Overview of Crohn Disease Stricturoplasty
Crohn’s disease is a long-term health condition that causes inflammation, or swelling, in your digestive tract – basically, it’s when your body’s immune system misfires and attacks the places it should protect. This condition was first recognized by doctors named Crohn, Ginsberg, and Oppenheimer back in 1932. Usually, the swelling happens in your ileum (the last part of your small intestine) or your colon (part of your large intestine), but it can occur anywhere along your digestive tract.
There are more people getting Crohn’s disease these days, especially in North America and certain parts of Europe. The typical signs of this disease include long-lasting diarrhea, stomach pain, weight loss, and sometimes blood or mucus in stool. In addition, about a quarter to a half of people with Crohn’s can also experience problems outside their digestive tract, such as skin rashes, eye problems, liver issues, or joint pain.
Doctors diagnose Crohn’s disease based on your symptoms, as well as things like medical imaging scans, endoscopic exams (where they insert a thin tube with a camera into your digestive tract), tissue biopsy (taking a small piece of tissue to examine under a microscope), and blood tests.
One of the more serious complications of Crohn’s disease is an intestinal obstruction or perforation – basically, this is when your intestine becomes blocked or gets a hole in it. Other complications can include abscesses (pockets of pus), fistulas (abnormal connections between parts of the body), bleeding in the intestines, and strictures. Strictures are segments of the intestine that have become narrow, often causing blockages and major discomfort for patients with Crohn’s disease.
When strictures happen, doctors might recommend a surgery called strictureplasty to help. This procedure widens the narrow part of the intestine, allowing food to pass normally again. It’s considered a safe and effective option for patients suffering from blockages due to Crohn’s disease. Plus, it helps keep the length of the bowel intact, reducing the risk of related health problems like short gut syndrome.
Anatomy and Physiology of Crohn Disease Stricturoplasty
When the small intestine goes through several rounds of inflammation and healing, it can sometimes lead to the formation of scar tissue. This scar tissue actually replaces the healthy cells that were there before. Sometimes, this can lead to the narrowing of the digestive tract or what doctors refer to as the gastrointestinal tract.
In some serious cases, this narrowing can become so severe that it blocks the small intestine. This is called small bowel obstruction. While this situation can occur anywhere along the gastrointestinal tract, it commonly happens in the ileum (last part of your small intestine) and the ileocecal valve (where your small intestine meets your large intestine). But it can also occur in the colon, rectum, and the anus.
Now, the symptoms a patient may experience will depend where the blockage is located. For example, it might cause nausea, vomiting, stomach pain, feeling bloated, or a difficulty in passing gas and stool.
Why do People Need Crohn Disease Stricturoplasty
Sometimes multiple surgeries in the belly area and the removal of parts of your intestines can lead to an issue called short bowel syndrome. This can cause digestive problems and nutritional deficiencies. To help reduce the risk of this condition, doctors have started using a surgical technique called stricturoplasty more often.
Simply put, stricturoplasty is a procedure used to widen narrow or blocked sections of the intestines. This method of surgery was traditionally used only when a small part of the intestine was affected. However, this thought has been revisited and now the length of the affected part does not necessarily dictate whether stricturoplasty is used. The only time the length of the affected part matters is when deciding on the specific surgical method to be used.
In the past, stricturoplasty was mostly used for nonacute fibrotic stricture. This refers to a blockage in the intestine due to hard, fibrous tissue which is not part of an immediate, acute illness. However, now, stricturoplasty is also utilized even when the disease is active.
Some conditions when stricturoplasty can be considered include:
* If you have multiple blockages over a large part of your intestine
* If you have previously had a significant part of your small intestine removed
* If you have short bowel syndrome
* If there’s a blockage without any associated inflammation or abnormal connections in your intestines
* If you have recurring Crohn’s disease, which is a type of inflammatory bowel disease, with symptoms of a blockage
* If there is a blockage without any symptoms of an overall infection.
Some terms for understanding:
1. Stricture: A narrowing or blockage in the tube-like structures in the body such as blood vessels or intestines.
2. Phlegmon: An area of inflammation in the body that has spread to nearby tissues.
3. Fistula: An abnormal connection between two parts inside your body.
4. Sepsis: A life-threatening condition that happens when your body’s response to an infection damages its own tissues and organs.
Remember, not all patients can have stricturoplasty. It’s essential to discuss your options with your doctor to determine the best treatment for your specific condition.
When a Person Should Avoid Crohn Disease Stricturoplasty
There are certain situations where a strictureplasty, a type of surgery used for bowel blockages, might not be suitable for a patient:
- If the patient has an inflamed lump of tissue (phlegmon) or abnormal connection in the body (fistula) at the site where the surgery would have taken place.
- If the blockage (the stricture) is located near a site where two parts of the bowel have been surgically connected together (an anastomosis site).
- If the patient has more than one stricture over a short section of the bowel.
- If there is a hint that the blockage may evolve into or already is a tumor.
