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Cwaliński J, Lorek F, Mazurkiewicz Ł, Mazurkiewicz M, Lizurej W, Paszkowski J, Cholerzyńska H, Zasada W. Surgical and non-surgical risk factors affecting the insufficiency of ileocolic anastomosis after first-time surgery in Crohn's disease patients. World J Gastrointest Surg 2024; 16:3253-3260. [PMID: 39575265 PMCID: PMC11577414 DOI: 10.4240/wjgs.v16.i10.3253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 07/20/2024] [Accepted: 08/01/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Crohn's disease (CD) often necessitates surgical intervention, particularly when it manifests in the terminal ileum and ileocecal valve. Despite undergoing radical surgery, a subset of patients experiences recurrent inflammation at the anastomotic site, necessitating further medical attention. AIM To investigate the risk factors associated with anastomotic insufficiency following ileocecal resection in CD patients. METHODS This study enrolled 77 patients who underwent open ileocolic resection with primary stapled anastomosis. Patients were stratified into two groups: Group I comprised individuals without anastomotic insufficiency, while Group II included patients exhibiting advanced anastomotic destruction observed endoscopically or those requiring additional surgery during the follow-up period. Surgical and non-surgical factors potentially influencing anastomotic failure were evaluated in both cohorts. RESULTS Anastomotic insufficiency was detected in 12 patients (15.6%), with a mean time interval of 30 months between the initial surgery and recurrence. The predominant reasons for re-intervention included stenosis and excessive perianastomotic lesions. Factors associated with a heightened risk of anastomotic failure encompassed prolonged postoperative obstruction, anastomotic bleeding, and clinically confirmed micro-leakage. Additionally, patients in Group II exhibited preoperative malnutrition and early recurrence of symptoms related to CD. CONCLUSION Successful surgical outcomes hinge on the attainment of a fully functional anastomosis, optimal metabolic status, and clinical remission of the underlying disease. Vigilant endoscopic surveillance following primary resection facilitates the timely identification of anastomotic failure, thereby enabling noninvasive interventions.
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Affiliation(s)
- Jaroslaw Cwaliński
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
| | - Filip Lorek
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
| | - Łukasz Mazurkiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
| | - Michał Mazurkiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
| | - Wojciech Lizurej
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
| | - Jacek Paszkowski
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
| | - Hanna Cholerzyńska
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
| | - Wiktoria Zasada
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan 60-355, Poland
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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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De Voogd FA, Mookhoek A, Gecse KB, De Hertogh G, Bemelman WA, Buskens CJ, D'Haens GR. Systematic Review: Histological Scoring of Strictures in Crohn's Disease. J Crohns Colitis 2020; 14:734-742. [PMID: 32645156 DOI: 10.1093/ecco-jcc/jjz177] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In Crohn's disease, many patients develop a stricture, which can due to inflammation, fibrosis and muscular changes or all at the same time. Determining the predominant component has therapeutic consequences but remains challenging. To develop imaging techniques that assess the nature of a stricture, a gold standard is needed and histopathology is considered as such. This paper provides an overview of published histological scoring systems for strictures in Crohn's disease. METHODS A systematic literature review according to PRISMA guidelines was performed of histological scoring indices that assessed whether a stricture was inflammation-predominant or fibrosis-predominant. Multiple libraries were searched from inception to December 2018. Two reviewers independently assessed abstracts and full-texts. RESULTS Sixteen articles were identified as suitable for this systematic review. A large number of parameters were reported. Extent of neutrophil infiltration and extent of fibrosis in the bowel wall were most frequently described to reflect severity of inflammation and fibrosis, respectively. Among the 16 studies, only two described a numerical scoring system for the inflammatory and fibrotic component separately. Smooth muscle changes were scored in a minority of studies. CONCLUSIONS Multiple scoring systems have been developed. There was large heterogeneity in scoring per parameter and construction of numerical scoring systems. Therefore, we feel that none of the systems is suitable to be used as gold standard. We offer an overview of histological parameters that could be incorporated in a future histological scoring index for strictures.
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Affiliation(s)
- F A De Voogd
- Amsterdam UMC, Amsterdam Medical Center, University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - A Mookhoek
- Amsterdam UMC, VU Medical Center, VU University, Department of Pathology, Amsterdam, The Netherlands
| | - K B Gecse
- Amsterdam UMC, Amsterdam Medical Center, University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - G De Hertogh
- University Hospitals Leuven, University of Leuven, Department of Pathology, Leuven, Belgium
| | - W A Bemelman
- Amsterdam UMC, Amsterdam Medical Center, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - C J Buskens
- Amsterdam UMC, Amsterdam Medical Center, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - G R D'Haens
- Amsterdam UMC, Amsterdam Medical Center, University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
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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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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: 11] [Impact Index Per Article: 1.8] [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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Lenti MV, Di Sabatino A. Intestinal fibrosis. Mol Aspects Med 2018; 65:100-109. [PMID: 30385174 DOI: 10.1016/j.mam.2018.10.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/19/2018] [Accepted: 10/28/2018] [Indexed: 02/07/2023]
Abstract
Extensive tissue fibrosis is the end-stage process of a number of chronic conditions affecting the gastrointestinal tract, including inflammatory bowel disease (Crohn's disease, ulcerative colitis), ulcerative jejunoileitis, and radiation enteritis. Fibrogenesis is a physiological, reparative process that may become harmful as a consequence of the persistence of a noxious agent, after an excessive duration of the healing process. In this case, after replacement of dead or injured cells, fibrogenesis continues to substitute normal parenchymal tissue with fibrous connective tissue, leading to uncontrolled scar formation and, ultimately, permanent organ damage, loss of function, and/or strictures. Several mechanisms have been implicated in sustaining the fibrogenic process. Despite their obvious etiological and clinical distinctions, most of the above-mentioned fibrotic disorders have in common a persistent inflammatory stimulus which sustains the production of growth factors, proteolytic enzymes, and pro-fibrogenic cytokines that activate both non-immune (i.e., myofibroblasts, fibroblasts) and immune (i.e., monocytes, macrophages, T-cells) cells, the interactions of which are crucial in the progressive tissue remodeling and destroy. Here we summarize the current status of knowledge regarding the mechanisms implicated in gut fibrosis with a clinical approach, also focusing on possible targets of antifibrogenic therapies.
