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Hudson AS, Wahbeh GT, Zheng HB. Imaging and endoscopic tools in pediatric inflammatory bowel disease: What's new? World J Clin Pediatr 2024; 13:89091. [PMID: 38596437 PMCID: PMC11000065 DOI: 10.5409/wjcp.v13.i1.89091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 03/06/2024] Open
Abstract
Pediatric inflammatory bowel disease (IBD) is a chronic inflammatory disorder, with increasing incidence and prevalence worldwide. There have been recent advances in imaging and endoscopic technology for disease diagnosis, treatment, and monitoring. Intestinal ultrasound, including transabdominal, transperineal, and endoscopic, has been emerging for the assessment of transmural bowel inflammation and disease complications (e.g., fistula, abscess). Aside from surgery, IBD-related intestinal strictures now have endoscopic treatment options including through-the-scope balloon dilatation, injection, and needle knife stricturotomy and new evaluation tools such as endoscopic functional lumen imaging probe. Unsedated transnasal endoscopy may have a role in patients with upper gastrointestinal Crohn's disease or those with IBD with new upper gastrointestinal symptoms. Improvements to dysplasia screening in pediatric patients with longstanding colonic disease or primary sclerosing cholangitis hold promise with the addition of virtual chromoendoscopy and ongoing research in the field of artificial intelligence-assisted endoscopic detection. Artificial intelligence and machine learning is a rapidly evolving field, with goals of further personalizing IBD diagnosis and treatment selection as well as prognostication. This review summarized these advancements, focusing on pediatric patients with IBD.
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Affiliation(s)
- Alexandra S Hudson
- Department of Pediatrics, University of Washington, Seattle, WA 98109, United States
| | - Ghassan T Wahbeh
- Department of Pediatrics, University of Washington, Seattle, WA 98109, United States
| | - Hengqi Betty Zheng
- Department of Pediatrics, University of Washington, Seattle, WA 98109, United States
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Halloran BP, Reeson M, Teshima C, Kroeker K, Huang V, Dieleman L, Holmes P, Baumgart DC, Wong K, Hoentjen F, Peerani F, Zepeda-Gomez S. Stricture dilation via balloon-assisted endoscopy in Crohn's disease: approach and intraprocedural outcomes with the single-balloon and double-balloon systems. Therap Adv Gastroenterol 2024; 17:17562848241230904. [PMID: 38425369 PMCID: PMC10903206 DOI: 10.1177/17562848241230904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 01/17/2024] [Indexed: 03/02/2024] Open
Abstract
Background Despite recent emerging literature involving the utility of endoscopic balloon dilation (EBD) of strictures via balloon-assisted endoscopy (BAE), specifically regarding the management of Crohn's disease (CD), the optimal clinical approach with balloon systems has been largely neglected in academic literature. Objectives This study assesses the intra-procedural success and safety of EBD via BAE for small bowel CD strictures while detailing our clinical approach and technique. Secondarily, we compare the single-balloon endoscope (SBE) and double-balloon endoscope (DBE) systems for EBD-related outcomes. Design Retrospective consecutive patient cohort analysis. Methods We retrospectively assessed a consecutive small bowel CD patient cohort undergoing BAE at the University of Alberta Hospital endoscopy unit from 2013 to 2020. The primary endpoint discerned the safety and immediate success rate of EBD during endoscopy, and comparisons of the dilation parameters and efficacy of SBE versus DBE were assessed as secondary outcomes. Results During the study period, 87 patients (44 male) with a mean age of 56 ± 14.7 years underwent 179 endoscopic procedures (92 DBE and 87 SBE). Of 358 strictures encountered, 320 (89.4%) were successfully dilated and traversed. The mean maximum dilation diameter was 15.76 ± 2.10 mm. There were no perforations or major adverse events. Conclusion EBD via BAE is a safe procedure in small bowel CD with a high intraprocedural success rate. Overall, SBE had a higher success rate in traversing strictures before and after dilation using our technique. This analysis is limited by the retrospective nature of our study and must be balanced against the inherent benefits of the DBE system.
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Affiliation(s)
- Brendan P. Halloran
- Director of the Small Endoscopy Bowel Program, Division of Gastroenterology, Department of Medicine, University of Alberta, 130 University Campus NW, Edmonton, AB, Canada T6G2X8
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Matthew Reeson
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | | | - Karen Kroeker
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Vivian Huang
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Levinus Dieleman
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Peter Holmes
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Daniel C. Baumgart
- Division of Gastroenterology
- Charité Medical Center – Virchow Hospital Berlin, Berlin, Germany
| | - Karen Wong
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Frank Hoentjen
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Farhad Peerani
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
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Ledder O, Viala J, Serban DE, Urlep D, De Ridder L, Martinelli M, Romano C, Church P, Griffiths C, Oliva S, Basude D, Sharma S, Thomson M. Endoscopic Balloon Dilatation in Pediatric Crohn Disease: An IBD Porto Group Study. J Pediatr Gastroenterol Nutr 2023; 77:62-69. [PMID: 36976584 DOI: 10.1097/mpg.0000000000003783] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVE/BACKGROUND Endoscopic balloon dilatation (EBD) has been shown to be effective and safe in adults with stricturing Crohn disease (CD) yet pediatric data is sparse. We aimed to assess efficacy and safety of EBD in stricturing pediatric CD. METHODS International collaboration included 11 centers from Europe, Canada, and Israel. Recorded data included patient demographics, stricture features, clinical outcomes, procedural adverse events, and need for surgery. Primary outcome was surgery-free over 12 months and secondary outcomes were clinical response and adverse events. RESULTS Eighty-eight dilatations were performed over 64 dilatation series in 53 patients. Mean age at CD diagnosis was 11.1 (±4.0) years, stricture length 4 cm [interquartile range (IQR) 2.8-5], and bowel wall thickness 7 mm (IQR 5.3-8). Twelve of 64 (19%) patients underwent surgery in the year following the dilatation series, at a median of 89 days (IQR 24-120; range 0-264) following EBD. Seven of 64 (11%) had subsequent unplanned EBD over the year, of whom two eventually underwent surgical resection. Two of 88 (2%) perforations were recorded, 1 of whom was managed surgically, and 5 patients had minor adverse events managed conservatively. There was a significant improvement in all clinical measures following EBD with weighted pediatric CD activity index-defined remission increasing from 13% at baseline to 44%, 46%, and 61%, and absence of obstructive symptoms in 55%, 53%, and 64% of patients at week 2, 8, and 24 respectively. CONCLUSIONS In this largest study of EBD in pediatric stricturing CD to date, we demonstrated that EBD is effective in relieving symptoms and avoiding surgery. Adverse events rates were low and consistent with adult data.
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Affiliation(s)
- Oren Ledder
- From the Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jérôme Viala
- Hôpitaux Universitaire Robert-Debré, APHP, Paris, France
| | - Daniela Elena Serban
- 2nd Clinic of Pediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Darja Urlep
- Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Lissy De Ridder
- Erasmus University MC/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Massimo Martinelli
- the Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Claudio Romano
- the Paediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi," University of Messina, Messina, Italy
| | - Peter Church
- the Division of Gastroenterology, Hepatology, and Nutrition, SickKids Hospital, Department of Paediatrics, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Chris Griffiths
- the Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Salvatore Oliva
- the Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, Rome, Italy
| | - Dharam Basude
- University Hospitals Bristol and Weston, United Kingdom
| | - Shishu Sharma
- Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Mike Thomson
- Sheffield Children's Hospital, Sheffield, United Kingdom
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Dandoy P, Louis E, Gast P, Poncin M, Seidel L, Loly JP. Factors associated with the efficacy and safety of endoscopic dilatation of symptomatic strictures in Crohn's disease: a retrospective cohort study. Scand J Gastroenterol 2023; 58:671-679. [PMID: 36533307 DOI: 10.1080/00365521.2022.2156808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/20/2022] [Accepted: 12/04/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Endoscopic balloon dilatation (EBD) is a standard treatment for intestinal strictures in Crohn's disease (CD). No evidence-based guidelines exist regarding the balloon diameter or the balloon pressure to be used, with recent studies suggesting the use of a smaller diameter than classically used. We sought to analyze the factors associated with safety and efficacy of EBD in CD strictures, particularly looking at balloon diameter and dilatation pressure. METHODS We conducted a monocentric retrospective study of patients who underwent EBD between 2005 and 2020. RESULTS Our endoscopy department performed EBD in 94 CD patients during the considered period. The mean size of balloon dilatation was 16 mm (±2.5; including 21 patients with balloon <14 mm) and the mean dilatation pressure was 5.3 atm (±1.5). No perforation was observed. Over a median follow-up of 5.6 years, the probability of being operated was 5.4% at 1 year and 10.4% at 3 years. Smaller height (HR = 0.90, p = 0.022) and a higher BMI (HR = 1.23, p = 0.014) were associated with the risk of operation. The probability of being operated or redilated was 30.1% at 1 year and 52.5% at 3 years. No factor was significantly associated with this risk. The size of the balloon had no impact on outcomes. CONCLUSION In this retrospective cohort, including a significant proportion of CD patients dilated with balloon <14 mm, no perforation was observed and the size of the balloon or the dilatation pressure had no impact on the risk of surgery or redilatation.
