A New Type of Strictureplasty for the Treatment of Multiple Long Stenosis in Crohnʼs Disease

To the Editor: Strictureplasty is widely accepted as an alternative to resection in nonperforating jejunoileal Crohn's disease.1,2 Particularly in patients with multiple or long stenosis, the desire to preserve as much functional intestine as possible led to the use of this conservative technique instead of resection.3 In 1996 Michelassi reported on the advantages of a novel technique of strictureplasty performed in patients with multiple or long strictures located in a segment of between 50 and 90 cm, which should be preferred to the Finney technique.4 A subsequent meta-analysis2,4 showed a lower rate of both reoperation and recurrence in patients receiving the Finney strictureplasty compared with those treated with the Heineke-Mikulicz technique. Poggioli et al described a different strictureplasty based on a side-to-side anastomosis between the strictured segment and the spared ileum proximal to it, arguing that it was easier to perform and achieved better results.5 Moreover, Fazio (personal communication) proposed to treat recurrence at the afferent limb of the Finney strictureplasty by suturing the proximal bowel to the Finney loop. The value of this option is that the Finney “pouch” is supple, soft, and dilated, making easier the side-to end anastomosis of the proximal bowel to the apex of the “inverted U”–shaped pouch. With this in mind, we proposed an alternative technique of strictureplasty for the treatment of 3 patients (1 male) with obstructive disease and a long jejunoileal stenosis. We fashioned an isoperistaltic side-to-side diseased–to–disease free strictureplasty with side-to-end anastomosis at the top of the loop. The entire ileum was explored to individuate the strictures both manually and by inserting a Foley catheter through an enterotomy and inflating the balloon with air until there was a volume of 8 mL (2.5 cm in diameter). Once the segment of small bowel to treat was identified, the mesentery and the vessels were divided and distally ligated. The ileum was divided at a distance from the stenosis similar to its length in no diseased bowel and then folded, putting the stenosed tract near the proximal tract of the stricture. Then, the 2 branches of the intestinal loop were approximated with stitches. The 2 parts, formed by the diseased bowel and its proximal tract, were opened longitudinally (Fig. 1A). A side to side entero-enteric anastomosis was performed with 2 layers of a running 3/0 synthetic polyester adsorbable monofilament suture on the mesenteric (posterior) side. The anterior (antimesenteric) side was fashioned with a running monolayer extramucosal suture of 3/0 polyester adsorbable monofilament (Fig. 1B). Then, at the top of the loop an enterotomy was accomplished, and a side-to-end anastomosis was fashioned to replace bowel continuity in an isoperistaltic way (Fig. 1C). The lengths of the stenoses were 46, 57, and 61 cm. There were no intraoperative complications. All the patients had a normal postoperative course without any morbidity or mortality. Every patient underwent a complete small-bowel examination with barium enema per os 4 months after surgery and no evidence of stenosis was found. At the last follow-up all patients were symptom free. Since 1982, with the first described use of strictureplasty by Lee and Papaioannu,6 many techniques have been developed. The treatment of short multiple stenosis depends on the length of affected bowel. For stenoses up to 7 cm and between 7 to 15 cm in length the Heineke-Mikulicz and the Finney techniques, respectively, seem to be satisfactory.7 For multiple stenoses at least 20 cm in length and when multiple short stenoses are in close proximity to each other, the best option is unclear.4,8 The use of multiple strictureplasties, even if feasible, is contraindicated because of the risk of higher tension at the suture line.5 However, Finney's technique, even if technically feasible, in the presence of stenosis or bowel tracts longer than 20 cm could result in a functional intestinal by-pass.7 Michelassi's technique has been criticized for the risk of postoperative complications (such as bleeding and dehiscence) and stenosis at the edge of the strictureplasty (mainly the proximal one),5 probably because of the rigidity of the 2 segments of diseased bowel sutured together and of the difficulty in dividing the thickened mesentery. On the other hand, the advantages posed by Poggioli's technique, performed in 2 patients with 65 and 73 cm of small bowel, were an easier division of the healthy mesentery, a diseased–to–disease free bowel anastomosis with no bowel tears, and the use of the dilated bowel, resulting in a wider-caliber anastomosis.5 Our technique seemed to show some advantages. The mesentery of proximal and distal bowel is not subjected to posterior traction as with the Michelassi and Poggioli techniques, but it is easily slackened. The edges of the anastomosis are both in disease-free bowel, and, as for Poggioli's technique, the use of prestenotic bowel leads to a wider caliber of strictureplasty. The side-to-terminal anastomosis at the top of the strictureplasty avoids the risk of a blind bulky segment as with Finney's strictureplasty. However, similarly to Poggioli's technique, if a dehiscence occurs, our strictureplasty might lose 2-fold the amount of bowel, including both affected and normal bowel used for the anastomosis. This risk is obviously absent in Michelassi's technique because only the diseased bowel is used for the strictureplasty. In contrast with Poggioli's technique, where at the distal and proximal angle of the anastomosis there is a suture between diseased and disease-free bowel, in our technique all the sutures with diseased bowel are linear. Moreover, there are some centimeters of disease-free bowel at the distal and proximal edges of the suture that could protect the anastomosis. This could reduce, in our opinion, the occurrence of dehiscence, which is more frequent at the angle of the anastomosis. The surgical treatment of multiple jejunoileal stenosis in Crohn's disease is still difficult and unclear. We performed a new type of strictureplasty that might carry some advantages over other reported techniques. This technique seems to avoid therisk of inlet and outlet stenoses because of the healthy tissue anastomosis. Furthermore, the proximal and distal edges of the anastomosis are completely in disease-free tissues. However, further and stronger evidence to support these observations is mandatory. (A) Longitudinal opening of the 2 parts, formed by the diseased bowel and its proximal tract with an electrocautery. (B) Anterior (antimesenteric) side fashioned with a running monolayer extramucosal suture of 3/0 synthetic polyester adsorbable monofilament. The mesenteric (posterior) side is already constructed. (C) Side-to-end anastomosis fashioned at the top of the loop to replace bowel continuity in an isoperistaltic way. (D) Schematic view of the procedure before and after strictureplasty