Heineke - Mikulicz Strictureplasty in Crohn's Disease

Video Type: CVideo
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Author: Iskander Bagautdinov
Published:
Specialties: General Surgery
Schools: Weill Cornell Medical College
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Basic Info

This video shows the performance of a Heineke - Mikulicz Strictureplasty in the treatment of stricturing Crohn's disease of the small bowel.

DOI: http://dx.doi.org/10.17797/jj8ee1q3mr

Editor Recruited By: Jeffrey B. Matthews, MD

Advanced

Procedure

Laparoscopic Heineke-Mikulicz strictureplasty in Crohn's disease of the small bowel

Indications

a. Duodenal, jejunal and neoterminal disease with single or multiple fibrotic strictures
b. Recurrences on previous small bowel and ileo-colonic anastomosis

Contraindications

a. Inflammatory masses
b. Generalized intra-abdominal sepsis
c. Long strictures with thick, unyielding intestinal wall
d. Dysplasia or carcinoma at the stricture site
e. Chronic bleeding from the diseased and strictured intestinal segment

Instrumentation

Setup

Regular laparoscopic set-up

Preoperative Workup

Complete assessment of disease extension with MR and/or CT enterography for the small bowel and colonoscopy for the colon

Anatomy and Landmarks

The entire small bowel must be ¢run¢ from the ligament of Treitz to the ileo-cecal valve to confirm the location of the diseased segment(s)

Advantages/Disadvantages

Advantages:
a. Bowel sparing
b. Quiescence of disease: Endoscopic, radiologic, and histopathologic evaluations after strictureplasty have highlighted complete Crohn¢s regression at strictureplasty sites in several reports. The mechanism associated with such regression remains unknown.
c. Protection against recurrence: A large meta-analysis from 2007 reported that recurrence on a previous strictureplasty requiring surgical management occurred in only 10% of cases, which compares favorably to results obtained with small bowel resection. The mechanism associated with such protective effect remains unknown.

Complications/Risks

a. A large number of publications have highlighted the safety of strictureplasties for Crohn¢s. A meta-analysis, including more than 3,000 strictureplasties has been published in 2007. Overall, mortality was nil and 13% of patients developed postoperative complications, including 4% septic complications (anastomotic leak, fistula, and abscess) and 3% postoperative hemorrhages.
b. Reports of small bowel adenocarcinoma developing at the site of strictureplasty have been documented. It is assumed that the risk of neoplastic transformation after strictureplasty is low and not sufficient to dissuade surgeons from performing those techniques.

Disclosure of Conflicts

Acknowledgements

References

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