Excellent long-term outcomes of strictureplasty in Crohn disease

Last Updated: 2016-01-05

By Will Boggs MD

NEW YORK (Reuters Health) - More than 90% of Crohn disease patients experience long-term resolution of symptoms after side-to-side isoperistaltic strictureplasty (SSIS), researchers from Italy report.

"In our opinion, absolutely SSIS should be the treatment of choice, in terms of recurrence and outcome, especially in patients with extended Crohn's disease or recurrent disease and have already undergone multiple small bowel resections," Dr. Marilena Fazi from the University of Florence told Reuters Health by email.

SSIS aims to avoid wide small-bowel resections in patients undergoing surgery for Crohn disease. While SSIS reportedly reduces recurrence rates, there are few data regarding the long-term outcomes or the risk factors for recurrence after surgery.

Dr. Fazi's team evaluated the long-term results of 91 Crohn disease patients who underwent SSIS by the same surgeon at their center. The mean extent of diseased bowel was 69.97 cm. Strictures were long (>6 cm) and continuous in 18 patients, short (6 cm) and multiple in 54, and both short and long in 19.

There were no deaths during surgery, but 24 patients experienced postoperative complications, according to the December 30 JAMA Surgery online report.

Intestinal activity returned between the third and 15th postoperative day (mean, day 5), and patients resumed nutrition gradually beginning on postoperative day 2.

All patients had resolution of obstructive symptoms after surgery, and only one patient relapsed within two weeks after discharge (the symptoms resolved after hospitalization and conservative medical therapy).

Among 83 patients followed up for six to 180 months (mean, 85.97 months), 37 (44.6%) had a clinical recurrence an average 55.46 months after surgery (range, 9-140 months). Recurrences were controlled with medical therapy in 15 (40.5%) and with reoperation in 22 (59.5%) of these patients.

Recurrences were outside of the SSIS in 13 patients and within the SSIS site in 24 patients.

In multivariate analysis, younger age at diagnosis and at surgery, positive family history, and smoking were independent risk factors for postoperative recurrence.

"We would like to underline that SSIS performed by experienced surgeons is a safe procedure, with optimal results in terms of early and late postoperative outcome and recurrence rate after a long-term follow-up," Dr. Fazi concluded.

"These observations support initial observations that the index disease goes into remission after an SSIS," wrote Dr. Fabrizio Michelassi from Weill Cornell Medicine, New York, in a related commentary. "It could potentially be practice-altering to demonstrate that anatomical disease remission eventuates in resumption of intestinal function of the diseased and strictureplastied intestinal segment."

"The authors state that performance of an SSIS resulted in resolution of preoperative symptoms in most patients," Dr. Michelassi added. "In five (6%), preoperative iron-deficiency anemia did not resolve. This experience may help in refining the indications to SSIS by excluding patients with long disease segments, failure of medical treatment, and iron-deficiency anemia but absence of major obstructive symptoms."

Dr. Burt Cagir, from Sacred Heart Hospital, Allentown, Pennsylvania, who has reviewed strictureplasty techniques in Crohn disease (http://bit.ly/1OKfTXC), told Reuters Health by email, "This technique is particularly useful because SSIS preserves long segment of bowel without resection, avoids blind or bypassed intestinal loop, palliates stenosis, and if fails, only diseased or strictured bowel is lost or resected."

He added, "Various types of strictureplasties, most importantly Michelassi SSIS, should be in all (gastrointestinal) surgeon's armamentarium."

Dr. Anthony de Buck van Overstraeten, from University Hospitals Leuven, Belgium, who recently described a modified SSIS for terminal ileal Crohn disease (http://bit.ly/1Z61Ksp), told Reuters Health by email, "In order to avoid short bowel syndrome and considering the similar recurrence rate after extensive resection compared to that after conservative resections, strictureplasties are probably an acceptable treatment method in stenotic Crohn's patients. Considering the safety and recurrence profile, this technique could be promoted in my humble opinion as a treatment of choice in selected cases. The only drawback I can think of is the technical challenge, although this could be overcome by tutorials and standardization."

"Despite the observed mucosal healing, which is very encouraging, further research should focus on functional recovery of the treated segment and on mechanisms of healing," Dr. de Buck van Overstraeten added. "It would be odd to spare non-functional bowel length, as it would be a pity to resect bowel length that could eventually turn into a functional bowel segment. Our group is presently initiating research in this field."

The authors reported no external funding or disclosures.

SOURCE: http://bit.ly/1OKhTPr and http://bit.ly/1OxzQ1L

JAMA Surg 2015.