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SURGICAL MANAGEMENT OF STRICTURING CROHN’S DISEASE.
Lorenzo Di Maira, Marco Casaccia, Giuseppe Caristo, Frascio Marco, Rosario Fornaro.
University of Genoa, Department of Surgery, San Martino Hospital - Genova
Largo Rosanna Benzi n 10, 16132 Genova, Italy
rfornaro@unige.it
Introduction. More than two thirds of patients with Crohn’s disease (CD) will face one or
more surgeries during the course of life. Stenosis is a frequent complication, occurring in one third
of patients, and obstruction is the most common indication for surgery. Stricturing and penetrating
disease often coexist in the same patient.
Aim and Methods. The purpose of this review is to focus the surgical approach in the
management of stricturing CD. The Aa have conducted a review of the literature of the last two
decades and have revised critically their own experience.
Results and Discussion. Evaluation of patients with suspect of stenosis can be performed by
endoscopy and imaging techniques, such as ultrasonography (US), CT-enterography (CTE) or MR-
enterography (MRE). Patients with CD-strictures who are not responders to conservative therapy
and show signs of vascular suffering or perforation risk should be operated urgently. Elective
surgery is indicated in patients with persistent obstruction, despite medical therapy, especially if it is
a long-lasting stenosis with a major fibrotic component. Also, in cases of stenosis without signs of
flogosis, early surgery is a valid alternative to medical therapy. In all patients it is important to
evaluate the ongoing therapy, considering that steroids increase the risk of postoperative
complications; also the biologicals lead to an increase in complications. Endoscopic balloon dilation
(EBD) is indicated in stenosis of large intestine, in stenosis of ileo-colonic anastomosis and ileum
also, when they can be reached by the colonscopy/enteroscopy. Surgery (resection or
strictureplasty, open or laparoscopic surgery) is based on a variety of factors, including the number,
length and location of the stenosis, the length of residual intestine, the presence or absence of
complications (perforation, abscesses), the experience of the surgeon and, not least, the patient's
preference. The intervention of choice is still resection. Concomitant abscess recommend TC-
guided drainage or surgical drainage. A wide stapled side-to-side anastomosis (SSSA) would be the
best, as it would have lower complication rates, compared to the conventional handsewen end-to-
end anastomosis(HEEA). The strictureplasty (Mikuliks, Finney, Michelassi, Taschieri, Fazio,
Poggioli and other variants) are reserved for selected cases with stenosis, especially of the small
bowel.
Conclusions. The management of patients with stricturing CD requires a multidisciplinary
approach. Optimization of preoperative medical treatment can reduce the incidence of
complications and probably of recurrence of the disease, and represents therefore the first step in the
management of strictures in CD patients. Stenosis treatment may require medical theray, EBD,
strictureplasty or intestinal resection. The choice between EBD, strictureplasty or resection, either
laparoscopic or open surgery, is based upon the occurrence of complications of the disease, the
residual intestinal length and upon the location, number and length of each stenosis. Surgery should
be performed when local and general conditions are such as to reduce, as much as possible, the risk
of complications.