Recurrence after strictureplasty or resection for Crohn's disease

This study attempts to define whether there is an increased need for reoperation in patients with small bowel Crohn's disease treated by strictureplasty compared with those treated by small bowel resection. Previous studies of the rate of reoperation for small bowel Crohn's disease do not distinguish between reoperation performed because of a lesion at the original operation site and that undertaken because of a lesion at a distant site. This study analyses the need for reoperation only at the original site of operation and measures operation-free intervals. The site specific operation-free intervals in 41 patients with small bowel Crohn's disease treated by strictureplasty were not significantly different from the similar intervals in 41 patients treated by a small bowel resection.     

Factors affecting the incidence of postoperative septic complications and recurrence after strictureplasty for jejunoileal Crohn's disease.

BACKGROUND: This retrospective study was undertaken to examine the long-term outcome of strictureplasty for Crohn's disease and factors affecting the incidence of postoperative septic complications and recurrence. METHODS: Eighty-seven patients who underwent 245 primary jejunoileal strictureplasties for jejunoileal Crohn's disease between 1980 and 1997 were reviewed. RESULTS: Septic complications (fistula/abscess) occurred in 7 patients (all at strictureplasty site). Only intra-abdominal sepsis with peritoneal contamination at laparotomy was significantly associated with these complications. After a median follow-up of 104 months, 49 patients (56%) developed symptomatic recurrence. In 11 patients, symptomatic recurrence was successfully managed by medical treatment. Thirty-eight patients (44%) required further surgery for recurrence. Only young age (< or = 37 years) was associated with high incidence of reoperation for recurrence. Preoperative steroid use, nutritional status, synchronous bowel resection, and number, site, or length of strictureplasties did not affect the incidence of septic complications and recurrence requiring reoperation. CONCLUSIONS: Intra-abdominal sepsis with peritoneal contamination increased the incidence of septic complications. Only young age was associated with the increased risk of recurrence requiring reoperation.     

Outcome of strictureplasty for duodenal Crohn's disease

BACKGROUND: The outcome of strictureplasty for duodenal Crohn's disease has not been critically documented. The aim of this study was to assess the outcome of strictureplasty for duodenal Crohn's disease. METHODS: A retrospective review was undertaken of 13 patients who underwent strictureplasty (including four pyloroplasties) for obstructive duodenal Crohn's disease between 1974 and 1997. RESULTS: Ten patients underwent strictureplasty as the primary procedure, and in three strictureplasty was used as a revision procedure after previous bypass surgery. Two patients developed anastomotic breakdown and were treated either by Roux-en-Y duodenojejunostomy or partial gastrectomy. Symptoms of obstruction persisted in four patients after strictureplasty; three eventually resolved after prolonged nasogastric aspiration, but the other required gastrojejunostomy. In the long term, six patients developed restricture at the previous strictureplasty site. Five required repeat strictureplasty and the other patient underwent duodenojejunostomy. One patient who had repeat strictureplasty required a further strictureplasty because of restricture at the previous strictureplasty site. Overall nine of 13 patients required further surgery because of early postoperative complications or restricture at the strictureplasty site. CONCLUSION: Strictureplasty for duodenal Crohn's disease is associated with a high incidence of postoperative complications and restricture.     

Early results of laparoscopic surgical procedures in Crohn's disease

INTRODUCTION: During the last years laparoscopic surgical procedures are used more frequently in benign bowel diseases like Crohn's disease. We are reporting early results of laparoscopic procedures in Crohn's disease at our hospital. PATIENTS AND METHOD: From 1994 to 2003 54 patients (20 male and 34 female) underwent laparoscopic colonic and small bowel surgery in Crohn's disease. The mean age was 32 years (range: 16 to 55 years). RESULTS: Complications occurred in 6 patients (11.1 %). 3 patients needed a laparotomy. One computed tomography puncture was performed due to a hematoma. The remaining patients are treated successfully non-operatively. No patient died during the perioperative period. The mean operating time was 152 minutes (range 35 to 360 minutes) and the mean postoperative stay in hospital was 10 days (range 6-35 days). 0.2 blood cell concentrates were needed per operation (range 0 to 6), on average. The patients needed no analgesics after the 5 (th) day (range 1 to 13 days), got liquid diet on the 2 (nd) (range 0 to 6 days) and solid diet on the 3 (rd) day after surgery (range 1 to 14 days). DISCUSSION: Laparoscopic surgery in Crohńs disease is safe when performed by an experienced surgeon. The laparoscopic procedure results in a better cosmetic result, while the longer operating time is the mean disadvantage. There are low complication rates during the early postoperative period.     

