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A 19 year old with a 3-week history of diarrhoea
Published in Tim French, Terry Wardle, The Problem-Based Learning Workbook, 2022
Obstruction: small bowel obstruction can occur in Crohn’s disease, presenting with abdominal pain, swelling, vomiting and constipation (which may be absolute) (see p. 68). This may be due to adhesions, stricturing disease, or an inflammatory mass. An abdominal X-ray may show dilated small bowel loops proximal to the obstruction. Medical treatment with steroids may not be successful. In an attempt to preserve the length of the small bowel, a ‘stricturoplasty’ will open the narrowing and can prevent resection.
Inflammatory bowel disease
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Aimee G. Kim, Samir K. Gadepalli, James D. Geiger
Stricturoplasty may be performed open or laparoscopically. The patient should be positioned supine. Incision and port placement are dependent on location of the strictures, but an initial umbilical port or periumbilical incision allows for greatest versatility, with additional port placements or vertical extension of the periumbilical incision as needed. Upon identification, each stricture is initially marked with a silk suture.
Crohn’s Disease
Published in Savio George Barreto, Shailesh V. Shrikhande, Dilemmas in Abdominal Surgery, 2020
Lohith Umapathi, Divya Manikandan, Govind Nandakumar
The need for a strictureplasty may arise in the presence of multiple strictures over a lengthy piece of bowel, a previous >100 cm small bowel resection, short bowel syndrome, duodenal stricture, or a recurrent stricture at an anastomotic site (Figure 17.4). Contraindications to strictureplasty include presence of a phlegmon or abscess, perforation with diffuse peritonitis, suspicion of malignancy at the stricture, or the weak nutritional condition of a patient. A strictureplasty can be performed relatively safely in the presence of active disease. Single layered seromuscular stitches are preferable, should make sure that there is no localized abscess or distal obstruction. Overall complication rate of the procedure is reported between 0–57% (avg. 13%), and a 6% incidence of major complications, including anastomotic leakage, formation of an abscess or fistula, and sepsis [3].
Factors associated with the efficacy and safety of endoscopic dilatation of symptomatic strictures in Crohn’s disease: a retrospective cohort study
Published in Scandinavian Journal of Gastroenterology, 2023
Pierre Dandoy, Edouard Louis, Pierrette Gast, Maxime Poncin, Laurence Seidel, Jean-Philippe Loly
When symptomatic, these strictures can be managed by resection surgery or stricturoplasty. However, surgical resection of the affected segment exposes the patient to short bowel syndrome if the resection is extensive [4]. Moreover, the surgical recurrence rate at 15 years is between 28% and 45%. Stricturoplasty is a useful alternative to decrease the length of resected intestine, but requires subsequent surgical resection in 24% of patients after 46 months [4]. Therefore, these surgical approaches are considered as a last resort [5].
Antitumour necrosis factor alpha treatment in Crohn’s disease: long-term efficacy, side effects and need for surgery
Published in Scandinavian Journal of Gastroenterology, 2022
Frode Lerang, René Holst, Magne Henriksen, Henrik Wåhlberg, Lars-Petter Jelsness-Jørgensen
Surgical resection was performed in 55/154 (36%) patients, of which 43/55 (78%) were surgically naïve. Twenty patients underwent surgery during anti-TNF therapy, and 35 patients underwent surgery shortly after discontinuation of anti-TNF therapy. The majority of patients had a limited surgical resection performed during follow-up (mostly an ileocecal resection), and in three patients intestinal stricturoplasty was performed in addition to resection.
Paediatric inflammatory bowel disease: review with a focus on practice in low- to middle-income countries
Published in Paediatrics and International Child Health, 2019
Anthony Mark Dalzell, Muhammad Eyad Ba’Ath
Despite recent significant advances in medical management, surgery continues to play a major role in the management of IBD. The operative care by the paediatric surgeon to the newly diagnosed patient with CD is very different in nature to the surgical needs of adult patients after decades of disease progression. While surgery is never curative in CD, it has the ability to transform the disease process in children, and appropriately timed surgery may have a tremendous effect on a child’s physical and mental maturation [78]. Surgical treatment of CD is a valid alternative in selected cases, contributing to resolution of acute complications and maintenance of remission, allowing a disease-free interval, nutritional recovery [79] and growth improvement [38]. In a review of the natural history of PIBD, surgery rates in CD ranged between 10% and 72%, while the colectomy rates in UC ranged from zero to 50% [38]. The main indications for surgery in CD are failure to thrive and unresponsive disease despite maximum medical therapy, fistulising, perforating or stricturing disease and severe peri-anal disease requiring temporary diverting colostomy or localised relieving procedures (e.g. abscess drainage and seton placement). Surgical options in CD include localised resections with the aim of preserving as much intestine as possible, for example undertaking an ileocaecectomy rather than a right hemicolectomy. The exception to this rule is when there is colonic CD distal to the transverse colon in which case the preferred option is subtotal colectomy; a primary anastomosis should be avoided [80]. Resection of an isolated, localised ileocaecal disease (which is affected in 50% of CD [78]) can have a particularly good outcome [80]. Stricturoplasty is an alternative that might allow preservation of more intestine but it should be weighed against the risk of suturing grossly affected bowel. CD is a well-recognised risk factor for anastomosis failure and leakage.