Stricture-plasty for tubercular strictures of the gastro-intestinal tract

Evaluation of Z-plasty versus Heineke-Mikulicz scrotoplasty in the management of penoscrotal web in pediatric age group

BACKGROUND

The penoscrotal web may be congenital or acquired following excessive ventral skin removal during circumcision. Several surgical techniques were described for the treatment of congenital webbed penis without a clear comparison between their outcomes. This prospective study aimed at comparing the surgical results of Z-scrotoplasty and Heineke-Mikulicz scrotoplasty in the treatment of congenital webbed penis in uncircumcised pediatric patients.

METHODS

Our study included 40 uncircumcised patients who were divided randomly into two groups; Group A included 20 patients who were treated by Z-scrotoplasty and Group B included the other 20 patients who were treated by Heineke-Mikulicz scrotoplasty. All patients were circumcised at the end of the procedure.

RESULTS

The surgical outcome was good without a significant difference between the two groups in 36 patients. Recurrent webbing developed in one patient of Group A and in three patients of Group B (FE p = 0.605) The only significant difference between the two groups was the operative duration which was shorter in Group B than in Group A (P < 0.001*).

CONCLUSIONS

Treatment of congenital penoscrotal web in the pediatric age group could be done with either Z-scrotoplasty or Heineke-Mikulicz scrotoplasty with satisfactory results, however, without significant difference in the surgical outcomes.

TRIAL REGISTRATION

• Registration Number: ClinicalTrials.gov ID: NCT05817760. • Registration release date: April 5, 2023.

Historical Perspectives: Malignancy in Crohn's Disease and Ulcerative Colitis

While both Crohn' disease (CD) and ulcerative colitis (UC) are known to predispose patients to certain intestinal malignancies, the exact mechanism of carcinogenesis remains unknown and optimal screening guidelines have not been established. This article will explore the history of our understanding of intestinal malignancy in inflammatory bowel disease (IBD). To contextualize the medical community's difficulty in linking each condition to cancer, the first section will review the discovery of CD and UC. Next, we discuss early attempts to define IBD's relationship with small bowel adenocarcinoma and colorectal cancer. The article concludes with a review of each disease's surgical history and the ways in which certain procedures produced poor oncologic outcomes.

Crohn disease: before and after 1932 year

The article describes the historical milestones in the study of Crohn's disease from the time of its original description in the 17th century, the revolution in the medical community after the landmark paper in 1932, to the present day. The history of Crohn's disease testifies to the discoveries of the past years, which open up to us the advantages of a scientific approach to the diagnosis and treatment of this disease.

Strictureplasties performed by laparoscopic approach for complicated Crohn's disease. A prospective, observational, cohort study

BACKGROUND

Laparoscopy is considered the best surgical approach for Crohn's Disease (CD), and strictureplasty a reliable alternative to intestinal resection. Nevertheless, their association has never been evaluated.

AIM

To investigate feasibility and safety of conventional (SP) and non-conventional (NCSP) strictureplasties, using laparoscopy, for complicated CD.

METHODS

Starting January 2008, a prospective cohort study was performed, in consecutive, unselected patients, undergoing primary surgery for CD (Group-A). The residential database (CD-CARD) was used for the retrospective extraction of control patients (Group-B). Univariate and multi-variate analysis of pre-operative characteristics, intra-operative findings, morbidity, and intra-abdominal septic complications (IASCs) was performed.

RESULTS

Between January 2008 and December 2019, 331 patients received 162 SPs, 138 NCSPs, and 373 resections (Group-A). From the CD-CARD, 227 control patients received 159 SPs, 117 NCSPs, and 271 resections (Group-B) (ns). Preoperatively, Group-A presented batter nutritional status and received more biological therapies, Group-B more steroids. Group-A presented less abdominal abscesses, planned ostomies, minor complications, shorter operating time and hospitalization than Group-B, but similar major complications, IASCs and anastomotic leaks. IASCs were related to older age, elevated inflammatory indices, and preoperative treatment with high-risk drugs.

CONCLUSIONS

SP and NCSP are feasible by laparoscopy, with low morbidity rate, confirming the advantages of both minimally invasive and conservative surgery.

Surgical management of abdominal tuberculosis: A prospective single-center study

Objective

Tuberculosis (TB) can affect any part of the gastrointestinal tract. It is estimated that in 2018, 10 million people were affected with TB worldwide and there were 1.2 million TB deaths among human immunodeficiency virus-negative people. India has the highest TB burden in the world (27%), a significant proportion of which are of intestinal TB. The aims of this study were to assess clinical features and investigations for the diagnosis of abdominal TB and to analyze its various surgical manifestations and its management.

Materials and Methods

From October 1, 2014, to October 30, 2016, a total of 50 patients meeting the inclusion criteria for the study, age between 15 and 65 years and diagnosis of symptomatic intestinal TB requiring surgery, were enrolled in the study. We used descriptive statistics to analyze the data.