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Affiliation(s)
- Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
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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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8
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Scoville EA, Schwartz DA. Endoscopy in inflammatory bowel disease: advances in disease management. Gastrointest Endosc 2017; 86:952-961. [PMID: 28886962 DOI: 10.1016/j.gie.2017.08.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Elizabeth A Scoville
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David A Schwartz
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Nishida Y, Hosomi S, Yamagami H, Yukawa T, Nagami Y, Tanaka F, Kamata N, Tanigawa T, Shiba M, Watanabe T, Tominaga K, Fujiwara Y, Arakawa T. Analysis of the Risk Factors of Surgery after Endoscopic Balloon Dilation for Small Intestinal Strictures in Crohn's Disease Using Double-balloon Endoscopy. Intern Med 2017; 56:2245-2252. [PMID: 28794359 PMCID: PMC5635294 DOI: 10.2169/internalmedicine.8224-16] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Balloon-assisted endoscopy enables access to and treatment of strictures in the small intestine using endoscopic balloon dilation (EBD); however, the long-term outcomes of EBD have not been sufficiently evaluated. This study evaluated the long-term outcomes of EBD in Crohn's disease to identify the risk factors associated with the need for subsequent surgical intervention. Methods We retrospectively analyzed patients with Crohn's disease who had undergone EBD with double-balloon endoscopy (DBE) for small intestinal strictures at a single center between 2006 and 2015. The long-term outcomes were assessed based on the cumulative surgery-free rate following initial EBD. Results Seventy-two EBD with DBE sessions and 112 procedures were performed for 37 patients during this period. Eighteen patients (48.6%) required surgery during follow-up. Significant factors associated with the need for surgery in a multivariate analysis were multiple strictures (adjusted hazard ratio, 14.94; 95% confidence interval, 1.91-117.12; p=0.010). One patient (6.7%) required surgery among 15 who had single strictures compared to 17 (77.3%) among 22 patients with multiple strictures. Conclusion In a multivariate analysis, the presence of multiple strictures was a significant risk factor associated with the need for surgery; therefore, a single stricture might be a good indication for EBD using DBE for small intestinal strictures in Crohn's disease patients.
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Affiliation(s)
- Yu Nishida
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Tomomi Yukawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Masatsugu Shiba
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Kazunari Tominaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Tetsuo Arakawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
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10
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Bharadwaj S, Shen B. Medical, endoscopic, and surgical management of ileal pouch strictures (with video). Gastrointest Endosc 2017; 86:59-73. [PMID: 28189635 DOI: 10.1016/j.gie.2017.01.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 01/31/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Shishira Bharadwaj
- Department of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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11
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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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12
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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: 171] [Impact Index Per Article: 21.4] [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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13
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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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14
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Bettenworth D, Lopez R, Hindryckx P, Levesque BG, Rieder F. Heterogeneity in endoscopic treatment of Crohn's disease-associated strictures: An international inflammatory bowel disease specialist survey. J Gastroenterol 2016; 51:939-948. [PMID: 26831355 DOI: 10.1007/s00535-016-1172-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards. METHODS IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated. RESULTS A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001). CONCLUSIONS EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.
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Affiliation(s)
- Dominik Bettenworth
- Department of Medicine B, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pieter Hindryckx
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Barrett G Levesque
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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15
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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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16
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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17
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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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18
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Irani S, Kozarek RA. Techniques and principles of endoscopic treatment of benign gastrointestinal strictures. Curr Opin Gastroenterol 2015; 31:339-350. [PMID: 26247823 DOI: 10.1097/mog.0000000000000200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio. RECENT FINDINGS Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition. SUMMARY Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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19
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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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20
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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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21
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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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22
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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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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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Antonopoulos P, Almyroudi M, Kolonia V, Kouris S, Troumpoukis N, Economou N. Toxic Megacolon and Acute Ischemia of the Colon due to Sigmoid Stenosis Related to Diverticulitis. Case Rep Gastroenterol 2013; 7:409-13. [PMID: 24163654 PMCID: PMC3806696 DOI: 10.1159/000355345] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
We present a rare case of toxic megacolon accompanied by necrosis of the colon due to chronic dilation caused by stenosis of the sigmoid colon as a complication of diverticulitis. The patient presented at the emergency department with diffuse abdominal pain, fever (38.8°C) and tachycardia (120 beats/min). Physical examination revealed distension and tenderness on deep palpation on the left lower quadrant without peritoneal signs. Abdominal computed tomography showed located stenosis in the sigmoid colon and marked dilation of the descending (12 cm diameter) and transverse (7.5 cm diameter) colon. A few hours later, the patient developed severe septic shock with electrolyte abnormalities. He had a history of two prior admissions to our hospital due to crises of acute diverticulitis. Based on Jalan's criteria the diagnosis was compatible with toxic megacolon. The patient's condition deteriorated suddenly and an emergency colectomy was performed. The operative findings revealed a necrotic colon. Histology examination confirmed the diagnosis of ischemia of the colon. To our knowledge this is the first published report in the literature which refers to a rare complication of diverticulitis, namely chronic stenosis which complicated to colonic ischemia and toxic megacolon.
