Side-to-side isoperistaltic strictureplasty in the treatment of extensive crohn’s disease

doi:10.1016/j.jss.2003.11.008

Journal of Surgical Research

Volume 117, Issue 1, March 2004, Pages 71-78

https://doi.org/10.1016/j.jss.2003.11.008 Get rights and content

Abstract

Background

First performed in 1992, the side-to-side isoperistaltic strictureplasty (SSIS) is a bowel-sparing surgical option for Crohn’s patients presenting with sequentially occurring stenoses over long intestinal segments (>15 cm). This investigation was designed to study the outcomes and patterns of recurrence after a SSIS.

Materials and methods

Between 1992 and 2003, 30 patients underwent SSIS at the University of Chicago. Their data were gathered prospectively in an Institutional Review Board-approved database.

Results

A total of 31 SSISs were constructed in 30 patients. As an indication of the severity of disease in these patients, 25 of 30 (83%) required a concomitant bowel resection, and 13 (43%) underwent at least one additional strictureplasty. The average length of diseased bowel used to construct the SSIS was 51 cm. The average length of residual small bowel after performance of SSIS was 275 cm, and the SSIS represented an average 19% of the remaining small bowel that would have otherwise been sacrificed with resection. Three patients experienced perioperative complications (10%) and one died (3%). Seven patients (23%) required reoperation to treat recurrence of symptoms within the first 5 years. In four of these patients, recurrence was found at or near the previous SSIS.

Conclusions

A side-to-side isoperistaltic strictureplasty (SSIS) is a safe and effective surgical option for sequentially occurring Crohn’s strictures over long intestinal segments.

Introduction

Multiple, repeated, or massive resections of the small bowel are associated with an increased risk of short-gut syndrome in Crohn’s disease patients. Side-to-side isoperistaltic strictureplasty (SSIS) has recently emerged as a bowel-sparing surgical alternative to resection in the treatment of extensive Crohn’s disease [1]. SSIS is distinct from other conventional strictureplasties (Heineke-Mikulicz, Finney), in that it can be used to treat very long (>15- to 20-cm) segments of disease with multiple sequential strictures by performing a longitudinal enterotomy and subsequent side-to-side enteroenterostomy. In so doing, SSIS widens the diameter of the diseased bowel without sacrificing any mucosal absorptive area.

Section snippets

Background

Crohn’s disease is a chronic inflammatory bowel disease of unknown etiology and with no known cure. Although it may present anywhere from the mouth to the anus, Crohn’s disease has a propensity for involvement of the small and large bowel [2]. There it manifests its cardinal pathology of mucosal ulceration and transmural inflammation. Chronic inflammation of the bowel wall may lead to intestinal strictures and bowel obstruction in its advanced forms [3].

Crampy, intermittent abdominal pain is

Data management and case identification

Data were assembled from the Crohn’s disease protocol and database of the Section of General Surgery, University of Chicago. The Crohn’s disease protocol and database is an Institutional Review Board-approved methodology for gathering prospective data on Crohn’s patients undergoing surgery. It involves two distinct data collection periods. Preoperatively, the patient is interviewed by the operating surgeon and a nurse clinician specialized in the management of inflammatory bowel disease. During

Results

Patients presented with a host of symptoms before surgery, most of which (87%) were obstructive in nature (Fig. 5). In addition, 28 of 41 (68%) primary indications for surgery were related to some degree of intestinal obstruction; other indications included failure of medical management (8 cases), fistula repair (2 cases), and hernia repair, resection of excluded bowel, and gastrointestinal hemorrhage (1 case each).

A total of 31 SSISs were constructed; of these, 20 (64%) were constructed with

Discussion

Strictureplasty was first proposed by Katariya et al. as a means to treat ileal strictures secondary to intestinal tuberculosis [14]. Stimulated by this concept, Lee and Papaioannou began using strictureplasty to treat fibrostenotic strictures in Crohn’s disease in the late 1970s [11]. The guiding principle behind the use of strictureplasty was that obstructive symptoms resulting from Crohn’s disease could be ameliorated without resection, thus reducing the risk of short-gut syndrome. This aim

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Citation Excerpt :
These interventions are indicated for the treatment of stenosis, especially when these are very extended or multiple, and when they arise in patients who had already undergone previous bowel resections. Furthermore in the case of multiple stenosis a strictureplasty can be usefully combined with a resection, during the same surgical procedure, to reduce the extent of surgical demolition.1,11,12,60,143 It has been repeatedly called attention to the fact that strictureplasty interventions, leaving in situ sections of affected bowel, may favor the onset of cancer.144
Crohn's disease is associated with high rates of postoperative recurrence. At 10 years after surgery a high percentage of patients suffer recurrence (as many as 75% and above) and many of these (up to 45%) require re-intervention. The aim of the study was to identify, amongst the various “potential predictive factors”, those which today should be considered “real risk factors” for postoperative recurrence.
A review of literature of the last 30 years was carried out. A medical literature search was conducted using Medline, Embase, Ovid Journals, Science Direct, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Potential risk factors related to the patient, disease, type of surgery and pharmacological treatment were analyzed.
According to most Authors predictive factors, in addition to smoke, are also represented by an extent of disease superior to 100 cm and by absence of postoperative pharmacological treatment. Moreover, according to “the second European evidence-based Consensus on the diagnosis and the management of Crohn's disease: Special situations”, localization of disease in the colon, penetrative behavior of disease, extensive small bowel resection and prior intestinal surgery should also be considered predictive factors.
The high incidence of postoperative recurrence in Crohn's disease mandates a strict follow up (clinical, laboratory and instrumental monitoring). Identifying patients with increased risk would enable physicians to plan a surveillance program and to implement a rational therapeutic prophylaxis.
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The second European evidence-based consensus on the diagnosis and management of Crohn's disease: Current management
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Citation Excerpt :
The majority opinion is that stricturoplasty is inadvisable for longer (> 10 cm) strictures. However, there are now series reported with non-conventional stricturoplasties for longer bowel segments, reporting good results.224–229 A phlegmon in the bowel wall, carcinoma, or active bleeding with mucosal disease are contraindications to stricturoplasty.

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GastrointestinalSide-to-side isoperistaltic strictureplasty in the treatment of extensive crohn’s disease

Abstract

Background

Materials and methods

Results

Conclusions

Introduction

Section snippets

Background

Data management and case identification

Results

Discussion

Gastroenterology

J. Am. Coll. Surg.

Am. J. Surg.

Side-to-side isoperistaltic strictureplasty for multiple Crohn’s strictures

Dis. Colon Rectum

Pathogenesis of inflammatory bowel disease

Prob. Gen. Surg.

Medical treatment of mild to moderately active Crohn’s disease

Aliment. Pharmacol. Ther.

Risk factors for surgery and postoperative recurrence in Crohn’s disease

Ann. Surg.

Risk factors for surgery and recurrence in 907 patients with primary ileocaecal Crohn’s disease

Br. J. Surg.

Primary and recurrent Crohn’s diseaseexperience with 1379 patients

Ann. Surg.

Gastrointestinal
Side-to-side isoperistaltic strictureplasty in the treatment of extensive crohn’s disease