How to manage a stricture 20 cm from the ileocaecal valve with symptoms of diarrhea and mild weight loss, but no fever or severe pain?

Management of Ileal Stricture 20 cm from Ileocaecal Valve

For a stricture 20 cm from the ileocaecal valve with diarrhea and mild weight loss but no fever or severe pain, stricturoplasty is the preferred surgical approach to preserve bowel length while resolving symptoms. 1, 2

Assessment and Decision Algorithm

Initial Evaluation:

• Location: 20 cm from ileocaecal valve (jejuno-ileal)
• Symptoms: Diarrhea, mild weight loss
• No acute inflammation signs: Absence of fever and severe pain

Management Decision Tree:

1. Stricture >15 cm from ileocaecal valve → Stricturoplasty preferred
2. Mild symptoms without acute inflammation → Surgical intervention appropriate
3. Need to preserve bowel length → Avoid resection when possible

Stricturoplasty Technique Selection

The type of stricturoplasty depends on the length of the stricture:

• For strictures <10 cm: Conventional Heineke-Mikulicz stricturoplasty 1, 2
• For strictures 10-25 cm: Modified techniques like Finney procedure or side-to-side isoperistaltic stricturoplasty (Michelassi technique) 1, 2, 3

Rationale for Stricturoplasty

Stricturoplasty is strongly indicated in this case because:

1. The stricture is located >15 cm from the ileocaecal valve 2
2. Symptoms are mild without signs of acute inflammation 1
3. Preserving bowel length is critical in Crohn's disease to prevent short bowel syndrome 1, 2
4. Early and late outcomes are comparable to resectional surgery 1

Important Considerations

Contraindications to Stricturoplasty:

• Presence of fistulae
• Fistula-associated abscesses
• Suspicion of carcinoma
• Colonic strictures (due to bowel wall characteristics, vascularization, and cancer risk) 1

Preoperative Assessment:

• Complete assessment of the bowel is necessary during surgery
• A balloon catheter can be used to assess luminal diameter 1
• Nutritional assessment and support are recommended before surgery 2

Expected Outcomes

Side-to-side isoperistaltic stricturoplasty has shown excellent outcomes:

• Resolution of intestinal obstruction and malnutrition in all patients 3
• Decrease in disease activity indices in 62.3% of patients within 6 months 3
• Long-term studies show that 92% of patients maintained their original stricturoplasty at nearly 6 years follow-up 4

Common Pitfalls to Avoid

1. Inadequate assessment: Failure to identify multiple strictures or skip lesions intraoperatively
2. Inappropriate technique selection: Using conventional stricturoplasty for long strictures
3. Overlooking bacterial overgrowth: Monitor for small bowel bacterial overgrowth postoperatively 2
4. Ignoring nutritional status: Ensure proper nutritional support before and after surgery

Alternative Options

1. Endoscopic balloon dilatation: Only recommended for strictures <5 cm in length 1, 2
2. Medical therapy: Consider for strictures <12 cm with moderate proximal dilatation and no fistulae 2
3. Surgical resection: Reserved for cases with complications like fistulae, abscesses, or when stricturoplasty is not technically feasible 1

By following this approach, bowel length is preserved while effectively treating the stricture, which is crucial for maintaining long-term quality of life and reducing morbidity in patients with Crohn's disease.