Strictureplasty Research Articles

The Molecular Mechanisms of Intestinal Inflammation and Fibrosis in Crohn's Disease.

Crohn’s disease (CD) is an inflammatory bowel disease (IBD) with repeated remissions and relapses. As the disease progresses, fibrosis and narrowing of the intestine occur, leading to severe complications such as intestinal obstruction. Endoscopic balloon dilatation, surgical stricture plasty, and bowel resection have been performed to treat intestinal stenosis. The clinical issue is that some patients with CD have a recurrence of intestinal stenosis even after the medical treatments. On the other hand, there exist no established medical therapies to prevent stenosis. With the progressive intestinal inflammation, cytokines and growth factors, including transforming growth factor (TGF-β), stimulate intestinal myofibroblasts, contributing to fibrosis of the intestine, smooth muscle hypertrophy, and mesenteric fat hypertrophy. Therefore, chronically sustained inflammation has long been considered a cause of intestinal fibrosis and stenosis. Still, even after the advent of biologics and tighter control of inflammation, intestinal fibrosis’s surgical rate has not necessarily decreased. It is essential to elucidate the mechanisms involved in intestinal fibrosis in CD from a molecular biological level to overcome clinical issues. Recently, much attention has been paid to several key molecules of intestinal fibrosis: peroxisome proliferator-activating receptor gamma (PPARγ), toll-like receptor 4 (TLR4), adherent-invasive Escherichia coli (AIEC), Th17 immune response, and plasminogen activator inhibitor 1 (PAI-1). As a major problem in the treatment of CD, the pathophysiology of patients with CD is not the same and varies depending on each patient. It is necessary to integrate these key molecules for a better understanding of the mechanism of intestinal inflammation and fibrosis.

Long-Term Outcomes and Patency Rate of Stricture Plasty for Crohn Disease

Long-Term Outcomes and Patency Rate of Stricture Plasty for Crohn Disease

Non-Steroidal Anti-Inflammatory Drug Induced Small Bowel Web Managed by Strictureplasty

Small bowel obstructions (SBOs) are usually caused by adhesions, neoplasms, hernias or inflammatory strictures. Intramural strictures are an uncommon cause of SBO. Here we report a case of a 45-year-old female with recurrent small intestinal obstruction caused by non-steroidal anti-inflammatory drug (NSAID) induced small bowel strictures. NSAID stricture in the small bowel was discovered by capsule endoscopy. Strictureplasty was done after presentation with small bowel obstruction. J Med Cases. 2018;9(1):21-22 doi: https://doi.org/10.14740/jmc2968w

Strictureplasty and intestinal resection: different options in complicated pediatric-onset Crohn disease

Background/PurposeSurgical resection or strictureplasty (SP) are different options for intestinal Crohn disease (CD) strictures. The aim of this article is evaluation of long-term outcome of SP and resection. MethodsFrom 1996 to 2011, 39 patients (23 male, 16 female) with symptomatic ileal and ileocolonic CD strictures resistant to medical/nutritional therapy and treated with surgery in 2 different surgical units were reviewed. The mean age at diagnosis was 11.82 years (range, 4-17 years). Mean age at surgery was 15.94 years (range, 4-24 years). Mean follow-up was 6.88 years (range, 0.5-15 years). Patients underwent resection (group A) or different SP techniques (group B). ResultsTwenty patients underwent intestinal resection (ileal or ileocolonic resection), and 19 patients underwent SP (jejunal, ileal, or ileocolic). Early postsurgical complications were observed in 2 patients of group A. Follow-up of group A patients revealed that 1 patient needed emergency treatment after 8 months surgery because of adhesions and 1 patient developed recurrence treated with medical therapy. In the follow-up group B, 3 patients experienced disease recurrence, 2 of them at the site of previous surgery. ConclusionsAt long-term follow-up, no significant difference in relapsing rate was observed between the 2 groups. Strictureplasty and resection represent an effective treatment of pediatric CD strictures. Strictureplasty could represent the first option for intestinal preservation.