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Affiliation(s)
- P Antonopoulos
- Computed Tomography and Magnetic Resonance Imaging Department, Sismanogleio General Hospital, Athens, Greece
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26
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Nanda K, Courtney W, Keegan D, Byrne K, Nolan B, O'Donoghue D, Mulcahy H, Doherty G. Prolonged avoidance of repeat surgery with endoscopic balloon dilatation of anastomotic strictures in Crohn's disease. J Crohns Colitis 2013; 7:474-80. [PMID: 22898397 DOI: 10.1016/j.crohns.2012.07.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 07/15/2012] [Accepted: 07/20/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There is a high rate of stricturing post-operative recurrence in Crohn's disease (CD) particularly at sites of surgical anastomosis, and over 50% of these patients will require a repeat resection. Endoscopic dilatation of anastomotic strictures is an alternative to surgical resection in selected patients. We aimed to evaluate the safety and long term efficacy of endoscopic balloon dilatation of symptomatic anastomotic strictures in CD. METHODS Retrospective analysis of a prospectively maintained inflammatory bowel disease database of patients attending a single academic centre (n=1244 patients with CD) who underwent dilatation. RESULTS Fifty-five dilatations were performed in 31 patients (mean age 43 ± SD 12, 47% female). Median follow-up period was 46 months (IQR 14-62). Ninety percent of patients had successful initial dilatation and no complications occurred. Six (21%) avoided further dilatations or surgery in the follow-up period. Stricture recurrence was detected in 22 patients; 15 (54%) patients had repeat dilatations and seven (25%) went straight to surgery. Eight (28%) patients were managed with repeat dilatations of the stricture (median dilatations=2 range 2-6) and seven (25%) required surgery despite repeat dilatations. Median time from first dilatation to repeat surgery was 14.5 months (IQR 3-28) and to repeat dilatation was 13.8 months (IQR 4-28). There was no difference in immunomodulator use, biologic use and smoking status between the groups requiring surgery versus dilatation only. CONCLUSION Endoscopic balloon dilatation of anastomotic strictures is safe and effective in providing symptomatic relief in CD patients. Forty-five percent of patients had a sustained response to single/serial balloon dilatation with avoidance of further surgical resection for a median interval of 46 months. Post-operative medical therapy and smoking status did not predict requirement for recurrent dilatation or surgery.
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Affiliation(s)
- Kavinderjit Nanda
- Centre for Colorectal Disease, St. Vincent's University Hospital/University College Dublin, Dublin, Ireland.
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de’Angelis N, Carra MC, Borrelli O, Bizzarri B, Vincenzi F, Fornaroli F, De Caro G, de’Angelis GL. Short- and long-term efficacy of endoscopic balloon dilation in Crohn's disease strictures. World J Gastroenterol 2013; 19:2660-2667. [PMID: 23674873 PMCID: PMC3645384 DOI: 10.3748/wjg.v19.i17.2660] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 12/31/2012] [Accepted: 01/18/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate short- and long-term efficacy of endoscopic balloon dilation in a cohort of consecutive patients with symptomatic Crohn's disease (CD)-related strictures. METHODS Twenty-six CD patients (11 men; median age 36.8 year, range 11-65 years) with 27 symptomatic strictures underwent endoscopic balloon dilation (EBD). Both naive and post-operative strictures, of any length and diameter, with or without associated fistula were included. After a clinical and radiological assessment, EBD was performed with a Microvasive Rigiflex through the scope balloon system. The procedure was considered successful if no symptom reoccurred in the following 6 mo. The long-term clinical outcome was to avoid surgery. RESULTS The mean follow-up time was 40.7 ± 5.7 mo (range 10-94 mo). In this period, forty-six EBD were performed with a technical success of 100%. No procedure-related complication was reported. Surgery was avoided in 92.6% of the patients during the entire follow-up. Two patients, both presenting ileocecal strictures associated with fistula, failed to respond to the treatment and underwent surgical strictures resection. Of the 24 patients who did not undergo surgery, 11 patients received 1 EBD, and 13 required further dilations over time for the treatment of relapsing strictures (7 patients underwent 2 dilations, 5 patients 3 dilations, and 1 patient 4 dilations). Overall, the EBD success rate after the first dilation was 81.5%. No difference was observed between the EBD success rate for naive (n = 12) and post-operative (n = 15) CD related strictures (P > 0.05). CONCLUSION EBD appears to be a safe and effective procedure in the therapeutic management of CD-related strictures of any origin and dimension in order to prevent surgery.
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Dubcenco E, MacDonald JK, Feagan BG. A comparison of endoscopic and surgical treatment of strictures in patients with Crohn’s disease. Hippokratia 2013. [DOI: 10.1002/14651858.cd010428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Elena Dubcenco
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London Ontario Canada N6A 5K8
| | - John K MacDonald
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London Ontario Canada N6A 5K8
| | - Brian G Feagan
- Robarts Research Institute; Robarts Clinical Trials; P.O. Box 5015 100 Perth Drive London Ontario Canada N6A 5K8
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Endo K, Takahashi S, Shiga H, Kakuta Y, Kinouchi Y, Shimosegawa T. Short and long-term outcomes of endoscopic balloon dilatation for Crohn’s disease strictures. World J Gastroenterol 2013; 19:86-91. [PMID: 23326167 PMCID: PMC3542755 DOI: 10.3748/wjg.v19.i1.86] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 10/08/2012] [Accepted: 10/30/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the short and long-term outcomes of endoscopic balloon dilatation (EBD) for Crohn’s disease (CD) strictures.