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Affiliation(s)
- Pierre Dandoy
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Edouard Louis
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Pierrette Gast
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Maxime Poncin
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Laurence Seidel
- Department of Clinical Research Support and Biostatistics, CHU Liège University Hospital, Liège, Belgium
| | - Jean-Philippe Loly
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
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Hong SM, Baek DH. A Review of Colonoscopy in Intestinal Diseases. Diagnostics (Basel) 2023; 13:diagnostics13071262. [PMID: 37046479 PMCID: PMC10093393 DOI: 10.3390/diagnostics13071262] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023] Open
Abstract
Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.
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Systematic Review of Endoscopic Management of Stricture, Fistula and Abscess in Inflammatory Bowel Disease. GASTROENTEROLOGY INSIGHTS 2023. [DOI: 10.3390/gastroent14010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background: Interventional inflammatory bowel disease (IIBD) therapies can play a key role in inflammatory bowel disease (IBD) related stricture/fistula/abscess deferring or avoiding invasive surgery. Methods: A total of 112 studies pertaining to IIBD therapy for strictures/fistula/abscess between 2002 and December 2022 were included by searching Pubmed, Medline and Embase with a focus on technical/clinical success, recurrence, re-intervention and complications. Results: IIBD therapy for strictures include endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES) and self-expanding metal stent (SEMS) placement. EBD is the primary therapy for short strictures while ES and SEMS can be used for refractory strictures. ES has higher long-term efficacy than EBD. SEMS is inferior to EBD although it can be useful in long, refractory strictures. Fistula therapy includes endoscopic incision and drainage (perianal fistula)/endoscopic seton (simple, low fistula) and endoscopic ultrasound-guided drainage (pelvic abscess). Fistulotomy can be done for short, superficial, single tract, bowel-bowel fistula. Endoscopic injection of filling agents (fistula plug/glue/stem cell) is feasible although durability is unknown. Endoscopic closure therapies like over-the-scope clips (OTSC), suturing and SEMS should be avoided for de-novo/bowel to hollow organ fistulas. Conclusion: IIBD therapies have the potential to act as a bridge between medical and surgical therapy for properly selected IBD-related stricture/fistula/abscess although future controlled studies are warranted.
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Lukas M. Porcine Model of Anastomotic Stricture in Crohn's Disease. Gastrointest Endosc Clin N Am 2022; 32:719-731. [PMID: 36202512 DOI: 10.1016/j.giec.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The development of new endoscopic methods is advancing rapidly. Current standard methods such as endoscopic balloon dilatation have only limited long-term effects. Surgery is more effective, but it also carries a higher risk of complications. Endoscopic stricturotomy and stricturoplasty are new methods expanding the range of possibilities of endoscopic treatment. These methods are advanced, technically demanding, and require adequate expertise and training. It is, therefore, necessary to have a tool for training and teaching these new methods. The live large animal model is a valuable tool in the development and testing of new, difficult, and dexterity intensive therapeutic methods thanks to its natural properties including bowel movements and tissue reactions such as swelling or bleeding. Animal model simulating secondary stricture in the site of the entero-colonic anastomosis has been created allowing not only to practice but also to develop new minimally invasive endoscopic techniques for the treatment of strictures in Crohn's disease (CD). High cost and stringent legislation represent the main limitations of more widespread use of large animal models in endoscopy.
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Affiliation(s)
- Martin Lukas
- IBD Clinical and Research Center, ISCARE a.s., Ceskomoravska 2510/19, Prague 19000, Czech Republic; PIGMOD Center, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; Department of Surgery, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic.
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Sivasailam B, Lane BF, Cross RK. Endoscopic Balloon Dilation of Strictures: Techniques, Short- and Long-Term Outcomes, and Complications. Gastrointest Endosc Clin N Am 2022; 32:675-686. [PMID: 36202509 DOI: 10.1016/j.giec.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
EBD is safe and effective for the treatment of strictures. Here we describe the technique of endoscopic balloon dilation (EBD) of strictures including preprocedure considerations, indications, contraindications, and postprocedure complications. The short- and long-term outcomes of EBD including factors associated with improved outcomes are also discussed.
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Affiliation(s)
- Barathi Sivasailam
- Department of Medicine, Division of Gastroenterology and Hepatology, NYU Langone, New York, NY, USA
| | - Barton F Lane
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 685 West Baltimore Street, Suite 8-00, Baltimore, MD 21201, USA.
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Las características de la estenosis, pero no el tratamiento, podrían influir en el resultado de la dilatación endoscópica en la enfermedad de Crohn recurrente. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:614-620. [DOI: 10.1016/j.gastrohep.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/13/2021] [Accepted: 01/05/2022] [Indexed: 11/17/2022]
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Sivasailam B, Manski S, Wentz A, Cross RK. Presence of Obstructive Symptoms and Absence of Perianal Crohn Disease Is Predictive of Surgery After Endoscopic Balloon Dilation. Inflamm Bowel Dis 2021; 27:1230-1236. [PMID: 33165536 DOI: 10.1093/ibd/izaa276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with Crohn disease (CD) often develop strictures that require surgery. Endoscopic balloon dilation (EBD) is an alternative treatment that can be safe and effective. The objective of this study was to assess factors associated with the need for repeat EBD and surgery after initial EBD for stricturing CD. METHODS Patients with stricturing CD who underwent EBD from 2007 to 2017 were identified. Demographic and clinical information was obtained from the electronic medical record. A Cox proportional hazards regression model and Kaplan-Meier curves were generated for variables associated with repeat EBD and surgical resection. RESULTS Ninety-nine patients underwent a total of 240 EBD proedures; 35% had a history of perianal disease, and 63% were on a biologic at the time of initial EBD. Fifty-one percent of patients had obstructive symptoms at the time of initial EBD, and 75% of the EBDs were successful. Complications occurred in 8 EBDs (3.3%). Repeat intervention after EBD was more likely in patients on biologics at baseline EBD (76% vs 54%; P = 0.029). Thirty-three percent of patients had surgical resection at a median of 5 months (interquartile ratio = 2.0-13.0 months) after initial EBD. The presence of obstructive symptoms at the time of EBD was associated with surgical resection (hazard ratio = 3.18; 95% confidence interval, 1.28-7.86). Conversely, a history of perianal disease was negatively associated with surgical resection (hazard ratio = 0.27; 95% confidence interval, 0.10-0.68). CONCLUSIONS Patients on biologic treatment at the time of EBD are more likely to need an intervention in the future. Patients with obstructive symptoms at the time of initial EBD and those without a history of perianal involvement are more likely to undergo surgical intervention.
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Affiliation(s)
- Barathi Sivasailam
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Scott Manski
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Alicia Wentz
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
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Schulberg JD, Wright EK, Holt BA, Wilding HE, Hamilton AL, Ross AL, Kamm MA. Efficacy of drug and endoscopic treatment of Crohn's disease strictures: A systematic review. J Gastroenterol Hepatol 2021; 36:344-361. [PMID: 33150989 DOI: 10.1111/jgh.15330] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Strictures are the commonest complication in Crohn's disease. Surgery and endoscopic dilation are the mainstays of treatment, while drug therapy has often been considered contraindicated. The benefit of nonsurgical treatments, particularly drug and endoscopic therapy, need to be defined. METHODS Ovid MEDLINE, Embase, Emcare, PsycINFO, CINAHL and the Cochrane Library (inception until August 30, 2019) were searched. Studies with ≥ 10 patients with Crohn's disease strictures, reporting on outcomes following medication or endoscopic treatment, were included. RESULTS Of 3480 records, 85 studies met inclusion criteria and formed the basis of this analysis. Twenty-five studies assessed drug therapy; none were randomized trials. Despite study heterogeneity anti-tumor necrosis factor (TNF) therapy appeared effective, with 50% of patients avoiding surgery after 4 years of follow up. No other drug therapy was of demonstrable benefit. Sixty studies assessed endoscopic therapy including 56 on endoscopic balloon dilation, two assessed needle knife stricturotomy, and two stent insertion. Dilation was equally effective for de novo and anastomotic strictures ≤ 5 cm in length, with most studies reporting a subsequent surgical rate of 30% to 50%. Repeat dilation was required in approximately half of all patients. CONCLUSIONS Anti-TNF drug therapy and endoscopic balloon dilation are effective strategies for avoiding surgery in patients with stricturing Crohn's disease. Additional endoscopic therapies require further evaluation. Early data suggest that combining these therapies may provide greater benefit than individual therapies. Optimization of current drug and endoscopic therapy, and the incorporation of newer therapies, are needed for stricturing Crohn's disease.
