Heineke-Mikulicz, Finney, and Michelassi Strictureplasty

Heather Yeo

Fabrizio Michelassi

INDICATIONS/CONTRAINDICATIONS

Surgical decision making is complex in Crohn’s disease because of the recurrent nature of the disease. Many patients require multiple operations throughout their lives for failure of medical management and 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 the intestinal absorptive surface area. It is the treatment of choice, and recommended by both American and European guidelines, for management of patients with symptomatic non-phlegmonous jejunoileo fibrotic strictures. Although the length of the 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 normal absorptive function after strictureplasty, but studies have demonstrated that endoscopically, radiographically, and histopathologically the appearance of the bowel does normalize after strictureplasty.

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

Absolute contraindications to strictureplasty include generalized sepsis, cancer, or dysplasia. Severely diseased segments with luminal obliteration or unyielding intestinal wall, and intestinal segments with inflammatory phlegmonous masses are probably best resected. Although fistulous disease or localized sepsis was initially thought to be contraindications, several studies have demonstrated that strictureplasty is safe. The degree of acute inflammation associated with fistulae or sepsis must be limited and the fistulous opening away from the mesenteric side of the bowel. A critically ill patient should not undergo strictureplasty secondary to the length and complexity of the operation.

PREOPERATIVE PLANNING

Appropriate preoperative evaluation for patients with Crohn’s disease includes thorough assessment of extent of disease. Patients may present with a single symptomatic area of disease. Preoperative evaluation of the extent of disease aids in operative planning and in patient preparation in those circumstances when the disease is widespread and complex.

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 or magnetic resonance enterography can provide greater detail on the intraluminal findings of mucosal disease. Endoscopic evaluation, including colonoscopy with ileal intubation, esophagogastroduodenoscopy, push-enteroscopy, and capsule endoscopy can help in assessing the disease. In patients with narrow strictures, a capsule endoscopy is contraindicated because the capsule could be retained proximal to a stenosis and cause obstruction.

Despite the increased accuracy of modern preoperative radiographic and endoscopic imaging, appropriate selection of operative procedures (strictureplasty, resection, bypass, or intestinal diversion)
can only be performed after careful intraoperative evaluation and creation of a “road map” at the time of the operative intervention. Therefore, preoperative discussions and informed consent should include all of the possible surgical options.

SURGICAL PROCEDURE

Preparation

The use of preoperative bowel preparation varies depending on the location of the disease. Mechanical bowel preparation is necessary for distal 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. The authors’ and editors’ practice is to use a standard oral antibiotic prep for any procedure that may involve colonic resection or repair.

Patients are given appropriate intravenous antibiotic coverage for clean-contaminated or contaminated surgical procedures before incision. Sequential compression devices are used perioperatively for deep venous thrombosis prophylaxis along with administration of subcutaneous low-molecular-weight heparin unless there is a contraindication. Patients receiving steroids should be given appropriate stress dose steroids to help prevent adrenal insufficiency.

Positioning

The patient is usually placed in the supine position on the operating 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. This latter positioning option is preferred by the editors.

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 prevent contamination of the surgical site. Operative towels or laparotomy pads are placed under the isolated bowel loop to prevent spillage of enteric contents 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 ongoing bleeding should be treated with precise application of electrocautery before starting to fashion the strictureplasty.

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 1-2 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, extensive and multisite disease,
and the disparity between wall thickness of normal and diseased intestine are all challenges that are best confronted through an open approach.

Operative Technique

Heineke-Mikulicz Strictureplasty (In Situ Strictureplasty)

The most commonly performed strictureplasty is the Heineke-Mikulicz strictureplasty. This type of strictureplasty is most appropriate for isolated short segments, no longer than 5-7 cm.

After isolation of the diseased segment, two stay sutures are placed on either side of the strictured area at the midpoint. A longitudinal incision is made along the antimesenteric border of the stricture (Fig. 70-1A) and is extended for 2 cm into the normal pliable bowel on either side of the stricture. The longitudinal enterotomy is then closed in a transverse manner (Fig. 70-1B) with either a singleor double-suture layer (Fig. 70-1C). The authors prefer the use of a braided absorbable suture for an internal running stitch followed by interrupted Lembert nonabsorbable sutures for the second layer.

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