From the Guidelines
The most appropriate operation for a small segment stricture of the terminal ileum about 2-3 cm from the ileocecal valve in a patient with intestinal obstruction is option B: Stricturoplasty. This procedure is preferred because it preserves intestinal length and function, which is crucial for maintaining quality of life and reducing the risk of long-term complications such as short bowel syndrome. According to the most recent and highest quality study 1, strictureplasty is a safe option to treat small-bowel strictures related to Crohn’s disease, and it may be preferable to resection of long segments of bowel, with potential reduction in surgical recurrence rates. The study also suggests that strictureplasty is an established and safe surgical option for treating strictures related to CD and is an alternative to bowel resection, with a 5-year recurrence rate of 28% and surgical morbidity in the range of 8–15%. Some key points to consider when deciding on the type of operation include:
- The length and location of the stricture: In this case, the stricture is localized to a small segment of the terminal ileum, making strictureplasty a feasible option.
- The presence of complications such as localized sepsis or fistulae: According to 1 and 1, the presence of fistulae or fistula-associated abscesses is a contraindication for strictureplasty, but this is not mentioned in the patient's case.
- The need to preserve intestinal length and function: Strictureplasty is preferred when bowel preservation is critical, as it allows for the preservation of intestinal length and function.
- The potential for reduction in surgical recurrence rates: Strictureplasty may reduce surgical recurrence rates compared to resection, as suggested by 1. Overall, strictureplasty is the most appropriate operation for this patient, as it preserves intestinal length and function, reduces the risk of long-term complications, and may reduce surgical recurrence rates.
From the Research
Surgical Options for Intestinal Obstruction
The patient has manifestations of intestinal obstruction due to a small segment stricture of the terminal ileum. Considering the location and nature of the stricture, the following surgical options are available:
- Resection and anastomosis: This involves removing the affected portion of the intestine and reconnecting the remaining segments 2, 3, 4.
- Stricturoplasty: This procedure involves making a longitudinal incision in the stricture and then closing it in a transverse fashion to widen the lumen 2, 3, 4, 5.
- Right hemicolectomy: This involves removing the right side of the colon, which may not be directly relevant to the stricture location in the terminal ileum.
- Ileocaecal resection & ileostomy: This involves removing the affected portion of the ileum and cecum, and creating an ileostomy 4, 5.
Considerations for Choosing a Surgical Option
When choosing a surgical option, considerations include:
- The location and length of the stricture: A stricture in the terminal ileum may be amenable to stricturoplasty or resection and anastomosis 2, 3, 4, 5.
- The patient's overall health and risk factors: Patients with a history of prior resections may be at increased risk for short bowel syndrome, making stricturoplasty a more attractive option 2, 3.
- The potential for recurrence: Stricturoplasty may be associated with a higher risk of recurrence compared to resection and anastomosis 3.