J Gastrointest Surg (2012) 16:1976–1980 DOI 10.1007/s11605-012-1891-9

HOW I DO IT

How I Do It: Side-to-Side Isoperistaltic Strictureplasty for Extensive Crohn’s Disease

Léon Maggiori & Fabrizio Michelassi

Received: 5 March 2012 /Accepted: 10 April 2012 /Published online: 27 April 2012 # 2012 The Society for of the Alimentary Tract

Abstract Introduction Bowel-sparing surgical techniques, such as the Heineke–Mikulicz and the Finney strictureplasty, have been proposed as an alternative to lengthy intestinal resection in the treatment of small bowel strictures in Crohn’s disease. However, these conventional strictureplasty techniques lend themselves poorly to cases of multiple short strictures closely clustered over a lengthy small bowel segment. Discussion In this article, we present the surgical technique of the side-to-side isoperistaltic strictureplasty, which is optimal in addressing these specific situations.

Keywords Crohn’s disease . Strictureplasty . Stricture . for repeated intestinal resections, patients may eventual- Side-to-side isoperistaltic strictureplasty ly develop intestinal insufficiency and short bowel syndrome.1 Bowel-sparing surgical techniques, such as the Hei- neke–Mikulicz and the Finney strictureplasty, have been Introduction proposed as an alternative to lengthy intestinal resection in the treatment of CD small bowel strictures. With Crohn’s disease (CD) is characterized by a transmural strictureplasties the intestinal absorptive capacity of inflammation that may affect any part of the gastroin- the normal bowel located between strictures is pre- testinal tract from the mouth to the anus. Chronic intes- served. However, these conventional strictureplasty tinal inflammation in CD can be responsible for the techniques lend themselves poorly to cases of multiple development of complications, including strictures, ab- short strictures closely clustered over a lengthy small scesses, or fistulas. Such complications occur in over bowel segment. The side-to-side isoperistaltic stricture- half of all patients within 10 years of diagnosis and plasty technique, first described in 1996,2 is optimal in constitute the major indication for surgery in CD. De- addressing these specific situations. spite recent medical therapy improvements, approxi- mately 70 % of the patients with CD require surgery during the course of their disease. Surgical Procedure Unfortunately, CD is a recurrent disease: at some time after the index procedure, 20 to 60 % of the patients develop Indications and Contraindications postoperative clinical symptoms of recurrence and 15 to 50 % need further surgical intervention. With the need Both American3 and European1 guidelines for CD “ ” : management list strictureplasty as the treatment of L. Maggiori F. Michelassi (*) choice for patients with nonphlegmonous small bowel Department of Surgery, New York-Presbyterian Hospital, CD fibrotic strictures responsible for symptomatic par- Weill Cornell Medical College, 525 East 68th Street, Box 129, New York, NY 10065, USA tial intestinal obstruction. The choice between the dif- e-mail: [email protected] ferent surgical strictureplasty techniques should be J Gastrointest Surg (2012) 16:1976–1980 1977 made according to the number of strictures, length of Surgical Technique each one, and relationship among strictures and poten- tial intestinal segments selected for resection. Several The entire small bowel is examined from the ligament of strictureplasty techniques have been described. The Treitz to the ileocecal valve with special care paid to record conventional Heineke–Mikulicz strictureplasty tech- all Crohn’s-related complications (strictures, phlegmonous nique, consisting of a longitudinal enterotomy closed masses, abscesses, fistulae) and their relationship to each in a transverse direction,4 is best applied to strictures other along the length of the entire small bowel. We call this up to 7 cm in length. A Finney strictureplasty, consist- phase of the procedure “the creation of a roadmap.” A ing of a side-to-side enteroenterostomy on the diseased strategic approach to the patient’s disease is then developed bowel loop folded onto itself, may be performed for by studying the “roadmap,” and it will include the use of strictures up to 15 cm in length. Yet, with multiple strictureplasties, intestinal resections, drainage of abscesses, short strictures closely grouped over a lengthy seg- repair of fistulous openings on target intestinal loops or ment, the side-to-side isoperistaltic strictureplasty lends hollow viscera, or a combination of the above. itself better than multiple single strictureplasties. When a side-to side isoperistaltic strictureplasty is cho- Like any strictureplasty, the side-to-side isoperistaltic sen, the mesentery of the small bowel loop to undergo the strictureplasty is contraindicated in the presence of a phleg- strictureplasty is first divided at its midpoint, and the small mon, generalized peritonitis, or profoundly impaired nutri- bowel is severed between atraumatic intestinal clamps. If the tional status, due to the high risk of postoperative leakage.5 midportion of the diseased loop contains a long continuous The presence of enteric fistulae has been hitherto viewed as stricture with a thick, unyielding wall, then a minimal re- a contraindication for performing a strictureplasty, but re- section is performed. The proximal intestinal loop is then cent reports have suggested that strictureplasty might be moved over the distal one in a side-to-side fashion (Fig. 1). performed in the presence of fistulae surrounded by chronic, Care is taken to ensure that stenotic areas of one loop are rather than active, inflammation without increasing postop- opposed to the dilated areas of the other loop, in order to erative morbidity.6 Finally, suspicion of small bowel adeno- avoid creation of narrow points. The two loops are then carcinoma should lead to intraoperative biopsy and, if approximated by a layer of interrupted seromuscular Lem- confirmed, resection of the bowel loop. bert stitches, using nonabsorbable 3-0 sutures (Fig. 2). A longitudinal enterotomy is performed on both loops, with Preoperative Preparation the intestinal ends tapered to avoid blind stumps (Fig. 3). Biopsies of suspicious areas of disease are obtained for As for all elective surgical procedures for CD, a complete frozen section, in order to exclude occult malignancy. He- assessment of disease extension should be performed using mostasis is obtained with suture ligatures or electrocautery. MR and/or CT enterography. Magnetic resonance imaging is the most sensitive and specific imaging procedure for CD extension assessment,7 and it allows distinction between active inflammatory strictures, which might be medically managed, and fibrotic strictures, which should be surgically treated.8 We also advocate a preoperative total , even in patients with CD apparently strictly limited to the small bowel. Several studies have focused on predictive risk fac- tors of postoperative morbidity in CD surgery. Yama- moto et al. identified three independent risk factors: preoperative corticosteroid medication, poor nutritional status, and intra-abdominal phlegmon or fistula.9 Poor nutritional status should be addressed preoperatively by enteric or intravenous nutrition; by contrast, abdominal phlegmons are frequently the reason for surgical inter- vention, and corticosteroid weaning is rarely feasible without a recrudescence of the disease. On the other hand, azathioprine has no impact on postoperative mor- bidity and can therefore be maintained.10 Finally, the Fig. 1 The mesentery of the small bowel loop to undergo the strictur- eplasty is divided at its midpoint, and the small bowel is severed influence of infliximab on postoperative CD complica- between atraumatic intestinal clamps. The proximal intestinal loop is tion is still controversial.10 moved over the distal one in a side-to-side fashion 1978 J Gastrointest Surg (2012) 16:1976–1980

