Double-balloon enteroscopy-assisted dilatation avoids surgery for small bowel strictures: A systematic review

Table 1 Descriptive analysis of the main variables in the studies

Author	Year of publication	# patients	# patients undergoing dilatations	Total # strictures dilated	Aetiology stricture	Length stricture (cm)	FU (months)
Yamamoto et al[13]	2004	23	6	6	Mixed	NR	NR
Pohl et al[16]	2006	19	9	13	CD	≤ 4	16 (4-26)
Ohmiya et al[17]	2009	66	22	47	Mixed	NR	16 (2-43)
Despott et al[18]	2011	11	9	18	CD	< 5	20.5 (2-41)
Hayashi et al[19]	2008	18	2	2	NSAID	NR	NR
Hirai et al[11]	2014	65	52	52	CD	≤ 5	41.8 ± 24.9
Gill et al[20]	2014	32	14	15	Mixed	NR	16 (3-60)
Irani et al[21]	2012	13	12	17	Mixed	≤ 2	46
Nishimura et al[22]	2011	8	7	11	Ischemic	≤ 3	16
Fukumoto et al[23]	2007	156	31	50	Mixed	NR	11.9 (1-40)
Sunada et al[24]	2016	99	85	291	CD	< 5	41.9
Kita et al[25]	2006	NR (at least 45)	45	45	Mixed	NR	NR
Kroner et al[2]	2015	71	16	16	Mixed	NR	NR
Total		626	310	583

CD: Crohn’s disease; NSAIDS: Non-steroidal anti-inflammatory drugs; NR: Not reported.

Table 2 Inclusion and exclusion criteria of the included studies

Author	Year of publication	Inclusion criteria	Exclusion criteria
Yamamoto et al[13]	2004	- Retrospective review of all DBEs	- NR
		- Dilatation criteria NR
Pohl et al[16]	2006	- Known or suspected CD and proven or suspicious small bowel strictures	- Strictures > 5 cm or including significant angulation or severe active inflammation with ulcerations
		- Dilatation criteria NR
Ohmiya et al[17]	2009	- Patients with SBO	- Acute obstruction with strangulation or suspected perforation
		- The stricture was assumed to be restricted within narrow limits in the small bowel assessed by radiologic imaging	- A stricture with a deep open ulcer
		- A second dilation session was only performed if obstructive symptoms recurred
Despott et al[18]	2011	- CD patients with small bowel stricture	- Strictures > 5 cm
		- Dilatation criteria NR
Hayashi et al[19]	2008	- Retrospective case series of all patients who had undergone DBE	-NR
		- In the case of a diaphragm-like stricture, all the strictures were dilated
Hirai et al[11]	2014	CD patients with:	- Stricture of the ileocolonic anastomosis
		- Small bowel strictures causing obstructive symptoms	- Post-dilatation observation period < 6 mo
		- Stricture length ≤ 5 cm	- Patients who did not meet dilatation criteria
		- No associated fistula or abscess
		- no deep ulcer
		- No severe curvature of the stricture
Gill et al[20]	2014	- Retrospective review: All patients with suspected strictures in the small bowel undergoing DBE	- Patients with severely ulcerated or inflamed strictures
		- Dilatation criteria NR	- Patients in whom the scope could not traverse the stricture
Irani et al[21]	2012	- Clinical and radiological evidence (CT or small bowel follow through) of small bowel obstruction	- Malignant strictures and masses found either at video capsule endoscopy or DBE
Nishimura et al[22]	2011	- Patients with ischemic enteritis and a segment of intestine that could not be passed by the enteroscope	- Deep ulcerations
		- Dilation was indicated when there were symptoms of intestinal obstruction and evidence of caliber change by CT scan
Fukumoto et al[23]	2007	A stricture was defined by 1 or more of the following criteria:	-Asymptomatic patient (even when the endoscope did not pass through the stricture)
		- DBE showed the internal diameter of the bowel lumen to be < 10 mm or the endoscope could not pass through the lesion
		- The patient complained of obstructive symptoms
		- Stricture was suggested or identified by other modalities.
Sunada et al[24]	2016	- Retrospective review of all DBEs	-NR
		- Dilatation criteria NR
Kita et al[25]	2006	- Retrospective review of all DBEs	-NR
		- Dilatation criteria NR
Kroner et al[2]	2015	- Retrospective review of consecutive patients who were found to have small bowel stricture at the time of DBE	- Malignant (appearance of) strictures
		- Benign appearance of the stricture

CD: Crohn’s disease; NR: Not reported; SBO: Small bowel obstruction; DBE: Double balloon enteroscopy.

