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Isoldi S, Mallardo S, Quitadamo P, Leter B, Cucchiara S. Review on Advances in Pediatric Endoscopy in the Management of Inflammatory Bowel Disease. Curr Pediatr Rev 2025; 21:154-165. [PMID: 38265388 DOI: 10.2174/0115733963268547231128101929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/26/2023] [Accepted: 10/19/2023] [Indexed: 01/25/2024]
Abstract
Over the past decades, an increased importance has been given to gastrointestinal (GI) endoscopy in the management of children with inflammatory bowel diseases (IBD), considering that mucosal healing has been recognized as the optimal endpoint in the treat-to-target paradigm. The recent advances in technology and anesthesia have facilitated the comprehensive evaluation of the GI tract. In this review, we will discuss the role of ileocolonoscopy, upper GI endoscopy, and device-assisted enteroscopy in the work-up and management of pediatric Crohn's disease (CD) and ulcerative colitis, with particular attention on non-invasive endoscopic techniques, such as wireless capsule endoscopy. We will also analyze the most commonly used endoscopic scoring systems, including small bowel scoring systems and endoscopic recurrence grading of neo-terminal ileum CD. Moreover, we will focus on the endoscopic management of complications, such as strictures, that commonly require surgery. Lastly, we will discuss cancer surveillance in children with IBD, with particular consideration of the role of high-definition endoscopic equipment and chromoendoscopy in dysplasia detection rates.
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Affiliation(s)
- Sara Isoldi
- Pediatric Gastroenterology and Hepatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
- Maternal and Child Health Department, Santa Maria Goretti Hospital, Sapienza-University of Rome, Latina, Italy
| | - Saverio Mallardo
- Maternal and Child Health Department, Santa Maria Goretti Hospital, Sapienza-University of Rome, Latina, Italy
| | - Paolo Quitadamo
- Pediatric Gastroenterology and Hepatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Beatrice Leter
- Department of Women's and Children's Health, Sapienza University of Rome, Rome, Italy
| | - Salvatore Cucchiara
- Department of Women's and Children's Health, Sapienza University of Rome, Rome, Italy
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2
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Sharma P, Stavropoulos SN. Endoscopic management of colonic perforations. Curr Opin Gastroenterol 2025; 41:29-37. [PMID: 39602135 DOI: 10.1097/mog.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2024]
Abstract
PURPOSE OF REVIEW We will review the current management of colonic perforations, with particular emphasis on iatrogenic perforations caused by colonoscopy, the leading etiology. We will focus on recently developed endoscopic techniques and technologies that obviate morbid emergency surgery (the standard management approach in years past). RECENT FINDINGS Colonic perforations are rare but potentially fatal complications of both diagnostic and therapeutic colonoscopy resulting in death in approximately 5% of cases with the mortality increasing with delay in diagnosis and treatment. As novel endoscopic techniques and tools have flourished in recent years, our approach to management of these perforations has evolved. With the availability of newer tools such as over the scope clips, enhanced through the scope clips and novel endoscopic suturing devices, colonic perforations can be managed effectively in many or most patients without the morbidity of surgical interventions. SUMMARY With expanding use of colonoscopy, inadvertent outcomes such as perforations are bound to increase as well. Early diagnosis permits minimally invasive, nonsurgical, endoscopic management in most cases if the expertise and tools are available. Centers with high colonoscopy volumes including therapeutic procedures would be well served to invest in the requisite technologies and expertise.
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Affiliation(s)
- Prabin Sharma
- Division of Gastroenterology, Hartford Healthcare- St. Vincent's Medical Center, Bridgeport, Connecticut
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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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Cooper JL, Rosentreter RE, Filyk A, Premji ZA, Shen H, Ingram R, Kaplan GG, Ma C, Novak K, Panaccione R, Seow CH, Rieder F, Raman M, Lu C. Nutritional interventions in adult fibrostenotic Crohn's disease: A systematic review. Front Nutr 2023; 10:1017382. [PMID: 36895272 PMCID: PMC9988909 DOI: 10.3389/fnut.2023.1017382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
Background Management of Crohn's disease (CD) using dietary interventions has become an area of increased research interest. There is a lack of specific research exploring if diet and nutrition interventions are beneficial in patients with strictures, as current dietary recommendations in fibrostenotic CD are often based on clinical judgment. The aim of this systematic review was to assess the impact of dietary interventions in fibrostenotic CD on medical and surgical outcomes. Methods A systematic search of MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and Cochrane Central Register of Controlled Trials (Ovid) was conducted. Studies reporting dietary interventions or nutritional factors in fibrostenotic CD were included. Outcomes for studies assessing dietary interventions such as enteral nutrition were evaluated as changes in (1) CD symptoms (CD Activity Index), (2) stricture parameters on diagnostic imaging, and (3) rates of surgical or medical intervention following dietary interventions. Results Five studies were included in this review. Three studies assessed exclusive enteral nutrition (EEN), one evaluated total parenteral nutrition (TPN), and one studied a liquid diet. All included studies evaluated symptoms as an outcome, while diagnostic imaging parameters and surgical outcomes in the studies were either absent or too heterogeneous to appraise improvement post dietary intervention. Included EEN studies displayed similar efficacy, with approximately 60% of patients having symptom improvement. The included TPN study also reported 75% of patients with symptom improvement, while the liquid diet did not. Conclusion Exclusive enteral nutrition and total parental nutrition may provide benefit for use as a dietary intervention for fibrostenotic CD. There remains a need for high-quality controlled trials which utilize standardized definitions of strictures.
