the results of end-to-end or end-to-side anastomosis
or comparing the methodology for performing the
anastomosis (either conventional or stapled). The
theoretic premise was the hypothesis that the cul-de-
sac ensuing from an end-to-side anastomosis could
make relapse of the disease easier. The results
obtained were not univocal [25–27].
Our experience suggests that anastomosis must be
wide and tension free. We believe that the best alter-
natives are the conventional sutured end-to-end
anastomosis with a longitudinal excision along the
antimesenteric margin of the ileum (to allow enlarge-
ment plasty) (Fig. 1) or the use of a stapled function-
al end-to-end anastomosis.
Fig. 1. Ileo-colic anastomosis with single layer suture
184 G.G. Delaini, G. Colucci, F. Nifosì
Laparoscopic Approach
As we will explain in another chapter, the use of the
laparoscopic approach in CD surgery seems to be
very convenient, both for its minor surgical impact
and for reduction in hospitalisation time. After
laparoscopic techniques spread and technical skill
increased, surgeons could not only create diverting
ileostomies but also ileal or ileocolic resections. In
the literature, results of the laparoscopic approach is
controversial, but it seems to reduce hospitalisation,
morbility, and the need for analgesics, as pointed out
in a recent study regarding open versus laparoscopic
resections [28]. However, we must report the experi-
ence of Kehlet the pioneer of “fast-track surgery”. In
a recent work [29], he reported excellent results in 29
consecutive patients operated for CD. Using a multi-
modal approach (peridural anaesthesia, early mobil-
isation, alimentation), the average postoperative hos-
pitalisation was 3 days and complications were
extremely low. In the light of this experience, we
must once more emphasise the importance of appro-
priate and intensive management of the patient dur-
ing the perioperative stage.
Stricturoplasties: Indications and Results
Stricturoplasties certainly constituted a basic turning
point for the surgical treatment of CD strictures.
They allow correction of the occlusion of the tract,
preserving the intestinal tissue without reducing (or
at least only partly reducing) the absorption surface.
In a recent and comprehensive review, Roy and
Kumar [30] conducted a meta-analysis on the studies
that appeared in the literature addressing both indi-
cations and results. As already described in the pre-
vious paragraph, the indications accepted in the lit-
erature regarding the use of stricturoplasties are:
multiple serrated stenoses, stenosis in absence of an
active disease (especially in the presence of former
extensive resections or short-bowel syndrome), a dis-
ease with a fast relapse and occlusive syndromes and
treatment of anastomotic stenoses already created
during resections. A clear contraindication to stric-
turoplasty is the presence of active disease. The risk
of fistulisation appears to be high, with very danger-
ous consequences for the patient. In a recent study,
the same authors [31] published a retrospective work
reporting the results achieved with 14 patients (73
stricturoplasties) with active CD (disease activity was
both histologically and clinically defined). The peri-
operative complication rate due to the procedure was
limited (one fistula needing a second surgery). These
results, even if positive, must be carefully evaluated.
They certainly need further confirmation, due not
only to the kind of study (retrospective) but also to
the poor number of samples. However, they certain-
ly constitute an essential point for further studies.
Other contraindications reported in this meta-analy-
sis were the very poor general condition of the
patients (serum albumin <2g/dl), tension on closure
of strictureplasty and a segment requiring resection
before a stricture suitable for plasty. The presence of
fistulae or abscesses near the stenosis is another con-
traindication.
The treatment of the terminal ileitis (especially as
first manifestation) is still at issue. While some
authors, such as Poggioli [32], propose the use of
stricturoplasty in this case as well, no agreement has
been reached. Moreover, as already written, if it is
performed in a few excellent centres, the laparoscop-
ic approach may reduce hospitalisation periods and
morbity of this operation, even if not all authors
agree on this fact.
Roy and Kuman [31] analysed long-term results of
stricturoplasties reported by seven studies published
since 2000 (a total of 461 patients with an average fol-
low-up of 68.8 months) comparing them with
Tichansky’s review published that same year [33].
Results of these meta-analyses are comparable, with
a rate of reoperations after 5 years of about 26% and
an overall perioperative complication incidence of
11% (slightly reduced in comparison with 13%
reported by Tichansky). In the light of these data, it is
clear that, even if it is not without complications,
stricturoplasty in selected patients suffering from CD
is a very good therapeutical option.
