What surgical operation is indicated for a patient with a short segment stricture of the terminal ileum, approximately 2-3 centimeters from the ileocecal valve, presenting with symptoms of intestinal obstruction?

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 resection and anastomosis (option A). This procedure involves removing the diseased segment of the ileum containing the stricture and then reconnecting the healthy ends of the bowel to restore intestinal continuity. Resection and anastomosis is preferred for short segment strictures because it completely removes the pathological tissue while preserving bowel length and function. The proximity to the ileocecal valve (2-3 cm) allows for preservation of this important anatomical structure, which helps regulate intestinal transit and bacterial colonization.

Key Considerations

• Stricturoplasty would be more appropriate for multiple strictures or in patients with extensive small bowel involvement where bowel preservation is critical, as stated in the ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1.
• Right hemicolectomy would be excessive as it removes the entire right colon when only the terminal ileum is affected.
• Ileocecal resection with ileostomy is unnecessarily extensive and creates a stoma that would require later reversal.

Supporting Evidence

• A study published in the Journal of Crohn's and Colitis in 2020 found that strictureplasty is a safe option to treat small-bowel strictures related to Crohn’s disease, but it may not be the best option for short segment strictures 1.
• The British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults also support the use of strictureplasty for multiple strictures or in patients with extensive small bowel involvement 1.
• However, for a small segment stricture of the terminal ileum, resection and anastomosis is the most appropriate operation, as it allows for complete removal of the diseased segment while preserving bowel length and function.

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 parts 2, 3.
• 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.
• Right hemicolectomy: This involves removing the right side of the colon, which may not be directly relevant to the stricture location in this case.
• Ileocaecal resection & ileostomy: This involves removing the affected portion of the ileum and cecum, and creating an ileostomy 3, 4, 5.

Considerations for Each Option

When choosing a surgical option, considerations include:

• The length and location of the stricture
• The presence of any underlying conditions, such as Crohn's disease
• The risk of short bowel syndrome with additional resections
• The potential for malignant transformation at strictureplasty sites 2, 3, 4
• The efficacy and safety of each procedure, including the risk of complications and the need for subsequent surgery 5, 6

Relevant Studies

Several studies have investigated the efficacy and safety of these surgical options:

• A study published in 2013 found that strictureplasty is a safe and effective procedure for patients with Crohn's disease and fibrostenotic stricture 2.
• A study published in 2001 recommended limited resection or strictureplasty to conserve bowel length in patients with small bowel disease 3.
• A study published in 2016 found that a modified side-to-side isoperistaltic strictureplasty over the ileocaecal valve is a safe and effective alternative to ileocaecal resection in patients with extensive terminal ileal Crohn's disease 4.
• A study published in 2019 compared the outcome of patients with ileocolonic anastomotic stricture treated with endoscopic stricturotomy versus ileocolonic resection, and found that endoscopic stricturotomy achieved comparable surgery-free survival with decreased morbidity 5.
• A study published in 2020 evaluated the outcome of endoscopic stricturotomy in the management of IBD and non-IBD-associated strictures, and found that the procedure was effective in both groups, but with some differences in complications and subsequent surgery rates 6.