Small Bowel

Laboratory Testing

There are no laboratory tests that are sensitive or specific for the diagnosis of SBO or that can reliably predict ischemic bowel. Recommended tests in patients with abdominal pain, nausea, and vomiting include a basic metabolic panel with magnesium and phosphate, a complete blood count with differential, and if bowel ischemia is suspected, a lactic acid level. A basic metabolic panel can identify electrolyte imbalances and renal dysfunction caused by hypovolemia. Patients with SBO may have hypokalemia, contraction alkalosis, or metabolic acidosis. A CBC (with differential) can assess leukocytosis. Leukocytosis with a left shift is a nonspecific indicator of inflammation and/or infection; it does not correlate with disease severity. An elevated lactic acid level can be seen with bowel ischemia, but notably, a normal lactate level does not rule it out. An elevated lactic acid level can also be a nonspecific indicator of inadequate perfusion of any number of organs.

Imaging

Plain Radiography

Plain radiographs may have a role in the initial diagnostic evaluation because of their widespread availability, low cost, and ability to follow disease progression serially; however, the sensitivity of plain films is 66% to 85%. In addition, over 20% of abdominal radiographs in patients with SBO are nonspecific or normal. The typical gas pattern for SBO on plain film demonstrates dilated gas- or fluid-filled loops of small bowel in the setting of a gasless or nondistended colon ( Fig. 1 ). However, a patient with SBO may demonstrate more subtle findings on x-ray study, and a plain film can simply show air-fluid levels with a normal or slightly distended colon. Small bowel perforation may be diagnosed with upright radiography, although not with an optimal level of accuracy. The severity of SBO can be underestimated on abdominal radiography if the dilated bowel loops are predominantly fluid-filled. If a strong suspicion for SBO is present, other testing is recommended as a negative radiograph cannot exclude the diagnosis.

Partial Small Bowel Obstruction

Patients with partial small bowel obstruction (pSBO) have incomplete obstruction with luminal narrowing, but some contents continue to pass through the intestine. Clinically, this is recognized when patients exhibit the signs, symptoms, and radiographic findings consistent with SBO, but exhibit a benign abdominal examination and continue to pass bowel movements and flatus.

Complete Small Bowel Obstruction

These patients have obstruction with no passage of luminal contents beyond the point of obstruction. Clinically, this is recognized when patients exhibit the signs, symptoms, and radiographic findings consistent with SBO and are not passing bowel movements or flatus.

Complete Small Bowel Obstruction with Bowel Compromise

The bowel is considered compromised when there is ischemia or injury that has led or may lead to necrosis and/or perforation of the bowel wall. There is a high risk of morbidity and mortality if compromised bowel is not treated in an expedient manner. Signs, symptoms, and imaging findings of bowel compromise are shown in Table 1 .

Nonoperative Management

Expectant therapy and symptomatic management are typically recommended for patients without peritonitis or hemodynamic instability, with high success rates.

The use of NGT decompression is based on old and often debated evidence. Supposedly, proximal decompression facilitates relief of the obstruction, but the pain and discomfort to the patient is not negligible. The exact population that can be managed safely without it has not been accurately determined, although it exists.

Patients with partial adhesive SBO without strangulation are good candidates for water-soluble contrast medium such as Gastrografin for both diagnostic and therapeutic purposes. Gastrografin is administered orally or most commonly by NG tube in doses of 100 mL in 50 mL of water, either immediately at admission, or if conservative therapy with decompression fails, after 48 hours. After administration, Gastrografin appearing in the colon within 24 hours on x-ray study predicts resolution without surgical intervention. The radiograph can be repeated every 8 to 12 hours as long as the patient’s examination, symptoms, laboratory tests, and vital signs improve or remain stable. Literature suggests that this intervention is safe and can reduce the need for surgery, SBO time to resolution, and hospital stay. Nonoperative techniques can be utilized for 2 to 3 days, but if the patient demonstrates no improvement or no passage of Gastrografin into the colon, operative therapy should be strongly considered.

Operative Management

Patients with signs of strangulation or generalized peritonitis, evidence of clinical deterioration (continuous or worsening pain, fever, hypotension, tachycardia, metabolic acidosis), or concern for bowel compromise based on imaging should undergo surgical exploration (level 1 recommendation per EAST guidelines). Nearly all other patients can be offered a trial of nonoperative management. Close monitoring during nonoperative management allows identification of patients with worsening symptoms who should be explored. A greater point of debate presents the time of surgery for those who have a benign abdominal examination but remain with a persistent obstruction. From the old dictum of “never let the sun rise or set on a small bowel obstruction,” we now accept that nonoperative treatment can continue for days. The likelihood for spontaneous resolution decreases after the third day, and a number of studies suggest that the likelihood of complications increases. However, the evidence is poor and controversial. The EAST guidelines for general operative management are shown in Table 2 .

