Side-to-side isoperistaltic strictureplasty in extensive Crohn's disease: a prospective longitudinal study

Abstract

Objective: To report on the results of a prospective longitudinal study of a new bowel-sparing procedure (side-to-side isoperistaltic strictureplasty [SSIS]) in patients with extensive Crohn's disease.

Methods: Between January 1992 and April 1999, the authors operated on 469 consecutive patients for Crohn's disease of the small bowel. Seventy-one patients (15.1%) underwent at least one strictureplasty; of these, 21 (4.5%; 12 men, 9 women; mean age 39) underwent an SSIS. The long-term changes occurring in the SSIS were studied radiographically, endoscopically, and histopathologically.

Results: The indication for surgical intervention was symptomatic partial intestinal obstruction in each of the 21 patients. Fourteen SSISs were constructed in the jejunum, four in the ileum, and three with ileum overlapping colon. The average length of the SSIS was 24 cm. Performance of an SSIS instead of a resection resulted in preservation of an average of 17% of small bowel length. One patient suffered a postoperative gastrointestinal hemorrhage. All patients were discharged on oral feedings after a mean of 8 days. In all cases, SSIS resulted in resolution of the preoperative symptoms. With follow-up extending to 7.5 years in 20 patients (one patient died of unrelated causes), radiographic, endoscopic, and histopathologic examination of the SSIS suggests regression of previously active Crohn's disease.

Conclusions: SSIS is a safe and effective procedure in patients with extensive Crohn's disease. The authors' results provide radiographic, endoscopic, and histopathologic evidence that active Crohn's disease regresses at the site of the SSIS.

Figure 1. The mesentery of the diseased loop is divided at its midpoint, and the small bowel is severed between atraumatic intestinal clamps. The proximal intestinal loop is moved over the distal one in a side-to-side fashion.

Figure 2. The two loops are approximated by a layer of interrupted seromuscular Cushing stitches using nonabsorbable sutures.

Figure 3. A longitudinal enterotomy is performed on both loops and the intestinal ends are spatulated to avoid blind stumps (inset).

Figure 4. Both outer and inner suture lines are continued and finished anteriorly. A completed side-to-side isoperistaltic strictureplasty is shown in the inset.

Figure 5. Follow-up enteroclysis demonstrating a side-to-side isoperistaltic strictureplasty without active disease 45 months after the original surgical procedure.

Figure 6. Endoscopic evaluation of a side-to-side jejunal strictureplasty located a short distance after a gastrojejunostomy in a patient with extensive duodenal, jejunal, and ileal Crohn’s disease. At the time of the exploratory laparotomy, careful examination of the intestine revealed Crohn’s disease of the third and fourth portion of the duodenum; strictures between 1″ and 3″ from the ligament of Treitz and then at 6″, 10″, 14″ to 16″, 18″, 20″, and 23″; and disease of the terminal ileum between 106″ and 130″. The patient required a gastrojejunostomy, a small bowel resection, a side-to-side isoperistaltic strictureplasty, and an ileocolectomy with end-to-side ileocolonic anastomosis. The location of the side-to-side isoperistaltic strictureplasty immediately distal to the gastrojejunostomy allowed us to view it endoscopically in the postoperative period.

Figure 7. Small bowel biopsy from the side-to-side strictureplasty depicted in the previous figure shows pyloric metaplasia and mild, mixed lamina propria inflammatory cell infiltrates, including focal neutrophilic invasion of the surface epithelium (hematoxylin and eosin, ×40). The lack of severe acute inflammation and the presence of pyloric metaplasia suggest regression of previously active Crohn’s disease.