Strictureplasty and Small Bowel Bypass in Inflammatory Bowel Disease
Douglas W. Jones
Kelly A. Garrett
DEFINITION
Strictureplasty and small bowel bypass are methods used to avoid bowel resection in patients with Crohn’s disease.
The technique of strictureplasty was initially described in the treatment of tuberculous strictures as an alternative to resection. This procedure is mainly used in patients with jejunoileal Crohn’s disease but may also be used in select patients with duodenal disease. There are different techniques, but all involve division of the strictured area either transversely or longitudinally with a distinctive closure that serves to widen the lumen.
Small bowel bypass involves bypass of an affected segment of small intestine that is deemed unsuitable for resection or strictureplasty. Resection of the diseased segment is usually preferred. Bypass may be used in gastroduodenal Crohn’s disease, complex small bowel disease, or ileocolic disease when a patient’s comorbidities preclude resection.
PATIENT HISTORY AND PHYSICAL FINDINGS
A thorough history and physical examination should be performed. History should include duration and distribution of disease as well as current or prior medical therapy.
Crohn’s disease may manifest in one of three disease patterns: fibrostenotic, inflammatory, or perforating. Fibrostenosing disease is the most common and typically presents with a progressive course in which stricturing of the small bowel leads to obstructive symptoms.1
Pattern of disease distribution should be determined prior to operative intervention. Anatomic location of disease can be classified as terminal ileal, colonic, ileocolonic, and upper gastrointestinal (GI). Over time, 15% of patients experience a change in anatomic location and 46% of patients demonstrate an alteration in disease behavior.2
Past surgical history is of particular importance because many Crohn’s disease patients have had prior abdominal surgery and this may affect operative planning. A detailed surgical history also allows for an estimation of the length of remaining small bowel.
A detailed description of the patient’s medical management should be obtained. The disease can be managed with antiinflammatory medications such as derivatives of 5-aminosalicylic acid; with immunosuppressors such as corticosteroids, azathioprine, 6-mercaptopurine, and methotrexate; and/or with immunomodulators such as antibodies targeting tumor necrosis factor-α. These medications can influence perioperative morbidity.
A detailed history should also be obtained in order to distinguish Crohn’s disease from ulcerative colitis. The two inflammatory bowel diseases can have similar patterns of presentation, although they have different principles of surgical management.
IMAGING AND OTHER DIAGNOSTIC STUDIES
The distribution of active disease needs to be mapped out preoperatively. Thought should be given to the risk of exposure to ionizing radiation as many patients with Crohn’s disease can have flares over the course of many decades and hence require repeat imaging studies.
Conventional radiologic techniques for imaging the small bowel include small bowel enteroclysis (SBE) and small bowel follow-through (SBFT). Strictures may appear as narrowed areas with delayed passage of contrast. Dynamic images may reveal impaired peristalsis in strictured areas. Computed tomography (CT) and magnetic resonance (MR) enterography have almost completely replaced the use of these studies at most academic centers.
CT performed with intravenous and oral contrast is helpful in identifying abscesses and other inflammatory processes outside the bowel lumen. Recent developments have also improved the ability of CT to identify strictures, fistulas, and areas of active inflammation. CT enterography uses lowdensity oral contrast in place of barium or iodine-based oral contrast used in standard scans. This in combination with intravenous iodinated contrast allows for better definition of the mucosa and thickness of the bowel wall.
MR enterography is being increasingly used to evaluate extent of active disease.3 MR enterography can also be performed using low-density oral contrast and offers the additional benefit of sparing patients’ exposure to radiation.
Ultrasound, although not as widely used, may be able to identify areas of bowel wall thickening, strictures, and decreased peristalsis. It is also useful for identifying abscesses and fistulas. Although ultrasound spares patients’ exposure to ionizing radiation, it is operator dependent and may not be able to distinguish inflammatory versus fibrotic strictures.
All of the previously described imaging studies may help determine whether an area of stricture has an active inflammatory component that may respond to medical therapy, aid in determining the extent of disease prior to surgery, and facilitate operative planning.