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Affiliation(s)
- Julien D Schulberg
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Bronte A Holt
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Helen E Wilding
- Library Service, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Amy L Hamilton
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Alyson L Ross
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Lukas M, Kolar M, Ryska O, Juhas S, Juhasova J, Kalvach J, Pazin J, Kocisova T, Foltan O, Kristianova H, Ptacnik J, Vitkova I, Bortlik M, Lukas M. Novel porcine model of Crohn's disease anastomotic stricture suitable for evaluation and training of advanced endoscopic techniques. Gastrointest Endosc 2021; 93:250-256. [PMID: 32535192 DOI: 10.1016/j.gie.2020.05.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/30/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Currently, treatment options in postsurgical recurrence of stricturing Crohn's disease (CD) are limited. However, development of new invasive endoscopic techniques in clinical practice has safety constraints. The aim of this study was to create a large animal model of anastomotic stricture with CD properties to enable development of new techniques and training. METHODS A side-to-side ileocolonic anastomosis was created in a modified Roux-en-Y manner with bowel continuity preserved. Two weeks after surgery, we began endoscopic submucosal injections of phenol/trinitrobenzenesulfonic acid solution. This solution was injected every 2 weeks in each quadrant of the anastomosis until development of a stricture. The anastomosis site was assessed endoscopically 2 weeks after the last application (baseline) and then every 2 months until month 6. Endoscopically nonpassable strictures were treated with balloon dilation, endoscopic stricturotomy, and stent placement to confirm the feasibility of such interventions. RESULTS Nineteen minipigs were included with no postoperative adverse events. After a mean of 4.4 ± .7 injection sessions with 10.5 ± 3.0 mL of the solution, anastomotic strictures were created in 16 pigs (84.2%). Mean diameter of the strictures at baseline was 11.6 ± 2.2 mm. The strictures were inflamed, and the endoscope could not pass. Follow-up was successfully completed in 15 animals (79.0%) with the mean deviation from the initial diameter in every measurement of -.02 ± 2.26 mm (P = .963) and a mean final diameter of 11.7 ± 3.4 mm. The histopathologic evaluation revealed the presence of submucosal fibrosis, chronic inflammation, and microgranulomas. All strictures were amenable to endoscopic therapeutic interventions. CONCLUSIONS We developed a novel, reproducible porcine model of anastomotic stricture with histologically verified changes mimicking CD and stable diameter for more than 6 months. It is suitable for further endoscopic interventions.
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Affiliation(s)
- Martin Lukas
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; IBD Clinical and Research Center, ISCARE a.s., Prague, Czech Republic
| | - Martin Kolar
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; IBD Clinical and Research Center, ISCARE a.s., Prague, Czech Republic
| | - Ondrej Ryska
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Stefan Juhas
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic
| | - Jana Juhasova
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic
| | - Jaroslav Kalvach
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; Department of Surgery, Military University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jaroslav Pazin
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; Department of Surgery, Military University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tereza Kocisova
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; Department of Surgery, Military University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Foltan
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; First Surgical Clinic of Thoracic, Abdominal and Injury Surgery, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hana Kristianova
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; First Surgical Clinic of Thoracic, Abdominal and Injury Surgery, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Ptacnik
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; First Surgical Clinic of Thoracic, Abdominal and Injury Surgery, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ivana Vitkova
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; Institute of Pathology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Bortlik
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; IBD Clinical and Research Center, ISCARE a.s., Prague, Czech Republic; Department of Internal Medicine, Military University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic; Institute of Pharmacology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Milan Lukas
- PIGMOD Center, Laboratory of Cell Regeneration and Plasticity, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic; IBD Clinical and Research Center, ISCARE a.s., Prague, Czech Republic; Institute of Medical Biochemistry and Laboratory Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
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13
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Andújar X, Loras C, González B, Socarras M, Sanchiz V, Boscà M, Domenech E, Calafat M, Rodríguez E, Sicilia B, Calvet X, Barrio J, Guardiola J, Iglesias E, Casanova MJ, Ber Y, Monfort D, López-Sanromán A, Rodríguez-Lago I, Bujanda L, Márquez L, Martín-Arranz MD, Zabana Y, Fernández-Bañares F, Esteve M. Efficacy and safety of endoscopic balloon dilation in inflammatory bowel disease: results of the large multicenter study of the ENEIDA registry. Surg Endosc 2020; 34:1112-1122. [PMID: 31144122 DOI: 10.1007/s00464-019-06858-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/18/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no information regarding the outcome of Crohn's disease (CD) patients treated with endoscopic balloon dilation (EBD) in non-referral hospitals, nor on the efficacy of EBD in ulcerative colitis (UC). We report herein the results of the largest series published to date. AIM To assess the efficacy and safety of EBD for inflammatory bowel disease (IBD) stenosis performed in 19 hospitals with different levels of complexity and to determine factors related to therapeutic success. METHODS We identified IBD patients undergoing EBD in the ENEIDA database. Efficacy of EBD was compared between CD and UC and between secondary and tertiary hospitals. Predictive factors of therapeutic success were assessed with multivariate analysis. RESULTS Four-hundred dilations (41.2% anastomotic) were performed in 187 IBD patients (13 UC/Indeterminate colitis). Technical and therapeutic success per dilation was achieved in 79.5% and 55.3%, respectively. Therapeutic success per patient was achieved in 78.1% of cases (median follow-up: 40 months) with 49.7% requiring more than one dilation. No differences related to either diagnosis or hospital complexity was found. Technical success [OR 4.12 (95%CI 2.4-7.1)] and not receiving anti-TNF at the time of dilation [OR 1.7 (95% CI 1.1-2.6)] were independently related to therapeutic success per dilation. A stricture length ≤ 2 cm [HR 2.43 (95% CI 1.11-5.31)] was a predictive factor of long-term success per patient. The rate of major complications was 1.3%. CONCLUSIONS EBD can be performed with similar efficacy and safety in hospitals with differing levels of complexity and it might be a suitable treatment for UC with short stenosis. To achieve a technical success and the short length of the stenosis seem to be critical for long-term therapeutic success.
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Affiliation(s)
- Xavier Andújar
- Department of Gastroenterology, Endoscopy Unit, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Plaça Dr Robert nº 5, Terrassa, 08221, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Carme Loras
- Department of Gastroenterology, Endoscopy Unit, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Plaça Dr Robert nº 5, Terrassa, 08221, Barcelona, Catalonia, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| | - Begoña González
- Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Milena Socarras
- Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Maia Boscà
- Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | | | - Esther Rodríguez
- Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz De Tenerife, Spain
| | | | - Xavier Calvet
- Corporació Sanitària Universitària Parc Taulí, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | - Eva Iglesias
- Hospital Universitario Reina Sofía, Córdoba, Spain
| | - María José Casanova
- Hospital Universitario de La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | | | | | - Luís Bujanda
- Hospital Universitario Donostia/Instituto Biodonostia, Universidad del País Vasco (UPV/EHU), Gipuzkua, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | | | - Yamile Zabana
- Department of Gastroenterology, Endoscopy Unit, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Plaça Dr Robert nº 5, Terrassa, 08221, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Fernando Fernández-Bañares
- Department of Gastroenterology, Endoscopy Unit, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Plaça Dr Robert nº 5, Terrassa, 08221, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - María Esteve
- Department of Gastroenterology, Endoscopy Unit, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Plaça Dr Robert nº 5, Terrassa, 08221, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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14
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Lee HW, Park SJ, Jeon SR, Ye BD, Park JJ, Cheon JH, Kim TI, Kim WH. Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Strictures in Patients with Inflammatory Bowel Disease. Gut Liver 2019; 12:530-536. [PMID: 29730904 PMCID: PMC6143444 DOI: 10.5009/gnl17396] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/08/2018] [Accepted: 02/09/2018] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Benign intestinal strictures are common complications in patients with inflammatory bowel disease (IBD). This study aimed to assess the long-term prognosis of endoscopic balloon dilation (EBD) to treat benign strictures in IBD patients. Methods Patients with IBD who had benign strictures and who underwent EBD in four tertiary referral university hospitals between January 2004 and February 2014 were retrospectively reviewed. Technical success was defined as the ability to pass the scope through the stricture after balloon dilation, and clinical success was defined as improved obstructive symptoms. Results Forty-two benign strictures were identified in 30 patients (15 males and 15 females). Technical success was achieved in 26 patients (86.7%) at the first EBD attempt and in all 30 patients (100%) at the second EBD attempt. Clinical success was seen in 28 patients (93.3%). The median follow-up duration was 134.8 months (range, 10.2 to 252.0 months), and recurrence occurred in eight patients (26.7%), who required repeat EBD. The median duration to relapse was 1.7 months (range, 0.2 to 6.3 months). During repeat EBD, perforation occurred in two cases (6.7%), which were both clipped successfully. Finally, only one patient (3.3%) underwent surgery for the relief of recurrent obstructive symptoms during the follow-up period. Conclusions The experience of 10 years shows that EBD is safe and effective for the treatment of benign strictures in IBD patients. Importantly, EBD may allow long-term effective palliation of the symptoms associated with benign intestinal strictures in IBD patients.