Laparoscopic Management

Historically, abdominal exploration through laparotomy was the standard treatment for SBO, but laparoscopy has been used with a higher frequency over recent years. In a systematic review and meta-analysis of 14 nonrandomized studies, laparoscopic adhesiolysis reduced the risk of morbidity, in-hospital mortality, and surgical infections. Predictors for successful laparoscopic treatment of SBO are the following: a history of ≤2 laparotomies, appendectomy as the sole previous operation and cause of the obstruction, no previous median laparotomy incision, and a single adhesive band.

Closed-Loop SBO

Patients with closed-loop SBO are at increased risk for both strangulation and failure of nonoperative treatment ( Fig. 3 ). The threshold for surgical exploration lowers significantly, and vigilance increases. However, it must be emphasized that not all closed-loop obstructions automatically need an operation. As stated earlier, the decision to operate is a combination of various factors, including clinical presentation and imaging findings, and not just a picture on CT.

SBO with a Transition Point at the Site of a Hernia

Patients presenting with a transition zone at the site of an abdominal wall hernia require special attention. These obstructions should only be reduced by the surgical team. Assessment for ischemic bowel is required to be performed by a member of a surgical team. If ischemic bowel is suspected (severe pain, tense hernia, overlying skin changes), urgent surgical exploration should be performed. The surgical team admitting the patient may decide to reduce the bowel and monitor post–hernia reduction (typically at least 24 hours) if there are no concerns for bowel compromise.

Geriatric Patients

Because of medical comorbidities, especially in the emergency setting, patients older than 60 years and 80 years have twice and thrice the risk of adverse outcomes after surgery, respectively, relative to younger adults. Preoperative cardiac risk stratification and physiologic optimization is desirable when not leading to undue delays. Overall, the decision to operate in geriatric patients should balance the desire to intervene early and before fragile physiologic reserves are exhausted, while not liberalizing major abdominal surgery on frail individuals. Goals of care, code status, and discharge disposition should ideally be discussed at the time of admission.

Pregnancy

SBO in pregnancy is rare; it is estimated that a practicing surgeon may manage 1 to 2 cases in a career. One-half of reported SBO cases during pregnancy are caused by adhesions. Fetal mortality averages 21% and is more likely with surgery in the first trimester. An urgent MRI is advised absent immediate indications for surgery. Pregnancy is not an absolute contraindication to ionizing radiation from radiographs or CT scans; however, the risks and benefits of fetal exposure to radiation must be carefully weighed. Overall, the same rules of operative versus nonoperative management that are used in the general population apply also to pregnancy.

Obstruction Due to Inflammatory Bowel Disease

Although most IBD patients are admitted to a medical service, early surgical consultation is recommended in the presence of an acute SBO. Evidence of intestinal obstruction represents one of the defining characteristics for severe/fulminant IBD. Although there is no strong evidence in support of specific treatment algorithms on the acute management of intestinal obstruction associated with IBD, a number of evidence-based recommendations have been made. It has been recommended that the treatment plan be based on factors such as the location and length of the stricture, degree of concomitant inflammation, degree of upstream bowel dilation, and other accompanying features, such as abscess or phlegmon. Early cross-sectional imaging with a CT enterography (CTE) protocol is essential as is the early involvement of both gastroenterology and colorectal surgery in the treatment team. The team should determine early surgery versus neoadjuvant antiinflammatory therapy and the need for antibiotics and/or abscess drainage.

Malignancy

Unlike nonmalignant etiologies, these patients tend to have a subacute clinical picture with a slow insidious onset that is typical of partial SBO. For patients who present with SBO caused by a nonmetastatic or locally advanced primary small bowel tumor, an operative intervention with curative intent remains the principal tenet of management. The differential for these tumors typically includes small bowel neuroendocrine tumors, adenocarcinomas, lymphomas, and gastrointestinal stromal tumors. For such patients, oncologic principles should include a resection of the involved segment of bowel along with a 5- to 10-cm margin proximally and distally as well as removal of all associated mesentery. Small bowel resection is a preferable approach when the site of obstruction is isolated, the tumor causing the obstruction is intrinsic to bowel, negative margins are a possibility, and the postoperative outcome is potentially curative. A small bowel bypass is preferable if the tumor causing the obstruction cannot be completely resected and multiple sites of bowel obstruction exist. The goal with bypass is palliation. For patients who present with obstruction from incurable advanced disease, the factors affecting the final treatment plan include established goals of care set forth by the patient with the guidance of the surgeon and the medical oncologist. It is beneficial to involve a palliative care specialist at this juncture as well.