SURGICAL MANAGEMENT
Preoperative Planning
Indications for surgery in patients with Crohn’s disease include the following: failure of medical therapy, perforation, obstruction, worsening inflammation, hemorrhage, neoplasia, growth retardation, and/or extraintestinal manifestations.3
When preoperative imaging reveals stricturing small bowel disease with minimal area of inflammation in patients with obstructive symptoms, additional medical therapy is unlikely to resolve the symptoms and the patient should be considered for surgery. Patients with suspected active inflammation who have failed medical therapy should also be considered for surgery.
Strictureplasty should not be performed in every patient with stricturing Crohn’s disease. In most patients, simple resection and reanastomosis is sufficient. Indications for strictureplasty are the following:4
Diffuse jejunoileitis causing obstructive symptoms unresponsive to medical therapy
Recurrent stricturing disease in patients with multiple prior intestinal resections (high risk for short bowel syndrome)
Recurrence of strictures within 12 months of prior resection
Isolated ileocolonic anastomotic strictures
Selected duodenal strictures such as proximal lesions near the pylorus5
Contraindications to strictureplasty are the following:4
Diffuse peritonitis
Free intraabdominal perforation of the affected bowel segment
Phlegmon or abscess of affected bowel segment
Fistulous disease with significant inflammation of affected bowel segment
Multiple areas of stricture, within a short distance of each other, more amenable to single resection
Suspicion for neoplasia
Hypoalbuminemia
In some cases, bypass of affected segments of the GI tract are indicated. These include the following:
Gastroduodenal Crohn’s disease—The duodenum is involved in 0.5% to 4% of patients with Crohn’s disease and can cause obstruction or hemorrhage.6 In this scenario, resection is excessively morbid, so strictureplasty and bypass play a larger role.
With obstruction of the first or second portions of the duodenum, a gastrojejunostomy should be performed. Although traditionally performed to prevent marginal ulceration, current use of effective acid-suppressing medications have rendered vagotomy unnecessary.6,7 Furthermore, vagotomy may increase morbidity in patients already predisposed to diarrhea from extensive or poorly controlled Crohn’s disease or short-gut syndrome.
In patients with obstruction of the third or fourth portions of the duodenum, a duodenojejunal bypass should be performed.
Active inflammation of the duodenum and small bowel can lead to duodenoenteric fistula formation, commonly involving recurrence at a previous ileocolic anastomosis. Resection of diseased areas may require partial resection of involved duodenum as well. In these cases, bypass with a gastrojejunostomy may be required.
In complex small bowel or ileocolonic Crohn’s disease.8 Bypass should be considered when resection would be unsafe as in the presence of an ileocecal phlegmon that is adherent to the retroperitoneum or iliac vessels.
Bypass of small bowel disease should be avoided if resection is possible. An excluded segment should eventually be resected in order to avoid development of perforation, recurrent disease, carcinoma, or blind loop syndrome.8
Preparation
A mechanical bowel preparation is not necessary for patients who are undergoing small bowel or ileocolic resection and should be avoided in patients with stricturing disease.
If there is a chance that a stoma will be created, the patient should be evaluated by an enterostomal nurse to help avoid the development of pouching problems postoperatively.
Appropriate antibiotic and venous thromboembolism prophylaxis are administered prior to incision.
Positioning
Supine position is useful for patients who have uncomplicated ileocolic disease or gastroduodenal disease.
Modified lithotomy position is preferred if patients have distal disease that may require intervention. This allows for intraoperative colonoscopy to be performed for diagnostic purposes or to interrogate an anastomosis or repair if necessary. This position is also advantageous if the procedure will be done laparoscopically as it allows the surgeon to stand between the patient’s legs, which can assist with running the small bowel or with mobilization of the flexures if needed.
TECHNIQUES
APPROACH
Placement of Incision
The procedure can be performed via a laparoscopic or open approach.
Laparoscopy for ileocolic Crohn’s disease has been shown to result in earlier return of bowel function, shorter length of stay, and decreased postoperative pain.9 This approach may not be feasible for all patients, however, as many will have had extensive previous abdominal surgery.
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