Continuing Education Activity

Stricturoplasty is a surgical procedure performed to alleviate bowel narrowing due to scar tissue that has built up in the intestinal wall from an inflammatory condition such as Crohn disease. Three techniques are utilized depending on the length of the stricture. This activity reviews the step by step approach of the stricturoplasty procedure and highlights the role of the interprofessional team in the care of patients with Crohn disease after undergoing the procedure.

Objectives:

• Identify the treatment considerations for patients with Crohn disease.
• Describe appropriate technique to be performed in Crohn disease stricturoplasty.
• Summarize the indications, contraindication, and complications for Crohn disease structuroplasty.
• Outline interprofessional team strategies for improving care coordination and communication in patients undergoing stricturoplasty and improve outcomes.

Introduction

Crohn disease is a chronic inflammatory bowel disease (IBD), first described by Crohn, Ginsberg, and Oppenheimer in 1932.[1] It usually presents as a transmural granulomatous inflammation affecting the gastrointestinal tract, most commonly the ileum, colon, or both.[2] The disease prevalence is on the rise with the highest incidence seen in North America, the United Kingdom, and northern Europe.[3] Patients usually present with chronic diarrhea, often accompanied by abdominal pain, weight loss, and blood or mucus in the stools.[4] Extraintestinal manifestations of IBD generally occur in 25 to 40%. Inflammatory manifestations can also occur outside of the gastrointestinal tract within the skin, eyes, liver, and joints.[5] Crohn disease is diagnosed clinically based on clinical signs and symptoms, imaging, including endoscopic with biopsy and tissue information in addition to laboratory results.[6]

Intestinal complications of Crohn disease include obstruction and perforation of the small intestine or colon, abscesses, fistulas, intestinal bleeding, and strictures. Strictures are narrowed segments of intestine that usually result in bowel obstruction and can be debilitating in patients with Crohn disease.  Strictureplasty is a surgical procedure that relieves bowel narrowing secondary to scar tissue formation that usually accumulates in the intestinal wall from repeated inflammation and healing in Crohn disease. It is a safe and effective procedure that will preserve the bowel length and prevent metabolic complications associated with short gut syndrome in patients with symptomatic obstruction.

Anatomy and Physiology

Following multiple cycles of recurrent inflammation and healing of the small bowel, scar tissue replaces normal cells. As a result, scar tissue can cause the narrowing of the gastrointestinal tract. Occasionally, this narrowing can get severe to an extent where it can cause small bowel obstruction. The most common locations for strictures are the ileum and the ileocecal valve; however, strictures can happen anywhere in the GIT, including the colon, rectum, and the anus. Depending on the location of the stricture, patients may present with symptoms of nausea, vomiting, abdominal pain, bloating, or inability to pass gas and stool.

Indications

Due to the risks of short bowel syndrome from multiple abdominal surgeries and removal of strictured bowel and its associated nutritional deficiencies, this has led to increased use of bowel sparing techniques such as stricturoplasty. Not all patients are candidates for stricturoplasty. Originally, stricturoplasty could only be performed in short length stricture; however, recently, this idea has been challenged. Now the length of the stricture is not the primary variable when planning stricturoplasty except when determining which type of operative approach to proceed with.[7] Historically, stricturoplasty was only utilized for nonacute fibrotic stricture strictures; however, stricturoplasty is now also utilized in cases of active disease.[8]

The following is a list of indications for stricturoplasty:[9]

• Multiple strictures over the large length of bowel
• Previous significant small bowel resection
• Patient with short bowel syndrome
• Stricture without associated phlegmon or fistula
• Crohn disease recurrence with obstructive symptoms
• Stricture without sepsis

Contraindications

Contraindications for strictureplasty include the following:[9]

• Phlegmon or fistula, at the affected site
• Stricture in proximity to an anastomosis site
• More than one stricture over a short bowel length 
• Any stricture with evidence of dysplasia or malignancy
• Preoperative malnutrition (albumin < 2.0 g/dL)
• Perforated bowel

Equipment

Equipment used for strictureplasty includes the following:

• Incision blade
• Retractors
• Suture scissors
• Clamps
• Electrocautery
• Mesentery ligation with a thermal device 
• Bowel sutures 
• Staples or suture for skin closure

Preparation

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.

Technique

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

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]

Clinical Significance

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.

Enhancing Healthcare Team Outcomes

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]