Diagnosis and treatment of hepatolithiasis complicated by bronchobiliary fistula: a study on 35 patients

Objective To investigate the diagnosis and treatment of hepatolithiasis complicated by bronchobiliary fistula.Method The data of 35 patients with hepatolithiasis and bronchobiliary fistula treated in our department in the last 10 years were retrospectively studied.Results The operations were:-repair of fistula in the diaphragm (n=35),hepatic segmentectomy (n=22) biliary stricturoplasty (n=13),T-tube drainage of common bile duct (n=19),hepaticojejunostomy (n=3) and bilateral hepatojejunostomy with a Roux-en-Y loop of jejunum (n=13).Residual stones were left in 4 patients.There was no recurrence of the bronchobiliary fistula on follow-up.Conclusions Expectoration of bitter and purulent yellow sputum was an important clinical feature of bronchobiliary fistula.The key steps in a successful operation were reliefing the obstructed bile duct and re-establishment of adequate biliary drainage. Key words: Hepatolithiasis; Bronchobiliary fistula

Surgical Management of Radiation Enterocolitis

Background: Pelvic irradiation has been a popular therapy modality for treating cervical cancer for many years, and its usage in rectal cancer and prostate cancer cases is also on the rise. In this study we retrospectively analyzed cases of surgical management for complications after pelvic irradiation. We also discuss the issue of resection of diseased bowel and the safety of anastomosis. Methods: From 1989 to 2007, a total of 31 patients in our hospital underwent gastrointestinal tract surgery for complications of pelvic irradiation and were enrolled in this study. A retrospective review was conducted for demographic data, preoperative status, operative strategy and recurrence of radiation enterocolitis. Results: For resection procedures, the mean length of hospital stay was 38.8 days and 18.8 days for diversion procedures (p=0.003). 21(58%) patients underwent resection procedures, and 15 (42%) patients underwent diversion procedures. The complication rate was 57% for resection procedures and 13% for diversion procedures (p=0.002). The mortality rate was 10% for resection procedures and 0 for diversion procedures (p=0.492). The total two-year recurrence rate for symptomatic radiation enterocolitis was 25%, and the re-operation rate was 22%. There was no significant difference in the recurrence rate and re-operation rate between resection procedures and diversion procedures. There was also no significant difference in the surgical outcome between the group with anastomosis and that without anastomosis. Conclusions: Surgery of radiation enterocolitis is associated with significant morbidity and mortality rates. Conservative procedures, such as bypass, stoma and stricturoplasty, should be considered for patients who are poor surgical candidates. Anastomosis did not increase surgical morbidity or mortality rates.

Long-term efficacy of strictureplasty for Crohn’s disease

Strictureplasty (SP) is an established surgical option for the management of obstructive Crohn's disease (CD) to avoid an extended resection. This study reviewed this department's extensive experience with SP as treatment for obstructive CD to clarify its long-term efficacy and recurrence. The medical records of 526 patients who underwent abdominal surgery for CD were retrospectively reviewed. The patients were divided into two surgical groups: those with or without SP. Surgical recurrences were limited to the site of the previous anastomosis or SP. Four hundred and thirty-five of the patients underwent surgery without SP and 91 with SP, performed in a total of 199 sites. Heineke-Mikulicz procedures and concomitant bowel resections were performed in 85.7% and 95.6%, respectively, of the patients in the With SP group. Postoperative septic complications included intra-abdominal abscesses in 2 patients (2.2%). The site-specific cumulative rate of reoperation at the previous surgical site after 10 years was 7.0% in the previous SP site and 18.0% in the previous anastomosis, which was significantly different (P < 0.01). Strictureplasty is a safe and effective method for obstructive CD, and should be considered when feasible. The recurrence rate was lower in the present study than that reported in Western countries.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn’s disease—review of the literature

Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence. We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP. The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months. Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.

Perforation of Stricturoplasty in Crohnʼs Disease

Perforation of Stricturoplasty in Crohnʼs Disease

Crohn’s disease-associated colorectal cancer in Japan: report of four cases

We report four cases of Crohn's disease (CD)-associated colorectal cancer (CRC) in our department. CASE 1: A 42-year-old Japanese man had a 14-year history of ileocolon CD. He had a history of an ileocecal resection and a stricture plasty. At the age of 42, sigmoid colostomy was performed because of the deterioration of the anal stenosis. After this operation, the perianal pain had remained, and a magnetic resonance imaging scan revealed a rectal tumor. CASE 2: A 30-year-old Japanese man had a 13-year history of ileocolon CD. He had a history of an ileostomy, a subtotal colectomy, and ileo-rectal anastomosis. At the age of 30, he had perianal pain, and a colonoscopy revealed a rectal cancer. An abdomino-perineal resection of the remnant rectum was performed. CASE 3: A 46-year-old Japanese man had a 9-year history of ileocolon CD. He experienced abdominal fullness. Colonoscopy revealed an ascending colon cancer. He underwent a subtotal colectomy and ileo-rectal anastomosis. CASE 4: A 33-year-old Japanese woman had a 16-year history of ileocolon CD. She had no changes in symptoms of CD. Surveillance colonoscopy revealed a transverse colon cancer. She underwent a subtotal colectomy and ileo-rectal anastomosis. As the number of patients with CD and with CD-associated CRC has increased in Japan, CD-associated CRC, as noted in these patients, should be kept in mind in the management of patients with CD. In addition, a surveillance system of patients with CD should be established and should prompt further study about CD-associated CRC.

