The more than three quarters of a million patients currently affected by Crohn’s disease in the United States face a lifetime of potential flares, repeated bowel obstructions, infectious complications, and the progressive loss of their large intestine. Although this chronic, relapsing, and recurrent inflammatory bowel disease was first described in 1932, there is still no cure 90 years later.
Dr. Fabrizio Michelassi
“While a cure is still being sought for Crohn’s disease, medicine and surgery together assume a very important role in patient care,” says Fabrizio Michelassi, MD, Surgeon-in-Chief at NewYork-Presbyterian/
According to Dr. Michelassi, a world-renowned gastrointestinal surgeon and trailblazer in the surgical treatment of Crohn’s disease, the past 20 to 30 years have shown that the recurrences of Crohn’s disease are very similar in appearance and length to the initial manifestation of the disease. “So, if a patient presents with a segment of 50 centimeters of Crohn’s disease and the surgeon resects that, the extent of their recurrence years later is likely to be another 50 centimeters. As a result, it doesn’t take too many resections of large amounts of intestine before, unfortunately, you create what is the dreaded ultimate complication, a short gut.”
With short gut, the intestine is unable to absorb enough nutrients to survive without supplements, ranging from vitamin supplements to, in the most extreme situations, nutritional supplements administered intravenously. This led surgeons many years ago to pursue the development of procedures that could alleviate the complications of Crohn’s without the need for bowel resection. “These complications are generally placed in two buckets,” says Dr. Michelassi. “One involves inflammatory infectious complications with abscesses, perforations, and fistulae that will need to be resected. Obstructions make up the second set of complications in which the intestine develops fibrostenotic strictures making the passage of food very difficult, leading to abdominal symptoms of pain, distention, nausea and sometimes vomiting, difficulty in having bowel movements, and occasionally bowel obstructions.”
In the late seventies and into the eighties, several strictureplasty procedures were devised to enlarge the lumen of the intestine without resecting bowel to treat patients with strictures. Referred to as conventional strictureplasties, these approaches such as the Heineke-Mikulicz strictureplasty, which is by far the most common, and the Finney strictureplasty are appropriate for patients with a limited disease burden. However, conventional strictureplasties are ill-suited to handle extensive Crohn’s disease with multiple sequential strictures such as patients with a “rosary bead” configuration of strictures.
A Game Changer for Crohn’s Disease: The Side-to-Side Isoperistaltic Strictureplasty
In 1992, Dr. Michelassi proposed a new technique, the side-to-side isoperistaltic strictureplasty (SSIS), for patients with extensive fibrostenotic Crohn’s disease of the small bowel. The advanced bowel-sparing procedure, now commonly referred to as the Michelassi strictureplasty, proved through numerous clinical studies over the years to be highly effective for avoiding extensive small bowel resections for cases of multiple short strictures closely clustered over a lengthy small bowel segment. Studies also demonstrated that the procedure facilitates quiescence of the acute disease affecting the diseased intestinal loops. The procedure was adopted by surgeons around the world and continues to this day as an important option in the reservoir of treatment approaches to Crohn’s disease. The long-term safety, effectiveness, and durability of the SSIS were further demonstrated in a 25-year review of patients undergoing the procedure at NewYork-Presbyterian/
“The unpredictable nature of Crohn’s disease makes preservation of the bowel critical for patients who are at risk of losing more of their intestine,” says Dr. Michelassi. “Side-to-side isoperistaltic strictureplasty is an important alternative to traditional methods that rely on removing part of the intestine. For example, if you have a rosary bead configuration with many strictures, the intestine in between strictures is totally normal. With the SSIS, not only do you preserve the strictured segment, but you also preserve the good intestine in between strictures. It has been a very good procedure for individuals who have sequential strictures over an extensive length of bowel. While you can resect six feet of bowel in less than an hour and discharge patients within a day or two, this does not take into account that the patient will probably return at some point in the future with a Crohn’s disease recurrence affecting another six feet of bowel. How many times can you resect six feet of bowel before creating a GI cripple?”
In a commentary by Dr. Michelassi published in the October 2022 issue of Diseases of the Colon & Rectum, he notes, “A common misconception is that the SSIS is indicated for strictures longer than 15 to 20 cm. In my opinion, the presence of a long stricture with thick walls and minimal lumen, the ‘garden hose’ configuration, is a relative contraindication to performing an SSIS…the best indication for an SSIS is the presence of sequential fibrostenotic strictures over a long segment of bowel in a rosary bead configuration.”
