Symptomatic duodenal Crohn's disease: is strictureplasty the right choice?

Primary duodenal localization of Crohn's disease (CD) is rare. Medical therapy can control symptoms, but surgery is required when progressive obstructive symptoms occur. Surgical options include bypass, resection, or strictureplasty, but it is still not clear which should be the treatment of choice. Reviewing the medical records of 1253 patients undergoing surgery for CD between January 1986 and December 2011 at the Digestive Surgery Unit of the Department of Clinical Physiopathology of the University of Florence, 10 patients (6 males and 4 females) underwent operations for duodenal CD. Four patients had only a duodenal localization, 6 patients had synchronous involvement of other intestinal tracts. Strictures were distributed in all the duodenal portions: in 7 patients there were single lesions, in 3 patients there were multiple lesions. Eight patients were treated with strictureplasty: 5 with the Heineke-Mikulicz technique, 2 with Jaboulay, and 1 with a pedunculated jejunal patch. Two patients were treated with resection: one with a B2 gastro-duodenal resection, and 1 with a duodenal-jejunal resection and an end to side duodeno-jejunal anastomosis. Follow up of the patients was from 2 to 18 years. No recurrence of duodenal CD was observed in the 2 patients treated with resection, while 2 of the 8 patients treated with strictureplasty had a recurrence. In our experience, strictureplasty is indicated when less than 2 strictures are present in the 2nd or 3rd duodenal portion. In cases with multiple strictures localized in the 1st or the distal duodenal portion, resection is preferable.