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Finney Strictureplasty

Figure 5.31. Crohn's disease with two different strictureplasties. (A) Single supine film from a double-contrast enteroclysis of a patient with Crohn's disease and multiple operations in the past for obstruction. In the left lower quadrant, a small deformity is seen secondary to a prior Heineke-Mikulicz procedure. In the upper abdomen a larger, almost saccular appearance is noted secondary to a prior Finney strictureplasty. (B) Spot film of the Heineke-Mikulicz strictureplasty showing saccular dilatation with interruption of the normally transverse valvulae conniventes. The seam of the strictureplasty is noted as an area devoid of folds. (C) Another spot film from the same examination demonstrates the sequelae of a Finney strictureplasty. The previously strictured loop is folded back upon itself with the two lumina joined into a common one. The seam of this longitudinal anastomotic line is evident on another spot film (D) from the small-bowel enema.

Figure 5.31. Crohn's disease with two different strictureplasties. (A) Single supine film from a double-contrast enteroclysis of a patient with Crohn's disease and multiple operations in the past for obstruction. In the left lower quadrant, a small deformity is seen secondary to a prior Heineke-Mikulicz procedure. In the upper abdomen a larger, almost saccular appearance is noted secondary to a prior Finney strictureplasty. (B) Spot film of the Heineke-Mikulicz strictureplasty showing saccular dilatation with interruption of the normally transverse valvulae conniventes. The seam of the strictureplasty is noted as an area devoid of folds. (C) Another spot film from the same examination demonstrates the sequelae of a Finney strictureplasty. The previously strictured loop is folded back upon itself with the two lumina joined into a common one. The seam of this longitudinal anastomotic line is evident on another spot film (D) from the small-bowel enema.

Another surgical technique utilized in cases of multiple strictures, long strictures, and lesions longer than 30 cm is that of a side-to-side isoperistaltic strictureplasty [104]. In this very complex technique, the bowel is divided in the middle of the diseased area. The two segments are lain together side by side in an isoperistaltic arrangement. Each bowel loop is then opened longitudinally along its antime-senteric border and joined together along this enterotomy [104] (Fig. 5.32).

There is some evidence that Crohn's disease leads to an increased rate of carcinoma in the small bowel [105]. It tends to develop in a younger age group than other small-bowel carcinomas [106]. Patients usually have had Crohn's disease for 15 to 20 years before malignancy develops [106]. Some patients undergo bypass of severely involved bowel without resection of these loops. Since the long-standing inflammatory process remains in situ with this type of procedure, carcinoma may develop within the bypassed but retained segments [107]. This has led to the near abandonment of this procedure [105]. Carcinoma may also develop at sites of chronic fistula formation

Figure 5.32. Side-to-side isoperistaltic enteroenterostomy. Schematic drawing shows how this technique may be used to bypass long strictures or to reestablish continuity of the small intestine following a segmental resection. A blind pouch may result at the distal end of the afferent limb.

Stricteroplasty

Figure 5.32. Side-to-side isoperistaltic enteroenterostomy. Schematic drawing shows how this technique may be used to bypass long strictures or to reestablish continuity of the small intestine following a segmental resection. A blind pouch may result at the distal end of the afferent limb.

Figure 5.33. Carcinoma in bypassed loop of small bowel. Coned down view of the transverse colon from a double-contrast barium enema reveals reflux into a loop of small bowel. The loop ends at an annular constricting lesion, a carcinoma that arose in a bypassed limb of small bowel in this patient with Crohn's disease.

Figure 5.33. Carcinoma in bypassed loop of small bowel. Coned down view of the transverse colon from a double-contrast barium enema reveals reflux into a loop of small bowel. The loop ends at an annular constricting lesion, a carcinoma that arose in a bypassed limb of small bowel in this patient with Crohn's disease.

Visualizing carcinomas in bypassed loops of small bowel must usually depend on the use of CT or other cross-sectional imaging modalities [105]. Occasionally, reflux into a bypassed segment may afford demonstration of a carcinoma (Fig. 5.33). However, the best clue to its presence is that of change in a stricture or fistula over a period of time, demonstrated on serial examinations [105].

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