Indications and Contraindications for Strictureplasty
Not all patients are candidates for bowel-preserving procedures. It was originally believed that strictureplasty should only be performed in short-length strictures, but this idea was challenged by Michelassi. Now the length of a stricture is not a significant variable when planning strictureplasty except for determining which type of procedure to perform. Another change in practice has been in dealing with strictures at active disease sites. Historically, only non-acute fibrotic strictures were considered amenable to strictureplasty, but this procedure has been shown to be safe and effective in cases of active disease.
Although the safety and efficacy of strictureplasty have become well established since its initial utilization, the indications and contraindications for strictureplasty have changed little and are as follows:
Indications for strictureplasty:
- Diffuse involvement of the small bowel with multiple strictures.
- Non phlegmonous fibrotic stricture.
- Rapid recurrence of Crohn’s disease manifested as obstruction.
- Stricture(s) in a patient who had undergone previous major resection(s) of small bowel (>100 cm).
- Stricture in a patient with intestinal failure or short bowel syndrome.
Contraindications to strictureplasty:
- Colonic strictures.
- Free or contained perforation of the small bowel.
- Hypoalbuminemia (<2.0 g/dL).
- Multiple strictures within a short segment.
- Phlegmonous inflammation involving the affected site.
- Stricture in close proximity to a site chosen for resection.
In the past, an internal or external fistula was viewed as a contraindication, but strictureplasty can be safely performed in this setting if any associated inflammation is chronic rather than active in appearance.
Preoperative Evaluation and Optimization:
Patients being considered for elective operative intervention should be extensively queried about their current illness. They should also undergo a comprehensive physical examination that includes inspection of the abdomen and anoperineal region. All relevant medical records should be requested and reviewed when available to better understand the results of prior endoscopic/imaging studies, laboratory tests, pathology reports, and intestinal operations.
The extent of disease is best ascertained by colonoscopy and imaging with computed tomography or magnetic resonance enterography. Small stricture luminal diameter and increased stricture wall thickness were predictors of strictures for which medical therapy typically fails.
Many surgeons feel that biologic agents should be discontinued several weeks prior to an elective procedure because they might interfere with the normal immune response and increase the likelihood of postoperative complications, although the impact of these agents is controversial and no strictureplasty-specific evidence is currently available.
Smoking cessation should be facilitated and any physiological deficits should be corrected during the preoperative period, but malnutrition is usually difficult to reverse, even with the use of hyperalimentation.
Mechanical bowel preparation, perioperative antibiotic therapy, and deep venous thrombosis prophylaxis are commonly prescribed while the need for stress-dose corticosteroids is debated.
The entirety of the small bowel should be carefully palpated and visually inspected to identify all areas of disease involvement and guide the operative plan.
Since the time of the initial strictureplasty descriptions, the Heineke-Mikulicz and Finney strictureplasty techniques are the two most widely utilized methods for short- (<10 cm) and medium-length (10–20 cm) strictures of the small intestine, respectively. A Michelassi side-to-side isoperistaltic strictureplasty with or without midstricture resection is indicated for long-length (>20 cm) strictured segments.
Other strictureplasty techniques have been described, but are much less frequently employed.
Nearly all strictureplasty techniques share a common feature, which is a full-thickness longitudinal incision along the antimesenteric aspect of the bowel wall that extends 1 to 2 cm into non diseased bowel on either side of the stricture.
Closure of the resultant enterotomy discriminates the different techniques from one another. The number of strictures, length of each stricture, and the distance between strictures as well as sites warranting resection primarily dictate the choice of strictureplasty configuration.
The Heineke-Mikulicz strictureplasty is constructed by creating a longitudinal enterotomy (A) that is transversely closed in one or two layers using interrupted sutures (B). The site is marked by applying a clip to the mesenteric margin (C).
The Finney strictureplasty is constructed by creating a longitudinal enterotomy and folding the bowel on itself (A). The back wall of the enterotomy is closed in two layers using running sutures reinforced with interrupted sutures (B). The front wall is closed in the same manner or with interrupted sutures placed in one or two layers (C).
The Michelassi strictureplasty is constructed by creating a longitudinal enterotomy and dividing the strictured segment in its midpoint before sliding the two segments into an isoperistaltic configuration (A). The back wall of the enterotomy is closed in two layers using running sutures reinforced with interrupted sutures (B). The front wall is closed in the same manner or with interrupted sutures placed in one or two layers (C).