METHODS: Between January 1995 and December 2011, 47 EBD procedures were performed in 30 patients (8 females and 22 males) with CD. All patients had strictures through which an endoscope could not pass, and symptoms of these strictures included abdominal pain, abdominal fullness, nausea, and/or vomiting. The 47 strictures included 17 anastomotic and 30 de novo strictures. Endoscopy and dilatation were performed under conscious sedation with intravenous diazepam or flunitrazepam. The dilatations were all performed using through-the-scope balloons with diameters from 8 mm to 20 mm on inflation and lengths of 30-80 mm. Each dilatation session consisted of two to four, 3-min multistep inflations of the balloon, repeated at intervals of 1 wk until adequate dilatation (up to 15-20 mm in diameter) was achieved. The follow-up data were collected from medical records and analyzed retrospectively. Primary success was defined as passage of the scope through the stricture after EBD. Long-term outcomes were analyzed focusing on intervention-free survival and surgery-free survival demonstrated by the Kaplan-Meier method. (Intervention-free meant cases in which neither endoscopic balloon re-dilatation nor surgery was needed after the first dilatation during the observation period). The log rank test was used to evaluate the difference in long-term outcomes between anastomotic and de novo stricture cases.
RESULTS: Primary success was achieved in 44 of the 47 strictures (93.6%). Balloon dilatations failed in 3 cases (6.4%). In 1 case, EBD was a technical failure because the guide-wire could not be passed through the stricture which showed severe adhesion and was a flexural lesion of the intestine. In 2 cases, unexpected perforations occurred immediately after balloon dilatation. Of the 47 treatments, complications occurred in 5 (10.6%). All 5 patients had de novo strictures. One suffered bleeding, two high fever and there were colorectal perforations. One of the patients with a colorectal perforation was treated surgically, the other was managed conservatively. These 2 cases correspond to the two aforementioned EBD failures. Long-term outcomes were evaluated for the 44 successfully-treated strictures after a median follow-up of 26 mo (range, 2-172 mo). During the observation period, re-strictures after EBDs occurred in 26 cases (60.5%). Fourteen of these 26 re-stricture cases underwent EBD again, but in two EBD failed and surgery was ultimately performed in both cases. Twelve of the 26 re-stricture cases were initially treated surgically when the re-strictures occurred. Finally, 30 of the 47 strictures (63.8%) were successfully managed with EBD, allowing surgery to be avoided. Intervention-free survival evaluated by the Kaplan-Meier method was 75% at 12 mo, 58% at 24 mo, and 43% at 36 mo. There was no significant difference between the anastomotic strictures (n = 16) and de novo strictures (n = 28) in the intervention-free survival as evaluated by the log-rank test. Surgery-free survival evaluated by the Kaplan-Meier method was 90% at 12 mo, 75% at 24 mo, and 53% at 36 mo. The 16 anastomotic strictures were associated with significantly better surgery-free survivals than the 28 de novo strictures (log-rank test: P < 0.05).
CONCLUSION: Anastomotic strictures were associated with better long-term outcomes than de novo strictures, indicating that stricture type might be useful for predicting the long-term outcomes of EBD.
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Hashash JG, Regueiro MD. The evolving management of postoperative Crohn's disease. Expert Rev Gastroenterol Hepatol 2012; 6:637-48. [PMID: 23061713 DOI: 10.1586/egh.12.45] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two-thirds to three-quarters of Crohn's disease patients require intestinal surgery for medically refractory disease or complications. Surgery is not a cure and most patients develop recurrent Crohn's disease and require additional intestinal resections. There are a number of medications that have been investigated for preventing and treating recurrence. Risk factors for postoperative disease recurrence help guide the physician in determining the appropriate treatment strategy after Crohn's disease surgery. The approach to Crohn's disease treatment has evolved over the years. No longer should surgery be considered a failure of treatment, rather an important intervention to correct irreversible disease. In combination with a better understanding of postoperative medication strategies, patients with Crohn's disease may achieve longer term remission than previously realized. This review elucidates current understanding of the natural course of postoperative Crohn's disease, monitoring for recurrence, the risk factors for recurrence, and provides insight into an evolving new paradigm for postoperative Crohn's disease treatment.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street-PUH, M2, C-Wing, Pittsburgh, PA 15213, USA.
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31
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Louis E, Gast P, Van Kemseke C, Reenaers C. Commentary: endoscopic dilatation for stricturing Crohn's disease. Aliment Pharmacol Ther 2012; 36:494-6. [PMID: 22860612 DOI: 10.1111/j.1365-2036.2012.05209.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- E Louis
- Department of Gastroenterology, University Hospital CHU of Liège, Belgium.
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32
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Gustavsson A, Magnuson A, Blomberg B, Andersson M, Halfvarson J, Tysk C. Endoscopic dilation is an efficacious and safe treatment of intestinal strictures in Crohn's disease. Aliment Pharmacol Ther 2012; 36:151-8. [PMID: 22612326 DOI: 10.1111/j.1365-2036.2012.05146.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 03/21/2012] [Accepted: 05/02/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bowel strictures are a major cause of morbidity, hospitalisation and surgery in Crohn's disease. AIM We report short- and long-term efficacy and safety of endoscopic balloon dilation of strictures due to Crohn's disease. METHODS Retrospective study of patients who underwent endoscopic balloon dilation between 1987 and 2009. RESULTS We performed 776 dilations, of which 621 (80%) were on anastomotic strictures, in 178 patients (94 women) with Crohn's disease. At first dilation, median (IQR) age of patients was 45 (37-56) years and disease duration 16 (8-22) years. Technical success rate was 689/776 (89%). A subset of 75 patients from the primary catchment area, with >5-year follow-up, underwent a total of 246 dilations. At 1-year follow-up, 60/75 (80%) patients had undergone no further intervention or one additional dilation only. At 3 and 5 years, corresponding figures were 43/75 (57%) and 39/75 (52%). Cumulative proportions of patients undergoing surgery at 1, 3 and 5 years were 13%, 28% and 36%. Complication rate per procedure for all 178 patients was 41/776 (5.3%), bowel perforation (n = 11, 1.4%), major bleeding requiring blood transfusion (n = 8, 1.0%), minor bleeding (n = 10, 1.3%) and abdominal pain or fever (n = 12, 1.5%). Ten patients underwent surgery due to complications (perforation n = 8, bleeding n = 2). There was no procedure-related mortality. CONCLUSIONS Endoscopic balloon dilation is an efficacious and safe alternative to surgical resection of intestinal strictures in Crohn's disease. At 5-year follow-up, 52% of patients required no further or one additional dilation only, whereas 36% had undergone surgical resection. Complication frequency was low.