Virgin Abdomen

Based on findings in recent reviews, SBO in virgin abdomen (VA) has a mostly benign cause; this is in contrast with older literature and surgical textbooks that suggest malignancy as the main cause of obstruction in VA patients. Etiology and treatment results for patients with SBO in VA are largely comparable to the results in patients with SBO after previous abdominal surgery. CT has a pivotal role in the assessment of SBO in VA to assess the etiology and to evaluate if the bowel is compromised, demanding early surgery. Moreover, modern high-resolution CT is also useful in minimizing the risk of failure to detect a malignant cause. As with ASBO in general, the majority of cases with SBO in VA can be treated by nonoperative trial initially. Nevertheless, a laparotomy remains indicated in case of a nonresolving obstruction. The need to perform surgical exploration in every patient with SBO in VA can be waived. Noninvasive diagnostics with high accuracy for detection of malignancy and a close follow-up are mandatory.

Bariatric Surgery

Bariatric patients can present with obstruction from the same causes as all other patients, but also carry a greater risk of internal hernia, intussusception, and closed-loop obstructions resulting from surgical creation of mesenteric defects. CT results for patients with a history of laparoscopic Roux-en-Y gastric bypass may be subtle. A significantly dilated small bowel with a transition point is often a late finding. Elevated amylase and/or lipase may be a significant finding in this patient population, especially with acute obstruction of the biliopancreatic limb. Reviewing the CT scan with the radiologist to discuss any subtle findings and having a lower threshold to proceed to the operating room for any suspicious findings is recommended. Early intervention is necessary to prevent the loss of significant portions of bowel to ischemia with resulting increased morbidity and mortality. Laparoscopic enterolysis is feasible and safe. Careful bowel handling and clearly identifying all three limbs is essential because mesenteric or internal hernia can occur at multiple sites.

Early Postoperative Small Bowel Obstruction

Pivotal problems in the management of obstruction in the early postoperative period (3–4 weeks after surgery) are differentiation of ileus from mechanical obstruction and distinction between simple and strangulating obstruction if mechanical obstruction is present. Early postoperative small bowel obstruction (ESBO) poses an interesting dilemma for the surgeon. Although some ESBOs will resolve with nonoperative/conservative treatment, waiting beyond the 2-week period after the index surgery can result in forcing the surgeon to operate in a “hostile abdomen” because of significant inflammatory/postoperative adhesions. The decision to reoperate should account for clinical and radiographic signs suggesting impending strangulation or closed-loop obstruction, elapsed length of time of nonoperative management, and the nature of the index operation. Early reoperation should be considered after certain laparoscopic procedures. Surgeons managing SBO can benefit from understanding the unique features of ESBO after Roux-en-Y gastric bypass.

Obstruction

Obstruction is the most common indication for surgery in Crohn’s disease. The natural history is that of gradual onset in the setting of chronic relapsing disease. The cycling of inflammation and repair over time in an affected segment eventually converts soft pliable bowel into a constricted “stovepipe.” Clinically as this process progresses, the symptomatology evolves from intermittent partial obstruction experienced during episodes of transmural inflammation to chronic partial obstruction that exists between episodes of acute inflammation. The latter situation is commonly referred to as a fibrostenotic stricture. Once this stricture has developed, minimal acute inflammation can lead to obstructive symptoms and an acute flare. On imaging, proximal bowel to the stricture is noted to be dilated, prompting treatment frequently with corticosteroids and antibiotics. All strictures have some component of chronic scarring, and it can be difficult to differentiate a stricture that is largely inflammatory versus one that is largely fibrostenotic. Both MRI and CT enterography have improved significantly over the past decade, making this differentiation somewhat clearer. In the authors’ practice, once the patient is treated acutely with anti-inflammatory medication and is noted to be asymptomatic, imaging is repeated. If persistent dilation of the bowel proximal to the stricture is appreciated, predominant fibrostenotic disease is assumed to be present. This is a clear indication for surgical intervention as medication will not be effective in the treatment of chronic scar tissue. If the bowel is noted to be decompressed, medical therapy should be optimized.

