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Figure 5.28. Recurrent Crohn's disease. (A) Frontal film from a double-contrast barium enema shows that the patient has undergone a right hemicolectomy with an ileotransverse colostomy. The neoterminal ileum shows classic findings of Crohn's disease with narrowing and a cobblestone appearance. (B) CT scan at the level of the neoterminal ileum shows narrowing of the lumen, a thickened wall, and slight infiltration of the surrounding mesentery correlating well with the conventional contrast examination.

Figure 5.28. Recurrent Crohn's disease. (A) Frontal film from a double-contrast barium enema shows that the patient has undergone a right hemicolectomy with an ileotransverse colostomy. The neoterminal ileum shows classic findings of Crohn's disease with narrowing and a cobblestone appearance. (B) CT scan at the level of the neoterminal ileum shows narrowing of the lumen, a thickened wall, and slight infiltration of the surrounding mesentery correlating well with the conventional contrast examination.

Gore et al. noted that the change from mural stratification to homogeneous enhancement heralded the change from edema to fibrosis [100]. Similarly, this loss of the target appearance was seen in postoperative patients who would eventually need strictureplasty [103]. Regional lymph nodes less than 8 m in diameter may be seen in Crohn's disease, but nodes larger than that may indicate associated lymphoma or carcinoma [100]. The appearance of sinus tracts and fistulas, as well as extraintestinal changes, should be similar in postoperative patients to that in newly diagnosed patients.

When small-bowel strictures occur, they may be resected and bowel continuity restored. However, strictureplasty may be performed maintaining bowel lengths with similar postoperative outcomes [91]. Two different types of strictureplasty result in radically different radiologic appearances. The Heineke-Mikulicz technique is used for strictures that are less than 7cm long [104]. The bowel is opened longitudinally through the stricture and then closed transversely, thereby increasing the effective diameter of the small bowel (as well as causing very minimal foreshortening of the gut) (Fig. 5.29). The Finney strictureplasty is used for longer strictures [104]. In this technique the bowel is configured to form a loop similar in shape to the Greek letter omega (W) with the stricture at the apex. The two loops are sutured together apposing the loops both proximal and distal to the small-bowel narrowing. A longitudinal incision is then made, opening the stricture. Next, the posterior walls of the two apposed limbs are sutured together, and ultimately the two anterior walls are brought together. The resulting configuration is that of an upside-down U-shaped loop in which the two limbs come together near the apex into a dilated area, replacing the stricture (Fig. 5.30). The Heineke-Mikulicz and Finney strictureplasties can be performed together in cases of stenoses and skip areas of involvement [104] (Fig. 5.31).

Heineke Mikulicz Strictureplasty
Figure 5.29. Heineke-Mikulicz strictureplasty. Schematic drawings show the longitudinal incision in the strictured region (A) and their subsequent closure in a transverse manner (B).
Finney Strictureplasty

Figure 5.30. Finney strictureplasty.

(A) Schematic drawing shows the formation of an omega-shaped loop from a strictured segment of small bowel with closure of the common posterior walls. (B) Subsequent closure of the anterior wall.

Figure 5.30. Finney strictureplasty.

(A) Schematic drawing shows the formation of an omega-shaped loop from a strictured segment of small bowel with closure of the common posterior walls. (B) Subsequent closure of the anterior wall.

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