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Affiliation(s)
- A Gustavsson
- Department of Medicine, Division of Gastroenterology, Örebro University Hospital, Sweden
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33
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Chan G, Fefferman DS, Farrell RJ. Endoscopic assessment of inflammatory bowel disease: colonoscopy/esophagogastroduodenoscopy. Gastroenterol Clin North Am 2012; 41:271-90. [PMID: 22500517 DOI: 10.1016/j.gtc.2012.01.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endoscopy plays an important role in the initial diagnosis of IBD, including the evaluation of disease severity, activity, and extent. The implications of complete mucosal healing further confirm the function of endoscopy in the follow-up of IBD patients. The use of therapeutic endoscopy, for example stricture dilatation, can avoid the need for bowel resection. Modalities such as capsule endoscopy, EUS, NBI, CE, and other emerging techniques are likely to have an increasing role in the management of IBD, particularly in the area of dysplasia surveillance and treatment.
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Affiliation(s)
- Grace Chan
- Gastroenterology Department, Connolly Hospital Blanchardstown, Dublin, Republic of Ireland
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Lorenzo-Zúñiga V, García-Planella E, Moreno De Vega V, Domènech E, Boix J. [Endoscopic management of luminal stenosis in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:404-10. [PMID: 22341673 DOI: 10.1016/j.gastrohep.2011.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 11/27/2022]
Abstract
Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.
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35
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Ko OB, Ye BD, Yang SK, Kim JH, Shin JH, Kim KM, Byeon JS, Myung SJ, Song HY, Kim JH. The outcome of fluoroscopically guided balloon dilation of pyloric stricture in Crohn disease. J Vasc Interv Radiol 2011; 22:1153-1158. [PMID: 21570874 DOI: 10.1016/j.jvir.2011.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 03/04/2011] [Accepted: 03/10/2011] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To evaluate the clinical efficacy and safety of fluoroscopically guided balloon dilation for pyloric stricture associated with Crohn disease (CD) while monitoring the outcome. MATERIALS AND METHODS Five patients (age range 15-34 y) were diagnosed with symptomatic pyloric stricture associated with CD between November 2006 and August 2009. All five patients underwent fluoroscopically guided balloon dilation one or more times. RESULTS The initial balloon dilations were technically successful in all patients. Two patients showed improvement of symptoms without further need of dilation, two patients had one more session of dilation, and one patient underwent two more sessions of repeated dilation. There were no procedure-related complications. Overall technical and clinical success rates were 100%. After the last dilation, all patients remained healthy, with no case of relapse of obstructive symptoms during the median follow-up of 16 months (range 6-22 mo). CONCLUSIONS Fluoroscopically guided balloon dilation seems to be a useful tool for management of symptomatic pyloric stricture in CD and may be a viable alternative to open surgery.
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Affiliation(s)
- Ock Bae Ko
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul 138-736, Republic of Korea
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36
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Vadlamudi N, Alkhouri N, Mahajan L, Lopez R, Shen B. Ileoscopy via stoma after diverting ileostomy: a safe and effective tool to evaluate for Crohn's recurrence of neoterminal ileum. Dig Dis Sci 2011; 56:866-70. [PMID: 20635144 DOI: 10.1007/s10620-010-1332-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 06/18/2010] [Indexed: 12/09/2022]
Abstract
BACKGROUND Recurrence of Crohn's disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied. OBJECTIVE To evaluate the safety and utility of retrograde ileoscopy via stoma in patients with CD. METHODS Patients with CD who underwent ileoscopy via stoma between January 1, 2001, through December 31, 2008 were included. This was a retrospective study in a tertiary referral center. The main outcome measures were procedural complications and findings. RESULTS A total of 243 ileoscopies were performed on 99 patients. The most common indications for ileoscopy were CD activity assessment in 34.5% and abdominal pain in 33.3%. The procedure was outpatient in 75.8%. Meperidine and midazolam were most commonly used. Average depth of intubation was 28.4 cm. CD recurrence was detected in 70% of patients. Biopsies were obtained during ileoscopy in 117 studies, and biopsy and ileoscopy findings correlated in 111 studies (94.8%). One polypectomy, 24 balloon stricture dilations, and 8 intralesional steroid injections were performed. All patients tolerated the procedure well without procedure- or anesthesia-related complications. No hospital admissions or procedure-related deaths occurred. CONCLUSIONS Retrograde ileoscopy via stoma is a safe and effective procedure for evaluating recurrence of CD of the neoterminal ileum. It also allows for therapeutic interventions such as balloon dilatation of ileal strictures and steroid injections.
