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 involves making a longitudinal incision in the stricture and then closing it in a transverse fashion to widen the lumen, thereby relieving the obstruction without removing the diseased segment. According to the ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1, strictureplasty is a safe option to treat small-bowel strictures related to Crohn’s disease and may be preferable to resection of long segments of bowel, with potential reduction in surgical recurrence rates. The Heineke-Mikulicz technique is the preferred method for stenotic segments up to 6–8 cm, which is suitable for this patient's condition 1. Additionally, the ECCO-ESCP consensus on surgery for Crohn's disease 1 supports the use of stricturoplasty as a first-line treatment whenever technically feasible, even in cases with multiple jejunoileal locations. Key benefits of stricturoplasty include preservation of bowel length and function, reduced risk of short-bowel syndrome, and lower rates of surgical recurrence compared to resection 1. In contrast, resection and anastomosis, while effective, may not be necessary for a small segment stricture, and right hemicolectomy or ileocecal resection with ileostomy would be more extensive than required for this specific condition. Some important points to consider when deciding on the type of operation include:
- The length and location of the stricture
- The presence of multiple strictures or complications such as fistulas or abscesses
- The patient's overall health and medical history
- The potential for bowel preservation and reduced risk of surgical recurrence. Given the information provided, stricturoplasty is the most appropriate operation for this patient, as it is a safe and effective procedure that can relieve the obstruction while preserving bowel length and function 1.
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 segment of the intestine and reconnecting the remaining portions 2, 3, 4.
- Stricturoplasty: This procedure involves making a longitudinal incision in the affected segment 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 segment of the ileum and creating an ileostomy, which may be considered in certain cases 4, 5.
Considerations for Strictureplasty
Strictureplasty is a viable option for patients with Crohn's disease and fibrostenotic strictures, as it conserves bowel length and minimizes the risk of short bowel syndrome 2, 3, 4, 5. However, it may be associated with a higher risk of recurrence compared to bowel resection 3. A modified side-to-side isoperistaltic strictureplasty over the ileocaecal valve has been proposed as an alternative to ileocaecal resection in extensive terminal ileal Crohn's disease 5.
Choice of Operation
Based on the provided information, the most suitable option for the patient would be either strictureplasty or resection and anastomosis, depending on the specific circumstances of the case 2, 3, 4, 5. Strictureplasty may be considered if the patient is at high risk for short bowel syndrome or intestinal failure, while resection and anastomosis may be preferred if the stricture is short and the patient has not had prior resections 3.