Results

Abdominal TB was most commonly seen in young adults. Intestinal obstruction was the most frequent presentation. The most common site of involvement in the present study was the ileum. Ultrasonography (USG) and X-ray were an integral part of the diagnosis, with computed tomography (CT) scan being rarely required. Although both anemia and erythrocyte sedimentation rate (ESR) are nonspecific, they may help in supporting the clinical and pathological findings. Most operations were elective, with intestinal obstruction being the most common indication and resection and end-to-end anastomosis performed most often. Histopathological examination was performed in all patients and showed caseating granuloma in 90% of cases, while 10% of cases had chronic noncaseating granulomas with ill-defined aggregates of epithelioid histiocytes.

Conclusion

Abdominal TB causes a significant problem in diagnosis due to nonspecific symptomatology and lack of specific laboratory tests. USG and X-ray were an integral part of the diagnosis. CT scan is rarely required. Although anemia and ESR are both nonspecific features, they may help in supporting the clinical and pathological findings. The most common site of involvement in the present study was the ileum. Intestinal obstruction was the most common indication for operation, with resection and end-to-end anastomosis being the most common operation. The mainstay of treatment is medical therapy and timely surgical intervention is required in a sizable number of patients.

Pathophysiology of Crohn's disease inflammation and recurrence

Chron’s Disease is a chronic inflammatory intestinal disease, first described at the beginning of the last century. The disease is characterized by the alternation of periods of flares and remissions influenced by a complex pathogenesis in which inflammation plays a key role. Crohn’s disease evolution is mediated by a complex alteration of the inflammatory response which is characterized by alterations of the innate immunity of the intestinal mucosa barrier together with a remodeling of the extracellular matrix through the expression of metalloproteins and increased adhesion molecules expression, such as MAcCAM-1. This reshaped microenvironment enhances leucocytes migration in the sites of inflammation, promoting a T_H1 response, through the production of cytokines such as IL-12 and TNF-α. IL-12 itself and IL-23 have been targeted for the medical treatment of CD. Giving the limited success of medical therapies, the treatment of the disease is invariably surgical. This review will highlight the role of inflammation in CD and describe the surgical approaches for the prevention of the almost inevitable recurrence.

Strictures in Crohn's Disease: From Pathophysiology to Treatment

Despite recent advances aimed to treat transmural inflammation in Crohn's disease (CD) patients, the progression to a structuring behavior still represents an issue for clinicians. As inflammation becomes chronic and severe, the attempt to repair damaged tissue can result in an excessive production of extracellular matrix components and deposition of connective tissue, thus favoring the formation of strictures. No specific and accurate clinical predictors or diagnostic tools for intestinal fibrosis exist, and to date, no genetic or serological marker is in routine clinical use. Therefore, intestinal fibrosis is usually diagnosed when it becomes clinically evident and strictures have already occurred. Anti-fibrotic agents such as tranilast, peroxisome proliferator-activated receptor gamma agonists, rho kinase inhibitors, and especially mesenchymal stem cell therapy have provided interesting results, but most of the evidence has been derived from studies performed in vitro. Therefore, current therapy of fibrotic strictures relies mainly on endoscopic and surgical procedures. Although its long-term outcomes may be debated, endoscopic balloon dilation appears to be the safest and most effective approach to treat appropriately selected strictures. The use of endoscopic stricturotomy is currently limited by the expertise needed to perform it and by the few data available in the literature. Some good results have been achieved by the positioning of self-expandable metal stents (SEMS). However, there is no concordance regarding the type of stent to use and for how long it should be left in place. The development of new specific SEMS may lead to better outcomes and to an increased use of this alternative in CD-related strictures.

Strictureplasty in Complex Crohn's Disease: Beyond the Basics

The strictureplasty operation was originally adopted for use in selected patients with Crohn's disease to allow for bowel conservation. The procedure and its usage have evolved over time as experience and confidence with the technique has grown. The short- and long-term outcomes of strictureplasty compared with resection attest to its safety and durable efficacy.

Crohn's disease associated strictures

Crohn's disease (CD) is a chronic relapsing and remitting disease that can affect any segments of the gastrointestinal tract. More than 50% of patients with CD develop stricturing or penetrating complications within the first 10 years after diagnosis. Strictures can lead to intestinal obstruction, which is a common indication for surgery. Despite significant advances in the understanding of the pathogenesis of intestinal fibrostenosis, imaging and therapeutic armamentarium of CD, the risk of intestinal surgery remained significantly high. Endoscopic balloon dilation is a promising first-line alternative to surgery as it is less invasive and could preserve intestinal length. In this review, we will evaluate the literature on the mechanism of intestinal fibrosis, emerging imaging techniques, and management strategies for CD associated strictures.

Tuberculosis of the gastrointestinal tract and associated viscera

Tuberculosis involvement of the gastrointestinal tract, peritoneum, and associated viscera is an uncommon but well described entity. While peritoneal tuberculosis and tuberculous enteritis are more common, involvement of the esophagus, stomach, colon, rectum, anus, liver, bile ducts, gallbladder, and pancreas can occur. Diagnosis is challenging as cases often mimic neoplasm or inflammatory bowel disease. In this review we outline the pathogenesis, clinical presentation, diagnostic testing, and treatment strategies pertaining to such cases.