Table 3 Technical details of dilatations

Author	Year of publication	Balloon diameter (mm)	Duration of dilatation per stricture (s)	Type of balloon	Fluoroscopy	Sedation CS/ GA
Yamamoto et al[13]	2004	NR	NR	Boston Scientific, CRE	NR	CS
Pohl et al[16]	2006	Up to 20	120	Boston Scientific, CRE	Yes	NR
Ohmiya et al[17]	2009	8-20	60	NR	NR	NR
Despott et al[18]	2011	12-20	60	Boston Scientific, CRE	No	CS and GA
Hayashi et al[19]	2008	NR	NR	Boston Scientific, CRE	NR	NR
Hirai et al[12]	2014	12-18	30-120	Boston Scientific, CRE	NR	CS
Gill et al[20]	2014	10-16.5	NR	Boston Scientific, CRE	No	CS or propofol
Irani et al[21]	2012	10-18	30 or until waist effacement	NR	Yes	CS and GA
Nishimura et al[22]	2011	8-12	30 (and 30 s interval)	Boston Scientific, CRE	Yes	CS
Fukumoto et al[23]	2007	NR	NR	NR	Yes	NR
Sunada et al[24]	2016	8-20	30-60	Boston Scientific, CRE	Yes	CS
Kita et al[25]	2006	NR	NR	NR	NR	NR
Kroner et al[2]	2015	13	NR	NR	NR	GA

CS: Conscious sedation; GA: General anesthesia; CRE: Controlled radial expansion; NR: Not reported.

Table 4 Overview of endoscopic balloon dilation-associated complications per study

Author	Complications	Type of complication	Complication rate per patient	Complication rate per dilatation	Short-term success2 (%)	Long-term success avoiding surgery2 (%)	Surgery2 (%)	Re-Dilatations23 (%)
Yamamoto et al[13]	NO	NA	0%	0%	6/6 (100)	NR	NR	NR
Pohl et al[16]	NO	NA	0%	0%	9/9 (100)	6/9 (67)	3/9 (33)	2/9 (22)
Ohmiya et al[17]	NO1	NA	0%	0%	22/22 (100)	18/22 (82)	4/22 (18)	3/22 (14)
Despott et al[18]	YES	Perforation (n = 1)	11%	5.6%	8/9 (89)	8/9 (89)	1/9 (11)	2/9 (22)
Hayashi et al[19]	NO	NA	0%	0%	2/2 (100)	NR	NR	NR
Hirai et al[12]	YES	Haemorrhage (n = 1)	12%	12%	48/52 (92.3)	44/52 (85)	8/52 (15)	26/52 (50)
		Acute pancreatitis (n = 1)
		Perforation (n = 1)
		Hyperamylasemia (n = 3)
Gill et al[20]	YES	Perforation (n = 2)	13%	13%	11/14 (79)	11/14 (79)	3/14(21)	1/14 (7)
Irani et al[21]	YES	Perforation (n = 1)	8%	6%	10/12 (83)	10/12 (83)	2/12 (15)	2/12 (15)
Nishimura et al[22]	NO	NA	0%	0%	6/7 (86)	4/7 (60)	3/7 (43)	1/7 (14)
Fukumoto et al[23]	NO	NA	0%	0%	NR	27/31 (87)	4/31 (13)	5/31 (16)
Sunada et al[24]	YES	Perforations (n = 4)	6%	2%	80/85 (94)	64/85 (75)	21/85 (25)	64/85 (75)4
		Bleeding (n = 1)
Kita et al[25]	NO	NA	0%	0%	45/45 (100)	NR	NR	NR
Kroner et al[2]	NO	NA	0%	0%	16/16 (100)	NR	NR	NR
Total		Haemorrhage (n = 1)	4.8%	3%	263/279 (94.3)	192/241 (80)	49/241 (20)	106/241(44)
		Acute pancreatitis (n = 1)
		Perforation (n = 9)
		Hyperamylasemia (n = 3)
		Bleeding (n = 1)

¹No complications mentioned in dilatation-cohort;

²1 patient lost to follow-up;

³Either because of a relapse or as prophylaxis;

⁴No data reported on indication for repeat dilatation and relapse rate. NA: Not applicable; NR: Not reported.