Fig. 4 The outer suture line is reinforced with an internal row of running, full-thickness 3-0 absorbable sutures, continued anteriorly as a running Connell suture Fig. 2 The two loops are approximated by a layer of interrupted seromuscular Lembert stitches, using nonabsorbable 3-0 sutures of affected bowel in the formation of a side-to-side isoper- istaltic strictureplasty or additional use of normal bowel, The outer suture line is reinforced with an internal row of length of bowel selected for strictureplasty, bowel location running, full-thickness 3-0 absorbable sutures, continued selected for procedure (i.e., terminal ileum where the side- anteriorly as a running Connell suture (Fig. 4); this layer is to-side isoperistaltic strictureplasty is performed between reinforced by an outer layer of interrupted seromuscular the ileum and the ascending colon), and condition for which Lembert stitches using nonabsorbable 3-0 sutures (Fig. 5). this technique is applied (Crohn’s, multiple NSAID small A hand-sewn anastomosis greatly facilitates the perfor- bowel strictures, and small bowel stricture arising from mance of side-to side isoperistaltic strictureplasty and chronic ischemic enteritis11). should be preferred over mechanical staplers, as it allows different degrees of tension to compensate for different Results thickness of either loop. Variations of this side-to-side isoperistaltic strictureplasty Postoperative Short-Term Outcomes technique have been described.11–18 These variations fall into six distinct categories: integration of other stricture- The first assessment of perioperative morbidity and mortality plasty techniques (e.g., Heineke–Mikulicz or Finney techni- following a side-to-side isoperistaltic strictureplasty was pub- ques) with the side-to-side isoperistaltic strictureplasty lished in 2000.19 In reporting the first 21 consecutive patients technique, integration of a with the side- undergoing a side-to-side isoperistaltic strictureplasty, the to-side isoperistaltic strictureplasty technique, exclusive use