Abdominal tuberculosis: Is there a role for surgery?

It is important that surgeons are familiar with the various manifestations of tuberculosis (TB). Although TB has been declining in incidence in the developed world, it remains an important problem in endemic areas of the developing world. The aim of the review was to elucidate the natural history and characteristics of abdominal TB and ascertain the indications for surgery. TB can affect the intestine as well as the peritoneum and the most important aspect of abdominal TB is to bear in mind the diagnosis and obtain histological evidence. Abdominal TB is generally responsive to medical treatment, and early diagnosis and management can prevent unnecessary surgical intervention. Due to the challenges of early diagnosis, patients should be managed in collaboration with a physician familiar with anti-tuberculous therapy. An international expert consensus should determine an algorithm for the diagnosis and multidisciplinary management of abdominal TB.

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

Is abdominal tuberculosis a surgical problem?

INTRODUCTION

Abdominal tuberculosis (TB) has always been a diagnostic challenge, even for the astute surgeon. In developing countries, extrapulmonary TB often presents as an acute abdomen in surgical emergencies such as perforations and obstructions of the gut. Abdominal TB in different forms has been found more often as an aetiology for the chronic abdomen. This paper aims to evaluate TB as a surgical problem.

METHODS

A comprehensive review of the literature on abdominal TB was undertaken. PubMed searches for articles listing abdominal TB/different types/diagnosis/treatment (1980-2012) were performed.

RESULTS

TB is still a global health problem and the abdomen is one of the most common sites of extrapulmonary TB. Presentation may vary from an acute abdomen to a number of different chronic presentations, which can mimic other abdominal diseases. While some may benefit from antitubercular therapy, others may develop surgical problems such as strictures or obstruction, which may necessitate surgical intervention.

CONCLUSIONS

Abdominal TB should always be considered one of the differential diagnoses of acute or chronic abdomen in endemic areas.

Strictureplasty

Over the past three decades, strictureplasty for Crohn disease with fibrostenotic stricture has been shown to be both efficacious and safe. Although segmental resection remains the standard of care for obstruction secondary to Crohn stricture, strictureplasty should be considered for patients with a history of prior resections who are at increased risk for short bowel syndrome with additional resections. There is ample evidence to support both conventional and nonconventional strictureplasty techniques for both jejunoileal and ileocolonic anastomotic strictures. The role of strictureplasty for both duodenal and colonic disease, as well as the risk of malignant transformation at strictureplasty sites, is yet to be determined.

Resection leads to less recurrence than strictureplasty in a paediatric population with obstructive Crohn's disease

Introduction. Resection and strictureplasty are used to treat patients with obstructive Crohn's disease. Strictureplasty is preferable in adults as it retains bowel length. This study aims to identify differences in outcomes of children undergoing strictureplasty and resection for obstructive Crohn's disease. Method. Patients under 20 years undergoing surgery over a nine-year period were included. Data was collected on procedures for stenotic Crohn's disease. Patients were divided into 2 groups: Group 1 treated with strictureplasties and Group 2 resections. Postoperative complications and recurrence rates were recorded. Kaplan-Meier method was used to analyze the data. Results. Twenty-six patients and 40 operations were identified. Mean age was 15.6 years (7.2–19.4) with equal numbers of males and females. Mean follow-up was 45.9 months (0.1–149.9). 20/40 procedures involved the terminal ileum; 9/40, the ileocolic junction; 8/40, the upper GI tract; and 3/40, the colon. Group 1 consisted of 19 strictureplasties and Group 2 consisted of 13 resections and 8 combined procedures. Significantly more patients in Group 1 required further surgery (11/19 versus 3/21; P = 0.008). Conclusion. Allowing for variations in disease duration, severity, and previous medical management, these data suggest that resection is preferable to strictureplasty in treating obstructive Crohn's disease in children and adolescents.

Surgery and diagnostic imaging in abdominal Crohn's disease

Surgery is well-established option for the treatment of Crohn's disease that is refractory to medical therapy and for complications of the disease, including strictures, fistulas, abscesses, bleeding that cannot be controlled endoscopically, and neoplastic degeneration. For a condition like Crohn's disease, where medical management is the rule, other indications for surgery are considered controversial, because the therapeutic effects of surgery are limited to the resolution of complications and the rate of recurrence is high, especially at sites of the surgical anastomosis. In the authors' opinion, however, surgery should not be considered a last-resort treatment: in a variety of situations, it should be regarded as an appropriate solution for managing this disease. Based on a review of the literature and their own experience, the authors examine some of the possibilities for surgical interventions in Crohn's disease and the roles played in these cases by diagnostic imaging modalities.

Tuberculous bowel obstruction at a university teaching hospital in Northwestern Tanzania: a surgical experience with 118 cases

BACKGROUND

Bowel obstruction resulting from intestinal tuberculosis has been reported to be more prevalent in developing countries including Tanzania. This study was undertaken to describe the clinicopathological profile, surgical management and outcome of tuberculous intestinal obstruction in our local setting and to identify factors responsible for poor outcome among these patients.

