Heineke-Mikulicz, Finney, and Michelassi Strictureplasty

Alessandro Fichera

Fabrizio Michelassi

Sharon L. Stein

Indications/Contraindications

Surgical treatment of Crohn’s disease is complicated by the recurrent nature of the disease. Many patients require multiple operations throughout their lives for failure of medical management, treatment of symptoms or complications of the disease including sepsis, stricture, bleeding, and cancer. Repeated intestinal resections may leave patients with inadequate intestinal mucosal surface leading to malabsorption of nutrients, vitamins, and fluids, resulting in malnutrition and chronic dehydration, a condition known as short gut syndrome.

Strictureplasty preserves intestinal absorptive surface area. Although the length of intestine may be reduced by modification of the shape of the bowel, total surface area remains the same in the preserved segment of bowel. Currently, it is not known whether the previously diseased segment regains absorptive function after strictureplasty, but studies demonstrate normalization of endoscopic and radiographic appearance in follow-up examinations after strictureplasty (1,2).

The concept of strictureplasty was first introduced by Katariya et al. to treat ileal strictures secondary to intestinal tuberculosis. In the 1980s, Emmanuel Lee began using this technique to treat fibrostenotic Crohn’s disease strictures in patients with extensive intestinal disease. Since that time the use and indications for strictureplasty have continued to expand.

Strictureplasty techniques were initially used only for quiescent small bowel disease; recently their use has been extended to duodenal disease as well as recurrent disease on small bowel anastomoses or ileocolic anastomoses. Strictureplasty can be coupled with bowel resections and several strictureplasty techniques can be used simultaneously to maximize bowel preservation.

Contraindications to strictureplasty include patients with generalized sepsis, cancer, or dysplasia. Severely diseased segments with luminal obliteration or unyielding intestinal wall, and intestinal segments with inflammatory phlegmonous masses or significantly thickened mesentery are probably best resected. Although the presence of fistulous
disease or localized sepsis was initially thought to be contraindications, several studies have demonstrated that strictureplasty is safe when the degree of acute inflammation associated with fistulae or sepsis is limited. An unstable patient should not undergo strictureplasty secondary to the length and complexity of the operation. At this time there is limited data regarding the use of strictureplasty in primary colonic disease.

Preoperative Planning

Appropriate preoperative evaluation for patients with Crohn’s disease includes thorough assessment of extent of disease. Although patients may present with a single symptomatic area of disease, preoperative knowledge of extent of disease aids in operative planning and in patient preparation.

A computed tomography (CT) scan is often the initial imaging study performed to evaluate symptomatic Crohn’s disease. CT scan is useful in that it evaluates both intraluminal and extraluminal findings including obstruction, edema, abscess, and fistula. CT enterography provides greater detail on intraluminal findings and presence of mucosal disease. Small bowel follow through, when performed and interpreted by experienced personnel, provides even greater accuracy for extent of disease. Endoscopic evaluation, including colonoscopy with ileal intubation, esophagogastroduodenoscopy, and capsule endoscopy can help in assessing the disease. In patients with narrow strictures, a capsule endoscopy is contraindicated as the capsule could be retained in an area of stenosis requiring surgical retrieval.

Despite the increased accuracy of modern preoperative radiographic and endoscopic imaging, appropriate selection of operative procedures (strictureplasty, resection, by-pass or intestinal diversion) can only be performed after accurate visualization at the time of the operative intervention. Therefore preoperative discussions and informed consent should include all of the above options.

Surgical Procedure

Preparation

The use of preoperative bowel preparation varies depending on the location of the disease. Mechanical bowel preparation is necessary for colonic disease, but may be avoided for small bowel and ileocolonic disease. In the presence of chronic obstructive small bowel disease, a preoperative period of clear liquids may be useful to reduce the amount of intraluminal-retained fluid.

Patients are given appropriate antibiotic coverage for clean-contaminated or contaminated surgical procedures prior to incision. Sequential compression devices are used perioperatively for deep venous thrombosis prophylaxis along with administration of subcutaneous low-molecular-weight heparin.

Positioning

The patient is usually placed in the supine position on the operative table. If access to the perineum is anticipated, the patient can be placed supine on the operating table and moved to the lithotomy position at the appropriate time. In this case, the patient’s hips and buttocks are placed protruding over the break of the operating table to ensure easy access to the perineum once moved to the lithotomy position. Alternatively the patient can be positioned in the modified lithotomy position for the entire procedure.

Technique—General Principles

Upon entering the abdomen, a thorough exploration of the abdominal cavity and a careful examination of the entire small and large intestine are mandatory. The total length
of intestine should be noted. Any diseased areas should be examined and the length and extent of disease should be recorded. If many areas of disease are found, it can be helpful to mark each one with sutures to facilitate subsequent planning. With a complete “road map” created, an operative strategy is then formulated.

Short isolated segments of stricture are appropriate for Heineke-Mikulicz (less than 7 cm) or Finney (up to 15 cm) strictureplasties. Longer segments or chain of lake formation may be considered for a Michelassi strictureplasty. Several different strictureplasty techniques with or without simultaneous bowel resections may be used in the same patient to maximize intestinal preservation.

Several maneuvers are universally used during strictureplasty to help minimize contamination of the operative field by enteric contents. Use of a wound protector may help to prevent subcutaneous contamination. While operative towels or laparotomy pads are placed under the isolated bowel loop to prevent soilage into the abdominal cavity. An atraumatic intestinal clamp is placed several centimeters proximal to the operative segment, where it will not hinder the surgeon, but prevents continued leakage of enteric contents into the operative field. An assistant should be assigned to handle suction following enterotomy.

After opening the disease segment in preparation for a strictureplasty, the mucosa must be inspected. If findings suspicious of cancer or dysplasia are found, a biopsy should be sent immediately to pathology for frozen section: if confirmed, the segment should be resected and strictureplasty aborted.

Meticulous hemostasis of the intestinal wall and overlying mucosa must be achieved. Diseased segments are often quite friable and bleed easily. Suturing of the intestinal wall during the performance of the strictureplasty may help with hemostasis, but any on-going bleeding should be treated with precise application of electrocautery prior to starting fashioning the strictureplasty.

At the end of the procedure, small metal clips are used to mark the strictureplasty site extraluminally for future identification in case of recurrent obstructive symptoms. Metals clips can be visualized radiographically on subsequent investigations or intraoperatively at successive operations.

Areas distal to the segment of diseased bowel should be intraoperatively examined. When patients have symptomatic proximal disease, strictures distally may be asymptomatic and may not cause bowel dilation. If areas of stenosis are suspected but not evident on inspection, a bladder catheter with a balloon inflated to a 2-cm diameter inserted through the enterotomy to be used for the strictureplasty can be used to assess the size of the internal lumen of the suspected sites.

Inspection of the bowel, identification of diseased segments, and mobilization of the intestinal loops may be laparoscopically performed. However, the authors suggest that performance of the actual strictureplasty be done through a limited abdominal incision through which the diseased loop of intestine has been exteriorized. The severely thickened mesentery, the strictured and fibrotic intestinal wall, and the disparity between wall thickness of normal and diseased intestine are all challenges which are best confronted through an open approach during which tactile feedback and control of the intestines are crucial to minimizing postoperative complications including hemorrhage, sepsis, and anastomotic dehiscence.

Operative Technique

Heineke-Mikulicz Strictureplasty (In-Situ Strictureplasty)

The most commonly performed strictureplasty is the Heineke-Mikulicz strictureplasty (2

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