Published online Nov 7, 2017. doi: 10.3748/wjg.v23.i41.7397
Peer-review started: August 19, 2017
First decision: August 30, 2017
Revised: September 11, 2017
Accepted: September 20, 2017
Article in press: September 19, 2017
Published online: November 7, 2017
Strictures in Crohn’s disease (CD) develop during the course of the disease or as the presenting feature. More than half of CD patients will need surgery within the first 10 years of diagnosis. Medical therapy for stricture management is limited due to the fibrotic nature. Endoscopic balloon dilation (EBD) has been proposed as a safe and effective therapeutic intervention for CD strictures, particularly for ileocecal and anastomotic strictures.
Data on long term efficacy and safety of EBD are limited due to lack of long-term outcome and small cohorts. Up to now there are also some uncertainties regarding the factors associated with long term success rate. Smoking status and disease activity status at the time of dilation may affect outcome of stricture dilation, though many studies are limited by short follow-up durations and small cohorts. Furthermore, as the primary therapeutic goal of CD has shifted from clinical remission to achieving mucosal healing, it may be important to access the mucosa proximal to strictures to evaluate disease recurrence and escalate therapy if needed.
This study aimed to evaluate anastomotic stricture development after intestinal resection in CD and demonstrate long-term efficacy and safety center of EBD in CD anastomotic and de novo strictures in a large referral centre cohort and determine the impact of dilation on the diagnosis of subclinical postoperative endoscopic recurrence.
CD patients who had undergone ileocecal resection/right hemicolectomy referred for endoscopic evaluation between March 2010 to February 2015 were included in this study. CD patients with non-anastomotic strictures who underwent EBD during the study period were included as a control group. EBD was performed for strictures that would not allow passage with a colonoscope, regardless of patients’ symptoms. Technical success was defined as the ability to pass the colonoscope through the stricture into the neoileum following dilation. Clinical success was defined as improvement of obstructive symptoms (in symptomatic patients). All patients who underwent dilation were endoscopically reevaluated 6-12 mo later. Long-term efficacy was defined as avoidance of surgical resection or repeat dilation after the initial dilation. Patients were followed until stricture resection, last clinic follow-up, or censor date of March, 2017. Escalation of medical therapy was defined as initiation of a thiopurine or anti-TNF within 6 months of first dilation, as determined by global physician assessment.
All data were prospectively collected in a database created for this purpose. After a 5 year follow up period all data were arranged, processed and analyzed with SPSS® v.24.0 data (Statistical Package for Social Sciences).
In this study we found that almost one-third of CD patients developed an anastomotic stricture after ileocecal resection/right hemicolectomy. Longer periods between surgery and index colonoscopy and higher lactoferrin levels were associated with the presence of stricture after surgery. Calprotectin levels > 83.35 μg/g and current or past history of smoking were associated with a shorter time until need for dilation (HR = 3.877, 95%CI: 1.480-10.152 and HR = 3.041, 95%CI: 1.213-7.627). Technical success of EBD was 97.7% and 100% for anastomotic and non-anastomotic strictures, respectively, and 63% and 41% of the patients needed repeat dilation during the 4.4-year follow-up. Anastomotic strictures had a greater need for repeat dilation (63% vs 41%, P = 0.047). No differences were found between asymptomatic and symptomatic cohorts. Disease recurrence was diagnosed only after EBD in a third of patients.
EBD is a feasible, simple, effective and safe alternative to surgery, with the possibility of being repeated as needed, with excellent symptomatic response, as well as good short-term and long-term outcomes, postponing or avoiding surgery. Considering that a significant number of patients with significant strictures remain asymptomatic with normal biomarkers, and the fact that the disease continues to evolve proximal to the strictures, we advocate EBD for all strictures regardless of the presence or absence of symptoms, in order to adjust treatment in an attempt to alter the natural history of the disease. Thus, EBD is useful not only for symptom resolution but also for evaluating mucosal healing.