- If the patient is malnourished, determined by having an albumin (a type of protein that your body needs to function properly) level of less than 2.0 g/dL.
- If the patient’s bowel is perforated or has a hole in it.
Equipment used for Crohn Disease Stricturoplasty
The tools that a doctor uses to perform a procedure called strictureplasty are:
* An incision blade: This is a special type of knife that doctors use to make precise cuts.
* Retractors: These tools help hold the skin or other tissues apart to give the doctors a clear view and access to the operation area.
* Suture scissors: Special scissors used to cut sutures, which are the threads used to sew tissues together.
* Clamps: These are used to hold or secure certain body parts during surgery.
* Electrocautery: A tool that uses heat to stop bleeding or to remove or burn tissue.
* Mesentery ligation with a thermal device: The mesentery is a fold of tissue in the abdomen. “Ligation” means the operation of tying or binding something. A thermal device provides heat to effectively seal this tissue.
* Bowel sutures: These are special threads used to stitch the bowel (part of the intestine) together.
* Staples or sutures for skin closure: These are used to close the wound on the skin after surgery.
Preparing for Crohn Disease Stricturoplasty
Before undergoing surgery, doctors will check your nutritional levels—specifically something called albumin—using a blood test. If you’re not getting enough nutrients, you might need some extra supplements or special nutrition to help your body heal properly after the surgery. Along with this, doctors will carry out scans using CT (a type of X-ray that creates detailed images) or magnetic resonance enterography (a special type of MRI scan), which helps them understand the exact spot and severity of the issue. This can also help them visualize any additional complications like fistulas (abnormal connections between organs) or perforations (holes).
It may also be necessary for you to meet with a specialist nurse who deals with stomas before your operation. A stoma is a small opening on the surface of the abdomen that can be made during surgery; this nurse will discuss the likelihood of needing one and where it would go.
Regarding the surgery itself, you’ll be given general anesthesia, which means you’ll be asleep and won’t feel anything during the procedure. You’ll be placed on your back (“supine position”) and the medical team will take care to ensure that all parts of your body that could suffer pressure sores are well protected and comfortable.
How is Crohn Disease Stricturoplasty performed
Strictureplasty is a treatment technique used on a narrow or constricted area called a stricture in the intestines. The ideal procedure depends on the length of the area that has been narrowed or strictured:
- If the strictured area is short (less than 10 cm long), doctors typically use what’s known as the Heineke-Mikulicz strictureplasty technique.
- If the area is of medium length (between 10 to 20 cm in length), they usually opt for the Finney strictureplasty technique.
- If the strictured part is very long (more than 20 cm), the “side-to-side isoperistaltic” strictureplasty technique is preferred. This is sometimes also referred to as the Michelassi Strictureplasty.
In a Heineke-Mikulicz strictureplasty, which is the most common technique for short strictures, the surgeon makes a long cut on one side of the intestine, just a couple of centimeters away from the strictured area on either side. After this, they will sew both ends of the opening close. This is done in a direction that is at a right angle to the length of the intestine. They then close the surgical cut in one or two layers.
For medium lengths, the Finney strictureplasty is commonly used. Here, the surgeon folds the bowel at the point of stricture, making a U shape. The surgeon then makes a long cut between two sides of the folded loop and sews the opposing edges of the bowel together, a technique called handsewn anastomosis.
If the strictured area is very long, surgeons typically opt for the side-to-side isoperistaltic strictureplasty, or Michelassi Strictureplasty. This technique is often used when there are long patches of narrow intestines caused by a condition called Crohn’s disease, and there’s a risk of losing a lot of small bowel. The surgeon divides the long loop of intestine affected by Crohn’s disease in the middle first. They then bring the two segments side by side, make a long opening between both loops, and sew them together.
Possible Complications of Crohn Disease Stricturoplasty
There can be some complications related to strictureplasty, a surgical procedure to widen a narrowed area of your bowel. These could include infection at the site of the surgical cut, bleeding, blockage of your bowel, a leak at the junction where the surgeon stitched together the parts of your bowel or new narrowing areas appearing over time.
A detailed analysis by the researchers, Yamamoto and his team found that the total overall complications related to the strictureplasty were at 13%. This is when it’s done on the jejunum or ileum, parts of your small intestine. Among these, severe infection cases were quite rare, occurring only in 4% of them.
What Else Should I Know About Crohn Disease Stricturoplasty?
Strictureplasty is a surgical procedure that has been effectively used for the treatment of Crohn’s disease for many years. Crohn’s disease is a type of inflammatory bowel disease that can cause complications like narrowing of the intestines, also known as a stricture. Strictureplasty helps to widen these narrow areas.
Several research studies have demonstrated that this procedure is successful in treating certain patients who are at risk of malabsorption. Malabsorption is a disorder that occurs when the small intestine isn’t able to absorb enough nutrients, often due to disease damaging the intestine. This issue can lead to a condition called short bowel syndrome, where there’s not enough bowel to support proper nutrient absorption.