The use of long stricturoplasties has always been
surrounded by skepticism because of the likely com-
plications and of a hypothetical risk of stenosis or
major disease relapse. In a recent work, Shatari [34]
compared long-term results between long and short
stricturoplasties, showing the former to give very
good functional results over time, with complications
and relapse rates absolutely similar with those of
short stricturoplasties.
Stricturoplasties: Notes on Surgical Technique
The first description of the use of stricturoplasty
dates back to 1977 when Katariya, an Indian surgeon,
published its use for the treatment of multiple tuber-
cular stenoses in a series of nine patients [35]. In
1982, Lee and Papaioannou published the first results
about the use of the stricturoplasty technique in nine
patients with CD [36]. Since then, many techniques
were proposed on how to perform stricturoplasties.
Surgical technique for this kind of operation must
be very strict. After laparotomy and accurate lysis of
Surgical Options in Small-Bowel Disease 185
any adhesions, the entire small bowel must be
explored for stenoses. Observation and palpation
allow detection of stenotic tracts. The presence of
more stenoses may be assessed after doing an
enterotomy on the already identified stricture by
introducing the index finger into the lumen and
passing the gut over the finger in a concertina fash-
ion or by the pull-through technique using an 18-Fr
Foley catheter [30]. Exploration must, obviously,
reach the duodenum proximally and the ileocecal
valve distally. Besides the stenoses site, it is essential
to evaluate its extension and any coexistence of fis-
tulous tracts. Even if indications for some of these
techniques are similar, many have their technical
limitation in the length of the stenoses. Regardless of
the kind of stricturoplasty, it is important to have a
precise technique. Tissues of the diseased segments
are thickened, inflamed and oedematous whereas
the mesentery may be retracted. The loops must not
be under tension, especially after long plasties.
Moreover, control of bowel vascularisation before
longitudinal incision is essential to avoid ischaemia
with an inevitable dehiscence and consequent fistu-
la. It is very delicate surgery requiring expert and
dedicated surgeons in reference centres.
Heineke-Mikulicz stricturoplasty: this technique
was originally used to treat hypertrophic stenosis of
the pylorus [37]. It allows treatment of small stenot-
ic tracts (8–10 cm). After the insertion of a stay
suture, the antimesenteric side of the bowel is
opened along the structure, and the longitudinal
incision is transversely closed using seromuscular
interrupted absorbable sutures (Fig. 2).
Finney stricturoplasy: this technique allows treat-
ment of longer stenoses (from 10 to 20 cm). The
antimesenteric side of the bowel is longitudinally
opened along the structure and bent into a U shape.
The posterior wall is first closed by a continuos, full
thickness, running suture, as is the anterior one (Fig. 3).
Fazio technique: Fazio and Tjandra [38] devel-
oped a method to treat two closed strictures by mix-
ing the two techniques described above. Both stric-
tures are opened with a long incision and then
closed in a Heineke-Mikulicz fashion.
Michelassi technique: this is a side-to-side
isoperistaltic stricturoplasty [39], which can be used
to treat long strictures. It is performed by transect-
ing the diseased segment and its mesentery at the
midpoint and longitudinally opening and then
suturing the proximal loop over the distal one by an
interrupted or running suture. In the first descrip-
tion, this methodology allowed treatment of stric-
tures up to 90 cm long in three patients with severe
jejunal-ileal disease (Fig. 4).
Poggioli technique: this is a side-to-side, disease-
to-disease-free anastomosis [40]. The first step
involves division of the bowel and its mesentery at
the beginning of the stricture. Then, the diseased
segment is opened in order to be anastomise it to the
proximal normal small bowel.
The literature describes many variations of the
above techniques, such as the plasties according to
Jaboulary, Judd, Moskel-Walske-Neuman [30] and
that recently proposed by Sasaki for reconstruction
following intestinal resection [41]. Every surgeon
dealing with inflammatory intestinal diseases must
know these techniques as well; Tichansky [32] point-
ed out, in a meta-analysis that stricturoplasty accord-
ing to Heineke-Mikulicz is surely the most used
(85%), followed by Finney’s (13%). We must empha-
sise that this meta-analysis refers to a historical sam-
Fig. 2. Heineke-Mikulicz stricturoplasty
Fig. 3. Finney stricturoplasty
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