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Affiliation(s)
- Narendra Vadlamudi
- Department of Pediatric Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Scimeca D, Mocciaro F, Cottone M, Montalbano LM, D'Amico G, Olivo M, Orlando R, Orlando A. Efficacy and safety of endoscopic balloon dilation of symptomatic intestinal Crohn's disease strictures. Dig Liver Dis 2011; 43:121-5. [PMID: 20561831 DOI: 10.1016/j.dld.2010.05.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 04/12/2010] [Accepted: 05/04/2010] [Indexed: 12/11/2022]
Abstract
AIM To evaluate prospectively the clinical efficacy and safety of endoscopic hydrostatic balloon dilation in a consecutive cohort of symptomatic intestinal Crohn's disease strictures. METHODS Between September 2003 and December 2008 we performed endoscopic balloon dilations in 37 Crohn's disease patients with 39 intestinal symptomatic strictures (4 naïve and 35 postoperative). Dilations were performed using a Rigiflex through-the-scope balloon. Clinical success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation, following technical success. Actuarial curves of clinical, endoscopic (redilation) and surgical recurrence were obtained by Kaplan-Meier method. Demographic and disease variables were related to the main outcomes. RESULTS After a mean follow-up of 26.3 months (range, 2-61 months), the long-term global benefit rate was 89% (33/37). The 1-2-3 years cumulative symptom-free rates were respectively: 76%, 55% and 46%. Four patients were operated upon. Technical success predicts a lower rate of surgery. There were no complications related to the endoscopic procedures. CONCLUSIONS Endoscopic balloon dilation of symptomatic Crohn's disease strictures may achieve clinical benefit in many patients and is a valid alternative to surgery in the management of the disease. Dilation may be repeated in recurrent intestinal obstructions and appears safe without morbidity.
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Affiliation(s)
- Daniela Scimeca
- Department of Medicine, Pneumology and Nutrition Clinic, V Cervello Hospital, Palermo University, Palermo, Italy.
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Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature. Int J Colorectal Dis 2010; 25:1149-57. [PMID: 20628881 DOI: 10.1007/s00384-010-1010-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence. METHODS We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP. RESULTS The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months. CONCLUSION Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.
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Mueller T, Rieder B, Bechtner G, Pfeiffer A. The response of Crohn's strictures to endoscopic balloon dilation. Aliment Pharmacol Ther 2010; 31:634-9. [PMID: 20047581 DOI: 10.1111/j.1365-2036.2009.04225.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic balloon dilation has been shown to be an alternative to surgery in the treatment of Crohn's symptomatic strictures. AIM To analyse the impact of the type of the strictures -de novo or anastomotic - their location and their length on the outcome of endoscopic balloon dilation. METHODS Between December 1999 and June 2008, 55 patients underwent 93 balloon dilations for 74 symptomatic strictures. One stricture was located in the duodenum, 39 strictures were in the terminal ileum, 17 at the ileocoecal anastomosis after a preceding resection and 17 in the colon. RESULTS Endoscopic treatment was successful in 76% of the patients during an observation period of 44 (1-103) months. Of the patients, 24% required surgery. All patients who underwent surgery had de novo strictures in the terminal ileum. These strictures were significantly longer compared with the ileal strictures that responded to endoscopic treatment [7.5 (1-25) cm vs. 2.5 (1-25) cm; P = 0.006]. CONCLUSIONS The long-term success of endoscopic balloon dilation depends on the type of the strictures, their location and their length. Failure of endoscopic treatment was observed only in long-segment strictures in the terminal ileum.
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Affiliation(s)
- T Mueller
- Department of Gastroenterology, Klinikum Memmingen, Memmingen, Germany.
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Kochhar R, Poornachandra KS. Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures. World J Gastrointest Endosc 2010; 2:61-8. [PMID: 21160692 PMCID: PMC2999060 DOI: 10.4253/wjge.v2.i2.61] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Revised: 09/07/2009] [Accepted: 09/15/2009] [Indexed: 02/05/2023] Open
Abstract
Esophageal strictures are a problem frequently encountered by gastroenterologists. Dilation has been the customary treatment for benign esophageal strictures, and dilation techniques have advanced over the years. Depending on their characteristics and the response to treatment, esophageal strictures can be classified into two types: 1, simple (Schatzki rings, webs, peptic injury, and following sclerotherapy) - these are easily amenable to dilation, with a low recurrence rate after initial treatment; and 2, complex (caused by caustic ingestion, radiation injury, anastomotic strictures, and photodynamic therapy) - these are difficult to dilate and are associated with higher recurrence rates. Refractory strictures are those in which it is not possible to relieve the anatomic restriction successfully up to a diameter of 14 mm over five sessions at 2-weekly intervals, due to cicatricial luminal compromise or fibrosis; and recurrent strictures are those in which it is not possible to maintain a satisfactory luminal diameter for 4 wk once the target diameter of 14 mm has been achieved. There are no standard recommendations for the management of refractory strictures. The various techniques used include intralesional steroid injection combined with dilation; endoscopic incisional therapy, with or without dilation; placement of self-expanding metal stents, Polyflex stents, or biodegradable stents; self-bougienage; and endoscopic surgery. This review discusses the indications, technique, results, and complications of the use of intralesional steroid injections combined with dilation and endoscopic incisional therapy with dilation in refractory strictures.
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Affiliation(s)
- Rakesh Kochhar
- Rakesh Kochhar, Kuchhangi Suresh Poornachandra, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Coelho J, Soyer P, Pautrat K, Boudiaf M, Vahedi K, Reignier S, Valleur P, Marteau P. [Management of ileal stenosis in patients with Crohn's disease]. ACTA ACUST UNITED AC 2009; 33:F75-81. [PMID: 19733458 DOI: 10.1016/j.gcb.2009.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Stenosis is the most frequent complication during Crohn's disease. The lesion can be inflammatory, or due to a fibrosing or neoplastic process. The medical treatment with anti-inflammatory drugs is usually sufficient as first line treatment; fibrous lesions require endoscopic or surgical procedures while neoplastic lesions require surgery. A multidisciplinary approach (radiologic, medical, surgical and endoscopic) is needed. In a first part, we discuss the definition of stenosis and the modalities of imaging (particularly MRI) and of treatment (particularly with TNFalpha antagonists). Then we expose the strategy for the management of the most frequent clinical situations: occlusion, ileal inflammatory stenosis, stenosis of an ileocolonic anastomosis and chronic fibrous stenosis. The treatment decision takes into account the results of radiological assessment, CRP level and the effects of the previous treatments.