Perforation

Perforation is the next most common indication for surgery. As a transmural inflammatory process, Crohn’s disease can cause localized perforation with abscess formation leading to fistulization. The pathophysiology is that of the inflammatory process in the affected bowel perforated into the peritoneal cavity, usually forming a walled off abscess. This abscess can become chronic requiring long-term antibiotics or percutaneous drainage. If an abscess persists, it ultimately will require surgical intervention. If the abscess can be treated nonoperatively, a multidisciplinary approach should be used to determine ongoing treatment on an individual basis. A small resolved abscess on a patient on minimal medical therapy would likely benefit from medical escalation and optimization, whereas a resolved abscess in a patient who has failed three biological medications would likely be offered surgery.

Frequently, these abscesses can “burrow” to adjacent “innocent” structures, creating a fistula. The structures most commonly involved are pieces of bowel (enteroenteric/enterocolonic fistula), the bladder (enterovesical fistula), or the skin (enterocutaneous fistula). When the process creates a clean fistula into another portion of the GI tract without an associated abscess, the decision regarding surgery depends on the impact of this connection. Thus, enteroenteric or enterocolonic fistula are not in themselves a definite indication for surgery. Only when the fistula causes worsening clinical symptoms or nutritional deficiencies should surgery be performed. In addition, studies have shown that TNF inhibitors have some effect in treating GI tract fistula. Enterovesical fistulas are usually not life-threatening, but they lead to recurrent urinary tract infections, pyelonephritis, and, in rare cases, urosepsis. In addition, the symptoms of pneumaturia and fecaluria are generally intolerable to most patients. Surgical repair should be pursued in this situation. Similarly, enterocutaneous fistulas require surgical intervention because of chronic drainage from the abdominal wall, chronic abdominal wall wounds, dehydration, and frequent nutritional deficiencies.

Failure of Medical Management

Failure of medical management is probably the most difficult indication to determine as it is largely patient dependent. The surgeon, gastroenterologist, and patient must work closely together to determine when during the treatment process surgical intervention is most appropriate for “medical refractory” disease. As medical therapies have advanced, new treatments continually become available that have allowed some patients to avoid surgery while only delaying it for others. Clearly, given their long-term consequences, inability to wean steroids after an acute flare and transition to maintenance therapy is an absolute indication for surgery. It is less clear how to proceed when a patient remains symptomatic and has tried multiple medications, but additional options exist. In these instances, attempting additional second- and third-line therapies can take several months to determine success and possibly delay the inevitable need for surgery. It should also be noted that eliminating the burden of active disease and inducing remission surgically can provide patients with a “fresh start” off all agents and allows previously failed medications to be reattempted.

Timing

The timing of surgery is important in maximizing the clinical outcome. The patient’s willingness or resistance to surgery affects decision making. The input of the surgeon and gastroenterologist regarding recommendations is imperative. Operating too soon when the bowel is intensely inflamed is technically challenging and puts non-diseased bowel at risk. Allowing an acute flare time to resolve, at least partially, can greatly affect outcome. Every effort should be made to convert more emergent situations to urgent and elective scenarios. Active abscesses should be drained percutaneously. Conversely, these patients frequently have some aspect of malnutrition, and waiting too long for intervention can worsen this situation. In rare instances when a significant length of bowel is at risk, bowel rest and total parenteral nutrition may be required.

Once a decision regarding elective surgery has been made, the patient’s current disease state must be assessed to inform preoperative planning. The patient’s general medical condition must be assessed and optimized. If nutritional deficits exist and time allows, nutritional improvement should be pursued. The authors follow a strict enhanced recovery protocol and surgical site infection bundle. A standard mechanical bowel preparation with oral antibiotics is given unless a prolonged high-grade bowel obstruction is present. In this case, an extended period of clear liquid diet is employed. Patients are maintained on a clear liquid diet until 2 hours before surgery and are given a carbohydrate-rich beverage preoperatively. If bowel diversion is anticipated, the patient is evaluated by an enterostomal therapist for preoperative stoma siting.