METHODS

This was a prospective descriptive study of patients operated for tuberculous intestinal obstruction at Bugando Medical Centre (BMC) in northwestern Tanzania from April 2008 to March 2012. Ethical approval to conduct the study was obtained from relevant authorities. Statistical data analysis was performed using SPSS version 17.0.

RESULTS

A total of 118 patients with tuberculous intestinal obstruction were studied. The male to female ratio was 1.8: 1. The median age was 26 years (range 11-67 years). The modal age group was 21-30 years. Thirty-one (26.3%) patients had associated pulmonary tuberculosis and 25 (21.2%) patients were HIV positive with a median CD4+ count of 225 cells /μl. Small bowel strictures were the most common operative findings accounting for 72.9% of cases. The ileo-caecal region was the commonest area of involvement in 68 (57.6%) patients. The right hemicolectomy with ileo-transverse anastomosis was the most frequent surgical procedure performed in 66 (55.9%) patients. Postoperatively all the patients received antituberculous drugs for a period of one year. Postoperative complication rate was 37.3% and surgical site infection (SSI) was the most frequent complication in 42.8% of cases. HIV positivity and low CD4+ count were the main predictors of SSI (p < 0.001). The overall median length of hospital stay was 24 days. Patients who had postoperative complications stayed longer in the hospital and this was statistically significant (p = 0.011). Mortality rate was 28.8% and it was significantly associated with co-existing medical illness, delayed presentation, HIV positivity, low CD 4 count (<200 cells/μl), ASA class and presence of complications (p < 0.001). The follow up of patients was generally poor as more than fifty percent of patients were lost to follow up.

CONCLUSION

Tuberculous bowel obstruction remains rampant in our environment and contributes significantly to high morbidity and mortality. The majority of patients present late when the disease becomes complicated. A high index of suspicion, proper evaluation and therapeutic trial in suspected patients is essential for an early diagnosis and timely definitive treatment, in order to decrease the morbidity and mortality associated with this disease.

Surgical management of Crohn's disease

Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease.

A comprehensive review of inflammatory bowel disease focusing on surgical management

The two main diseases of inflammatory bowel disease are Crohn's disease and ulcerative colitis. The pathogenesis of inflammatory disease is that abnormal intestinal inflammations occur in genetically susceptible individuals according to various environmental factors. The consequent process results in inflammatory bowel disease. Medical treatment consists of the induction of remission in the acute phase of the disease and the maintenance of remission. Patients with Crohn's disease finally need surgical treatment in 70% of the cases. The main surgical options for Crohn's disease are divided into two surgical procedures. The first is strictureplasty, which can prevent short bowel syndrome. The second is resection of the involved intestinal segment. Simultaneous medico-surgical treatment can be a good treatment strategy. Ulcerative colitis is a diffuse nonspecific inflammatory disease that involves the colon and the rectum. Patients with ulcerative colitis need surgical treatment in 30% of the cases despite proper medical treatment. The reasons for surgical treatment are various, from life-threatening complications to growth retardation. The total proctocolectomy (TPC) with an ileal pouch anal anastomosis (IPAA) is the most common procedure for the surgical treatment of ulcerative colitis. Medical treatment for ulcerative colitis after a TPC with an IPAA is usually not necessary.

Surgical management of Crohn's disease

INTRODUCTION

Crohn's disease is an inflammatory bowel disease that can affect the entire gastrointestinal tract. It is chronic and incurable, and the mainstay of therapy is medical management with surgical intervention as complications arise. Surgery is required in approximately 70% of patients with Crohn's disease. Because repeat interventions are often needed, these patients may benefit from bowel-sparing techniques and minimally invasive approaches. Various bowel-sparing techniques, including strictureplasty, can be applied to reduce the risk of short-bowel syndrome.

METHODS

A review of the available literature using the PubMed search engine was undertaken to compile data on the surgical treatment of Crohn's disease.

RESULTS AND CONCLUSION

Data support the use of laparoscopy in treating Crohn's disease, although the potential technical challenges in these settings mandate appropriate prerequisite surgical expertise.

A comprehensive review of strictureplasty techniques in Crohn's disease: types, indications, comparisons, and safety

INTRODUCTION

Crohn's disease is one of the chronic inflammatory diseases of the gastrointestinal tract that is often complicated by stricture formation with resulting obstructive symptoms. The technical repertoire of strictureplasty procedures has increased over the years in an effort to manage the diverse presentations of this condition while limiting the need for bowel resection. In this comprehensive review, we describe, compare, categorize, and appraise the strengths and weaknesses of 15 unique strictureplasty techniques.

METHODS

To identify all unique strictureplasty procedures, a Medline search utilizing "Crohn's disease," "surgical therapy," "strictureplasty," "enteroenterostomy," "Heineke-Mikulicz," and "side-to-side isoperistaltic" strictureplasty as medical subject headings was completed. PubMed, Ovid, Embase, and Cochrane database searches were conducted. Relevant articles between 1980 to December 2010 were reviewed. We initially selected 58 articles, but only 18 introduced novel surgical procedures related to 15 types of strictureplasty in Crohn's disease.

