Crohn Disease Stricturoplasty

Pre-procedure planning:

• Assessing the nutritional status before surgery by obtaining an albumin level should be performed. Malnourished patients require preoperative supplements or parenteral nutrition to optimize wound healing postoperatively.[10] Imaging using CT or magnetic resonance enterography (MRE) should also be obtained to describe the degree and location of strictures, visualize any fistulas or perforations, and gain an estimate of small-bowel length.
• An ostomy nurse should also meet with the patient prior to the procedure to review the possibility of a stoma and mark the possible site of an ostomy if there is a possibility of one being required.

Patient preparation:

• General anesthesia is utilized. The patient is positioned in the supine position, with care taken to ensure that all pressure points are well padded.

The ideal strictureplasty technique depends on the length of the stricture to be stricturoplastied, as follows:[11]

• Short strictures (fewer than 10 cm in length), the Heineke Miulicz strictureplasty technique 
• Medium strictures (10 to 20 cm in length), the Finney strictureplasty technique
• Long strictures (more than 20 cm in length), the side-to-side isoperistaltic strictureplasty technique

The Heineke-Mikulicz strictureplasty is the commonest among the conventional stricturoplasties. This technique is done by making an elongated cut on the antimesenteric side of the intestine, extending from 2 cm proximal to 2 cm distal to the stricture. Two sutures are then placed at both ends of the opening of the stricture. The stay sutures are then approximated perpendicular to the long axis of the bowel. The enterotomy is then closed in one or two mucosal layers.[12]

The Finney strictureplasty is the most commonly used intermediate strictureplasty. The bowel is folded at the stricture site, forming a U shape. A long cut between the mesenteric and the antimesenteric side of the folded loop is performed. The opposed edges of the bowel are then sutured together in a side-to-side handsewn anastomosis.[13]

The side-to-side isoperistaltic strictureplasty, sometimes known as the Michelassi Stricureplasty, is used to prevent losing high amounts of small bowel when long segments strictures are detected and caused by Crohn disease.[7] In this technique, the long loop of the bowel affected by Crohn disease is first divided at its midpoint. The two segments are then approximated side to side, and a long opening is formed between both loops, which are then sutured together.[14]

Complications of strictureplasty include:[15][16]

• Infection at the surgical incision
• Bleeding
• Bowel obstruction
• Anastomotic leak 
• Additional strictures may form over time

A systematic review and meta-analysis performed by Yamamoto et al. found that the overall complications of jejunal and/or ileal strictureplasties were 13% with septic complications occurring in only 4% of cases.[15]

Strictureplasty has been used for Crohn disease for many years. Multiple studies have shown that it is efficacious in the treatment of selected patients at risk of malabsorption secondary to short bowel syndrome.

Crohn disease is a relapsing inflammatory bowel disorder that is challenging to diagnose and manage. Management of Crohn disease should include a multidisciplinary team, including a physician assistant, nurse practitioner, hospitalists, gastroenterologist, surgeon, dietitian, ostomy nurse, and a pharmacist. Crohn can affect any organ in the body, and thus, appropriate specialists should be consulted early in the disease course. 

Nurse practitioners or physician assistants can follow the patient throughout the hospitalization and monitor the course of the disease. The pharmacist should educate the patient on different medications, their benefits, adverse effects, and the importance of compliance. Ostomy nurses will guide the patient on proper care of the ostomy bag. Nutritionists will provide diet recommendations to avoid symptoms exacerbation, disease flare-up, and possible readmissions. [Level 5]