PAKISTAN ARMED FORCES MEDICAL JOURNAL (Category Y) A Journal of Army Medical & Dental Corps Being published since 1956 ISSN (online) 2411-8842 ISSN (print) 0030-9648 PAFMJ Menu Toggle navigation HOME EDITORIAL BOARD CURRENT ISSUE PAST ISSUES SUPPLEMENTS POLICIES INFORMATION For Authors For Reviewers Join as Reviewer Request for Hard Copy ADVERTISING CONTACT US VOL 57, No. 1, MARCH 2007 ROLE OF STRICTUREPLASTY IN THE MANAGEMENT OF TUBERCULOUS STRICTURES OF SMALL INTESTINE Abrar Hussain Zaidi, Mazhar Abbas Butt, Abdul Haleem, Ghulam Rasool Tariq, Muhammad Tahir, Khalil Ah Abstract Objective: To evaluate the outcome and assess the reliability of strictureplasty in the management of small intestinal strictures due to tuberculosis. Design: A retrospective observational and descriptive study. Place and Period of Study: PNS-Shifa, Karachi. Clinical data of cases of intestinal tuberculosis reporting over a period of five years-(Aug 1999-to-Aug 2004) was studied. Subjects and Methods: Thirty patients with small intestinal tuberculosis who underwent strictureplasty alone or in combination with limited resection were selected for the study. Results: In 20 cases (66.67%) the strictureplasty was performed in combination with limited resection. Remaining 10 cases (33.33%) were managed by strictureplasty alone. Anastomotic leakage with fistula formation occurred in 3 cases (10%), Burst abdomen occurred in 2 cases (6.67%). Sub-diaphragmatic abscess formation occurred in 3 cases (10%). On prolonged follow- up averaging two years, re-admission was required in 5 cases (16.67%). Re exploration to relieve obstruction due to adhesions was required in 2 cases (6.67%). Late incisional hernia was seen in 4 cases (13.33%). There was no procedure related mortality. Conclusion: Strictureplasty is a simple, quick, and safe operative technique to manage tuberculous small intestinal strictures, in combination with limited resection or as a sole procedure. Keywords : Strictureplasty, intestinal tuberculosis, surgery Article INTRODUCTION Correspondence: Lt Col Abrar Hussain Zaidi, Classified Surgeon, Combined Military Hospital, Sargodha. Intestinal tuberculosis complicated by stricture formation and obstruction has significant world wide prevalence, particularly in the developing countries including Pakistan [1-5]. Surgical intervention may be required as in acute emergency due to complete luminal occlusion and perforation or as a planned procedure for chronic abdominal symptoms. Clinically, a long segment of gut may be involved in the disease process or the patient could have multiple strictures [3,4]. Preservation of maximum length of the gut should be the goal during surgery. Strictureplasty is a time honored technique to manage the short intestinal strictures resulting because of various reasons including tuberculosis. [5-8]. As regards its use in managing tuberculous intestinal strictures, the fear of operating on a disease segment, the possibility of suture line failure with resulting complications, recurrence of strictures and recrudense of tuberculosis are the clinical issues which need to be critically viewed to define the reliability of this procedure. This study is presented as an audit and evaluation of the outcome of strictureplasty in patients with intestinal tuberculosis. PATIENTS AND METHODS Cases of intestinal tuberculosis reporting to PNS-Shifa hospital at Karachi over a period of five years (Aug 1999 to Aug 2004) were studied. A total of thirty cases were included in the present study. Histopathologically proven cases of small intestinal tuberculosis that had undergone strictureplasty - alone or in combination with limited resection were included. All other cases of intestinal tuberculosis treated surgically with any method that did not include strictureplasty were excluded from the study. Patients were of different age groups and of either sex. Mode of clinical presentation was recorded with a detailed history and clinical examination. Blood complete picture, Mantoux test, X-ray chest examination, urine routine examination, plain X-ray of abdomen, ultrasonography abdomen were done in all cases. Barium follow through study was done only in cases presenting with chronic abdominal symptoms. All the patients underwent exploratory laparotomy. Their operative findings and details of operative procedures including the technique of strictureplasty and gut anastomosis were recorded. Total number of strictureplasties and anastomosis in an individual case were documented. Operative difficulties were described. Per-operative biopsy of small intestinal wall was obtained in all the cases for the histopathological confirmation of the diagnosis. Patient’s post operative recovery was monitored. Complications were documented. All the cases were prescribed full course of anti tuberculosis treatment. Post operative follow-up proforma and anti tuberculosis treatment card was issued to all the patients. All the patients were followed up for an average period of eighteen months. Statistical analysis Data had been analyzed using SPSS ver-10.0. Descriptive statistics i.e percentages, mean, ratio were used to describe the data. RESULTS A Total of 30 patients were included in the study. Age and sex distribution is given in (table-1). Age range was 20-65 years with a mean age of 33 years. Female to male ratio was 1.3:1, suggesting a slight female preponderance. Patients belonged to middle and poor socioeconomic classes. Mode of presentation is described in (table-2). 