Stricturoplasties Indications and Results

Stricturoplasties certainly constituted a basic turning point for the surgical treatment of CD strictures. They allow correction of the occlusion of the tract, preserving the intestinal tissue without reducing (or at least only partly reducing) the absorption surface. In a recent and comprehensive review, Roy and Kumar [30] conducted a meta-analysis on the studies that appeared in the literature addressing both indications and results. As already described in the previous paragraph, the indications accepted in the literature regarding the use of stricturoplasties are: multiple serrated stenoses, stenosis in absence of an active disease (especially in the presence of former extensive resections or short-bowel syndrome), a disease with a fast relapse and occlusive syndromes and treatment of anastomotic stenoses already created during resections. A clear contraindication to stric-turoplasty is the presence of active disease. The risk of fistulisation appears to be high, with very dangerous consequences for the patient. In a recent study, the same authors [31] published a retrospective work reporting the results achieved with 14 patients (73 stricturoplasties) with active CD (disease activity was both histologically and clinically defined). The perioperative complication rate due to the procedure was limited (one fistula needing a second surgery). These results, even if positive, must be carefully evaluated.

They certainly need further confirmation, due not only to the kind of study (retrospective) but also to the poor number of samples. However, they certainly constitute an essential point for further studies. Other contraindications reported in this meta-analy-sis were the very poor general condition of the patients (serum albumin <2g/dl), tension on closure of strictureplasty and a segment requiring resection before a stricture suitable for plasty. The presence of fistulae or abscesses near the stenosis is another contraindication.

The treatment of the terminal ileitis (especially as first manifestation) is still at issue. While some authors, such as Poggioli [32], propose the use of stricturoplasty in this case as well, no agreement has been reached. Moreover, as already written, if it is performed in a few excellent centres, the laparoscop-ic approach may reduce hospitalisation periods and morbity of this operation, even if not all authors agree on this fact.

Roy and Kuman [31] analysed long-term results of stricturoplasties reported by seven studies published since 2000 (a total of 461 patients with an average follow-up of 68.8 months) comparing them with Tichansky's review published that same year [33]. Results of these meta-analyses are comparable, with a rate of reoperations after 5 years of about 26% and an overall perioperative complication incidence of 11% (slightly reduced in comparison with 13% reported by Tichansky). In the light of these data, it is clear that, even if it is not without complications, strictureplasty in selected patients suffering from CD is a very good therapeutical option.

The use of long stricturoplasties has always been surrounded by skepticism because of the likely complications and of a hypothetical risk of stenosis or major disease relapse. In a recent work, Shatari [34] compared long-term results between long and short stricturoplasties, showing the former to give very good functional results over time, with complications and relapse rates absolutely similar with those of short stricturoplasties.

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