Stricturoplasties Notes on Surgical Technique

The first description of the use of stricturoplasty dates back to 1977 when Katariya, an Indian surgeon, published its use for the treatment of multiple tubercular stenoses in a series of nine patients [35]. In 1982, Lee and Papaioannou published the first results about the use of the strictureplasty technique in nine patients with CD [36]. Since then, many techniques were proposed on how to perform stricturoplasties.

Surgical technique for this kind of operation must be very strict. After laparotomy and accurate lysis of any adhesions, the entire small bowel must be explored for stenoses. Observation and palpation allow detection of stenotic tracts. The presence of more stenoses may be assessed after doing an enterotomy on the already identified stricture by introducing the index finger into the lumen and passing the gut over the finger in a concertina fashion or by the pull-through technique using an 18-Fr Foley catheter [30]. Exploration must, obviously, reach the duodenum proximally and the ileocecal valve distally. Besides the stenoses site, it is essential to evaluate its extension and any coexistence of fis-tulous tracts. Even if indications for some of these techniques are similar, many have their technical limitation in the length of the stenoses. Regardless of the kind of stricturoplasty, it is important to have a precise technique. Tissues of the diseased segments are thickened, inflamed and oedematous whereas the mesentery may be retracted. The loops must not be under tension, especially after long plasties. Moreover, control of bowel vascularisation before longitudinal incision is essential to avoid ischaemia with an inevitable dehiscence and consequent fistula. It is very delicate surgery requiring expert and dedicated surgeons in reference centres.

Heineke-Mikulicz stricturoplasty: this technique was originally used to treat hypertrophic stenosis of the pylorus [37]. It allows treatment of small stenotic tracts (8-10 cm). After the insertion of a stay suture, the antimesenteric side of the bowel is opened along the structure, and the longitudinal incision is transversely closed using seromuscular interrupted absorbable sutures (Fig. 2).

Finney stricturoplasy: this technique allows treatment of longer stenoses (from 10 to 20 cm). The antimesenteric side of the bowel is longitudinally opened along the structure and bent into a U shape. The posterior wall is first closed by a continuos, full

Heineke Mikulicz Strictureplasty

Fig. 2. Heineke-Mikulicz stricturoplasty

Stricturoplastie Finney

Fig. 3. Finney stricturoplasty

Fig. 2. Heineke-Mikulicz stricturoplasty

Fig. 3. Finney stricturoplasty thickness, running suture, as is the anterior one (Fig. 3).

Fazio technique: Fazio and Tjandra [38] developed a method to treat two closed strictures by mixing the two techniques described above. Both strictures are opened with a long incision and then closed in a Heineke-Mikulicz fashion.

Michelassi technique: this is a side-to-side isoperistaltic stricturoplasty [39], which can be used to treat long strictures. It is performed by transecting the diseased segment and its mesentery at the midpoint and longitudinally opening and then suturing the proximal loop over the distal one by an interrupted or running suture. In the first description, this methodology allowed treatment of strictures up to 90 cm long in three patients with severe jejunal-ileal disease (Fig. 4).

Poggioli technique: this is a side-to-side, disease-to-disease-free anastomosis [40]. The first step involves division of the bowel and its mesentery at the beginning of the stricture. Then, the diseased segment is opened in order to be anastomise it to the proximal normal small bowel.

The literature describes many variations of the above techniques, such as the plasties according to Jaboulary, Judd, Moskel-Walske-Neuman [30] and that recently proposed by Sasaki for reconstruction following intestinal resection [41]. Every surgeon dealing with inflammatory intestinal diseases must know these techniques as well; Tichansky [32] pointed out, in a meta-analysis that stricturoplasty according to Heineke-Mikulicz is surely the most used (85%), followed by Finney's (13%). We must emphasise that this meta-analysis refers to a historical sam-

Michelassi Stricturoplasty
Fig. 4. Michelassi technique

ple and that, in the past, "long" plasties were not yet validated for this; even if they were already known and used [42], they had little approval.

Recently, the indication for conservative treatment extended to the treatment of terminal ileitis. Poggioli proposed a "side-to-side entero-colic anastomosis [32]", contemplating the section of the terminal loop, of the ileocecal valve and the colon along the tenia and a Finney-fashion suture. Taschieri [43] described an analogous technique to be applied in the case of important narrowing of the ileocecal valve requiring resection of the cecum and the ileocolic junction. The anastomosis is between the ileum and the right colon.

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