Overview
Definition:
Finney strictureplasty is a surgical technique used to widen a narrowed segment of the small intestine (stricture) by converting a longitudinal incision into a transverse closure, thereby increasing the lumen diameter
It is particularly useful for longer strictures where resection and anastomosis might lead to significant bowel loss or complications like short bowel syndrome.
Epidemiology:
The incidence of small bowel strictures varies depending on the etiology, with inflammatory conditions like Crohn's disease being a common cause
Long strictures, especially those associated with chronic inflammation, pose a surgical challenge
Finney strictureplasty is an alternative to resection in selected cases.
Clinical Significance:
Finney strictureplasty preserves bowel length, which is crucial for maintaining intestinal function and nutrient absorption, especially in patients with multiple or long strictures
It offers a less morbid alternative to extensive resection, reducing the risk of short bowel syndrome and its associated complications, making it vital for surgical residents to understand its indications and execution.
Indications
Primary Indications:
Management of long (>5 cm) benign small bowel strictures
Strictures caused by Crohn's disease, radiation enteritis, or adhesions
Patients at high risk for or with previous short bowel syndrome where resection is contraindicated.
Contraindications:
Malignant strictures requiring oncologic resection
Acute intestinal obstruction with proximal distension and ischemic changes
Extensive transmural inflammation with fistulation or abscess formation
Very short strictures amenable to simple longitudinal stricturotomy and closure.
Patient Selection:
Careful patient selection is paramount
Assess the length and extent of the stricture, degree of obstruction, presence of complications (fistula, abscess), and overall patient health
Preoperative imaging (CT enterography, MRI enterography) is essential.
Preoperative Preparation
Medical Optimization:
Nutritional support (TPN if needed)
Correction of anemia and electrolyte imbalances
Antibiotic prophylaxis as per institutional guidelines.
Bowel Preparation:
Mechanical bowel preparation may be considered depending on the degree of obstruction and surgeon preference
Clear liquid diet preoperatively.
Imaging Review:
Thorough review of CT or MRI scans to delineate the stricture length, location, and involvement of adjacent structures
Assess for any signs of ischemia or perforation.
Procedure Steps
Approach:
Laparotomy or laparoscopy can be used
Laparoscopy is feasible for carefully selected cases, but open surgery often provides better exposure for extensive dissection.
Identification And Mobilization:
The affected segment of the small bowel is identified
The bowel proximal and distal to the stricture is mobilized sufficiently to allow for adequate manipulation and the longitudinal enterotomy.
Longitudinal Enterotomy:
A longitudinal incision is made through the antimesenteric border of the bowel, extending through the strictured segment and for a few centimeters into the normal bowel on either side
The length of the enterotomy should correspond to the length of the stricture.
Transverse Closure:
The longitudinal enterotomy is then closed transversely using sutures, creating a wider lumen
This is typically performed in two layers using absorbable or non-absorbable sutures, ensuring adequate tension and hemostasis.
Tension Assessment:
Care must be taken to avoid tension on the suture line
If tension is a concern, side-to-side isoperistaltic anastomosis or limited resection may be considered instead
Test the patency of the new lumen before closing the abdomen.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and abdominal distension
Pain management is crucial.
Nasogastric Tube:
A nasogastric tube is typically placed for decompression in the immediate postoperative period, and its removal is guided by return of bowel function.
Nutrition:
Parenteral nutrition is usually continued until bowel function returns and oral intake is tolerated
Gradual advancement of diet is essential.
Ambulation And Mobilization:
Early ambulation is encouraged to prevent complications like deep vein thrombosis and pneumonia.
Complications
Early Complications:
Anastomotic leak
intra-abdominal abscess
bleeding
ileus
wound infection
anastomotic stricture at the closure site.
Late Complications:
Recurrence of stricture
adhesions leading to small bowel obstruction
malabsorption
incisional hernia.
Prevention Strategies:
Meticulous surgical technique
adequate bowel preparation
appropriate suture material and technique for closure
careful postoperative management
early recognition and management of complications.
Prognosis
Factors Affecting Prognosis:
The underlying etiology of the stricture (Crohn's disease has a higher recurrence rate than radiation-induced strictures)
The length and number of strictures treated
Patient's overall health and nutritional status.
Outcomes:
Finney strictureplasty can significantly improve symptoms of obstruction and preserve bowel length, leading to good functional outcomes
However, recurrence is possible, especially in Crohn's disease.
Follow Up:
Regular follow-up with clinical assessment and imaging (e.g., CT enterography) is necessary to monitor for recurrence of strictures or development of new ones
Surveillance is particularly important in patients with Crohn's disease.
Key Points
Exam Focus:
Finney strictureplasty is primarily for long (>5cm) benign small bowel strictures, preserving bowel length
It involves a longitudinal enterotomy closed transversely
Key complications include leak and recurrence.
Clinical Pearls:
Consider Finney when resection would lead to significant bowel loss
Ensure adequate length of normal bowel proximal and distal to the stricture for mobilization and closure
Avoid tension on the suture line.
Common Mistakes:
Performing Finney on malignant strictures
Inadequate bowel mobilization leading to tension during closure
Incorrect assessment of stricture length
Failure to adequately decompress the bowel postoperatively.