18 cases (60%) presented with chronic abdominal pain and 12 cases (40%) presented as acute abdominal emergency. 18 cases (60%) had a history of previous treatment by quacks and hakims. Pre-operative findings are described in (table-3). 17 cases (56.67%) had multiple stricture and 13 cases (43.33%) had solitary strictures. Operative procedures performed are described in (table-4). Strictureplasty was performed in all the cases. It was the sole procedure in 10 cases (33.33%). In 20 cases (66.67%) it was combined with limited resection of the gut. Strictureplasty was performed by a single layer of interrupted serosubmucosal mattress suture in all the cases (100%), as the conventional two layer repair was not possible due to local oedema and indurations of gut wall. Two layer anastomosis was applied at the sites of gut resection and anastomosis (66.67%). Polyglycolic acid (vicryl) suture was used in all the cases. 25 cases (83.33%) had two or more sites of anastomoses and 5 cases (17.67%) had only a single site of anastomosis i.e; the site of strictureplasty. Tissue biopsies perfomed in all the cases were confirmatory for the diagnosis of tuberculosis. Anastomotic leakage with fistula formation occurred in 3 cases (10%). Burst abdomen in 2 cases (6.67%) and sub-diaphragmatic abscess formation in 3 cases (10%). During follow-up, readmission was required in 5 cases (16.67%) on account of abdominal pain and sub-acute intestinal obstruction. Out of these only 2 cases (6.67%) required re-exploration for intestinal obstruction due to adhesions and remaining 3 cases (10%) were treated conservatively. Late incisional hernia was seen in 4 cases (13.33%). There was no procedure related mortality. Table-1: Distribution of age and sex in 30 patients. Age (yrs) No. of cases Males Females %age 20-30 6 3 3 20% 31-40 12 5 7 40% 41-50 08 3 5 26.7% 51-60 3 1 2 10% 61-65 1 1 0 3.3% Table-2: Mode of presentation in 30 cases. Symptomatology No. of cases %age Acute symptoms Acute intestinal obstruction 03 10% Intestinal perforation / generalized peritonitis 08 26.67% Pain right iliac fossa 01 3.33% Chronic symptoms III defined chronic abdominal pain 13 43.33% Chronic/sub-acute obstruction 05 16.67% Table-3: Pre-operative findings in 30 cases. Type of lesion No. of cases %age Multiple strictures 17 56.67% With long distal ileal narrow segment 08 47.06% With perforation 04 23.53% Isolated short strictures involving ileum and jejunum 05 29.41% Single stricture 13 43.33% With an ileocaecal mass 04 30.77% With a perforation 04 30.77% Single distal ileal stricture-with no mass or perforation 05 38.46% Table-4: Operative procedures performed in 30 cases. Surgical procedure No. of cases %age Strictureplasty with limited gut resection 20 66.67% Multiple structure plasties + resection of distal ileal segment 8 40% Multiple strictureplasties + resection of perforated proximal segment 4 20% Single strictureplasty + resection of distal ileal segment 4 20% Single strictureplasty + resection of proximal perforated segment 4 20% Strictureplasty without gut resection 10 33.33% Multiple strictureplasties 5 50% Single strictureplasty 5 50% DISCUSSION Whereas western literature abundantly explains the role of strictureplasty in Crohn’s disease [9], there is not much published on strictureplasty in intestinal tuberculosis. It is probably due to the fact that tuberculosis is not a common disease in the west and is seen mainly among the immigrants [10,11]. In the underdeveloped world tuberculosis is a major cause of concern leading to more than 2 million deaths per year [12]. Tuberculosis of the gastrointestinal tract is considered the sixth most frequent form of extra-pulmonary tuberculosis and is one of the major causes of intestinal obstruction [14-16]. Higher Incidence among females has been suggested in our country [18-20]. The diagnosis of intestinal tuberculosis is difficult, because there are no specific signs and symptoms. There may be no pulmonary symptoms and the chest X-ray may be normal [7,21-28]. In majority of the cases the diagnosis is confirmed only after laparotomy [23,24]. In our study final diagnosis in all the cases was made on histopathology of intestinal wall biopsy as supported by Kapoor [7] and Ahmad [23]. There are 3 main forms of intestinal lesions: ulcerative, hypertrophic and sclerosing fibro stricturous [27,28]. It is in the sclerosing form that the reactionary fibrosis leads to single or multiple stricture formation. Cicatricial healing of circumferential ulcers and occlusive arterial changes producing ischaemia also contribute to the development of strictures [7]. Ileum is involved in most of the cases [3,6,28] .Baloch and collaegues [3] have described more than 58% involvement of distal ileum in cases