**5. Medium-length stricture**

The Jaboulay technique requires 2 incisions in normal segments avoiding the center of the stenosis (**Figure 11**).

The Finney technique (**Figure 11**) consist in one incision along the stenosis reaching up the normal tissue and them the bowel is folded in a U shape to be closed.

*Current Elective Surgical Treatment of Inflammatory Bowel Disease DOI: http://dx.doi.org/10.5772/intechopen.100112*

#### **Figure 11.**

*The Jaboulay technique (1): two incisions in normal segments. A1 - the diseased segment is escluded fron the incision; B1 - Posterior and C1 - anterior sutures are made. The Finney technique (2): A2- one incision including the deseased segment is made; B2 and C2 show the posterior and anterior sutures.*

### **6. Long-length stricture**

In the Michelassi technique [35] the stenotic segment is divided in the middle and a longitudinal incision is made in both segments. A restoring anastomosis is

made with the overlapping of both diseased segments (**Figure 12**). The Sasaki technique is a modification of Michelassi technique with the use of nonspatulated bowel ends to create an additional Heineke-Mikulicz strictureplasty on both ends (**Figure 12**) [36].

The Poggioli technique [37] is a modification of Michelassi technique and the difference is that we overlap a diseased segment with a non-diseased segment (**Figure 13**).

A combination of resection and enterostomy was described by Hotokezaka (**Figure 14**) [38]. The bowel segment with severe stenosis is removed. The remaining segment with stenosis is divide in the midpoint. A side-to-side antimesenteric

#### **Figure 12.**

*The Michelassi technique (1): A1 - anastomosis of two stenotic segments B1 - the edges of bowel can be trimmed to allow better approximation; C1 - latero-lateral anastomosis; D1- final aspect. The variation is the Sasaki technique (2): A2 - anastomosis of two diseased segments; B2 - the edges of bowels are mantained; C2 - the end of the anastomosis is then transversely closed; D2 - final aspect.*

*Current Elective Surgical Treatment of Inflammatory Bowel Disease DOI: http://dx.doi.org/10.5772/intechopen.100112*

#### **Figure 13.**

*The Poggioli technique. A - long diseased segment; B - the diseased segment is separated from normal segment; C - a longitudinal incision is made in both segments; D - lateral enterostomy with overlap of affected and normal segments.*

enterostomy with the 2 bowel segments are made and them and end-to-end anastomosis are made between the strictureplasty and the resection site.

Results Strictureplasty vs. Resection.

The rate of complication for strictureplasty is about 4% to abscess, fistula and leakage [31]. Bowel resection is associated with lower recurrence rate (25.1%) compared to structureplasty (35.9%; p = 0.04). Recurrence-free survival was longer for bowel resection vs. strictureplasty (p = 0.02) [39, 40].

Surgical recurrence was higher for bowel resection (29.4%) vs. strictureplasty (39.7%; p = 0.002). No difference was observed for medical recurrence for bowel resection (12.4%) vs. strictureplasty (18.0%; p = 0.82) and also for overall morbidity between bowel resection (18.1%) vs. strictureplasty (10.7%; p = 0.65) [39, 40].

In fact, most cases a combination of techniques are used: resection for the severe lesion and plasty for the other. This approach seems to have the same rate of complications. This approach may decrease the risk of intestinal failure because patients may need future interventions and additional resection. Young age may be a risk for recurrent stricture. The 5-year reoperation rate for recurrent obstruction was 22%

**Figure 14.**

*The Hotokezaka technique. A - cecum and terminal ilium are resectes; B - a less affected segment is used to strictureplasty; C - Diseased segment is divide at the midle; D - side-to-side antimesenteric enterostomy with the 2 bowel segments is made; E - final aspect.*

for resection alone, 30% for strictureplasty alone and 42% for strictureplasty and resection (P = 0.038) [39, 40].

#### **7. Kono-S anastomosis**

Kono et al. [41] reported a new technique of anchored anastomosis that could prevent recurrence. After resection of a severe stenosis with linear staple both end are put together with suture and a Jaboulay like side-to-side anastomosis is performed (**Figure 15**) [42].

*Current Elective Surgical Treatment of Inflammatory Bowel Disease DOI: http://dx.doi.org/10.5772/intechopen.100112*

#### **Figure 15.**

*Kono-S anastomosis: A - stenosis is removed; B - the ends of both segments are closed; C - both ends are put send-to-end; D - longitudinal incisions are made in both segments; E - the suture column beside the laterallateral anastomosis may sustain the lumen open and prevent stenosis; F - final aspect.*

### **8. Fecal diversion**

The use of fecal diversion is not common but in some clinical conditions may be indicated [31]:


#### **9. Colonic disease**

Colonic Crohn disease may be treated by segmental or total colectomy with ileorectal anastomosis. Total proctocolectomy with definitive ileostomy are indicated in those patients with severe perineal disease. Ileal pouch–anal anastomosis is less indicated due to pouch complications.

Strictureplasty should not be used in large bowel because the risk of malignization. Chronic inflammation is a risk factor for colon cancer and dysplasia is considered to be the precursor of most colorectal cancer in IBD patients [43].

#### **10. Duodenal Crohn disease**

Due to its anatomical characteristics duodenal stricture may require different therapeutic alternatives: endoscopic dilatation, bypass, resection or strictureplasty. The incidence of duodenal or upper gastrointestinal tract by Crohn disease varies according to age: adults 0.3 to 5%, adolescents 28% and 43% in pediatric patients with CD [44]. Patients with duodenal CD may present more aggressive evolution with high rates of recurrence and needs for surgical treatments [45].

Clinically patient complain: Epigastric pain, nausea, anorexia, early satiety, blation and belching, weight, Less common symptoms are: anemia, diarrhea, feculent vominiting, hematemesis or melena [46].

Surgical treatment indication: outlet obstruction (83%), refractory pain (11%), and bleeding (5%) [47]. Surgical options are: resection, gastrojejunostomy, duodeno- jejunostomy, gastroduodenostomy and by-pass.

### **11. Ulcerative Colitis**

Ulcerative colitis (UC) is a chronic inflammatory condition of the colon and rectum. Initial therapeutic approach is based in different classes of medicine: antiinflammatory, immunosuppressant (aminosalicylates, corticosteroids, thiopurines) and biological treatment as anti-tumor necrosis factor (anti-TNF), anti-integrins, anti-jak and other. However, most patients have successful clinical control and good evolution approximately 20–30% of patients will require surgery during their life [48].

However, surgery is a curative treatment for UC, the decision about an elective surgery is preference-sensitive. Generally, the indications for surgery are: medically refractory disease, dysplasia and carcinoma.

The surgery basically is total proctocolectomy with anastomosis or end ileostomy. The proctocolectomy with anastomosis is the ileal pouch–anal anastomosis (IPAA).

Total abdominal colectomy with ileorectal anastomosis is not indicated to patients with UC. The reasons are: half of patients will have a worsen disease in the rectum that will need protectomy and the risk of rectal cancer is 7–8% [49].

Proctocolectomy and ileal pouch–anal anastomosis (IPAA) IPAA procedure may be done in stages:


There are different types of pouch and most surgeons favor the J pouch due to the simplicity to construct and good outcomes. The procedure may be done by laparotomy, laparoscopy, robotic or associated approaches.

#### **12. Continent ileostomy or Kock pouch**

It is indicated for those patients who does not meet the criteria for IPAA. It is contraindicated in obese patients. The patient has to be able to handle the ostomy and do self-intubation.
