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A1-G Surg Note Small Bowel > Use of Strictureplasty > Flashcards

Use of Strictureplasty Flashcards

1
Q

What are the three phenotypes of Crohn’s disease?

A

1) Nonpenetrating/nonstricturing disease > inflammatory masses
2) Penetrating disease > fistulae and abscesses
3) Fibrostenotic disease > fibrotic strictures.

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2
Q

How are strictures in Crohn’s disease defined?

A

constant luminal narrowing with prestenotic dilation or obstructive signs without penetrating disease

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3
Q

What are the main treatment options for fibrostenotic Crohn’s disease?

A

-Endoscopic > Dilation, stricturotomy, and endoscopic stenting.

-surgical treatments > Proximal diverting stoma, resection, intestinal bypass, and strictureplasty

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4
Q

What are common symptoms for patients with gastroduodenal strictures?

A

Early satiety, postprandial fullness, burping, and vomiting.

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5
Q

From where do symptoms originate in patients with multiple strictures?

A

From the most proximal critical stricture.

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6
Q

Which noninvasive imaging modalities are useful for mapping strictures?

A

CTE and MRE.

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7
Q

What can CTE and MRE show in patients with strictures?

A

Luminal narrowing
intestinal wall thickening
prestenotic bowel dilation
and they can help estimate small-bowel length for preoperative planning.

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8
Q

What is the role of endoscopic evaluation in stricturing disease?

A

To assess the extension and severity of luminal disease and check for malignancy, although it may be limited by tight strictures or angulations

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9
Q

What risks do patients with multifocal, extensive, and recurrent stricturing disease face?

A

Short gut syndrome, especially after prior extensive bowel resections

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10
Q

Indications for Strictureplasty

A

1

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11
Q

Contraindications

A

2

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12
Q

Contraindications

A

3

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13
Q

For what type of strictures is strictureplasty indicated?

A

Fibrotic strictures in the duodenum and small bowel, especially when multiple strictures are present or in patients with previous bowel resections at risk for short bowel syndrome

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14
Q

When is a fistula not a contraindication for strictureplasty?

A

When the fistulous opening is devoid of acute inflammation and located on the antimesenteric side of the bowel.

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15
Q

What must be done if there is concern for malignancy in a stricture?

A

The affected intestinal segment must be resected according to standard oncologic principles.

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16
Q

Should asymptomatic strictures be resected

A

No, asymptomatic strictures should not be resected but can be strictureplastied or included in a strictureplasty for an adjacent symptomatic stricture to prevent progression

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17
Q

Why are patients requiring surgical intervention for obstructive symptoms often malnourished?

A

Because of their compromised nutritional state due to the disease

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18
Q

What should be done for malnourished patients before undergoing surgery?

A

They should receive nutritional repletion with a liquid enteral diet or parenteral diet supplementation to reverse their catabolic state

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19
Q

Why is careful preoperative evaluation critical in Crohn’s disease surgery?

A

To ensure proper operative planning by evaluating past and current disease activity (obstructive, septic, hemorrhagic, or neoplastic) and understanding the patient’s current gastrointestinal anatomy.

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20
Q

What imaging modalities are used for preoperative evaluation in Crohn’s disease?

A

(CTE) and (MRE).

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21
Q

What role does MRE, CTE and endoscopic evaluation play in preoperative planning for Crohn’s disease?

A

It provides a visual map of disease distribution, checks for entero-enteral fistulae, perforations, and helps estimate the overall small bowel length

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22
Q

What is the first step in any CD abdominal procedure?

A

Thorough examination of the entire bowel either laparoscopically or via laparotomy

The bowel must be visually inspected, palpated digitally or through laparoscopic instruments,

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23
Q

How can subtle luminal narrowings be identified during surgery?

A

By passing a well-lubricated Foley or Fogarty balloon through the bowel and retracting it partially inflated.

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24
Q

What are common characteristics of small bowel disease in Crohn’s?

A

Creeping fat, wall thickening, and mesenteric thickening.

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25
Q

Why is preoperative endoscopic evaluation important for colonic disease?

A

Because mucosal disease may be present even if the external wall appears normal.

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26
Q

What should the surgeon document after the bowel examination?

A

A mental road map of the gastrointestinal tract, noting bowel length, disease location, phenotypic appearance, and previous resections or strictureplasties

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27
Q

What procedures are used for short-segment strictures?

A

Heineke-Mikulicz strictureplasty.

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28
Q

What is the preferred treatment for longer-segment strictures?

A

Finney strictureplasty.

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29
Q

Which strictureplasty is used for multiple sequential strictures?