RESULTS

We identified 15 types of strictureplasty techniques. These were categorized into three main groups. The revised nomenclature will facilitate the reader to understand the differences and utility of each technique. These groups include the Heineke-Mikulicz-like strictureplasties, the intermediate procedures, and the enteroenterostomies. Heineke-Mikulicz strictureplasty was the most frequently used technique.

CONCLUSION

Various techniques of strictureplasty have been reported in the published literature. Strictureplasty has been shown to be a safe and efficacious technique that is comparable to bowel resection for stricturing Crohn's disease. This technique spares bowel length and puts the Crohn's disease patient at a lower risk of developing short bowel syndrome with repeated resections.

The surgical options and management of intestinal Crohn's disease

Crohn's disease (CD) is a pan-gastrointestinal illness. It is notorious for recurrences which can develop in any segment of the gastrointestinal tract. There are many indications and surgical options for intestinal Crohn's disease . We discuss these options based on the current literature. It is important to note however, that operative treatment is based on the correct diagnosis, clinical presentation, sphincter function and patient motivation. Early and timely referral to a surgeon is paramount. The goals of continued medical therapy need to be clearly defined as do the criteria for referral to surgery.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature

BACKGROUND

Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence.

METHODS

We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP.

RESULTS

The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months.

CONCLUSION

Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.

Prospective study of long-term results and prognostic factors after conservative surgery for small bowel Crohn's disease

BACKGROUND & AIMS

Several bowel-sparing techniques have been proposed for treating patients with CD, but there have been no prospective studies analyzing risk factors and long-term outcome. We prospectively evaluated safety and long-term efficacy of conservative surgery for patients with complicated CD.

METHODS

From 1993-2007, 393 of 502 consecutive patients underwent surgery for complicated CD of the small bowel. Those with colonic involvement were excluded. The Student t test, chi(2) test, Kaplan-Meier estimates, and Cox proportional hazard model were used to analyze postoperative complications and long-term outcome.

RESULTS

A total of 865 jejunoileal segments underwent 318 small bowel resections and 367 strictureplasties (either classic or nonconventional). There were no deaths; the complication rate was 5.6%, and the cumulative 10-year recurrence rate was 35%. None of the prognostic factors were correlated with postoperative complications. Younger age, an upper jejunoileal location, stricturing behavior, and small-bowel wall thickening 12 months after surgery showed hazard ratios of 2.4 (95% confidence interval [CI], 1-5.4; P = .03), 2.5 (95% CI, 1.3-4.7; P = .004), 2.2 (95% CI, 1.1-4.1; P = .01), and 4.5 (95% CI, 2.3-8.6; P = .000), respectively. Immunomodulator therapy failed to reduce long-term surgical recurrence.

CONCLUSIONS

Young patients with extended and stricturing disease are at high risk for disease recurrence after surgery. Bowel wall thickening was a reliable prognostic factor for these patients. Conservative surgery is safe and effective in treating patients with jejunoileal CD and should be considered as the first-line surgical treatment, preventing the risk of short bowel syndrome caused by repeated resections.

[Crohn's disease small bowel strictureplasties: early and late results]

BACKGROUND

Strictureplasty is an alternative surgical procedure for Crohn's disease, particulary in patients with previous resections or many intestinal stenosis.

AIM

To analyze surgical complications and clinical follow-up in patients submitted to strictureplasty secondary to Crohn's disease.

METHODS

Twenty-eight patients (57.1% male, mean age 33.3 years, range 16-54 years) with Crohn's disease and intestinal stenosis (small bowel, ileocecal region and ileocolic anastomosis) were submitted to strictureplasty, at one institution, between September 1991 and May 2004. Thirteen patients had previous intestinal resections. The mean follow-up was 58.1 months. A total of 116 strictureplasties were done (94 Heineke-Mikulicz--81%, 15 Finney--13%, seven side-to-side ileocolic strictureplasty--6%). Three patients were submitted to strictureplasty at two different surgical procedures and two in three procedures.

RESULTS

Regarding to strictureplasty, postoperative complication rate was 25% and mortality was 3.6%. Early local complication rate was 57.1%, with three suture leaks (10.7%) and late complication was present in two patients, both with incisional hernial and enterocutaneous fistulas (28.6%). Patients remained hospitalized during a medium time of 12.4 days. Clinical and surgical recurrence rates were 63% and 41%, respectively. Among the patients submitted to another surgery, two patients had two more operations and one had three. Recurrence rate at strictureplasty site was observed in 3.5%, being Finney technique the commonest one. Presently, 19 patients had been asymptomatic with the majority of them under medical therapy.

CONCLUSION

Strictureplasties have low complication rates, in spite of having been done at compromised site, with long term pain relief. Considering the clinical course of Crohn's disease, with many patients being submitted to intestinal resections, strictureplasties should be considered as an effective surgical treatment to spare long intestinal resections.