Medications

Prolonged and chronic use of corticosteroids has clearly been shown to adversely affect wound healing and to increase the risk of surgical site infection. This is especially an issue as dosages increase from lower to higher daily prednisone equivalents. All efforts should be made to wean or discontinue steroids before surgery, but this is frequently not an option in the actively inflamed patient. In addition, patients may require perioperative steroid supplementation depending on duration of use and dosage to prevent acute adrenal insufficiency. More recently, the question of TNF inhibitor impact on wound healing has come into question. Unfortunately, the literature provides no definitive guidance on this matter. Some studies have shown no effect, with others showing a significantly increased incidence of infectious complications when patients have taken the medications within 6 to 8 weeks before surgery.

Consideration of bowel diversion with stoma creation must be entertained when patients are on long-term steroid treatment. This is likely true to a lesser extent when a patient has taken a TNF inhibitor in the perioperative period. Malnutrition and bowel quality also must be taken into account when considering stoma creation. This ideally will be discussed with the patient preoperatively and the patient will be referred to enterostomal therapy for evaluation.

Resection

The mainstay of surgical therapy for Crohn’s disease of the small intestine is resection. The most commonly faced initial operative scenario is a tight, but reasonably short segment of chronically obstructed and scarred terminal ileum. The most common operation, therefore, is an ileocecectomy. This accounts for approximately half of the surgery for Crohn’s disease on the small intestine. Additional ascending colon may need to be included with the resection specimen depending on the disease activity noted on colonoscopy. Consideration of isolated terminal ileal resection should be considered only if 15 centimeters or more of normal small intestine is present just proximal to the ileocecal valve. A short, isolated segment of terminal ileum is extremely susceptible to recurrent inflammation.

In virtually all cases, the authors attempt laparoscopic access, dissection, and mobilization of the targeted diseased tissue. The laparoscope is placed in a periumbilical or umbilical position with a Hassan port via a direct cut-down technique. A 10-mm 30-degree scope is used to maximize visualization from a variety of angles. Generally, three 5-mm ports are employed on the left side of the abdomen as working ports. Upon entrance into the abdomen, full evaluation of the GI tract should be performed. This should be correlated with the visual information from the preoperative evaluation. If isolated mid small bowel disease is noted, this can be identified and easily externalized through extension of the umbilical port for resection and re-anastomosis. If a fistula exists, it must be identified. Enteroenteric fistula of the terminal ileum to itself can usually be preserved as the entire segment of bowel usually requires en bloc resection as an inflammatory mass. If the terminal ileum is fistulizing to otherwise “innocent” portions of the GI tract, the fistula must be transected and the healthy bowel must be assessed. This situation typically occurs with a small bowel to sigmoid colon fistula. In this scenario, the fistula opening in the sigmoid colon must be debrided to healthy tissue and can be closed primarily. The author prefers a handsewn two-layer approach in this situation, but a stapled repair can also be performed. In some instances, colonic resection will be required given associated inflammation in the area. A similar approach to fistulas must be employed for “innocent” small bowel involvement. A fistula to the bladder is usually taken down with primary repair of the bladder if a definite opening is noted, and prolonged Foley catheter drainage is performed. The catheter is removed after CT cystogram confirms healing of the bladder.

Sufficient mobilization of tissue for resection must be performed. This almost always involves some mobilization of the cecum, right colon, and terminal ileal mesentery from the retroperitoneum. This can be performed in a lateral-to-medial or medial-to-lateral approach. However, the medial-to-lateral technique cannot always be performed because of significantly thickened mesentery. Care must be taken in this dissection to ensure that the proper plane is identified and retroperitoneal tissue is preserved. The ureter should be identified clearly. In rare cases of extreme inflammation, this is not possible. In this situation, dissection of the ureter should be performed in the pelvis to better evaluate its course. In addition, if this inflammation is noted and expected, preoperative ureteral catheter placement should be performed.

As stated earlier, the specimen is generally extracted through an extended umbilical incision. If extensive pelvic inflammation is noted, the incision may need to be extended inferiorly. Vascular transection can be performed intracorporeally, however frequently the bowel mesentery is significantly foreshortened and thickened from chronic inflammation. Transecting this mesentery can be tortuous and may require proximal vascular control to prevent extensive blood loss. Attempt at laparoscopic transection should be considered carefully.

The basic principle of small bowel resection for Crohn’s disease is to remove all of the grossly involved disease while preserving as much bowel length as possible. The authors attempt to measure pre-resection and post-resection bowel length so it will be notated if additional surgery is performed in the future. Grossly involved bowel is best determined by visual and tactile evaluation. Fat creeping should not be present, and the mesenteric margin should be palpable in unaffected intestine. Division of the mesentery, as previously noted, can be difficult. The authors generally use a combination of approaches including a vessel-sealing energy device, vascular staplers, and sutures to control bleeding from exceptionally thickened mesentery. When at all possible, transection of mesentery distally should be attempted so as not to compromise the vascular supply of otherwise healthy bowel.