Expanding the Role of Strictureplasty: Can Resections be Made Obsolete?

Expanding the Role of Strictureplasty: Can Resections be Made Obsolete?

炎症性腸疾患に対する外科治療の長期予後 ＶＩ．Ｃｒｏｈｎ病に対する狭窄形成術：現況とその成績

240例のCrohn病手術例のうち,狭窄形成術は計151例に対して行い,2回目手術以降は狭窄形成術施行例の比率が増加していた.施行部位は,回腸,大腸,回盲弁などに行われ,回腸がもっとも多い適応部位であったが,2回目以降の手術では前回吻合部,前回狭窄形成部に対しても狭窄形成術が行われた.施行術式は,Heineke-Mikulicz法が最も多いが,病変の長さ,固さに応じて他の術式も行われた.狭窄形成術の長期成績を累積再手術についてみると,手術施行部位では狭窄形成部と吻合部とで差はなく,症例毎でも狭窄形成術併用群と,腸切除単独例とでも差はなかった,また,狭窄形成術併用群と腸切除単独群との比較では,病変長が長いにもかかわらず切除腸管の長さ,残存小腸長に差はなく狭窄形成術による腸管温存効果が認められた.狭窄形成術は,腸管温存効果も見られ,繰り返す狭窄性小腸病変には良い適応で切除に匹敵する成績が得られた.

A prospective, longitudinal study of nonconventional strictureplasty in Crohn's disease.

Bowel-sparing techniques have been proposed to avoid extended or repeated resections in patients with Crohn'rsquo;s disease (CD), but without precise indications, prospective evaluation, and with a technically limited repertoire. A prospective longitudinal study of new nonconventional strictureplasties (NCSP) in order to evaluate the safety, type and site of recurrence, and longterm clinical and surgical efficacy. Between January 1993 and December 2002, 102 among 305 consecutive patients underwent at least one NCSP for complicated CD. Patients were treated following precise indications and then included in a prospective database with scheduled followup. Factors claimed to influence postoperative and longterm outcomes and type and site of recurrence were analyzed. We performed 48 ileoileal side-to-side isoperistaltic strictureplasty (SP), 41 widening ileocolic SP, 32 ileocolic side-to-side isoperistaltic SP, associated with Heineke-Mikulicz SP (in 80 procedures) or with minimal bowel resections or both (in 47 procedures). Postoperative mortality was nil; complication rate was 5.7%. Ten years clinical and surgical recurrence rates were 43% and 27%, respectively. Recurrence rate on an NCSP site was 0.8%. No specific factor was identified as related to postoperative or longterm outcomes. Perioperative and longterm results of NCSP are comparable to or even better than both conservative and resective surgery as reported in the literature, with a low recurrence rate on the NCSP site. Considering the unpredictability of the clinical course of CD and the lifetime need for surgical procedures, NCSP, together with minimal resection and classic SP repertoire, should be considered first-line treatment in complicated CD.

Early Perioperative Results and Surgical Recurrence after Strictureplasty and Miniresection for Complicated Crohn’s Disease