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Affiliation(s)
- J Coelho
- Département médicochirurgical de pathologie digestive, hôpital Lariboisière, 2 rue Ambroise-Paré, Paris, France
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Stienecker K, Gleichmann D, Neumayer U, Glaser HJ, Tonus C. Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn's disease: a prospective study. World J Gastroenterol 2009. [PMID: 19496192 DOI: 10.3748/wjg.15.2623.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
AIM To examine the long-term results of endoscopic treatment in a prospective study conducted over a period of 10 years, 1997 to January 2007. METHODS A total of 25 patients (20 female and five male: aged 18-75 years), with at least one symptom of stricture not passable with the standard colonoscope and with a confirmed scarred Crohn's stricture of the lower gastrointestinal tract, were included in the study. The main symptom was abdominal pain. The endoscopic balloon dilatation was performed with an 18 mm balloon under endoscopic and radiological control. RESULTS Eleven strictures were located in the colon, 13 at the anastomosis after ileocecal resection, three at the Bauhin valve and four in the ileum. Four patients had two strictures and one patient had three strictures. Of the 31 strictures, in 30 was balloon dilatation successful in a single endoscopic session, so that eventually the strictures could be passed easily with the standard colonoscope. In one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart, sufficient dilatation was not possible. This patient therefore required surgery. Improvement of abdominal symptoms was achieved in all cases which had technically successful balloon dilatation, although in one case perforation occurred after dilatation of a recurrent stricture. Available follow-up was in the range of 54-118 mo (mean of 81 mo). The relapse rate over this period was 46%, but 64% of relapsing strictures could be successfully dilated again. Only in four patients was surgery required during this follow-up period. CONCLUSION We conclude from these initial results that endoscopic balloon dilatation, especially for short strictures in Crohn's disease, can be performed with reliable success. Perforation is a rare complication. It is our opinion that in the long-term, the relapse rate is probably higher than after surgery, but usually a second endoscopic treatment can be performed successfully, leading to a considerable success rate of the endoscopic procedure.
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Affiliation(s)
- Klaus Stienecker
- Department of Visceral Surgery, Herz-Jesu-Hospital Fulda, Buttlarstrasse 74, D-36039 Fulda, Germany
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Abstract
Spiral enteroscopy is a new technique for endoscopic evaluation of the small bowel. Currently, more than 3000 cases have been performed worldwide. The Discovery SB device has been approved by the Food and Drug Administration and has been granted a CE mark. The technique is safe and effective for management and detection of small bowel pathology. Recent studies of spiral enteroscopy have demonstrated diagnostic yield, total time of procedure, and depth of insertion that compare favorably with double and single balloon enteroscopy. The strengths of spiral enteroscopy are rapid advancement in the small bowel and controlled, stable withdrawal that facilitates therapy. Future studies will be needed to compare competing technologies. Push enteroscopy is a readily available, safe and effective technique for detecting and treating proximal gut pathology. If performed without an overtube, complications are rare. Use of a dedicated push enteroscope with an overtube is generally reserved for specific indications in which a moderate increase in depth of insertion into the small bowel is required. When capsule endoscopy and deep small bowel enteroscopy are not available, push enteroscopy is a reasonable option with low risk and moderate yield. Push enteroscopy will remain an important part of the armamentarium of the modern endoscopist.
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Stienecker K, Gleichmann D, Neumayer U, Glaser HJ, Tonus C. Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn’s disease: A prospective study. World J Gastroenterol 2009; 15:2623-7. [PMID: 19496192 PMCID: PMC2691493 DOI: 10.3748/wjg.15.2623] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the long-term results of endoscopic treatment in a prospective study conducted over a period of 10 years, 1997 to January 2007.
METHODS: A total of 25 patients (20 female and five male: aged 18-75 years), with at least one symptom of stricture not passable with the standard colonoscope and with a confirmed scarred Crohn’s stricture of the lower gastrointestinal tract, were included in the study. The main symptom was abdominal pain. The endoscopic balloon dilatation was performed with an 18 mm balloon under endoscopic and radiological control.
RESULTS: Eleven strictures were located in the colon, 13 at the anastomosis after ileocecal resection, three at the Bauhin valve and four in the ileum. Four patients had two strictures and one patient had three strictures. Of the 31 strictures, in 30 was balloon dilatation successful in a single endoscopic session, so that eventually the strictures could be passed easily with the standard colonoscope. In one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart, sufficient dilatation was not possible. This patient therefore required surgery. Improvement of abdominal symptoms was achieved in all cases which had technically successful balloon dilatation, although in one case perforation occurred after dilatation of a recurrent stricture. Available follow-up was in the range of 54-118 mo (mean of 81 mo). The relapse rate over this period was 46%, but 64% of relapsing strictures could be successfully dilated again. Only in four patients was surgery required during this follow-up period.
CONCLUSION: We conclude from these initial results that endoscopic balloon dilatation, especially for short strictures in Crohn’s disease, can be performed with reliable success. Perforation is a rare complication. It is our opinion that in the long-term, the relapse rate is probably higher than after surgery, but usually a second endoscopic treatment can be performed successfully, leading to a considerable success rate of the endoscopic procedure.