A

Michelassi strictureplasty.

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30
Q

How are terminal ileum and colon strictures typically managed?

A

With segmental resection.

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31
Q

What is an alternative for Crohn’s terminal ileitis?

A

A modified Michelassi strictureplasty

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32
Q

How are anastomotic strictures treated if they are endoscopically accessible?

A

With endoscopic dilation.

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33
Q

What should be done if anastomotic strictures are not accessible for endoscopic treatment?

A

Resection or strictureplasty should be performed.

34
Q

What is required to perform a tension-free strictureplasty at a prior anastomosis?

A

Adequate mobilization of the intestinal loop and lysis of adhesions

35
Q

What is the long-term recurrence rate of anastomotic strictureplasty?

A

57%.

36
Q

Gastroduodenal strictures

A

are most often endoscopically accessible and can be treated with endoscopic dilation.

37
Q

When surgery is indicated ?

A

short strictures throughout the first three portions of the duodenum may be treated with the Heineke-Mikulicz strictureplasty,

38
Q

strictures of the fourth portion of the duodenum

A

may be treated with the Finney strictureplasty by recruiting the first loop of jejunum.

To treat a duodenal stricture, the duodenum must be fully mobilized to allow for a strictureplasty without tension. If a strictureplasty is not feasible, a gastrojejunal bypass is a viable alternative.

39
Q

Jejunal-ileal strictures

A

combination of resection and strictureplasty techniques.

40
Q

Strictureplasty Operative Strategy

A

see

41
Q

What must be evaluated after opening the bowel during a strictureplasty?

A

The mucosal surface of the affected and neighboring bowel for disease severity and presence of dysplasia/carcinoma.

42
Q

What should be done if dysplasia or malignancy is confirmed during strictureplasty?

A

The strictureplasty should be aborted, and an oncologic resection should be performed.

43
Q

Why is hemostasis important during strictureplasty?

A

Because bleeding from the strictureplasty site is a common and challenging postoperative complication

44
Q

How can persistent bleeding from a strictureplasty site be managed?

A

Endoscopic techniques can be used if within reach, or selective mesenteric angiography with intraarterial vasopressin infusion can be employed for inaccessible bleeding

45
Q

What technique can aid in localizing the site of bleeding during mesenteric angiography

A

In the presence of multiple suture lines (strictureplasties, anastomoses), Injection of India ink blue dye for subsequent intraoperative localization

46
Q

What is the purpose of biopsying suspicious areas during strictureplasty

A

To analyze for dysplasia or carcinoma using frozen-section analysis

47
Q

What type of strictures is the Heineke-Mikulicz strictureplasty best suited for?

A

Short strictures up to 5 cm in length.

48
Q

What is the first step in performing a Heineke-Mikulicz strictureplasty?

A

-Place two 3-0 sutures on each side of the bowel at the midportion of the stricture to act as stay sutures.
-enterotomy made On the antimesenteric side
-1 to 2 cm beyond the length of the stricture both proximally and distally to healthy bowel
-one-layer closure > Modified Gambee stitch with an absorbable suture
- two-layer closure > running absorbable suture for the inner layer and an interrupted Lembert suture (nonabsorbable) for the outer layer

49
Q

What is the advantage of using the Modified Gambee stitch?

A

It ensures appropriate approximation of the mucosa and serosa while preserving the blood supply between sutures.

50
Q

Modified Gambee stitch

A

-First the stitch penetrates all layers of the bowel wall from the serosa to the luminal mucosa approximately 0.5 cm from the cut edge.
-The mucosa of the other limb is traversed out of the bowel lumen
-then the mucosa of the first side is traversed back into the bowel lumen
-Finally, on the other limb, the stitch penetrates all layers of the bowel wall from the luminal mucosa to the serosa approximately 0.5 cm from the cut edge.

51
Q

What is the Sasaki modification of the Heineke-Mikulicz strictureplasty used for?

A

To treat two short-segment strictures that are in very close proximity.

52
Q

Where is the enterotomy created in the Sasaki modification?

A

Along the antimesenteric border through both strictures and the intervening healthy segment of intestine

53
Q

What is the benefit of using the Sasaki modification for two close strictures?

A

It allows for a combined approach that treats both strictures with a single enterotomy, reducing the number of suture lines and preserving bowel length

54
Q

What is the Moskel-Walske-Neumayer strictureplasty used for?

A

To address strictures where there is a disparity in size between a very dilated proximal bowel and a nondilated distal bowel

55
Q

What type of closure technique is used in the Moskel-Walske-Neumayer strictureplasty?