Two surgical procedures for strictures at Finney strictureplasty for small bowel Crohn's disease

In patients with Crohn's disease, long small bowel strictures are sometimes treated by a Finney strictureplasty. Strictures at an entrance and exit of a previous Finney strictureplasty are associated with severe obstructive symptoms and sometimes blind loop syndrome. Those strictures are difficult to manage. We herein introduce two different surgical procedures: one is a continuous T-shaped strictureplasty and the other is anastomosis between the Finney pouch and the divided small bowel. Both procedures immediately relieved obstructive symptoms and required no major resection of the bowel. After a 2-year follow-up, there has been no recurrence at the previous Finney strictureplasty.     

Long-term follow-up of strictureplasty for Crohn's disease

BACKGROUND: Strictureplasty is an effective means of alleviating obstructive Crohn's disease while conserving bowel length. The aim of this study was to establish long-term outcomes of strictureplasty. METHODS: Between 1978 and 2003, 479 strictureplasties were performed in 100 patients during 159 operations. Information on Crohn's disease, medical therapy, laboratory indices, surgical details, complication rates and outcomes was recorded. The primary endpoint was abdominal reoperation. RESULTS: Mean follow-up was 85.1 (range 0.2-240.9) months. The overall morbidity rate was 22.6 per cent, with septic complications in 11.3 per cent, obstruction in 4.4 per cent and gastrointestinal haemorrhage in 3.8 per cent. The 30-day mortality rate was 0.6 per cent and the procedure-related series mortality rate 3.0 per cent. Perioperative parenteral nutrition was the only marker for morbidity (P < 0.001). Reoperation rates were 52 per cent at a mean of 40.2 (range 0.2-205.8) months after a first, 56 per cent at 26.1 (range 3.5-63.5) months after a second, 86 per cent at 27.4 (range 1.4-74.5) months after a third, and 62.5 per cent at 25.9 (range 7.3-70.5) months following a fourth strictureplasty procedure. The major risk factor for reoperation was young age (P < 0.001). CONCLUSION: Long-term follow-up has confirmed the safety of strictureplasty in Crohn's disease. Morbidity is appreciable, although the surgical mortality rate is low. Reoperation rates are comparable following first and repeat strictureplasty procedures.     

Long-term results after surgical therapy of Crohn's disease

We performed a retrospective analysis in patients after operative therapy of Crohn's disease in our institution. PATIENTS AND METHODS: 81 patients that underwent surgery from 1990-1995 were analysed retrospectively. The follow up period in these patients was 42 months. RESULTS: In 81 patients a total of 88 operations were performed. 56 patients were operated for the first time. The average patient's age was 35 years (range 14-76 years). Crohn's disease was located predominantly in the area of the ileocoecal valve. The most frequent operation was the ileocoecal resection. The prevalent operative indication in patients with small intestine Cohn's disease was the obstruction, in small intestine and colon manifestation the fistula. Complications in the early postoperative course appeared in 14 % of the patients. Postoperative mortality was 1.1 %. In a postoperative observation period of 3.5 years 3 of 57 patients (5 %) had to undergo surgery again, due to recurrence. Altogether 25 of 81 (31 %) patients revealed a recurrence. CONCLUSIONS: The surgical therapy of Crohn's disease can be performed safely and provides long-term recurrence and complaint free periods.     

Ten-year experience of strictureplasty for obstructive Crohn's disease

Strictureplasty is controversial in the management of obstructive Crohn's disease. Only a small proportion of patients undergoing surgery for obstructive Crohn's disease are suitable for strictureplasty. Lesions which are most amenable for this procedure are short, fibrous strictures. Over a 10-year period 24 patients have undergone 30 operations at which 86 strictureplasties were performed. The median follow-up has been 40 (range 4-112) months. No leaks or fistulae arose from the strictureplasties. The median weight gain 3 months postoperatively was +4.0 kg. Four patients subsequently required a further 13 strictureplasty procedures, between 12 and 36 (median 18) months after the initial operation; all but one of the previous strictureplasties were patent. Thirteen patients have been symptom free following surgery, four have required further medical therapy for recurrent Crohn's disease and three have sustained episodes of self-limiting intestinal colic. Strictureplasty is a safe and effective procedure in selected patients undergoing surgery for obstructive Crohn's disease.     