The worst complication in any bowel surgery is anastomotic dehiscence, and this is no different for the Crohn’s disease patient. Anastomotic techniques have been studied at length with no definitive determination on the superiority of stapled or handsewn anastomosis. It is the authors’ opinion, however, that the technique employed should be that which is most comfortable for the primary surgeon. This should hopefully maximize reproducibility and quality. The mesenteric defect is closed, when possible, to prevent internal herniation but is left fully open for large defects that cannot be reapproximated.

Ileostomy

As previously noted, sometimes patients will require temporary bowel diversion after surgery for Crohn’s disease of the small intestine. This usually is required when the bowel or the patient is not healthy enough to undergo primary anastomosis. This can occur with extensive contamination from a drained abscess or if the bowel is noted to be significantly dilated precluding healthy anastomosis. High-dose steroid use and severe malnutrition can also create such an environment. Rarely, a proximal diversion is required when significant inflammation of long segments of small intestine are noted. In this situation, too much bowel is involved to resect, and proximal diversion is performed as a last-ditch effort to induce remission. Unfortunately, this diversion will undoubtedly be accompanied by a high-output stoma requiring parenteral nutrition.

Disease of the Duodenum

Crohn’s disease of the duodenum frequently presents with nausea, epigastric fullness, and emesis. It is easily diagnosed with imaging and upper endoscopy. Initial attempts at management can be performed with endoscopic balloon dilation. However, recurrence is common. When surgery is indicated, strictureplasty is the procedure of choice. Frequently, the disease is too diffuse, making a bypass procedure necessary. Gastrojejunostomy is most commonly employed. It is recommended that the patient undergo a pH study before the procedure to determine the need for associated vagotomy. In addition, when possible, gastroduodenal bypass is recommended for proximal disease of the duodenum to prevent marginal ulceration in the future.

Strictureplasty

Bowel-sparing procedures and strictureplasty are discussed directly in a separate chapter in this text, but we will discuss them briefly as they are a critical tool in the inflammatory bowel disease surgeon’s armamentarium. In patients with small bowel Crohn’s disease, 20% to 30% can be managed with some form of strictureplasty. Technically, a strictureplasty can be performed laparoscopically, but because of the extensive suturing required, it is often performed through a small laparotomy after identification of strictures laparoscopically. The most challenging operative situation involving structuring disease is the case of diffuse jejunoileitis. In this situation, multiple strictures separated by inches throughout the small intestine are encountered. Deciding what requires resection, what will resolve with strictureplasty, and what can be left alone requires careful consideration and judgment. It has been described that inflating a Foley catheter with 3 mL to 10 mL of saline and inserting it into the bowel through an enterotomy can be used to determine clinically significant strictures. Once it has been determined that a strictureplasty is to be performed, the mucosa of the affected bowel must be examined once opened to evaluate for underlying pathology. Biopsies with possible frozen section must be performed if malignancy is suspected.

Heineke-Mikulicz Strictureplasty

The Heineke-Mikulicz strictureplasty is the most commonly employed technique and the simplest to perform. It is generally used for strictures less than 7 cm in length. An incision is made parallel to the bowel on the antimesenteric border. It should extend approximately 2 cm past the active inflammation on either side. The incision is then reapproximated transversely. This can be performed with a running or interrupted suturing technique in one or two layers.

Finney Strictureplasty

The Finney strictureplasty is generally used for medium-length strictures between 8 and 15 cm. Once again, a longitudinal incision is made on the antimesenteric border of the actively inflamed bowel. The defect is then closed as a U-shaped enterotomy with the bowel folded on itself at the midpoint of the enterotomy. This is usually performed in two layers with interrupted sutures on the outside and running or interrupted sutures on the inside.

Side-to-Side Isoperistaltic Strictureplasty (Michelassi Strictureplasty)

The Michelassi strictureplasty is a specialized technique that should only be employed by the most experienced Crohn’s disease surgeons. It allows for preservation of long segments of diseased small intestine. It entails transection of actively inflamed portions of small intestine and aligning them in isoperistaltic side-to-side fashion. The bowel is usually anastomosed by a two-layer handsewn technique while spatulating the ends for full closure.