Overview
Definition:
Strictureplasty is a surgical technique used to widen narrowed segments of the intestine, typically caused by fibrotic strictures in Crohn's disease, without resecting the involved bowel
The Heineke-Mikulicz (H-M) technique involves a longitudinal incision followed by a transverse closure, creating a wider lumen
It is an alternative to bowel resection when preserving bowel length is paramount.
Epidemiology:
Crohn's disease affects approximately 1 in 250 individuals in Western countries, with stricturing being a common complication, occurring in up to 50% of patients over time
Strictureplasty is considered in specific scenarios, particularly in patients with short bowel syndrome or multiple, short, fibrotic strictures where resection would lead to significant bowel length loss.
Clinical Significance:
Strictureplasty offers a bowel-sparing approach, which is crucial for patients with extensive disease or those at risk of developing short bowel syndrome
By avoiding resection, it aims to preserve intestinal absorptive function and reduce the need for parenteral nutrition, thereby improving quality of life and long-term outcomes
It is a vital option in the surgical armamentarium for managing complex Crohn's disease.
Indications
Indications:
Strictureplasty is indicated for symptomatic fibrotic strictures in Crohn's disease where bowel resection is undesirable or would lead to significant bowel length compromise
Key indications include: Multiple, short, fibrotic strictures
Strictures amenable to a Heineke-Mikulicz or similar technique
Patients with or at high risk for short bowel syndrome
Patients with a single, accessible fibrotic stricture without active inflammation or significant complications like fistulas or abscesses
Absolute contraindications include active transmural inflammation, significant abscess formation, fistulas, or malignancy within the stricture segment.
Contraindications:
Absolute contraindications include: Active transmural inflammation or phlegmon
Intra-abdominal abscess
Enteroenteric or enterocutaneous fistulas involving the stricture
Suspicion of malignancy within the strictured segment
Extensive, long strictures (>10-15 cm) not amenable to H-M technique
Short, diffusely diseased bowel
Relative contraindications include severe malnutrition or very elderly, frail patients where extensive surgery may be too risky.
Preoperative Preparation
Assessment:
Thorough pre-operative assessment is vital
This includes detailed history to assess symptoms of obstruction (abdominal pain, vomiting, constipation), nutritional status, and previous surgeries
Physical examination focuses on signs of inflammation, tenderness, and palpable masses
Comprehensive investigations are crucial.
Investigations:
Key investigations include: Complete blood count (CBC) to assess for anemia and inflammation (elevated ESR, CRP)
Electrolytes and renal function tests to assess hydration and electrolyte balance
Nutritional assessment (albumin, prealbumin)
Imaging: CT enterography or MR enterography are gold standard for delineating stricture length, number, location, and presence of complications like fistulas or abscesses
Contrast-enhanced ultrasound can also be useful
Endoscopy may be used to assess the luminal extent but is limited in evaluating transmural disease.
Medical Optimization:
Medical optimization involves correcting malnutrition through nutritional support (enteral or parenteral), managing anemia with iron or blood transfusions, and addressing any electrolyte imbalances
Antibiotics are typically initiated perioperatively to reduce the risk of surgical site infection and treat any co-existing infection.
Procedure Steps
Surgical Approach:
The procedure is typically performed via laparotomy or laparoscopy
Laparoscopic approach offers advantages of smaller incisions, reduced postoperative pain, and faster recovery, but requires significant surgical expertise for managing Crohn's disease.
Heineke Mikulicz Technique:
The Heineke-Mikulicz strictureplasty involves the following steps: 1
Identification and mobilization of the strictured segment
2
A longitudinal enterotomy is made across the center of the fibrotic stricture
3
The edges of the longitudinal incision are then carefully sutured in a transverse direction using absorbable or non-absorbable sutures, creating a wider, flap-like closure
This widens the lumen significantly
Careful approximation of the seromuscular layers is essential to prevent dehiscence
Multiple strictureplasties may be performed sequentially if needed, ensuring adequate spacing between them.