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Affiliation(s)
- Hye Won Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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15
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Sarani B, Paspulati RM, Hambley J, Efron D, Martinez J, Perez A, Bowles-Cintron R, Yi F, Hill S, Meyer D, Maykel J, Attalla S, Kochman M, Steele S. A multidisciplinary approach to diagnosis and management of bowel obstruction. Curr Probl Surg 2018; 55:394-438. [PMID: 30526888 DOI: 10.1067/j.cpsurg.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/11/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Babak Sarani
- Center for Trauma and Critical Care, George Washington University School of Medicine, Washington, DC.
| | | | - Jana Hambley
- Department of Trauma and Acute Care Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Efron
- Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jose Martinez
- Division of Minimally Invasive Surgery, Minimally Invasive Surgery/Flexible Endoscopy Fellowship Program, University of Miami Miller School of Medicine, Miami, FL
| | - Armando Perez
- University of Miami Miller School of Medicine, Miami, FL
| | | | - Fia Yi
- Brooke Army Medical Center, San Antonio, TX
| | - Susanna Hill
- University of Massachusetts Medical Center, Worcester, MA
| | - David Meyer
- Division of Colon and Rectal Surgery, University of Massachusetts Medical Center, Worcester, MA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts Medical Center, Worcester, MA
| | - Sara Attalla
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael Kochman
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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16
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Oliva S, Thomson M, de Ridder L, Martín-de-Carpi J, Van Biervliet S, Braegger C, Dias JA, Kolacek S, Miele E, Buderus S, Bronsky J, Winter H, Navas-López VM, Assa A, Chong SKF, Afzal NA, Smets F, Shaoul R, Hussey S, Turner D, Cucchiara S. Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:414-430. [PMID: 30130311 DOI: 10.1097/mpg.0000000000002092] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.
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Affiliation(s)
- Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Lissy de Ridder
- Pediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Javier Martín-de-Carpi
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Christian Braegger
- Division of Gastroenterology and Nutrition, University Children's Hospital, Zurich, Switzerland
| | - Jorge Amil Dias
- Pediatric Gastroenterology Unit, Hospital Sao João, Porto, Portugal
| | - Sanja Kolacek
- Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, "Federico II," University of Naples, Italy
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Harland Winter
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | | | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, affiliated to the Sackler faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sonny K F Chong
- Queen Mary's Hospital for Children, Epsom & St Helier University Hospitals NHS Trust, Carshalton, Surrey
| | - Nadeem Ahmad Afzal
- Department of Paediatric Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Francoise Smets
- Pediatric Gastroenterology and Hepatology Unit, IREC, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Séamus Hussey
- National Children's Research Centre and Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
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17
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Bessissow T, Reinglas J, Aruljothy A, Lakatos PL, Van Assche G. Endoscopic management of Crohn's strictures. World J Gastroenterol 2018; 24:1859-1867. [PMID: 29740201 PMCID: PMC5937203 DOI: 10.3748/wjg.v24.i17.1859] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/14/2018] [Accepted: 04/23/2018] [Indexed: 02/06/2023] Open
Abstract
Symptomatic intestinal strictures develop in more than one third of patients with Crohn's disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.
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Affiliation(s)
- Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Jason Reinglas
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Achuthan Aruljothy
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Peter L Lakatos
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1085, Hungary
| | - Gert Van Assche
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Belgium and University of Leuven, Leuven 3000, Belgium
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18
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Bharadwaj S, Narula N, Tandon P, Yaghoobi M. Role of endoscopy in inflammatory bowel disease. Gastroenterol Rep (Oxf) 2018; 6:75-82. [PMID: 29780594 PMCID: PMC5952948 DOI: 10.1093/gastro/goy006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/04/2018] [Indexed: 12/12/2022] Open
Abstract
Crohn’s disease (CD) and ulcerative colitis (UC) constitute the two most common phenotypes of inflammatory bowel disease (IBD). Ileocolonoscopy with biopsy has been considered the gold standard for the diagnosis of IBD. Differential diagnosis of CD and UC is important, as their medical and surgical treatment modalities and prognoses can be different. However, approximately 15% of patients with IBD are misdiagnosed as IBD unclassified due to the lack of diagnostic certainty of CD or UC. Recently, there has been increased recognition of the role of the therapeutic endoscopist in the field of IBD. Newer imaging techniques have been developed to aid in the differentiation of UC vs CD. Furthermore, endoscopic balloon dilation and stenting have become an integral part of the therapeutic armamentarium of CD stricture management. Endoscopic ultrasound has been recognized as being more accurate than magnetic resonance imaging in detecting perianal fistulae in patients with CD. Additionally, chromoendoscopy may help to detect dysplasia earlier compared with white-light colonoscopy. Hence, interventional endoscopy has become a cornerstone in the diagnosis, treatment and management of IBD complications. The role of endoscopy in the field of IBD has significantly evolved in recent years from small-bowel imaging to endoscopic balloon dilation and use of chormoendoscopy in dysplasia surveillance. In this review article, we discuss the current evidence on interventional endoscopy in the diagnosis, treatment and management of IBD compications.
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Affiliation(s)
- Shishira Bharadwaj
- Department of Gastroenterology/Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Parul Tandon
- Department of Medicine, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
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19
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Findings of Retrograde Contrast Study Through Double-balloon Enteroscopy Predict the Risk of Bowel Resections in Patients with Crohn's Disease with Small Bowel Stenosis. Inflamm Bowel Dis 2017; 23:2097-2103. [PMID: 28837520 DOI: 10.1097/mib.0000000000001175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with Crohn's disease (CD) with small bowel strictures are at risk of surgery. Double-balloon enteroscopy (DBE) can evaluate the status of the small intestine, and retrograde contrast through the scope enables the surgeon to obtain information beyond the reach of the scope. This study aimed to examine whether a retrograde contrast study through DBE could be used as a predictor of subsequent surgery in patients with CD with small intestinal strictures. METHODS The findings of DBE with retrograde contrast in 48 patients CD with small bowel strictures were examined. RESULTS Of the 48 patients, 14 (29%) underwent surgery for small intestinal strictures during a median observation period of 2.4 years (interquartile range: 1.4-3.7 yr). According to the results of the multivariate analysis, a maximum length of strictures ≥20 mm and the ratio of the maximum diameter of prestenotic dilations to the diameter of the normal small intestine ≥1.4 were independent risk factors of surgery for small intestinal strictures (risk ratio = 7.6 [95% confidence interval, 1.8-42.0], P = 0.006; and risk ratio = 52.0 [95% confidence interval, 3.5-2485.1], P = 0.002, respectively). The latter predicted subsequent surgery with 92% sensitivity and 88% specificity. Cumulative surgery-free rates were discriminated significantly according to the presence or absence of these 2 risk factors (log-rank test: P < 0.001). CONCLUSIONS Findings of retrograde contrast through DBE are helpful to predict risk of surgery in patients with CD with small intestinal strictures.
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20
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Lopes S, Andrade P, Rodrigues-Pinto E, Afonso J, Macedo G, Magro F. Fecal marker levels as predictors of need for endoscopic balloon dilation in Crohn’s disease patients with anastomotic strictures. World J Gastroenterol 2017; 23:6482-6490. [PMID: 29085198 PMCID: PMC5643274 DOI: 10.3748/wjg.v23.i35.6482] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/22/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the accuracy and best cut-off value of fecal calprotectin (FC) and fecal lactoferrin (FL) to predict disease recurrence in asymptomatic patients presenting with anastomotic strictures.
METHODS This was a longitudinal single tertiary center study based on prospectively collected data (recorded in a clinical database created for this purpose) performed between March 2010 and November 2014. Crohn’s disease (CD) patients with anastomotic stricture who submitted to postoperative endoscopic evaluation were included. Stools were collected on the day before bowel cleaning for FC and FL. Endoscopic balloon dilation (EBD) was performed if the patient presented an anastomotic stricture not traversed by the colonoscope, regardless of patients’ symptoms. Successful dilation was defined as passage of the colonoscope through the dilated stricture into the neotermimal ileum. Postoperative recurrence was defined as a modified Rutgeerts score of ≥ i2b.
