Introduction. Resection and strictureplasty are used to treat patients with obstructive Crohn’s disease. Strictureplasty is preferable in adults as it retains bowel length. This study aims to identify differences in outcomes of children undergoing strictureplasty and resection for obstructive Crohn’s disease. Method. Patients under 20 years undergoing surgery over a nine-year period were included. Data was collected on procedures for stenotic Crohn’s disease. Patients were divided into 2 groups: Group 1 treated with strictureplasties and Group 2 resections. Postoperative complications and recurrence rates were recorded. Kaplan-Meier method was used to analyze the data. Results. Twenty-six patients and 40 operations were identified. Mean age was 15.6 years (7.2–19.4) with equal numbers of males and females. Mean follow-up was 45.9 months (0.1–149.9). 20/40 procedures involved the terminal ileum; 9/40, the ileocolic junction; 8/40, the upper GI tract; and 3/40, the colon. Group 1 consisted of 19 strictureplasties and Group 2 consisted of 13 resections and 8 combined procedures. Significantly more patients in Group 1 required further surgery (11/19 versus 3/21; ). Conclusion. Allowing for variations in disease duration, severity, and previous medical management, these data suggest that resection is preferable to strictureplasty in treating obstructive Crohn’s disease in children and adolescents. 1. Introduction Children and adolescents account for 25% of all patients with Crohn’s disease and can have a significant impact on growth and development [1]. Over their lifetime, affected patients have a 70–90% chance of surgical intervention [2, 3]. Furthermore, recrudescence of the disease requiring additional surgical intervention can occur in 50% of patients [4, 5]. Indications for surgical intervention in Crohn’s disease include perforation, abscess formation, bleeding, malignancy, and fibrotic strictures [6]. This study aims to concentrate on the outcomes of patients treated for the latter of these indications. Strictureplasty and resection are both used to treat obstructive Crohn’s disease. First described in the 1970s as a treatment for tuberculosis, strictureplasty was employed for the management of Crohn’s strictures in the early 1980s [7, 8]. The indications for its use are to preserve small bowel length in patients who would otherwise require a large resection, single site fibrotic strictures in inactive disease, recurrence of strictures less than 1 year since resection, isolated ileocolonic strictures, and selected duodenal strictures [9, 10]. The
References
[1]
J. Kelsen and R. N. Baldassano, “Inflammatory bowel disease: the difference between children and adults,” Inflammatory Bowel Diseases, vol. 14, pp. S9–S11, 2008.
[2]
J. Canin-Endres, B. Salky, F. Gattorno, and M. Edye, “Laparoscopically assisted intestinal resection in 88 patients with Crohn's disease,” Surgical Endoscopy, vol. 13, no. 6, pp. 595–599, 1999.
[3]
H. S. Mekhjian, D. M. Switz, and H. D. Watts, “National Cooperative Crohn's Disease Study: factors determining recurrence of Crohn's disease after surgery,” Gastroenterology, vol. 77, no. 4, pp. 907–913, 1979.
[4]
V. W. Fazio, F. Marchetti, J. M. Church et al., “Effect of resection margins on the recurrence of Crohn's disease in the small bowel: a randomized controlled trial,” Annals of Surgery, vol. 224, no. 4, pp. 563–573, 1996.
[5]
R. G. Farmer, G. Whelan, and V. W. Fazio, “Long-term follow-up of patients with Crohn's disease. Relationship between the clinical pattern and prognosis,” Gastroenterology, vol. 88, no. 6, pp. 1818–1825, 1985.
[6]
K. R. Gardiner and B. V. M. Dasari, “Operative management of small bowel Crohn's disease,” Surgical Clinics of North America, vol. 87, no. 3, pp. 587–610, 2007.
[7]
R. N. Katariya, S. Sood, P. G. Rao, and P. L. N. G. Rao, “Stricture plasty for tubercular strictures of the gastro intestinal tract,” British Journal of Surgery, vol. 64, no. 7, pp. 496–498, 1977.
[8]
E. C. G. Lee and N. Papaioannou, “Minimal surgery for chronic obstruction in patients with extensive or universal Crohn's disease,” Annals of the Royal College of Surgeons of England, vol. 64, no. 4, pp. 229–233, 1982.
[9]
R. R. Cima and J. H. Pemberton, “Current surgical therapy,” in Strictureplasty in Crohn's Disease, J. L. Cameron, Ed., Mosby-Elsevier, Philadelphia, Pa, USA, 9th edition, 2008.
[10]
J. W. Milsom, “Strictureplasty and mechanical dilation in strictured Crohn’s disease,” in Operative Strategies in Inflammatory Bowel Disease, F. Michelassi and J. W. Milsom, Eds., pp. 259–267, 1999.
[11]
D. Tichansky, B. Cagir, E. Yoo, S. M. Marcus, and R. D. Fry, “Strictureplasty for Crohn's disease: meta-analysis,” Diseases of the Colon and Rectum, vol. 43, no. 7, pp. 911–919, 2000.
