Published online Sep 16, 2021. doi: 10.4253/wjge.v13.i9.382
Peer-review started: March 24, 2021
First decision: June 3, 2021
Revised: June 15, 2021
Accepted: August 12, 2021
Article in press: August 12, 2021
Published online: September 16, 2021
Currently up to 75% of patients with Crohn's disease (CD) are expected to need surgery due to disease related complications. Intestinal fibrostenosing disease is a common complication and biologic therapy has not limited its appearance even with much improved clinical response rates. Due to a high risk for surgery, attempts to find alternatives to surgery need to be made. Endoscopic balloon dilation with adequate technique promises to have an important role in his area.
Endoscopic balloon dilation has already been shown to be efficacious in adults but no large case series involving pediatric patients exists currently in literature.
We aimed to evaluate the short and long term outcomes of CD who developed fibrostenosing disease and underwent endoscopic balloon dilation as primary or secondary therapy.
This is a single-center case series in which all subjects who were diagnosed with diagnosed between 2012 and 2019 were included in the study, and those that developed fibrostenosing disease were identified. Their records were then reviewed for types of interventions performed and outcomes. Patients were classified into primary surgical or endoscopy-treated subjects and those that subsequently required surgery or endoscopy were thus classified. Demographic data included: age at diagnosis of CD, age at time of procedure, body mass index (BMI) at time of procedure, and race. Disease characteristics included: modality of CD diagnosis, time (years) from diagnosis of CD until the development of symptomatic strictures, the Paris classification of disease, and medication at the time of the procedure.
We identified 139 subjects diagnosed with CD in this study period. Of these patients, 25 (17%) were noted to have a fibrostenotic lesion anywhere in the small and large bowel. 13 (52%) underwent primary endoscopic therapy vs 12 (48%) who underwent surgical management. Of the patients who went to surgery, 4 (16%) had to have further endoscopic treatment after surgery, compared to just 2 (8%) of those who had endoscopy as primary therapy. Of note, 5 (20%) required just one endoscopic therapy session for resolution of their stricture.
Endoscopic balloon dilation is a safe and effective treatment in children with CD-related fibrostenosing disease. Adequate patient selection is key to ensure a high success rate. Pediatric patients undergoing surgery for fibrostenosing disease should be cautioned that a 1 in 5 risk of requiring further endoscopic therapy is a distinct possibility.
Our data suggested an interesting correlation between higher BMI and risk of stricturing disease. Pediatric patients with BMI > 85% and < 95% had a higher risk of complex strictures requiring surgery. This brings into new light publications associating an increase in visceral adipose tissue with intestinal inflammation through dysregulated leptin and adiponectin production.