RESULTS In a total of 178 patients who underwent colonoscopy, 58 presented an anastomotic stricture, 86% were asymptomatic, and 48 (54% male; median age of 46.5 years) were successfully dilated. Immediate success rate was 92% and no complications were recorded. FC and FL levels correlated significantly with endoscopic recurrence (P < 0.001) with an optimal cut-off value of 90.85 µg/g (sensitivity of 95.5%, specificity of 69.2%, positive predictive value (PPV) of 72.4%, negative predictive value (NPV) of 94.7% and accuracy of 81%] for FC and of 5.6 µg/g (sensitivity of 77.3%, specificity of 69.2%, PPV of 68%, NPV of 78.4% and accuracy of 72.9%) for FL.
CONCLUSION Fecal markers are good predictors of CD endoscopic recurrence in patients with asymptomatic anastomotic stricture. FC and FL may guide the need for EBD in this context.
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Affiliation(s)
- Susana Lopes
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, 4200-319 Porto, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, 4200-319 Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, 4200-319 Porto, Portugal
| | - Joana Afonso
- Department of Pharmacology and Therapeutics, University of Porto, 4200-319 Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, 4200-319 Porto, Portugal
| | - Fernando Magro
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, 4200-319 Porto, Portugal
- Department of Pharmacology and Therapeutics, University of Porto, 4200-319 Porto, Portugal
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21
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Chen Q, Yu Q, Yu JJ, Liu M, Xie HP, Cheng B, Guao QZ, Liao GQ, Qin H. Observational study of colonoscopy techniques used for acute colorectal obstruction: A single-center experience. Mol Clin Oncol 2017; 6:355-361. [PMID: 28451412 PMCID: PMC5403636 DOI: 10.3892/mco.2017.1133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/09/2016] [Indexed: 12/16/2022] Open
Abstract
The prevalence of acute colorectal obstruction at the hospital setting is high. There is need for improvement in the quality of colonoscopy for relieving obstruction. A retrospective, uncontrolled, open-label study was conducted, with the aim of documenting the causes of acute colorectal obstruction and the quality of colonoscopy practice in managing obstruction at a university hospital in China. A total of 61 adult patients with acute colorectal obstruction treated with urgent colonoscopy between February, 2011 and January, 2016 were identified at the Endoscopic Unit of Tongji Hospital (Wuhan, China). The technique success rate was the primary outcome. The etiology was mainly related to malignant diseases, including colorectal cancer in 53 patients (86.9%) and advanced peritoneal serous carcinoma leading to extrinsic colonic compression in 1 patient (1.6%). Benign causes of obstruction included foreign bodies in 3 patients (4.9%) and fecal impaction in 2 patients (3.3%); furthermore, anastomotic strictures were found in 2 patients (3.3%). The technique success rate was 98.4% (60/61). All colorectal cancer patients who underwent urgent colonoscopy were admitted to the Department of Surgery for placement of a self-expanding metallic stent; 1 patient who had an extracolonic malignancy underwent placement of a transanal colonoscopic decompression tube as palliative therapy and 2 patients with anastomotic strictures underwent endoscopic balloon dilation. Furthermore, colonoscopy was used for extracting the foreign body, as well as removing fecal stones in all the patients. In conclusion, urgent colonoscopy as a minimal invasive approach is associated with certain advantages for diagnosing and managing acute colorectal obstruction. Furthermore, experienced operators achieved a better outcome when managing colorectal obstruction.
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Affiliation(s)
- Qian Chen
- Endoscopic Unit, Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Qin Yu
- Hepatic Surgery Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Jing-Jing Yu
- Hepatic Surgery Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Mei Liu
- Endoscopic Unit, Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Hua-Ping Xie
- Endoscopic Unit, Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Bin Cheng
- Endoscopic Unit, Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Qiao-Zhen Guao
- Endoscopic Unit, Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Guang-Quan Liao
- Endoscopic Unit, Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
| | - Hua Qin
- Endoscopic Unit, Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei 430030, P.R. China
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Hirai F. Current status of endoscopic balloon dilation for Crohn's disease. Intest Res 2017; 15:166-173. [PMID: 28522945 PMCID: PMC5430007 DOI: 10.5217/ir.2017.15.2.166] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 12/31/2016] [Accepted: 01/02/2017] [Indexed: 12/12/2022] Open
Abstract
The therapeutic target in Crohn's disease (CD) has been raised to the achievement of mucosal healing. Although effective treatments that target cytokines and other molecules has been widely used for CD, intestinal strictures are still a major cause of surgery. Endoscopic balloon dilation (EBD) is known to be an effective and safe intervention for intestinal strictures in CD. Since frequent intestinal resection often results in short bowel syndrome and can decrease the quality of life, EBD can help avoid surgery. EBD with a conventional colonoscope for Crohn's strictures of the colon and ileo-colonic anastomosis has established efficacy and safety. In addition, EBD using balloon-assisted enteroscopy has recently been applied for small bowel Crohn's strictures. Although the evidence is not strong, EBD may become an alternative to surgery in small bowel strictures in CD. EBD and other new methods such as self-expanding stent implantation for Crohn's strictures may be useful and safe; however, it is important to address several issues regarding these interventions and to establish a protocol for combined therapies.
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Affiliation(s)
- Fumihito Hirai
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
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Kumar AS, Lee JK. Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions. Clin Colon Rectal Surg 2017; 30:136-144. [PMID: 28381945 DOI: 10.1055/s-0036-1597312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists.
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Affiliation(s)
- Anjali S Kumar
- Colorectal Surgery Program, Virginia Mason Medical Center, Seattle, Washington
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Rieder F, Fiocchi C, Rogler G. Mechanisms, Management, and Treatment of Fibrosis in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:340-350.e6. [PMID: 27720839 PMCID: PMC5209279 DOI: 10.1053/j.gastro.2016.09.047] [Citation(s) in RCA: 354] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 02/08/2023]
Abstract
In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases-associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Claudio Fiocchi
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland; Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
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Yamamoto-Furusho J, Bosques-Padilla F, de-Paula J, Galiano M, Ibañez P, Juliao F, Kotze P, Rocha J, Steinwurz F, Veitia G, Zaltman C. Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Bettenworth D, Gustavsson A, Atreja A, Lopez R, Tysk C, van Assche G, Rieder F. A Pooled Analysis of Efficacy, Safety, and Long-term Outcome of Endoscopic Balloon Dilation Therapy for Patients with Stricturing Crohn's Disease. Inflamm Bowel Dis 2017; 23:133-142. [PMID: 28002130 DOI: 10.1097/mib.0000000000000988] [Citation(s) in RCA: 175] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) is widely used to manage Crohn's disease-associated strictures. However, most studies of the safety and efficacy are small and heterogenous. We performed a combined analysis of published studies and evaluated 676 comprehensive individual participant data sets to determine the overall effects of EBD. METHODS Citations from the Embase, MEDLINE, and the Cochrane library from 1991 through 2013 were systematically reviewed, and references of cited articles were assessed for relevant publications. We collected data from studies including ≥15 patients and additionally generated a unique individual patient database containing 676 individual data sets derived from 12 studies. Technical feasibility, short-term and long-term efficacies, and safety were evaluated. RESULTS In 1463 patients with Crohn's disease who underwent 3213 EBD procedures, 98.6% of strictures were ileal and 62% anastomotic. The technical success rate of the EBDs was 89.1% with a clinical efficacy of 80.8%. Complications occurred in 2.8% per procedure. After 24 months of follow-up, 73.5% of subjects underwent redilation and 42.9% surgical resection. In a multivariate analysis of 676 individual patients, a stricture length of ≤5 cm was associated with a surgery-free outcome; every 1 cm increase of stricture length increased the hazard of need for surgery by 8% (P = 0.008). Inflammation did not affect outcomes or rate of complications. CONCLUSIONS Based on a systematic literature review and analysis of data sets from 676 patients, EBD has a high rate of short-term technical and clinical efficacies, with substantial long-term efficacy and acceptable rates of complication.