Smoking and disease recurrence after operation for Crohn's disease

BACKGROUND: There is increasing speculation about the role of smoking in the pathogenesis of inflammatory bowel diseases. The purpose of this study is to review the impact of smoking on disease recurrence after operation for Crohn's disease. METHODS: A Medline-based literature review (1966-1999) was carried out; ten studies examined the relationship between smoking and disease recurrence after operation. RESULTS: Approximately half of the patients were smokers at the time of operation. In most studies smoking significantly increased the risk of postoperative disease recurrence. Smokers had an approximately twofold increased risk of recurrence compared with non-smokers and the effect of smoking was dose dependent. The increased risk of recurrence among smokers was more prominent in women than in men, and a longer duration of smoking increased the risk of recurrence. Ex-smokers had a similar recurrence rate to non-smokers and giving up smoking soon after operation was associated with a lower probability of recurrence. CONCLUSION: Smoking significantly increases the risk of recurrence of disease after operation for Crohn's disease, especially in women and heavy smokers. Encouraging patients to stop smoking is an important part of the management of Crohn's disease.     

Multivariate analysis suggests improved perioperative outcome in Crohn's disease patients receiving immunomodulator therapy after segmental resection and/or strictureplasty

BACKGROUND: Medical management of moderate to severe Crohn's disease (CD) using immunomodulator agents has not eliminated surgical treatment of disease complications. The effect of improved medical treatment on perioperative CD surgical outcome is not known. We analyzed the impact of immunomodulator therapy on the rate of intraabdominal septic complications (IASC) in CD patients undergoing bowel reanastomosis or strictureplasty. METHODS: Surgical outcome was reviewed in 100 consecutive CD patients who underwent segmental resection with primary anastomosis or strictureplasty between 1998 and 2002. Multivariate analysis was performed to determine the effect of immunomodulator therapy on rate of IASC (intraabdominal abscess, anastomotic leak, or enterocutaneous fistulae). Immunomodulator agents included azathioprine, 6-MP, methotrexate, and infliximab. RESULTS: IASC developed in 11 of 100 (11%) operations. Immunomodulator use was associated with fewer IASC (4/72 procedures; 5.6%), compared with 7/28 (25%) cases with patients not on therapy (P<.01). IASC were not influenced by steroid use, smoking status, preoperative abscess, or fistula or albumin levels. Immunomodulator use did not affect the length of resection or the rate and number of strictureplasties. CONCLUSION: Medical management with immunomodulator therapy is safe and significantly decreases postoperative IASC in CD patients undergoing surgical procedures requiring bowel anastomosis or strictureplasty.     

The role of strictureplasty in Crohn's disease.

Crohn's disease is a panintestinal disease of unknown aetiology and a tendency to recrudescence throughout the patient's life. It is therefore impossible to cure Crohn's disease by medical therapy or surgical excision. In spite of this, the majority of patients can be managed through their disease and maintained in a good state of health by a combination of medical and surgical treatment. Early attempts at surgical management of Crohn's disease in the 1930's and 1940's involved bypass procedures which were marred with serious complications of sepsis, development of cancer and increased rate of recurrence. By the 1950's resection became the preferred operation but there soon arose a controversy about the amount of bowel that should be removed. There were some who advocated radical excision; removing all diseased bowel with a large margin of apparently normal tissue on each side of the resection. Others found less radical resection safer as it preserved gut and also had no apparent effect on the rate of recurrence of the disease. Although this argument continued, the balance gradually shifted towards less radical surgery. Furthermore, the wave of conservatism led to the evolution of the concept of minimal surgery.     

Resolving sphincter of Oddi incontinence for primary duodenal Crohn's disease with strictureplasty

INTRODUCTIONCrohn's involvement of duodenum is a rare event and may be associated to proteiform symptoms and uncommon pathological aspects which make diagnosis and treatment complex.PRESENTATION OF CASEThe peculiar aspect of this case was a suspected duodeno-biliary fistula. The patient (female, 22 years old) was affected by duodenal Crohn's disease. Magnetic resonance imaging showed a dilated common bile duct, whose final part linked to a formation containing fluid, and characterized by filling of the contrast medium in the excretory phase. Abdominal ultrasound showed intra-hepatic and intra-gallbladder aerobilia. At surgery, the duodenum was mobilized showing an inflammatory stricture and a slight dilatation of the common bile duct, with no signs of fistulas. The opened duodenum was anastomized side to side to a transmesocolic loop of the jejunum. After surgery, the general condition of the patient improved.DISCUSSIONOnly two cases of fistula between a narrow duodenal bulb and the common bile duct have been described in literature and the Authors were not be able to verify the occurrence of a duodenal biliary fistula at surgery. The association between duodenal Crohn's disease and Sphincter of Oddi incontinence is a very rare finding with different etiology: chronic intestinal pseudo-obstruction, common bile duct stones, progressive systemic sclerosis.CONCLUSIONThe treatment to resolve Sphincter of Oddi incontinence for primary duodenal Crohn's disease is not clear. Strictureplasty could be the treatment of choice, because, resolving the stricture, the duodenal pressure is likely to decrease and the reflux through the incontinent sphincter can be avoided.     