[12]
G. Poggioli, S. Laureti, F. Pierangeli, and F. Ugolini, “A new model of strictureplasty for multiple and long stenoses in Crohn's ileitis: side-to-side diseased to disease-free anastomosis,” Diseases of the Colon and Rectum, vol. 46, no. 1, pp. 127–130, 2003.
[13]
T. Yamamoto, V. W. Fazio, and P. P. Tekkis, “Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis,” Diseases of the Colon and Rectum, vol. 50, no. 11, pp. 1968–1986, 2007.
[14]
M. Uchino, H. Ikeuchi, H. Matsuoka, T. Matsumoto, Y. Takesue, and N. Tomita, “Long-term efficacy of strictureplasty for Crohn's disease,” Surgery Today, vol. 40, no. 10, pp. 949–953, 2010.
[15]
P. Roy and D. Kumar, “Strictureplasty,” British Journal of Surgery, vol. 91, no. 11, pp. 1428–1437, 2004.
[16]
L. A. Weston, P. L. Roberts, D. J. Schoetz Jr., J. A. Coller, J. J. Murray, and L. C. Rusin, “Ileocolic resection for acute presentation of Crohn's disease of the ileum,” Diseases of the Colon and Rectum, vol. 39, no. 8, pp. 841–846, 1996.
[17]
R. P. Kiran, P. J. Nisar, J. M. Church, and V. W. Fazio, “The role of primary surgical procedure in maintaining intestinal continuity for patients with crohns colitis,” Annals of Surgery, vol. 253, no. 6, pp. 1130–1135, 2011.
[18]
C. Hassan, A. Zullo, V. De Francesco et al., “Systematic review: endoscopic dilatation in Crohn's disease,” Alimentary Pharmacology and Therapeutics, vol. 26, no. 11-12, pp. 1457–1464, 2007.
[19]
A. G. Wibmer, A. J. Kroesen, J. Gr？ne, H.-J. Buhr, and J.-P. Ritz, “Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease—review of the literature,” International Journal of Colorectal Disease, vol. 25, no. 10, pp. 1149–1157, 2010.
[20]
D. W. Dietz, S. Laureti, S. A. Strong et al., “Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel crohn's disease,” Journal of the American College of Surgeons, vol. 192, no. 3, pp. 330–338, 2001.
[21]
G. Ozuner, V. W. Fazio, I. C. Lavery, J. W. Milsom, and S. A. Strong, “Reoperative rates for Crohn's disease following strictureplasty: long-term analysis,” Diseases of the Colon and Rectum, vol. 39, no. 11, pp. 1199–1203, 1996.
[22]
J. Sayfan, D. A. L. Wilson, A. Allan, H. Andrews, and J. Alexander-Williams, “Recurrence after strictureplasty or resection for Crohn's disease,” British Journal of Surgery, vol. 76, no. 4, pp. 335–338, 1989.
[23]
G. M. Sampietro, M. Cristaldi, T. Porretta, G. Montecamozzo, P. Danelli, and A. M. Taschieri, “Early perioperative results and surgical recurrence after strictureplasty and miniresection for complicated Crohn's disease,” Digestive Surgery, vol. 17, no. 3, pp. 261–267, 2000.
[24]
N. R. Borley, N. J. M. Mortensen, M. A. Chaudry et al., “Recurrence after abdominal surgery for Crohn's disease: relationship to disease site and surgical procedure,” Diseases of the Colon and Rectum, vol. 45, no. 3, pp. 377–383, 2002.
[25]
S. R. Hamilton, J. Reese, and L. Pennington, “The role of resection margin frozen section in the surgical management of Crohn's disease,” Surgery Gynecology and Obstetrics, vol. 160, no. 1, pp. 57–62, 1985.
[26]
S. Barrena, L. Martínez, F. Hernandez, et al., “Surgical treatment of chronic inflammatory bowel disease in children,” Pediatric Surgery International, vol. 27, no. 4, pp. 385–390, 2011.
[27]
M. Schwartz and M. Regueiro, “Prevention and treatment of postoperative Crohn's disease recurrence: an update for a new decade,” Current Gastroenterology Reports, vol. 13, no. 1, pp. 95–100, 2011.
[28]
T. Yamamoto, “Factors affecting recurrence after surgery for Crohn's disease,” World Journal of Gastroenterology, vol. 11, no. 26, pp. 3971–3979, 2005.
[29]
N. Gupta, S. A. Cohen, A. G. Bostrom et al., “Risk factors for initial surgery in pediatric patients with Crohn’s disease,” Gastroenterology, vol. 130, no. 4, pp. 1069–1077, 2006.
[30]
D. C. Aronson, F. van Coevorden, H. S. A. Heijmans, and H. G. Gooszen, “Surgical treatment of Crohn disease in children and adolescents; how conservative can the paediatician be?” European Journal of Pediatrics, vol. 152, no. 9, pp. 727–729, 1993.
[31]
E. I. Benchimol, A. Guttmann, T. To, L. Rabeneck, and A. M. Griffiths, “Changes to surgical and hospitalization rates of pediatric inflammatory bowel disease in Ontario, Canada (1994–2007),” Inflammatory Bowel Diseases, vol. 17, no. 10, pp. 2153–2161, 2011.