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Affiliation(s)
- Dominik Bettenworth
- *Department of Medicine B, University Hospital of Münster, Münster, Germany; †Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden; ‡Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; §Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; ‖Division of Gastroenterology, University of Leuven, Leuven, Belgium; ¶Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; and **Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Yamamoto-Furusho JK, Bosques-Padilla F, de-Paula J, Galiano MT, Ibañez P, Juliao F, Kotze PG, Rocha JL, Steinwurz F, Veitia G, Zaltman C. Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGIA DE MEXICO 2017; 82:46-84. [PMID: 27979414 DOI: 10.1016/j.rgmx.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/23/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023]
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) has increased in recent years in several Latin American countries. There is a need to raise awareness in gastroenterologists and the population in general, so that early diagnosis and treatment of ulcerative colitis (UC) and Crohn's Disease (CD) can be carried out. It is important for all physicians to have homogeneous criteria regarding the diagnosis and treatment of IBD in Latin America. The Pan American Crohn's and Colitis Organisation (PANCCO) is an organization that aims to include all the countries of the Americas, but it specifically concentrates on Latin America. The present Consensus was divided into two parts for publication: 1) Diagnosis and treatment and 2) Special situations. This is the first Latin American Consensus whose purpose is to promote a perspective adapted to our Latin American countries for the diagnosis, treatment, and monitoring of patients with UC and CD.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - F Bosques-Padilla
- Gastroenterology Division, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - J de-Paula
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - M T Galiano
- Clínica de Enfermedad Inflamatoria Intestinal, Clínica Marly, Bogotá, Colombia
| | - P Ibañez
- Programa de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - F Juliao
- Clínica de Enfermedad Inflamatoria Intestinal, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P G Kotze
- Hospital Universitario Cajuru, Universidad Católica del Paraná (PUCPR), Curitiba, Brasil
| | - J L Rocha
- Grupo Académico y de Investigación sobre Enfermedad de Crohn y Colitis Ulcerosa Crónica Idiopática de México, Ciudad de México, México
| | - F Steinwurz
- Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - G Veitia
- Servicio de Gastroenterología, Hospital Vargas, Caracas, Venezuela
| | - C Zaltman
- Servicio de Gastroenterología, Hospital Clementino Fraga Filho, Departamento de Medicina Interna, Universidade Federal do Rio de Janeiro (UFRJ), Río de Janeiro, Brasil
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Bálint A, Törőcsik D, Palatka K, Szepes Z, Szűcs M, Tamás F, Nagy F, Farkas K, Fábián A, Bor R, Milassin Á, Rutka M, Molnár T. Prognostic factors, effectiveness and safety of endoscopic balloon dilatation for de novo and anastomotic strictures in Crohn’s disease—A multicenter “real life” study. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1233687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Anita Bálint
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Dalma Törőcsik
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Károly Palatka
- 2nd Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szepes
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Mónika Szűcs
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ferenci Tamás
- Physiological Controls Group, John von Neumann Faculty of Informatics, Óbuda University, Budapest, Hungary
| | - Ferenc Nagy
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Klaudia Farkas
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Anna Fábián
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Renáta Bor
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Ágnes Milassin
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Mariann Rutka
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Tamás Molnár
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
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Arebi N, Hart AL, Thomas-Gibson S. A review of endoscopic balloon dilatation techniques for treating Crohn's strictures: time to standardise therapy. Expert Rev Gastroenterol Hepatol 2016; 10:1101-1107. [PMID: 27411078 DOI: 10.1080/17474124.2016.1212656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endoscopic balloon dilatation (EBD) is a recognised treatment for symptomatic Crohn's disease strictures. Over 3000 procedure are reported in the literature and yet the long term benefits are unclear. This is largely because of different populations, study designs, techniques, types of strictures, the outcome measures used and follow-up periods. Areas covered: We summarised the techniques reported in the literature based on a systematic review and key factors that may influence outcome: pre-intervention imaging, stricture length and type, balloon size in relation to intestinal lumen diameter, duration of dilatation, frequency of repeat dilatation and instructions on follow-up. Expert commentary: We noted that shorter, non-ulcerated and anastomotic strictures fare better and 2 mins dilatation duration was the commonest technique used without an increased risk of complications. The findings were translated into a standardised protocol and a management pathway to guide clinicians on the therapeutic strategy for Crohn's strictures. To resolve the uncertainty about long-term benefits, future studies should adopt a replicable standardised EBD technique, define degree of fibrosis to decide therapy accordingly, compare it to alternative interventions (strictureplasty or stents) within a randomised controlled trial and apply a validated outcome measure to include intestinal damage and quality of life.
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Affiliation(s)
- Naila Arebi
- a Department of Gastroenterology , St. Mark's Hospital , London , UK
| | - Ailsa L Hart
- a Department of Gastroenterology , St. Mark's Hospital , London , UK
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Keihanian S, Moss AC. Crohn’s disease stricture evaluation and management. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016; 18:136-144. [DOI: 10.1016/j.tgie.2016.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.
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Navaneethan U, Lourdusamy V, Njei B, Shen B. Endoscopic balloon dilation in the management of strictures in Crohn's disease: a systematic review and meta-analysis of non-randomized trials. Surg Endosc 2016; 30:5434-5443. [PMID: 27126619 DOI: 10.1007/s00464-016-4902-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 04/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Crohn's disease (CD) is associated with strictures. Endoscopic balloon dilatation (EBD) may prevent or delay the need for surgical resection. The aim of this systematic review was to determine the efficacy and safety of EBD in the management of Crohn's strictures. METHODS A comprehensive search of MEDLINE and EMBASE databases from January 1980 to May 2015 was performed. The primary outcome measurements were surgical intervention rates and major adverse events. RESULTS A total of 24 studies involving 1163 patients were included in the analysis. The median duration from the initial diagnosis of CD to the first EBD was 10.2-17.0 years. The majority of strictures (69 %) treated were anastomotic, while the remaining strictures were naive (primary). Surgical intervention rate over a median follow-up period of 15-70 months in the reported studies was 27 %. The surgical intervention rate after dilation of anastomotic strictures was 18 % versus 29 % for primary strictures. The risk ratio for the surgical requirement of anastomotic versus primary strictures was [0.88 (95 % confidence interval [CI] 0.59-1.32); p = 0.54]. Stricture length <4 cm was associated with a significantly decreased risk of surgical intervention [risk ratio = 0.48 (95 % CI 0.26-0.90); p = 0.02]. EBD resulted in major adverse events in 4 % of the patients. CONCLUSIONS EBD appears to be a safe alternative for surgery in the management of Crohn's strictures. Stricture length <4 cm treated with EBD is associated with a significantly decreased risk of surgical intervention.
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Affiliation(s)
- Udayakumar Navaneethan
- Center for Interventional Endoscopy, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
| | - Vennisvasanth Lourdusamy
- Center for Interventional Endoscopy, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.,Department of Internal Medicine, Brandon Regional Hospital, Brandon, FL, USA
| | - Basile Njei
- Section of Digestive Diseases, Yale University, New Haven, CT, USA
| | - Bo Shen
- Department of Gastroenterology, The Cleveland Clinic, Cleveland, OH, USA
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Karstensen JG, Christensen KR, Brynskov J, Rønholt C, Vilmann P, Hendel J. Biodegradable stents for the treatment of bowel strictures in Crohn's disease: technical results and challenges. Endosc Int Open 2016; 4:E296-300. [PMID: 27004247 PMCID: PMC4798842 DOI: 10.1055/s-0042-101940] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND STUDY AIMS In patients with Crohn's disease, the idea of biodegradable stents for treatment of bowel strictures with limited effect of endoscopic balloon dilation is tempting and initial results have been promising. The aim of this study was to evaluate the technical and clinical success of biodegradable stents for treatment of inflamed Crohn's strictures refractory to endoscopic balloon dilatation. PATIENTS AND METHODS Consecutive patients treated with biodegradable stents due to Crohn's disease and inflamed bowel strictures refractory to endoscopic balloon dilatation were included. Technical and clinical success were evaluated. RESULTS Six patients were included in the study. Technical success was obtained in five patients (83 %). Clinical success was limited to one patient (20 %); failure was observed due to mucosal overgrowth (n = 2), stent migration (n = 1), and stent collapse (n = 1). CONCLUSIONS In Crohn's disease, it is technically feasible to treat bowel strictures with biodegradable stents. However, we have stopped using biodegradable stents due to lack of clinical success and side effects such as mucosal overgrowth and stent collapse.