Strictureplasty

Strictureplasty in patients with Crohn's disease is an option in the colorectal surgeon's armamentarium for fibrostenotic obstructive disease. Common types include the Heineke-Mikulicz strictureplasty, Finney strictureplasty, and the side-to-side isoperistaltic strictureplasty. The procedure has potential for significant morbidity; therefore, it should be chosen for the patient carefully. Strictureplasty complements bowel resection in Crohn's disease; it is an excellent procedure to reduce the risk of developing short-bowel syndrome and its associated complications.

Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis

PURPOSE

This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.

METHODS

A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.

RESULTS

A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.

CONCLUSIONS

Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.

Intra-abdominal and gastrointestinal tuberculosis

OBJECTIVE

Reports suggest that the rates of tuberculosis (TB) continue to rise in the UK and throughout the world. The spread of the disease is aided by poverty, overcrowding, co-infection with human immunodeficiency virus and drug resistance. Consistent with the overall trend, intra-abdominal and gastrointestinal (GI) TB rates are rising. Tuberculosis is a treatable disease, whether occurring in the lungs or at extra-pulmonary sites but the nonspecific features of the disease result in difficulty in establishing a diagnosis. In this report, we have concentrated on the benefits and potential pitfalls of diagnostic methods.

METHOD

A literature review was performed using the National Library of Medicine's Pubmed Database using the keywords diagnosis, management, abdominal and GI TB.

RESULTS

Abdominal TB presents a particular challenge, as the diverse features of the disease do not readily suggest a particular diagnosis and diagnostic delays lead to significant morbidity and mortality. A number of investigative methods have been used to aid in the diagnosis of abdominal and GI TB.

CONCLUSION

The nonspecific presentation of abdominal and GI TB present challenges in the diagnosis of this increasingly common disease. A high index of suspicion is an important factor in early diagnosis. After a diagnosis has been established, prompt initiation of treatment helps prevent morbidity and mortality.

Operative management of small bowel Crohn's disease

Despite advances in medical treatment, most patients who have Crohn's disease of the small intestine need surgery at some point during the course of their disease. Surgery is currently indicated for intractable disease and complications of the disease (strictures, abscesses, fistulas, hemorrhage). There is increasing interest in nonsurgical and minimal access strategies of dealing with complicated disease, however. These new approaches may enable postponement of surgery to a more favorable time, or conversion of a two-stage procedure involving a stoma to a one-stage resection with anastomosis. A continuing challenge is prevention of disease recurrence postoperatively.

Strictureplasty for active Crohn's disease

BACKGROUND AND AIMS

Several studies over the last 20 years have confirmed the safety and efficacy of strictureplasty in the treatment of obstructive Crohn's disease. However, almost all of these studies use strictureplasty to treat fibrotic strictures: limited resection being preferred to treat active disease strictures. One study dating from 1986 used strictureplasty to treat purely active disease strictures, with disappointing results. No other similar studies have been published. We investigate the complication and recrudescence rates together with the intervention-free intervals in patients undergoing strictureplasty for active disease strictures.

METHODS

A retrospective review of 14 patients who underwent strictureplasty either in isolation or in combination with limited resection for active small bowel Crohn's disease between 1996 and 2004 was undertaken.

RESULTS

A total of 73 strictureplasties were carried out. There was no operative mortality; however, one patient subsequently died from metastatic small bowel adenocarcinoma arising from existing Crohn's disease. One patient subsequently developed complications directly attributed to strictureplasty and required further surgery. Three patients developed recrudescent disease and required further surgery in the form of either strictureplasty, limited resection or both. All patients undergoing strictureplasty with resection and over 70% of patients undergoing strictureplasty alone were intervention-free at 41 months. With extended follow-up, the same proportion of patients would remain intervention-free at 70 months or longer.

CONCLUSIONS

The use of strictureplasty in active disease strictures is well tolerated and has similar, if not better, recurrence and complication rates when compared with limited resection in patients with similar disease profiles.

Intervention-free Interval following Strictureplasty for Crohn’s Disease

INTRODUCTION

Strictureplasty is now well established as a bowel-sparing alternative for surgical treatment of complicated Crohn's disease. Limited resection is still preferred in patients with uncomplicated disease, as subsequent reoperation rates are low.

METHODS

A retrospective review of 26 patients who underwent surgery for small bowel Crohn's disease between 1996 and 2004 was undertaken. A total of 96 small bowel strictureplasties had been performed; 19 patients had strictureplasties performed in isolation, and the remaining 7 patients underwent strictureplasty with concomitant limited resection.

RESULTS

There was no operative mortality. The median follow-up was 41 months. Four patients developed complications that required further surgery. At 41 months, 73.3% of patients undergoing strictureplasty alone and 79.7% undergoing strictureplasty with concomitant resection were intervention-free. If followed up to 70 months or more, the same proportion of patients would remain intervention-free. Four patients developed further recrudescent disease and required surgery: strictureplasty, limited resection, or both. Of these patients, 25% were intervention-free at 41 months.