Dr. Michelassi has operated on thousands of patients with Crohn’s disease since starting his clinical practice in 1984, ranging from a simple resection and anastomosis to the most complex procedures such as the side-to-side isoperistaltic strictureplasty. It is not unusual for Dr. Michelassi to be referred patients needing a simple strictureplasty in addition to a short, limited bowel resection as well as a side-to-side strictureplasty. “The patients who are referred to me in general are those with a level of complexity that requires intraoperative decision-making to devise the best possible individualized solution on site in the OR for a challenging disease presentation.”
Patients with complex Crohn’s disease come to Dr. Michelassi from across the country and around the globe for his expertise and experience honed over nearly four decades. Now with an average of 10 to 12 years and up to 30 years of follow-up of patients in his practice who have undergone SSIS, Dr. Michelassi has unequivocally demonstrated that the bowel preserving surgery for extensive stricturing is durable and has spared patients from losing large amounts of bowel.
With nearly four decades of treating patients with Crohn’s disease, I understand when a patient comes to me for surgery where they stand and what they’re going through. I’m able to help guide them through a decision knowing that I have the full armamentarium of surgical options in my quiver.
— Dr. Fabrizio Michelassi
In general, patients with duodenal, jejunoileal, and neoterminal diseases with single or multiple fibrotic strictures or recurrences of a previous small bowel and ileocolic anastomosis are candidates for strictureplasties. The procedure is contraindicated for patients with Inflammatory masses; long strictures with a thick, unyielding intestinal wall; presence of dysplasia or carcinoma; and continuous hemorrhage originating from the stricture.
“Our understanding of strictureplasty techniques has matured over the past 40 years,” says Dr. Michelassi, whose surgical practice is now dedicated only to patients with Crohn’s disease. “We now know that the strictureplasty techniques are very safe with a lower perioperative rate of complications than a resection. And recurrences following strictureplasty techniques occur less frequently than after resection, which is a very interesting concept.”
Preventing Post-Operative Recurrence: Kono-S Anastomosis versus Side-to-Side Functional End Anastomosis
“For years, surgeons have tried a number of techniques and different anastomatic configurations after an intestinal resection to reduce the recurrence rate of Crohn’s disease,” says Dr. Michelassi. “The first attempt focused on resecting longer pieces of intestine, which didn’t work. This transitioned to resecting large amounts of mesentery, which also did not work. And then surgeons tried reconstructing the intestine in different configurations hoping that one configuration would lead to a lesser recurrence rate than another one. Unfortunately, none of these endeavors worked with clear success until 2003 when Prof. Toru Kono, a surgeon from Japan, devised a new antimesenteric functional side-to-side handsewn anastomosis.”
In a 2011 study published in Diseases of the Colon & Rectum, Dr. Kono presented findings that suggested that the Kono-S anastomosis — as evidenced on endoscopic evaluation — prevented post-operative recurrence of Crohn’s disease at greater rates than the traditional side-to-side functional end anastomosis. Additionally, disease recurrence was of lesser intensity at five years than patients who underwent a regular anastomosis, both endoscopic and surgical.
“But a particularly important finding of this study, which has not been emphasized,” says Dr. Michelassi, “was that none of the patients who underwent the Kono-S anastomosis required surgery for a recurrence in the first five years after the surgery, while 15 percent of patients who had a regular anastomosis did need surgery for a recurrence. This is a significant finding that speaks to the potential superiority of the Kono-S anastomosis.”
A Practice Defining Clinical Trial
The pivotal study of the Kono-S anastomosis and its encouraging results are now being further investigated in a prospective randomized controlled study initiated by Dr. Michelassi in 2017. Sponsored by Weill Cornell Medicine, the international multicenter study, for which Dr. Michelassi serves as Principal Investigator, is comparing recurrence rates in patients with Crohn’s terminal ileitis needing initial resection who undergo a Kono-S anastomosis to those having a side-to-side functional end anastomosis. With 14 centers participating across the globe, the goal is to enroll an estimated 360 patients by June 2023. Patients will be followed for five years to determine if there is a difference in endoscopic recurrence measured by the Rutgeert score and in the rate of surgical recurrence at 3 to 6 months, 12 months, and 60 months.
“This study will answer whether surgical technique can influence the natural history of Crohn’s disease following resection and help to prevent anastomotic recurrence of disease,” says Dr. Michelassi. “Additionally it will provide a foundation for further correlative studies to explore the relationship between post-operative recurrence of Crohn’s disease and the microbiome, as well as genetic factors that influence the development and progression of Crohn’s disease recurrences. This could be a practice altering study.”