of multiple strictures. In our study ileum was involved in all the cases, while jejunum was also involved in 5% cases. Relief of obstructing intestinal lesions with antituberculosis drugs alone has been described by Anand and collaegues [29], showing clinical and radiological resolution of tuberculous strictures. Similar observations were made by Balasubramaniam et al [30]. In our study all the cases were prescribed antituberculosis treatment after the operation and histological diagnosis, and we doubt the efficacy of prolonged drug therapy without a confirmed diagnosis. Endoscopic balloon dilatation has been tried in other types of intestinal strictures [31] but its use in intestinal tuberculosis remains only a future research project. As regard surgical management of intestinal strictures, various operative options as per clinical situation have been described as below: [1,3,5,18,19,21,22] · Resection with primary anastomosis. · Resection with ileostomy and delayed anastomosis. · Strictureplasty combined with limited resection. · Strictureplasty alone. · By-pass. Strictureplasty for tuberculous strictures of intestine was first described by Katarya [32] in 1977. In the western world strictureplasty has been mainly used in surgery for Crohn's disease [33] In terms of time, both the conditions have prevailed, crohns disease in the west and tuberculosis in east. Today the recommended surgical protocole in both these conditions is, to be as conservative as possible. [9,32-34]. A period of pre-operative drug therapy is advisable if there is a strong preoperative suspiscion of tuberculosis. Pujari [34] has suggested that the strictures which reduce the lumen by half or more and which cause proximal hypertrophy or dilation be treated by stricturcplasty. It can also be rationally suggested that a segment of bowel bearing multiple strictures in close proximity or a single long tubular stricture should be resected. All other strictures can be managed by strictureplasty. In our study the cases of multiple strictures with non-strictured interval of more than 5cm and all short segment solitary strictures were managed by strictureplasty. Reliability of strictureplasty has been well decribed in regional Pakistani as well as Indian literature [5,6,32] and our study too is strongly supportive of the procedure. In our cases, strictureplasty was performed with a single layer of interrupted serosubmucosal sutures making the procedure easy and quick as supported by Mirza et al [35]. Low incidence of post operative leakage using this technique of repair supports its recommendation. Strictureplasty has an undoubted value in preservation of gut length in order to avoid the possibility of short gut syndrome. In this regard our study supports the views of Zafar et al [36] who considered strictureplasty superior to resection. Abdominal tuberculosis is known to end in multifactorial complications [37,38] due to nutritional debility, peritoneal contamination after perforation and multi-drug resistance. Complications therefore, can not be exclusively attributed to a surgical procedure. Our complication rate of about 10% in early post operative period thus could not be attributed to strictureplasty alone. CONCLUSION Strictureplasty is a simple, easy, quick, and safe surgical procedure to manage the small intestinal strictures due to tuberculosis. It can be employed as a sole procedure or in combination with limited gut resection. It is of great value in preservation of gut length when a long segment of gut is involved in the disease process. Reference 1. Sharma MP, Bhatia V. Abdominal tuberculosis. Indian J Med Res 2004; 120: 305-315. 2. Sherman S, Rohwedder JJ, Ravikrishnan KP. Tuberculosis enteritis and peritonitis: Report of 36 general hospital cases. Arch Intern Med 1980; 140(4): 506-8. 3. Baloch NA, Babar KM, Mengal M, Babar SA. Spectrum of mechanical Intestinal Obstruction. J Surg Pak 2002; 7(1): 7-9. 4. Ahmad M, Farogh A, Ahmad I, SohailA, Gill K M, Ahmad M. Intra-abdominal Tuberculosis. J Surg Pak 2002; 7: 16-18. 5. Akbar M. Sricturoplasty in Tuberculous small bowel Strictures. J Ayub Med Coll Abbottabad 2003; 15: 37-40. 6. Bhansali SK. Abdominal tuberculosis. 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Hochart L, Naidoo M, Thomson SR. Small-bowel strictures and perforation in tuberculosis. S Afr Med J 2002; 92: 519-20. This is an Open Access article distributed under the terms of the Creative Commons Attribution License Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Current Supplement ( VOL 67, No. 3, ___ - Aug 2017 ) Search from PAFMJ enter keywords Search Advanced Search News & Announcements Advertise in PAFMJ Join as Reviewer Request for Hard Copy PAKISTAN ARMED FORCES MEDICAL JOURNAL PAFMJ is a bi - monthly medical journal of the Pakistan Army Medical and Dental Corps that publishes new medical research, original articles, review articles, editorial opinions and original case reports on a wide variety of topics on importance to biomedical science, clinical practice, public health and medical education. 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