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Affiliation(s)
- John Gásdal Karstensen
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark,Gastro Unit, Division of Surgery, Copenhagen University Hospital Hvidovre, Denmark,Corresponding author John Gásdal Karstensen, MD, PhD Gastro Unit, Division of EndoscopyCopenhagen University Hospital Herlev2730 HerlevDenmark
| | | | - Jørn Brynskov
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
| | - Claus Rønholt
- Gastro Unit, Division of Surgery, Copenhagen University Hospital Herlev, Denmark
| | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
| | - Jakob Hendel
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
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Abstract
BACKGROUND Endoscopic balloon dilation and surgery are commonly practiced in stricturing Crohn's disease. Nonetheless, there are still scant data directly comparing these 2 strategies. OBJECTIVE The aim of this study was to compare the short- and long-term outcomes of endoscopic balloon dilation versus surgical resection in symptomatic Crohn's strictures. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a single tertiary center. PATIENTS Seventy-nine patients were identified, 40 in the surgical group and 39 in the endoscopic balloon dilation group (mean age 42.8 ± 13.9 versus 38.5 ± 12.2 years). MAIN OUTCOME MEASURES The outcomes of all patients referred for endoscopic balloon dilation were compared with patients referred to surgery because of stricturing disease between the years 2006 and 2013. The primary outcome was the need for reintervention (either endoscopic balloon dilation or surgery) for symptomatic Crohn's disease during follow-up. RESULTS The proportion of patients who required any reintervention during follow-up was significantly lower in the surgical group versus the endoscopic balloon dilation group (OR = 5.62 (95% CI, 1.66-19.01); p = 0.005). The need for surgery/resurgery during follow-up was also significantly lower in the surgically treated group (OR = 3.53 (95% CI, 1.01-12.29); p = 0.047). Reintervention-free survival and surgery-free survival were both significantly shorter in the endoscopically treated group in a Kaplan-Mayer analysis. The rate of major complications was similar in the endoscopically and surgically treated groups (7.6% versus 7.5%; p = 0.7). LIMITATIONS The small cohort and the retrospective data collection were limitations of this study. CONCLUSIONS In our cohort of patients with fibrostenotic Crohn's disease, a direct comparison showed reduced need for reinterventions with a similar rate of immediate major complications after surgery compared with endoscopic balloon dilation.
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Morar PS, Faiz O, Warusavitarne J, Brown S, Cohen R, Hind D, Abercrombie J, Ragunath K, Sanders DS, Arnott I, Wilson G, Bloom S, Arebi N. Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures. Aliment Pharmacol Ther 2015; 42:1137-1148. [PMID: 26358739 DOI: 10.1111/apt.13388] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/16/2015] [Accepted: 08/11/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. AIM To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. METHODS A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. RESULTS Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. CONCLUSIONS Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.
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Affiliation(s)
- P S Morar
- Department of Surgery and Cancer, Imperial College, London, UK
- St Mark's Hospital, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College, London, UK
- St Mark's Hospital, London, UK
| | - J Warusavitarne
- Department of Surgery and Cancer, Imperial College, London, UK
- St Mark's Hospital, London, UK
| | - S Brown
- Sheffield Teaching Hospitals, Sheffield, UK
| | - R Cohen
- University College Hospital, London, UK
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - J Abercrombie
- NIHR Nottingham Digestive Disease Biomedical Research Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Ragunath
- NIHR Nottingham Digestive Disease Biomedical Research Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - I Arnott
- Departments of Gastroenterology and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - G Wilson
- Departments of Gastroenterology and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - S Bloom
- University College Hospital, London, UK
| | - N Arebi
- Department of Surgery and Cancer, Imperial College, London, UK
- St Mark's Hospital, London, UK
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Abstract
Stricture and fistula are common complications of Crohn's disease. Endoscopic balloon dilation and needle-knife stricturotomy has become a valid treatment option for Crohn's disease-associated strictures. Endoscopic therapy is also increasingly used in Crohn's disease-associated fistula. Preprocedural preparations, including routine laboratory testing, imaging examination, anticoagulant management, bowel cleansing and proper sedation, are essential to ensure a successful and safe endoscopic therapy. Adverse events, such as perforation and excessive bleeding, may occur during endoscopic intervention. The endoscopist should be well trained, always be cautious, anticipate for possible procedure-associated complications, be prepared for damage control during endoscopy, and have surgical backup ready. In this review, we discuss the principle, preparation, techniques of endoscopic therapy, as well as the prevention and management of endoscopic procedure-associated complications. We propose that inflammatory bowel disease endoscopy may be a part of training for "super" gastroenterology fellows, i.e., those seeking a career in advanced endoscopy or in inflammatory bowel disease.
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Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches. Inflamm Bowel Dis 2015; 21:2194-213. [PMID: 25985249 DOI: 10.1097/mib.0000000000000403] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.
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Li Y, Stocchi L, Shen B, Liu X, Remzi FH. Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease. Br J Surg 2015; 102:1418-25; discussion 1425. [PMID: 26313750 DOI: 10.1002/bjs.9906] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/03/2015] [Accepted: 06/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear. METHODS An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013. RESULTS Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028). CONCLUSION Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.
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Affiliation(s)
- Y Li
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - L Stocchi
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - B Shen
- Departments of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - X Liu
- Departments of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - F H Remzi
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Malgras B, Pautrat K, Dray X, Pasquier P, Valleur P, Pocard M, Soyer P. Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease. Dig Dis Sci 2015; 60:1152-68. [PMID: 25381203 DOI: 10.1007/s10620-014-3421-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.
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Affiliation(s)
- Brice Malgras
- Department of Surgery, Laiboisiere Hospital, Paris 7 University and AP-HP, 2 rue Ambroise Paré, 75475, Paris Cedex 10, France,
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Buda A, Okolo PI. Endoscopic treatment of Crohn's complications. Expert Rev Gastroenterol Hepatol 2014; 8:887-95. [PMID: 24849124 DOI: 10.1586/17474124.2014.919850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.
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Affiliation(s)
- Andrea Buda
- Department of Surgical, Gastroenterological and Oncological Sciences, Division of Gastroenterology, University of Padova, 35100, Padova, Italy
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41
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Hendel J, Karstensen JG, Vilmann P. Serial intralesional injections of infliximab in small bowel Crohn's strictures are feasible and might lower inflammation. United European Gastroenterol J 2014; 2:406-12. [PMID: 25360319 DOI: 10.1177/2050640614547805] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/07/2014] [Accepted: 07/18/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Crohn's disease can cause strictures throughout the gastrointestinal tract. Endoscopic balloon dilatation is a well-established treatment, but recurrence is seen in up to three out of four cases. Infliximab is playing an increasingly important role in the modern systemic treatment of severe Crohn's disease. Combining the anti-inflammatory effects of infliximab with the proven effect of endoscopic balloon dilatation could possibly improve outcome. In small studies, intralesional injections in perianal fistulas have been effective and endoscopic injection therapy in colonic strictures is feasible. OBJECTIVE We wanted to assess whether serial intralesional injection of infliximab in small bowel strictures is feasible and reduces local inflammation. METHODS We included six patients with Crohn's disease and inflammatory small bowel strictures. They were treated with endoscopic serial balloon dilatation. Subsequent to each dilatation, 40 mg infliximab was injected submucosally. A modified simplified endoscopic score for Crohn's disease was used for the involved area before the initial treatment and at the final follow-up after six months. Complications and development of symptoms were registered. RESULTS Balloon dilatation and serial injection of infliximab were accomplished in five out of six patients. One patient completed the serial balloon dilatations and follow-up but received only one infliximab injection. The modified simplified endoscopic score for Crohn's disease decreased in all patients. There were no adverse events registered and all patients described themselves as feeling well. CONCLUSIONS Combining balloon dilatation of strictures with serial intralesional injection of infliximab in Crohn's disease of the small bowel is feasible and seems successful in reducing inflammation.
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Affiliation(s)
- Jakob Hendel
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
| | | | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
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Hirai F, Beppu T, Takatsu N, Yano Y, Ninomiya K, Ono Y, Hisabe T, Matsui T. Long-term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease. Dig Endosc 2014; 26:545-51. [PMID: 24528293 DOI: 10.1111/den.12236] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Endoscopic balloon dilation (EBD) is an alternative to surgery for small bowel strictures of patients with Crohn's disease (CD). However, little is known about the long-term efficacy of EBD. The aim of the present study was to clarify the long-term outcome of EBD for small bowel strictures in patients with CD. METHODS Subjects comprised 65 patients with CD who underwent EBD for small intestinal strictures and were followed up for at least 6 months. All subjects had obstructive symptoms as a result of small bowel strictures. Short-term success was defined as technical success and the disappearance of obstructive symptoms. The short-term success rate of EBD, its safety profile, the cumulative surgery-free rate and the cumulative redilation-free rate were investigated. RESULTS Short-term success rate was 80.0% (52/65). Complications were encountered in six of the 65 patients (9.2%). Seventeen patients (26.2%) underwent surgery during the observation period of this study. Cumulative surgery-free rate after initial EBD was 79% at 2 years and 73% at 3 years, respectively. EBD successful cases showed significantly higher surgery-free rates than unsuccessful cases (P < 0.0001). In 52 of the successful cases, the cumulative redilation-free rate after initial EBD was 64% at 2 years and 47% at 3 years, respectively. CONCLUSION EBD for small bowel strictures secondary to CD provides not only short-term success but also long-term efficacy. However, the high redilation rate is one of the clinical problems of this procedure.
