Strictureplasty Technique

Updated: Feb 16, 2021
  • Author: Mustafa W Aman, MD; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Approach Considerations

The optimal strictureplasty technique depends on the length of the stricture, as follows [4] :

  • Short strictures (< 10 cm) – Heineke-Mikulicz strictureplasty
  • Medium-length strictures (10-20 cm) – Finney strictureplasty
  • Long strictures (>20 cm) – Side-to-side isoperistaltic strictureplasty [10, 11, 12, 13]

Multiple variations of these techniques have been described in the literature [14] ; however, the most common strictureplasty is the Heineke-Mikulicz version.

Regardless of the type of strictureplasty performed, the following important surgical principles must always be observed:

  • The bowel should always be incised along the antimesenteric border
  • The enterotomy must be extended 1-2 cm proximal and distal to the diseased segment
  • Any lesions suggestive of disease should be resected to rule out carcinoma
  • Excellent hemostasis should be obtained
  • After the strictureplasty, the surgeon should ensure that the lumen is patent and will accommodate peristalsis
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Heineke-Mikulicz Strictureplasty

Standard technique

A longitudinal incision is made along the antimesenteric border of the bowel. This incision is carried 1-2 cm proximal and distal to the diseased segment onto normal bowel.

Two 3-0 stay sutures are placed at the ends of the opening of the stricture. The stay sutures are then pulled perpendicular to the long axis of the bowel (see the image below). The enterotomy is closed transversely in one or two mucosal layers with 3.0 polyglactin sutures; the seromuscular layer is closed with 3-0 silk sutures.

Heineke-Mikulicz strictureplasty. Heineke-Mikulicz strictureplasty.

Modified technique

The modified Heineke-Mikulicz strictureplasty is used when two short-segment strictures are positioned very close to one another on the small bowel. A single enterotomy is made and extends through both strictures, as well as through the normal intervening segment. The enterotomy is then closed in a transverse fashion as described above.

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Finney Strictureplasty

Finney strictureplasty is ideal for medium-length strictures (10-20 cm). The bowel is folded at the stricture site, bringing the normal proximal and normal distal bowel alongside one another. The strictured segment is then opened up along the antimesenteric border and closed in a side-to-side hand-sewn anastomosis (see the image below).

Finney strictureplasty. Finney strictureplasty.
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Jaboulay Strictureplasty

Jaboulay strictureplasty is used for bypass of strictures wherein the lumen is too narrow to allow passage of food contents; it is also used if the bowel wall at the stricture site is unsuitable to hold a suture line. The small bowel is folded at the stricture site so as to bring together normal proximal and distal small-bowel segments. These normal bowel segments are then opened up at the antimesenteric border and handsewn to each other in two layers as described above (see the image below).

Jaboulay strictureplasty. Jaboulay strictureplasty.
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Complications

Complications of strictureplasty include recurrence of stricture, abscess, fistula, obstruction, and postoperative ileus. [1, 2]  A retrospective review with 7.7 years of follow-up data cited intraluminal bleeding as the most common complication [3] ; however, this was almost always self-limited and rarely required surgical intervention.

One meta-analysis found that the overall complication rate for jejunal and/or ileal strictureplasties was 13%, with septic complications (eg, leak, fistula, and abscess) occurring in as few as 4% of cases. [1]

The location of Crohn disease in the ileum and the use of biologics before surgery have been reported to be strong predictors of early site-specific recurrence after strictureplasty. [15]

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