A

V-Y advancement flap closure

56
Q

Where is the enterotomy created in the Moskel-Walske-Neumayer technique?

A

Along the antimesenteric border of the stricture, extending into a Y shape on the antimesenteric border of the dilated proximal bowel.

57
Q

How is the Y-flap used in the Moskel-Walske-Neumayer strictureplasty?

A

The Y-flap of the proximal dilated bowel is advanced into the strictured area and closed in a transverse fashion

58
Q

What is the Judd strictureplasty used for?

A

It is a variation of the Heineke-Mikulicz strictureplasty used when the strictured segment includes a fistula opening.

59
Q

Where must the fistula opening be located for the Judd strictureplasty to be used?

A

On the antimesenteric side of the bowel.

60
Q

How is the anti-mesenteric incision made in the Judd strictureplasty?

A

The incision is made to include the fistula opening as part of the longitudinal enterotomy

61
Q

What step must be taken with the fistula opening before closure?

A

The fistula opening is debrided, leaving healthy tissue.

62
Q

What is the Finney strictureplasty?

A

surgical technique used to treat intestinal strictures 5 to 12 cm long or segments with closely grouped short strictures. It involves folding the stricture in a U-shape and suturing it side-to-side.

63
Q

How is the Finney strictureplasty performed?

A

The strictured segment is folded to create a U-shaped loop, sutured side-to-side using interrupted Lambert sutures near the mesenteric borders, followed by a longitudinal enterotomy and a side-to-side anastomosis

64
Q

What type of sutures are used in the Finney strictureplasty?

A

Interrupted Lambert sutures are used for the posterior outer layer, and running absorbable sutures are used for the inner layer, with anterior outer reinforcement of interrupted Lambert sutures.

65
Q

What if the strictured bowel lacks pliability for the Finney technique?

A

If the strictured bowel cannot fold on itself, normal bowel may be folded onto diseased bowel, or the Jaboulay strictureplasty may be considered

66
Q

What is the Jaboulay strictureplasty?

A

A modification of the Finney strictureplasty where a side-to-side anastomosis is made between healthy bowel segments proximal and distal to the stricture, leaving the stricture in place as a short bypassed segment.

67
Q

What are potential complications of the Jaboulay strictureplasty?

A

bacterial overgrowth, septic complications, and long-term malignant degeneration of the bypassed segment.

68
Q

When is SSIS indicated?

A

SSIS is used for bowel segments greater than 12 cm containing a single long stricture or a series of shorter strictures closely grouped over a long intestinal segment.

69
Q

How is luminal hemostasis achieved in SSIS?

A

obtained with suture ligation and electrocautery.

70
Q

What is the inner layer suture technique in SSIS?

A

Running full-thickness absorbable sutures start at the middle of the posterior suture line and progress anteriorly as a continuous Connell stitch.

71
Q

What can restrict the mobility of the small bowel during SSIS?

A

Thick and friable mesentery may limit bowel mobility and restrict the ability to transect and slide the loops side-by-side.

72
Q

How can the Michelassi strictureplasty be adapted when a diseased loop has a long rigid stricture?

A

If a long, rigid stricture is present, that segment can be resected before sliding the proximal and distal loops together for SSIS.

73
Q

What is Michelassi II strictureplasty used for?

A

It is used when three severely fibrotic and deformed bowel segments are separated by two strictures, allowing for a modified SSIS after resection

74
Q

In which region are strictureplasties most often performed?

A

In the jejunoileal region (94%).

75
Q

What were significant risk factors for postoperative complications after strictureplasty?

A

Emergency surgery
intraabdominal abscess
low hemoglobin
hypoalbuminemia
preoperative weight loss
and older age.

76
Q

What was the 5-year recurrence rate following strictureplasty reported by Yamamoto?

A

A 28% recurrence rate, with only a 3% site-specific recurrence rate.

77
Q

What was the rate of septic complications after jejunoileal strictureplasty?

A

4% of cases had septic complications, with 78% related to the strictureplasty site.

78
Q

What was the risk of postoperative hemorrhage requiring transfusion?

A

3% of patients, often managed nonoperatively, with only 6% requiring laparotomy

79
Q

What was the rate of postoperative ileus following strictureplasty?

A

2% of patients.

80
Q

What percentage of patients developed postoperative bowel obstruction, and how many required laparotomy?

A

1% developed obstruction, with 27% of them requiring laparotomy.

81
Q

In terms of disease recurrence

A

the site-specific operation-free interval is similar for patients who undergo resection or strictureplasty.

A1-G Surg Note Small Bowel (10 decks)

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