The Michelassi II, or the end-to-side-to-side-to-end strictureplasty, is a variant of the original SSIS technique to address severe and extensive small bowel Crohn’s disease after resection of 3 intervening intestinal segments resulting in 2 loops of bowel in discontinuity. Michelassi’s new technique (Michelassi II) involves resecting diseased small bowel which leads to discontinuous loops of varying diameters. These are then sewn in a side-to-side fashion to form the anastomosis with the bowel appearing to have an end-to-end anastomosis when the suturing is completed. He advises that this should be considered when there is a segment <2 feet which represents 10% of the entire small bowel length, or >2 feet of primary or recurrent bowel diseases.
Different studies compare the effectiveness of these techniques. We would like to highlight a meta-analysis in which the authors compared the short-term and long-term results of conventional – CSPs (Heineke-Mikulicz and Finney techniques) and non- conventional – NCSPs (Michelassi technique and modifications) strictureplasties.
The 6 immediate complications include small-bowel obstructions, sepsis, other infections, reoperations, early postoperative gastrointestinal bleeds, and other early complications.
The 5 long-term complications include recurrent strictures, small-bowel obstructions, reoperations, carcinoma, and death.
A total of 1616 patients who underwent 4538 strictureplasties were identified from the 32 studies. One thousand one hundred fifty-seven patients underwent conventional strictureplasties with an early complication rate of 15%; 459 patients underwent nonconventional strictureplasties with an early complication rate of 8%. A late complication rate of 29% for the conventional strictureplasty group and 17% for the nonconventional strictureplasty group were noted.
32% of patients in the CSP group and 17.8% of patients in the NCSP group presented with overall recurrent stricturing disease over a mean follow-up period of 50 months. Delayed recurrent obstructive symptoms occurred in approximately 32% of patients in the CSP group in comparison with only 11.3% of patients in the NCSP group after the index SP procedure.
Early septic complications of SP such as abscess formation, phlegmon, fistula formation, and wound infections have been noted in both groups. The overall septic complication rate was 4.6% in the CSP group and 3.8% in the NCSP group. There was no significant difference in the 2 groups, showing again that NCSP procedures are not worse than CSP procedures in terms of septic complications and do afford comparable safety rates.
Postoperative GI bleeding rate of 1.9% in the NCSP group in comparison with a GI bleeding rate of 4.6% in the CSP group. This difference was statistically significant.
Late complications such as recurrent stricturing disease, the development of small intestinal carcinoma, and mortality are comparable between both groups.
Occurrence of small-bowel carcinoma in Crohn’s disease has been reported in the literature, but the resection of diseased bowel has not been shown to reduce the risk of development of small-bowel carcinoma. Small-bowel carcinoma in Crohn’s disease can occur in the diseased bowel irrespective of the SP site. Obtaining biopsies at intended SP sites before performing any SP procedures is encouraged by most authors. A 0.34% rate of small-bowel carcinoma was reported in the CSP group compared with 0.21% in the NCSP group, which reveals no statistically significant difference.
A recent study by Michellassi analyzes Long-term Results of the Side-to-side Isoperistaltic Strictureplasty (SSIS) in Crohn’s Disease.
Sixty patients underwent 61 SSISs for partial intestinal obstruction. Median length of preserved small bowel was 50 (2018) cm. Associated strictureplasties and bowel resection were performed in 44% and 80%, respectively. There were no sutureline dehiscences.
SSIS resulted in resolution of preoperative symptoms in all. After a median follow-up of 11 years (range 1 mo–25 yrs), symptomatic recurrence was observed in 61% of patients: 15 patients at the SSIS and 19 away from it. Of 15 recurrences at SSIS, 11 required surgical treatment. Fifty-one patients (86%) maintain the original SSIS to date.
They concluded that SSIS is a safe, effective, and durable strictureplasty in patients with extensive fibrostenosing CD of the small bowel. Half the surgical recurrences in SSIS can be managed by subsequent revision or strictureplasty.
NCSPs demonstrate safety profiles that compare favorably with outcomes from CSPs, although they are used to treat dissimilar strictures. However, we acknowledge that further considerations of comparing NCSP vs resection, because both can be applied in similar stricture situations, would strengthen the discussion regarding the safety and efficacy of NCSP.
Given the multiple techniques available, each SP procedure could possibly be tailored to the particular stricture anatomy in terms of length, proximity, and surrounding tissue conditions. Nevertheless, institutional practices and surgeon preference remain vital in deciding which technique to apply in each case.