CONCLUSIONS

Our results show that strictureplasty alone or with concomitant resection can confer intervention-free periods of 41 months or more in 73.3% of patients, suggesting that strictureplasty can be utilized as an alternative to limited resection in uncomplicated Crohn's disease.

Strictureplasty

BACKGROUND

Advances in the use of bowel-sparing surgery for Crohn's disease have led to the development of strictureplasty as an important technique to conserve small bowel length and reduce morbidity associated with malabsorption.

METHODS

A literature review of long-term studies on strictureplasty was undertaken, and evidence of its safety and efficacy was evaluated.

RESULTS

The safety and efficacy of strictureplasty is confirmed in retrospective studies carried out over a period of 5-10 years, particularly when employed in patients at risk of short bowel syndrome, but certain questions regarding bowel function and disease activity after surgery remain unanswered. There is also concern that diseased tissue is left in situ after strictureplasty; this tissue has the potential for malignant transformation in the long term.

CONCLUSION

Strictureplasty has been used in surgery for Crohn's disease for the past 25 years. Studies have proven its efficacy in the treatment of carefully selected patients at risk of malabsorption owing to short bowel syndrome.

Side-to-side isoperistaltic strictureplasty in the treatment of extensive Crohn's disease

BACKGROUND

First performed in 1992, the side-to-side isoperistaltic strictureplasty (SSIS) is a bowel-sparing surgical option for Crohn's patients presenting with sequentially occurring stenoses over long intestinal segments (>15 cm). This investigation was designed to study the outcomes and patterns of recurrence after a SSIS.

MATERIALS AND METHODS

Between 1992 and 2003, 30 patients underwent SSIS at the University of Chicago. Their data were gathered prospectively in an Institutional Review Board-approved database.

RESULTS

A total of 31 SSISs were constructed in 30 patients. As an indication of the severity of disease in these patients, 25 of 30 (83%) required a concomitant bowel resection, and 13 (43%) underwent at least one additional strictureplasty. The average length of diseased bowel used to construct the SSIS was 51 cm. The average length of residual small bowel after performance of SSIS was 275 cm, and the SSIS represented an average 19% of the remaining small bowel that would have otherwise been sacrificed with resection. Three patients experienced perioperative complications (10%) and one died (3%). Seven patients (23%) required reoperation to treat recurrence of symptoms within the first 5 years. In four of these patients, recurrence was found at or near the previous SSIS.

CONCLUSIONS

A side-to-side isoperistaltic strictureplasty (SSIS) is a safe and effective surgical option for sequentially occurring Crohn's strictures over long intestinal segments.

Indications and results of side-to-side isoperistaltic strictureplasty in Crohn's disease

PURPOSE

Strictureplasty has commonly been used for short stenotic tracts, but it has rarely been applied to stenoses longer than 10 cm. Michelassi proposed a side-to-side isoperistaltic strictureplasty for single or multiple strictures that affected long bowel tracts. The experience and results obtained to date with this type of strictureplasty are limited. We therefore decided to review the cases in which we performed this procedure.

METHODS

Thirty-one patients, aged 21 to 66 years, underwent this operation between August 1996 and October 2002. Indications for surgery included subocclusion in 22 patients, malnutrition in 9 patients, and fistula or abscess in 6 patients. Two side-to-side isoperistaltic strictureplasties have been performed in jejunum, 6 in jejunum-ileum, 16 in the proximal ileum, 1 in terminal ileum, and 6 in the ileo-cecal tract.

RESULTS

The average length of side-to-side isoperistaltic strictureplasty as 32.1 cm (range, 10-54 cm). Sixteen patients also underwent concomitant bowel resection and 17 patients have received additional strictureplasty. There was no perioperative mortality, nor were there any postoperative complications requiring reoperation. In all patients intestinal occlusion and malnutrition were resolved. Decrease of activity indices was observed in 62.3 percent of patients within 6 months after surgery. At an average follow-up of 26.4 months, six patients required reoperation, but in only one of them did the recurrence involve a previous strictureplasty site. In that case the side-to-side isoperistaltic strictureplasty was soft and was without signs of inflammation or stenosis.

CONCLUSIONS

Side-to-side isoperistaltic strictureplasty seems to provide a technical solution leading to improvement when long intestinal inflamed tract are treated. Longer follow-up and larger experience is needed to validate this observation.

[The role of strictureplasty in the treatment of Crohn's disease]

Crohn's disease is pandigestive disease of unknown aethiology, with tendency to reccurrences. Until now it is impossible to heal this disease either by medical or surgical treatment. All unfavourable consequences of this disease are result of inadequate treatment of complications which are leading to systemic weakening, with further progression of morbid process. Therefore, the principle of timely and minimal invasive surgical procedure has been generally adopted. Introduced in eighties, strictureplasty is a procedure of such characteristics. During the period 1980-2001 this method was used in 1/3 of 126 patients with Crohn's disease. There were 79 strictureplaties performed, 9 long and 70 short. Out of these 42, 12(28.6%) were postoperative recurrences, and there was one case of duodenal strictureplatsty. Postoperative small bowel fistulae were not observed, and there was no mortality in this group. During the follow up period of at least 5 years, in only two cases (4.76%) some functional disturbances of digestive functions were observed, without indications for reoperation. In this article indications and details of operative technique are discussed.

Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease

BACKGROUND

Since its introduction in the early 1980s, strictureplasty (SXP) has become a viable option in the surgical management of obstructing small bowel Crohn's disease. Questions still remain regarding its safety and longterm durability in comparison to resection. Precise indications and contraindications to the procedure are also not well defined.

STUDY DESIGN

A retrospective review of all patients undergoing SXP for obstructing small bowel Crohn's disease at the Cleveland Clinic between 1984 and 1999 was conducted. A total of 314 patients underwent a laparotomy that included the index SXP The total number of SXPs performed was 1,124, with a median of two (range 1 to 19) per patient. Sixty-six percent of patients underwent a synchronous bowel resection. Recurrence was defined as the need for reoperation. Followup information was determined by personal interviews, phone interviews, or both.

RESULTS

The overall morbidity rate was 18%, with septic complications occurring in 5% of patients. Preoperative weight loss (p = 0.004) and older age (p = 0.008) were found to be significant predictors of morbidity. The surgical recurrence rate was 34%, with a median followup period of 7.5 years (range 1 to 16 years). Age was found to be a significant predictor of recurrence (p = 0.02), with younger patients having a shorter time to reoperation.

CONCLUSIONS

This large series of patients with longterm followup confirms the safety and efficacy of strictureplasty in patients with obstructing small bowel Crohn's disease. The 18% morbidity and 34% operative recurrence rates compare favorably with reported results of resective surgery. Caution should be used in patients with preoperative weight loss, because they experienced higher complication rates. Although young patients seem to follow an accelerated course, SXP remains indicated as part of an overall strategy to conserve intestinal length.

The history of Crohn's disease

Although it is likely that cases of what we know as granulomatous inflammatory bowel disease (Crohn's disease) may have been recorded as early as 1769, this illness is basically a disease of the 20th century. This historical review traces the development of our understanding of the disease and the evolution of its operative management.

Abdominal tuberculosis

Tuberculosis has staged a global comeback and forms a dangerous combination with AIDS. The abdomen is one of the common sites of extrapulmonary involvement. Patients with abdominal tuberculosis have a wide range and spectrum of symptoms and signs; the disease is therefore a great mimic. Diagnosis, mainly radiological and supported by endoscopy, is difficult to make and laparotomy is required in a large number of patient. Management involves judicious combination of antitubercular therapy and surgery which may be required to treat complications such as intestinal obstruction and perforation. The disease, though potentially curable, carries a significant morbidity and mortality.

Abdominal tuberculosis in Ahmadi, Kuwait: a clinico-pathological review

For studying abdominal tuberculosis (TB) in Ahmadi, files off all patients admitted to our hospital with abdominal TB over 15 years (1981-1996) were reviewed. Nineteen patients are reported here. Young adults were predominant in our study. The non-Arab Asians were the most frequently affected group in relation to their population in Ahmadi, and Kuwaitis were the least frequently affected group. Abdominal pain, sweating, anorexia and fever were the most frequent presenting symptoms. Ascites and intestinal obstruction were the most frequent clinical presentations. Two patients presented with acute appendicitis and one patient had tuberculous pancreatitis. Abdominal lymph nodes, peritoneum, ileum and and caecum were the most frequently affected abdominal structures. We found laparoscopy very helpful in diagnosis of abdominal TB and we recommend it as the diagnostic method of choice. All our patients responded well to antituberculous chemotherapy. It should be kept in mind that abdominal TB still affects the indigenous and expatriate population of Kuwait.

Intestinal tuberculosis: return of an old disease

OBJECTIVE

Tuberculosis (TB) can no longer be considered a rare disease in the United States due, in part, to the AIDS epidemic. Because the signs and symptoms of intestinal TB are nonspecific, a high index of suspicion must be maintained to ensure a timely diagnosis. The aim of this article is to review the history, epidemiology, pathophysiology, and treatment of TB.

METHODS

This review is based on an examination of the world literature.

RESULTS

In only 20% of TB patients is there associated active pulmonary TB. Areas most commonly affected are the jejunoileum and ileocecum, which comprise >75% of gastrointestinal TB sites. Diagnosis requires colonoscopy with multiple biopsies at the ulcer margins and tissue sent for routine histology, smear, and culture. If intestinal TB is suspected, empiric treatment is warranted despite negative histology, smear, and culture results. Treatment is medical, and all patients should receive a full course of antituberculous chemotherapy. Exploratory laparotomy is necessary if the diagnosis is in doubt, in cases in which there is concern about a neoplasm, or for complications that include perforation, obstruction, hemorrhage, or fistulization.

CONCLUSIONS

This review draws attention to the resurgence of tuberculosis in the United States. An increased awareness of intestinal tuberculosis, coupled with knowledge of the pathophysiology, diagnostic methods, and treatment should increase the number of cases diagnosed, thus improving the outcome for patients with this disease.