Finney and Jaboulay Strictureplasty
Pamela C. Sivathondan
Bruce D. George
The behavior of Crohn’s disease may be considered to be nonstricturing, nonpenetrating (B1), stricturing (B2), or penetrating (B3). About one-third of patients with Crohn’s disease will develop stricturing disease. Strictures may be single or multiple, short or long, and may occur at any part of the gastrointestinal tract. The most common sites are the small bowel, especially terminal ileum, and at surgical anastomoses.
Established fibrotic strictures require a mechanical solution. Short strictures may be amenable to endoscopic balloon dilatation. Thienpont et al. reported their experience of 237 dilatations in 138 patients. All strictures treated were less than 5 cm and were predominantly at ileocolic anastomoses. Immediate success, judged by the ability to pass an adult colonoscopy through the stricture, was achieved in 97%. Six perforations occurred (2.5% risk per procedure, 4.3% risk per patient). At median follow-up of 5 years, 24% of patients required surgery and 46% repeat dilatation. Forty-four percent of patients remained free of dilatation and surgery after the first dilation.
In broad terms, surgery is indicated for symptomatic strictures not amenable to endoscopic balloon dilatation or when medical/endoscopic therapy has failed. However, further factors need to be considered, ideally within a multidisciplinary team environment:
Degree of certainty that symptoms are due to stricture(s)
Patients with obstructive symptoms and radiologic evidence of a stricture with associated proximal bowel dilatation are most likely to benefit from intervention. Alternatively, patients with nonspecific symptoms or irritable-bowel-like symptoms and lack of proximal bowel dilatation are much less likely to benefit clinically from intervention.
Is the stricture mainly fibrotic or inflammatory?
Conceptually, inflammatory strictures are likely to respond to anti-inflammatory medical therapy, whereas fibrotic strictures are likely to require mechanical treatment. In practice, most strictures are a mixture of both inflammatory and fibrotic. Assessment of which is dominant depends on a combination of clinical and radiologic features. Strictures occurring early in the natural history of the disease are more likely to be inflammatory. Serum inflammatory markers, erythrocyte sedimentation rate and C-reactive protein, and fecal calprotectin will tend to be raised in inflammatory strictures. Magnetic resonance and computed tomography may demonstrate discriminatory features such as wall thickening with contrast enhancement pointing toward inflammation or lack of such wall enhancement and the “fat halo” sign favoring fibrosis.
The decision to recommend surgery for stricturing disease is ultimately a balance between potential benefits such as relief of symptoms, improved nutrition, and possible reduction of medication and risks including early surgical risks such as anastomotic leakage, stoma, altered symptoms, changed body image and later recurrence and short bowel syndrome.
Once the decision to operate has been made, it is important to preoperatively optimize to reduce the risks of surgery:
Recent small bowel imaging and colonoscopy
Reduce risk factors: improve nutrition, reduce/stop steroids, eliminate/reduce sepsis
Multidisciplinary team discussion
For patients with small bowel stricturing disease, a period of clear fluid intake is needed for the 24-48 hours before surgery. Bowel preparation is not required unless there is distal colonic or rectal disease or the need for intraoperative colonoscopy is anticipated. Standard antibiotics and venous thromboprophylaxis should be given.
The initial phase of surgery involves careful assessment of the extent of stricturing disease. While most first operations may be laparoscopically undertaken, recurrent disease or cases of extensive small bowel stricturing may require laparotomy.
Most strictures may be detected by the presence of bowel wall thickening, mesenteric fat wrapping, or serosal neovascularization. Subtle strictures can be easily overlooked and balloon characterization of the whole small bowel from duodenum to cecum is recommended. The use of a calibrated Foley catheter inserted via a suitable enterotomy (at a site of planned resection or strictureplasty (SP)) is recommended (Fig. 69-1A and 1B). The length of the small bowel should be measured.