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Affiliation(s)
- Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
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Hagel AF, Hahn A, Dauth W, Matzel K, Konturek PC, Neurath MF, Raithel M. Outcome and complications of endoscopic balloon dilatations in various types of ileocaecal and colonic stenosis in patients with Crohn's disease. Surg Endosc 2014; 28:2966-72. [PMID: 24853850 DOI: 10.1007/s00464-014-3559-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 04/17/2014] [Indexed: 12/12/2022]
Abstract
AIM We examined the outcome and the complications of endoscopic balloon dilatation (EBD) of ileocaecal and colonic strictures due to Crohn's disease. METHODS We examined 237 dilatation procedures in 77 patients with symptomatic ileocaecal and colonic stenosis regarding outcome, individual perforation risk, the need for further interventions, and other complications within a 10 years observation period. RESULTS In 50 of 77 patients (64.9%), endoscopic dilatation procedures were successful within a median follow-up period of 24 months (25th and 75th percentile 10-38.5 months). Thirty five patients (45.5%) were successfully dilated with only one endoscopic procedure, while the remaining patients required two or more EBDs. Albeit the EBD, 27 patients of the whole cohort (35.1%) underwent surgical repair of the stenosis in due course. Overall complication rate was 7.6%, with postdilatation bleeding in 1.7% and abdominal pain longer than 24 h in 4.2%. Perforation occurred in 4 of 77 patients (5.2%), resulting in a perforation rate of 1.7% per intervention, or, more importantly, for the individual patient in a long-term perforation rate of 5.2% per patient, respectively. DISCUSSION Endoscopic balloon dilatation (EBD) is a safe and effective approach to ileocaecal and colonic stenosis in approximately 65% of Crohn's disease patients. Even in case of recurrence, further endoscopic treatments can be undertaken. The perforation rate depending on the number of interventions is low, but for the individual patient a cumulative per patient perforation risk of 5.2% in the long-term should be considered during patient information and decisions for or against surgical interventions.
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Affiliation(s)
- Alexander F Hagel
- Department of Medicine I, University of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany,
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Govani SM, Stidham RW, Higgins PDR. How early to take arms against a sea of troubles? The case for aggressive early therapy in Crohn's disease to prevent fibrotic intestinal strictures. J Crohns Colitis 2013; 7:923-7. [PMID: 23880128 DOI: 10.1016/j.crohns.2013.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 06/17/2013] [Indexed: 02/08/2023]
Abstract
While potent anti-inflammatory medications have reduced the symptoms of Crohn's disease, more than 60% of patients eventually require surgery due to the development of fibrosis. Even after the introduction of biologic drugs, the population-based rate of surgery for Crohn's disease has not decreased. We suspect this is due to late initiation of these therapies, after the fibrosis cascade is unstoppable. We review the evidence that suggests early aggressive therapy is beneficial, especially in patients diagnosed before age 40, and with ileal or perianal disease. Patients with symptomatic strictures may benefit from early surgery (before penetrating complications) followed by initiation of biologics. With increased early use of biologics and better control of inflammation, we hope to see a global reduction in intestinal fibrosis and related complications of Crohn's disease.
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Affiliation(s)
- Shail M Govani
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI 48109, United States
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45
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Paine E, Shen B. Endoscopic therapy in inflammatory bowel diseases (with videos). Gastrointest Endosc 2013; 78:819-835. [PMID: 24139079 DOI: 10.1016/j.gie.2013.08.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/15/2013] [Indexed: 02/08/2023]
Abstract
Endoscopic therapies are important modalities in the treatment of IBD, adjunct to medical and surgical approaches. These therapeutic techniques are particularly useful in the management of IBD-associated or IBD surgery–associated strictures, fistulas, and sinuses and colitis-associated neoplasia. Although the main focus of endoscopic therapies in IBD has been on balloon stricture dilation and ablation of adenoma-like lesions, new endoscopic approaches are emerging, including needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement, and fistula tract injection. Risk management of endoscopy-associated adverse events is also evolving. The application of endoscopic techniques in novel ways in the treatment of IBD is just beginning and will likely expand rapidly in the near future.
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Affiliation(s)
- Elizabeth Paine
- Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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Annese V, Daperno M, Rutter MD, Amiot A, Bossuyt P, East J, Ferrante M, Götz M, Katsanos KH, Kießlich R, Ordás I, Repici A, Rosa B, Sebastian S, Kucharzik T, Eliakim R. European evidence based consensus for endoscopy in inflammatory bowel disease. J Crohns Colitis 2013; 7:982-1018. [PMID: 24184171 DOI: 10.1016/j.crohns.2013.09.016] [Citation(s) in RCA: 578] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 09/20/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Vito Annese
- Dept. Gastroenterology, University Hospital Careggi, Largo Brambilla 3, 50139 Florence, Italy.
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Bevan R, Rees CJ, Rutter MD, Macafee DAL. Review of the use of intralesional steroid injections in the management of ileocolonic Crohn's strictures. Frontline Gastroenterol 2013; 4:238-243. [PMID: 28839732 PMCID: PMC5370054 DOI: 10.1136/flgastro-2012-100297] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/06/2013] [Accepted: 03/07/2013] [Indexed: 02/04/2023] Open
Abstract
Most patients with Crohn's disease present with either terminal ileal or colonic disease, with 70% requiring surgery by 10 years after diagnosis. Recurrent stricturing at the anastomotic site is common, often symptomatic and can require re-operation with its inherent risks. Balloon dilation has been shown to provide good symptom relief from such strictures. However, repeat dilations may be required, and further surgical intervention to an anastomotic stricture is needed in up to 30% of cases. Injection of corticosteroids has been suggested as an adjunct to dilation in order to improve outcomes. This paper reviews the current literature on the use of intralesional steroid injections following endoscopic balloon dilation of anastomotic and de novo Crohn's strictures. There have been only two randomised placebo controlled trials and five small non-controlled or retrospective studies. Study numbers vary from 10 to 29 patients. The two randomised trials conflict in their conclusions and numbers are small in these studies. Currently therefore, no firm support can be given to the routine use of intralesional steroid injections.
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Affiliation(s)
- Roisin Bevan
- Northern Region Endoscopy Group, UK,Department of Gastroenterology, South Tyneside District General Hospital, South Shields, UK
| | - Colin J Rees
- Northern Region Endoscopy Group, UK,Department of Gastroenterology, South Tyneside District General Hospital, South Shields, UK,Durham University, Durham, UK
| | - Matthew D Rutter
- Northern Region Endoscopy Group, UK,Durham University, Durham, UK,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - David A L Macafee
- Northern Region Endoscopy Group, UK,James Cook University Hospital, Middlesbrough, UK
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49
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Honzawa Y, Nakase H, Matsuura M, Higuchi H, Toyonaga T, Matsumura K, Yoshino T, Okazaki K, Chiba T. Prior use of immunomodulatory drugs improves the clinical outcome of endoscopic balloon dilation for intestinal stricture in patients with Crohn's disease. Dig Endosc 2013; 25:535-43. [PMID: 23363364 DOI: 10.1111/den.12029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 11/28/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic balloon dilation is a promising procedure to improve symptoms of intestinal stricture in patients with Crohn's disease (CD). However, the long-term efficacy of endoscopic balloon dilation combined with immunomodulatory drugs remains unclear. The aim of the present study is to investigate whether prior use of immunomodulatory drugs affects the clinical outcome of endoscopic balloon dilation for intestinal stricture in CD. PATIENTS AND METHODS Between January 2004 and December 2011, 83 dilations were carried out in 25 patients with CD. Median follow-up period was 46 months. Patients were categorized into two groups based on their medications at the first endoscopic balloon dilation: early immunomodulatory drug-induction group (early IM-induction group) in which patients were already treated with immunomodulatory drugs before the dilation; and post-immunomodulatory drug-induction group (post-IM-induction group) in which patients were not yet treated withimmunomodulatory drugs before dilation. We compared the long-term cumulative non-surgical rate and the mean number of dilation procedures per patient between early and post-IM-induction groups to clarify the influence of prior use of immunomodulatory drugs on the clinical outcome of endoscopic balloon dilation. RESULTS There was a significant difference in the mean number of dilation procedures per patient between the early IM-induction and post-IM-induction groups (P = 0.04), although no significant difference in the cumulative non-surgical rate was observed between the two groups (P = 0.14). CONCLUSION Prior use of immunomodulatory drugs may improve the clinical outcome of endoscopic balloon dilation for intestinal stricture in CD.
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Affiliation(s)
- Yusuke Honzawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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50
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Wu XR, Mukewar S, Kiran RP, Remzi FH, Shen B. Surgical stricturoplasty in the treatment of ileal pouch strictures. J Gastrointest Surg 2013; 17:1452-61. [PMID: 23690206 DOI: 10.1007/s11605-013-2216-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/22/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures. METHOD Consecutive inflammatory bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses. RESULTS A total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6 ± 13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2 ± 0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures (p = 0.019). After a mean follow-up of 4.1 ± 2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group (p < 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups. CONCLUSION Surgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.
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Affiliation(s)
- Xian-rui Wu
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
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