Improvised Techniques for Enhanced Detection of Crohn’s Strictures During Surgery

Abstract

rohn's disease affects approximately 780,000 people in the United States, and the incidence appears to be rising. 1 Fibrostenotic strictures are common in Crohn's disease, with an estimated incidence of 50% at 5 and 70% at 10 years after diagnosis. 2 Thin, diaphragm-like strictures can be difficult to detect using conventional imaging techniques and often evade intraoperative detection. Failure to detect these strictures during surgery can lead to recurrent symptoms. Several techniques have been proposed to improve intraoperative detection of these strictures, including steel calibration balls, intraoperative endoscopy, and marble. [3][4][5][6] We present 2 improvised techniques that have proven effective in detecting subtle strictures in our clinical practice. The first technique involves careful examination of the bowel to identify visible clues indicating the presence of an underlying occult stricture: a narrow band of creeping fat or a small erythematous patch on the antimesenteric surface. The second technique involves creating an improvised luminal calibration device using a Foley balloon tip introduced into the bowel lumen via a strictureplasty incision or an anastomosis site. The Foley is inflated to a diameter of 2 cm, following the precedence set by prior similar studies. 3,4 Luminal patency is confirmed by guiding the balloon to the ligament of Treitz and back into the distal bowel via the anastomosis. This method also confirms the patency of the ileocecal valve by passing the balloon into the cecum. Deflation of the balloon with a needle stick via the cecal wall through a figure of 8 suture allows easy passage of the deflated tip with stool.Improvised techniques discussed in this vignette are cost-effective and pragmatic and require no specialized equipment. They have been proven helpful in detecting indistinct strictures and can be incorporated into the intraoperative evaluation of Crohn's disease to improve the detection of subtle strictures and reduce the risk of recurrent symptoms. See Video Vignette.