Other Techniques:
Other strictureplasty techniques include the Finney strictureplasty (a Y-V plasty), the Jaboulay-Haynes technique (a side-to-side functional end-to-end anastomosis), and the Dubois strictureplasty (a clamshell incision with transverse closure)
The choice depends on the stricture morphology and surgeon preference.
Postoperative Care
Early Management:
Postoperative care involves meticulous fluid and electrolyte management, analgesia, and monitoring for complications
Nasogastric (NG) tube decompression is often utilized initially to rest the bowel
Parenteral nutrition may be continued until adequate bowel function is restored.
Feeding Advancement:
Dietary advancement is gradual, starting with clear liquids and progressing to a low-residue diet as bowel function returns (passage of flatus and stool)
Close monitoring for signs of anastomotic leak or ileus is essential
Prophylactic antibiotics are continued as per institutional protocols.
Monitoring:
Patients are monitored for signs of infection, wound complications, deep vein thrombosis (DVT), and pulmonary embolism
Regular laboratory tests (CBC, electrolytes) are performed
Long-term follow-up involves assessing for recurrence of strictures or disease progression and optimizing medical management.
Complications
Early Complications:
Early complications include: Anastomotic leak or dehiscence at the site of strictureplasty
Intra-abdominal abscess formation
Ileus (bowel obstruction)
Wound infection
DVT/Pulmonary embolism
Bleeding.
Late Complications:
Late complications include: Recurrence of stricture at the site of previous strictureplasty or elsewhere in the bowel
Development of new strictures
Malabsorption if multiple segments are involved or bowel length is significantly reduced
Adhesonic bowel obstruction
Incisional hernia
Fistula formation
The risk of recurrence is a significant concern.
Prevention Strategies:
Prevention strategies involve careful patient selection, ensuring no active inflammation or complications exist at the stricture site, meticulous surgical technique with adequate tension-free closure, judicious use of prophylactic antibiotics, and prompt recognition and management of any early postoperative complications
Long-term medical therapy optimization is crucial for disease control and preventing recurrence.
Prognosis
Factors Affecting Prognosis:
Prognosis is influenced by the extent and nature of Crohn's disease, the number and location of strictures treated, the patient's nutritional status, the presence of extra-intestinal manifestations, and adherence to long-term medical therapy
The risk of recurrent disease and the need for future surgery remain significant.
Outcomes:
Successful strictureplasty can alleviate obstructive symptoms and improve quality of life by preserving bowel length
However, recurrence rates can be substantial, with some studies reporting re-operation rates due to recurrent stricturing or other complications in a significant percentage of patients within 5-10 years
Patient selection is key to achieving favorable outcomes.
Follow Up:
Lifelong follow-up is essential for patients with Crohn's disease
This typically involves regular clinical assessments, laboratory monitoring (ESR, CRP, nutritional markers), and interval imaging (CT or MR enterography) to detect disease recurrence or new strictures
Optimizing medical management with immunomodulators or biologics is crucial for long-term disease control and reducing the need for re-operation.
Key Points
Exam Focus:
Heineke-Mikulicz strictureplasty is a bowel-sparing technique for fibrotic Crohn's strictures
Indications: multiple, short, fibrotic strictures
high risk of short bowel syndrome
Contraindications: active inflammation, abscess, fistula, malignancy
Key technique: longitudinal incision, transverse closure
Risk of recurrence is high
Differentiate from enterectomy.
Clinical Pearls:
Always assess for active inflammation, fistulas, or abscesses before considering strictureplasty
these are contraindications
Preserving bowel length is paramount in Crohn's surgery
Consider the number and length of strictures
multiple long strictures may necessitate resection
Careful surgical technique is crucial to avoid dehiscence and leaks.
Common Mistakes:
Performing strictureplasty in the presence of active transmural inflammation or abscess
Underestimating the length of the stricture or the extent of bowel disease
Failing to adequately counsel patients on the risk of recurrence and the need for lifelong medical therapy
Not considering the impact on nutritional status and the risk of short bowel syndrome.