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Van Assche G, Vermeire S, Rutgeerts P. What can we expect from endoscopic dilation of the stenotic tract in Crohn's disease? Inflamm Bowel Dis 2008; 14 Suppl 2:S275-6. [PMID: 18816706 DOI: 10.1002/ibd.20648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Gert Van Assche
- Division of Gastroenterology, Leuven University Hospital, Leuven, Belgium
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Hoffmann JC, Heller F, Faiss S, von Lampe B, Kroesen AJ, Wahnschaffe U, Schulzke JD, Zeitz M, Bojarski C. Through the endoscope balloon dilation of ileocolonic strictures: prognostic factors, complications, and effectiveness. Int J Colorectal Dis 2008; 23:689-96. [PMID: 18338175 DOI: 10.1007/s00384-008-0461-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS About half of all Crohn's disease (CD) patients undergo surgery at some point, many because of strictures. An alternative possibility is to dilate strictures endoscopically. However, little is known about prognostic factors. PATIENTS AND METHODS Thirty-two patients with primary CD (n=2), radiogenic strictures (n=1), or postoperative strictures (27 because of CD; 2 after resection because of cancer), were planned to undergo colonoscopic dilatation of which 25 patients were dilated (10 men; 15 women; median age 48). Length of stenosis, diameter of stricture, balloon size, smoking status, ulcer in the stricture, passage postdilatation, hemoglobin level, complications, redilatation, and subsequent surgery were recorded. Only patients with at least 6 months follow up were included. RESULTS Five out of 32 patients had no stenosis, marked inflammation, or fistulas adjacent to the stricture. One patient each had a long stricture (8 cm) or a filiform stenosis ruling out dilatation [technical success, 25/27 (92.6%)]. Among these 25 patients, 39 colonoscopies with 51 dilatations were performed. After a single dilatation, 52% were asymptomatic while 48% needed another intervention, half of them surgery. Bleeding without need for transfusion occurred in 3 out of 39 colonoscopies and one perforation required surgery. Significant prognostic factors were smoking and ulcers in the stricture (P<0.05 each). Some ulcers led to intussusception requiring surgery in spite of good dilatation results. CONCLUSION Through the endoscope balloon stricture dilatation is a relatively safe and often effective treatment modality in ileocolonic strictures. The presence of ulcers in the stricture have a worse outcome as do smokers.
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Affiliation(s)
- Jörg C Hoffmann
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Charité, Campus Benjamin Franklin, 12200 Berlin, Germany.
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Hassan C, Zullo A, De Francesco V, Ierardi E, Giustini M, Pitidis A, Taggi F, Winn S, Morini S. Systematic review: Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther 2007; 26:1457-1464. [PMID: 17903236 DOI: 10.1111/j.1365-2036.2007.03532.x] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic dilatation for Crohn's disease has been evaluated only in some small and heterogeneous studies. AIM To evaluate any association between the main clinical variables and endoscopic variables and the efficacy and safety of endoscopic dilatation in Crohn's disease. METHODS A Medline search regarding pneumatic dilatation in Crohn's disease was performed. Several technical and clinical variables were extracted from each study to build up a descriptive, pool-data analysis. Data on individual patients were extracted from suitable studies to create a simulated population upon which a multivariate statistical analysis was performed. RESULTS Thirteen studies enrolling 347 Crohn's disease patients were reviewed. Endoscopic dilatation was mainly applied to postsurgical strictures, being technically successful in 86% of the cases. Long-term clinical efficacy was achieved in 58% of the patients. Mean follow-up was as long as 33 months, corresponding to 800 patient years of follow-up. Major complication rate was 2%, being higher than 10% in two series. At multivariate analysis, a stricture length < or = 4 cm was associated with a surgery-free outcome (OR: 4.01; 95% CI: 1.16-13.8; P < 0.028). CONCLUSIONS Endoscopic dilatation is an effective and safe treatment for short strictures caused by Crohn's disease, impacting substantially on the natural history of these patients.
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Affiliation(s)
- C Hassan
- Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.
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Strong SA, Koltun WA, Hyman NH, Buie WD. Practice parameters for the surgical management of Crohn's disease. Dis Colon Rectum 2007; 50:1735-46. [PMID: 17690937 DOI: 10.1007/s10350-007-9012-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Scott A Strong
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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Gisbert JP, Gomollón F. Errores frecuentes en el manejo del paciente ambulatorio con enfermedad inflamatoria intestinal. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:469-86. [DOI: 10.1157/13110491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Fukumoto A, Tanaka S, Yamamoto H, Yao T, Matsui T, Iida M, Goto H, Sakamoto C, Chiba T, Sugano K. Diagnosis and treatment of small-bowel stricture by double balloon endoscopy. Gastrointest Endosc 2007; 66:S108-12. [PMID: 17709019 DOI: 10.1016/j.gie.2007.02.027] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 02/12/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The source of small-bowel stricture is often difficult to diagnose due to the difficulty of placing an endoscope into the small bowel. It has recently become possible to examine the entire small bowel and perform balloon dilatation for stricture by means of double balloon endoscopy (DBE). OBJECTIVE To identify clinical features of small-bowel stricture and determine the validity of balloon dilatation as a treatment option. DESIGN Retrospective multicenter study. SETTING Researchers at 7 institutions affiliated with the DBE Working Group. PATIENTS One hundred seventy-nine patients with stricture among a total of 1035 patients who underwent DBE at the 7 institutions. INTERVENTIONS Surgical treatment or balloon dilatation was performed as clinically indicated. MAIN OUTCOME MEASUREMENTS Ability to detect stricture lesions by DBE, types of lesions, locations of small-bowel strictures, details of strictures, treatments for strictures, and outcomes of balloon dilatation for strictures associated with inflammatory disease. RESULTS The total number of patients with strictures was 179. Lesions were detected within the small bowel in 156 patients. Inflammatory disease was the most common (n = 87) in patients with small-bowel stricture, and the ileum was the most common site of the inflammatory disease. Crohn's disease was the most common of the inflammatory diseases (n = 57). Balloon dilatations were performed in 31 patients with inflammatory disease, and long-term success was achieved in 22 patients. LIMITATIONS The number of patients treated by balloon dilatation was small. CONCLUSION DBE appears to be useful for the detection as well as treatment of small-bowel lesions.
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Affiliation(s)
- Akira Fukumoto
- Department of Endoscopy, Hiroshima University Hospital, Japan
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