Background/Aims: Strictureplasty (SP) or miniresective ‘bowel-sparing’ techniques (MR) can prevent the risk of intestinal stomia and short bowel syndrome in patients affected by Crohn’s disease (CD). The aim of this study was to analyze the perioperative morbidity and mortality in 104 of 138 consecutive patients treated for CD complications using bowel-sparing techniques. We also considered the factors that may be related to the risk of perioperative complications and the long-term outcome. Methods: One hundred and four patients were treated with SP and/or MR and then included in a prospectively maintained database. The factors claimed to influence perioperative complications were analyzed using Fisher’s exact test for categorical observations and the Mann-Whitney U test for continuous variables. A multivariate analysis, using logistic regression, and a long-term time-to-event analysis using the Kaplan-Meier function, were also performed. Results: Perioperative mortality was nil. In relation to the 6 postoperative complications (5.8%), 4 patients underwent minimal bowel resection (MR), 1 a MR with SP, and 1 SP alone. Three of these patients (2.9%) needed reoperation for septic complications, and 3 (2.9%) were treated as outpatients for enterocutaneous fistulas. A correlation (p < 0.05) was found between low serum hemoglobin levels and postoperative complications at univariate and multivariate analyses. The 5-year surgical recurrence-free rate was 75% overall, 73% for patients treated with SP, 78% with MR, and 77% with MR + SP. Conclusions: Postoperative complications are not related to conservative or miniresective surgery even when active disease is present at the resection margins or the site of SP. The higher risk reported for patients with low serum hemoglobin and hematocrit levels suggests that surgeons should consider using preoperative iron and vitamin support, parenteral nutrition and erythropoietin therapy, when necessary, in those cases. Our postoperative morbidity, mortality and long-term surgical recurrence rate results support the efficacy and safety of SP and MR surgery in the treatment of complicated CD.

A CASE OF SUPERIOR MESENTERIC VEIN THROMBOSIS WITH MULTIPLE STENOSIS OF THE SMALL INTESTINE

A 37-year-old man was admitted to the hospital because of abdominal pain. Abdominal CT scan revealed thrombosis in the superior mesenteric vein. Fluoloscopic study of the small intestine revealed, at least, two stenoses in the superior portion of the jejunum. We diagnosed the case superior mesenteric vein thrombosis and multiple stenosis of the small intestine. Resection of the stenotic portions of the small intestine and stricture plasty were porformed. Microscopic examination revealed regenerational epithelium without submucosal tissue in stenotic portions, and fibrous tissue replaced muscle layer, which changed to a scar. The postoperative course was uneventful. He gained 10kg in weight, and improved nutritional condition.

Results of multiple strictureplasties in diffuse Crohn's disease of the small bowel.

With extensive small bowel strictures due to Crohn's disease, resectional surgery may lead to short bowel syndrome. Strictureplasty (SP) has emerged as a useful alternative for selected strictures. This study reviews the results of 42 patients with diffuse obstructive Crohn's disease of the small bowel in whom at least four SP were performed in each patient (median: 7; range: 4-15; total SP: 315). Twenty-three patients (55%) had had 1-5 previous small bowel resections. Co-existing perforative disease was present in four patients (10%). Synchronous resection of a separate segment of small bowel was performed in 22 patients (52%). There was no operative mortality. Enterocutaneous fistula and/or intra-abdominal abscess developed in three patients (7%) and only one of these needed operative intervention. The median follow-up was 3 years (range: 10 months to 7 years). After SP, all patients experienced relief from obstructive symptoms. The median weight gain was 3 kg (range: -1-21 kg) and more than half the patients were weaned off steroids. Symptomatic recurrence occurred in 10 patients (24%) and was due to strictures (N = 9) and/or perforative disease (N = 2) at new site(s) unrelated to previous SP. Rate of symptomatic restricture of the SP site was 1.6% and was associated with new strictures elsewhere in all cases. Thus, in selected cases, SP is a safe and effective treatment for diffuse Crohn's strictures.

Newer Operations for Ulcerative Colitis and Crohn’s Disease

Four options are currently available to surgeons for the management of ulcerative colitis: the brooke ileostomy, ileorectostomy, Kock pouch, and ileal pouch-anal anastomosis. The latter comes closest to the ideal operation, as it is curative and physiological and restorative of quality of life. It is the authors' preferred alternative in most patients. Obstructive Crohn's disease of the small intestine can be ameliorated without loss of bowel by stricture plasty.

A CASE OF CROHN'S DISEASE WITH RECTOVAGINAL FISTULA

A recto-vaginal fistula in 30-year-old woman with ileo-colic Crohn's disease was recently experienced. Trans ano-vaginal fistulectomy with a diverting temporary colostomy at the ascending colon was performed. At laparotomy, stricture plasty was performed for the small intestinal stenotic lesion at the same time.The postoperative course was good and the patient can take sufficient food orally. In Crohn's disease, fistula formation is a rather frequent complication and often needs surgical treatment. However recto-vaginal fistula of Crohn's disease is a rare complication and no definite treatment has yet been established.