Fig. 3 A longitudinal enterotomy is performed on both loops, with the Fig. 5 This layer is reinforced by an outer layer of interrupted sero- intestinal ends tapered to avoid blind stumps muscular Lembert stitches using nonabsorbable 3-0 sutures J Gastrointest Surg (2012) 16:1976–1980 1979 senior author observed no mortality and a 5 % morbidity rate. author.26 It is assumed that the risk of neoplastic transfor- The morbidity was limited to a gastrointestinal hemorrhage mation after strictureplasty is low and not sufficient to presumably originating from the strictureplasty suture line. dissuade surgeons from performing those techniques. How- There were no episodes of suture line dehiscence. ever, the specific risk for development of an adenocarcino- A meta-analysis, including more than 3,000 strictureplas- ma after side-to-side isoperistaltic strictureplasty is not ties of which 148 (5 %) were side-to-side isoperistaltic known. It could be speculated that such strictureplasty is at strictureplasties, has been published in 2007.20 Overall, a higher risk than conventional strictureplasties to develop a mortality was nil and 13 % of patients developed postoper- malignant transformation due to the more extensive chronic ative complications, including 4 % septic complications inflammation left in situ. Yet, it is known that the acuity of (anastomotic leak, fistula, and abscess) and 3 % postopera- the inflammation undergoes quiescence after a side-to-side tive hemorrhages. The strictureplasty technique had no ad- strictureplasty14,19,28 and no cases of adenocarcinoma in verse impact on postoperative outcomes, highlighting the side-to-side strictureplasties have been described in the lit- safety of the side-to-side isoperistaltic strictureplasty as erature to the present. compared to conventional procedures. In 2007, a study reported the initial experience of six international centers with 184 patients undergoing a side-to- Conclusion side isoperistaltic strictureplasty technique.21 To date, this is the largest study. The results confirmed the previous obser- ’ 19 Crohn s disease is a recurrent panintestinal inflammatory vations: no mortality and a morbidity rate of 11 %. A disorder. Surgical treatment is indicated to address compli- recent comparative study has evaluated strictureplasty vs. 22 cations of the disease or failure of medical treatment. Symp- resection in small bowel CD and has established that the tom alleviation expected from the procedure should be postoperative outcomes of strictureplasty compare favorably balanced with potential postoperative morbidity and long- to those obtained after small bowel resection. term side effects. In this context, strictureplasty for CD- related small bowel stenosis has been demonstrated to be a Long-Term Outcomes safe and effective solution, relieving obstructive symptoms without any bowel sacrifice. The 2007 study from six international centers with experi- Conventional strictureplasty techniques lend themselves ence in the side-to-side strictureplasty technique attempted poorly to cases of multiple short strictures closely clustered to define the long-term results obtained with this new 21 over a lengthy small bowel segment. In these cases, the side- technique. These results were encouraging, as only 14 of to-side isoperistaltic strictureplasty technique offers an ele- a total of 184 patients required surgery for recurrent disease gant and effective solution to a most challenging problem. at the side-to-side isoperistaltic strictureplasty site, after an Since its introduction in 1996, the side-to-side isoperistaltic average follow-up of 35 months. These results are consistent strictureplasty technique has been implemented worldwide. with overall results of strictureplasty, as reported in the 20 Several reports have demonstrated its safety and efficacy. meta-analysis published in 2007. Recurrences occurred The side-to-side isoperistaltic strictureplasty, along with mostly at the inlet and at the outlet of the side-to-side other bowel-sparing procedures, allows managing extensive strictureplasty, leading some authors to suggest the addition CD patients without unwarranted small bowel resections, – of a Heineke Mikulicz strictureplasty at the inlet and the minimizing the risk of long-term short bowel syndrome. outlet of the side-to-side strictureplasty during its original construction.23 Acknowledgments This work has been supported in part by the Alice Bohmfalk Charitable Trust, the French Société Nationale de Questions to Answer Coloproctologie, and a Fullbright scholarship.

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