Side-to-side isoperistaltic strictureplasty in the treatment of extensive Crohn's disease

BACKGROUND: First performed in 1992, the side-to-side isoperistaltic strictureplasty (SSIS) is a bowel-sparing surgical option for Crohn's patients presenting with sequentially occurring stenoses over long intestinal segments (>15 cm). This investigation was designed to study the outcomes and patterns of recurrence after a SSIS. MATERIALS AND METHODS: Between 1992 and 2003, 30 patients underwent SSIS at the University of Chicago. Their data were gathered prospectively in an Institutional Review Board-approved database. RESULTS: A total of 31 SSISs were constructed in 30 patients. As an indication of the severity of disease in these patients, 25 of 30 (83%) required a concomitant bowel resection, and 13 (43%) underwent at least one additional strictureplasty. The average length of diseased bowel used to construct the SSIS was 51 cm. The average length of residual small bowel after performance of SSIS was 275 cm, and the SSIS represented an average 19% of the remaining small bowel that would have otherwise been sacrificed with resection. Three patients experienced perioperative complications (10%) and one died (3%). Seven patients (23%) required reoperation to treat recurrence of symptoms within the first 5 years. In four of these patients, recurrence was found at or near the previous SSIS. CONCLUSIONS: A side-to-side isoperistaltic strictureplasty (SSIS) is a safe and effective surgical option for sequentially occurring Crohn's strictures over long intestinal segments.     

The role of strictureplasty in the treatment of Crohn's disease

Crohn's disease is pandigestive disease of unknown aethiology, with tendency to reccurrences. Until now it is impossible to heal this disease either by medical or surgical treatment. All unfavourable consequences of this disease are result of inadequate treatment of complications which are leading to systemic weakening, with further progression of morbid process. Therefore, the principle of timely and minimal invasive surgical procedure has been generally adopted. Introduced in eighties, strictureplasty is a procedure of such characteristics. During the period 1980-2001 this method was used in 1/3 of 126 patients with Crohn's disease. There were 79 strictureplaties performed, 9 long and 70 short. Out of these 42, 12(28.6%) were postoperative recurrences, and there was one case of duodenal strictureplatsty. Postoperative small bowel fistulae were not observed, and there was no mortality in this group. During the follow up period of at least 5 years, in only two cases (4.76%) some functional disturbances of digestive functions were observed, without indications for reoperation. In this article indications and details of operative technique are discussed.     

Long-term results of strictureplasty for ileocolonic anastomotic recurrence in Crohn’s Disease

This study examined the outcome of strictureplasty for recurrence at the ileocolonic anastomosis after resection (ileocolonic strictureplasty) in Crohn’s disease. The records of 42 patients who underwent ileocolonic strictureplasty between 1980 and 1997 were reviewed. The method of ileocolonic strictureplasty was Heineke-Mikulicz reconstruction for a short stricture (<-6 cm) in 41 patients and Finney reconstruction for a long stricture (20 cm) in one. Synchronous operations were performed for coexisting small bowel Crohn’s disease in 17 patients: strictureplasty in eight, resection in two, and both in seven. Postoperatively there were two intra-abdominal abscesses, which were treated conservatively. There were no deaths. All except two patients had complete relief of symptoms after operation. Most of the patients who had preoperative weight loss gained weight (median gain +2.6 kg). After a median follow-up of 99 months, 24 patients (57%) had a symptomatic recurrence. Three patients were successfully managed by medical treatment. The other 21 patients (50%) required surgery for recurrence (20 for recurrence at the previous ileocolonic strictureplasty site). At present, two patients are symptomatic and currently receiving corticosteroid therapy. All other patients have had no recurrent symptoms. None of the patients have developed short bowel syndrome or small bowel carcinoma. Strictureplasty is a safe and efficacious procedure for ileocolonic anastomotic recurrence in Crohn’s disease.