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Affiliation(s)
- Jared L. Cooper
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ryan E. Rosentreter
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alexis Filyk
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Hua Shen
- Department of Mathematics and Statistics, University of Calgary, Calgary, AB, Canada
| | - Richard Ingram
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gilaad G. Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Kerri Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cynthia H. Seow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Maitreyi Raman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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Systematic Review of Endoscopic Management of Stricture, Fistula and Abscess in Inflammatory Bowel Disease. GASTROENTEROLOGY INSIGHTS 2023. [DOI: 10.3390/gastroent14010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background: Interventional inflammatory bowel disease (IIBD) therapies can play a key role in inflammatory bowel disease (IBD) related stricture/fistula/abscess deferring or avoiding invasive surgery. Methods: A total of 112 studies pertaining to IIBD therapy for strictures/fistula/abscess between 2002 and December 2022 were included by searching Pubmed, Medline and Embase with a focus on technical/clinical success, recurrence, re-intervention and complications. Results: IIBD therapy for strictures include endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES) and self-expanding metal stent (SEMS) placement. EBD is the primary therapy for short strictures while ES and SEMS can be used for refractory strictures. ES has higher long-term efficacy than EBD. SEMS is inferior to EBD although it can be useful in long, refractory strictures. Fistula therapy includes endoscopic incision and drainage (perianal fistula)/endoscopic seton (simple, low fistula) and endoscopic ultrasound-guided drainage (pelvic abscess). Fistulotomy can be done for short, superficial, single tract, bowel-bowel fistula. Endoscopic injection of filling agents (fistula plug/glue/stem cell) is feasible although durability is unknown. Endoscopic closure therapies like over-the-scope clips (OTSC), suturing and SEMS should be avoided for de-novo/bowel to hollow organ fistulas. Conclusion: IIBD therapies have the potential to act as a bridge between medical and surgical therapy for properly selected IBD-related stricture/fistula/abscess although future controlled studies are warranted.
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Yamamoto H, Yano T, Araki A, Esaki M, Ohtsuka K, Ohmiya N, Oka S, Nakase H, Bamba S, Hirai F, Hosoe N, Matsuda T, Mitsui K, Watanabe K, Ogata H, Katsuki S, Matsumoto T, Fujishiro M, Fujimoto K, Inoue H. Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures (supplement to the Clinical Practice Guidelines for Enteroscopy). Dig Endosc 2022; 34:1278-1296. [PMID: 36073310 DOI: 10.1111/den.14429] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/05/2022] [Indexed: 12/13/2022]
Abstract
Balloon-assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease-associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure-related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline.
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Affiliation(s)
| | - Tomonori Yano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akihiro Araki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Motohiro Esaki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazuo Ohtsuka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Ohmiya
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shiro Oka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroshi Nakase
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shigeki Bamba
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Fumihito Hirai
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Hosoe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Tomoki Matsuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Keigo Mitsui
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenji Watanabe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Haruhiko Ogata
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | | | | | - Haruhiro Inoue
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Sivasailam B, Lane BF, Cross RK. Endoscopic Balloon Dilation of Strictures: Techniques, Short- and Long-Term Outcomes, and Complications. Gastrointest Endosc Clin N Am 2022; 32:675-686. [PMID: 36202509 DOI: 10.1016/j.giec.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
EBD is safe and effective for the treatment of strictures. Here we describe the technique of endoscopic balloon dilation (EBD) of strictures including preprocedure considerations, indications, contraindications, and postprocedure complications. The short- and long-term outcomes of EBD including factors associated with improved outcomes are also discussed.
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Affiliation(s)
- Barathi Sivasailam
- Department of Medicine, Division of Gastroenterology and Hepatology, NYU Langone, New York, NY, USA
| | - Barton F Lane
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 685 West Baltimore Street, Suite 8-00, Baltimore, MD 21201, USA.
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McSorley B, Cina RA, Jump C, Palmadottir J, Quiros JA. Endoscopic balloon dilation for management of stricturing Crohn’s disease in children. World J Gastrointest Endosc 2021; 13:382-390. [PMID: 34630888 PMCID: PMC8474695 DOI: 10.4253/wjge.v13.i9.382] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/15/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn’s disease (CD) has a multitude of complications including intestinal strictures from fibrostenotic disease. Fibrostenotic disease has been reported in 10%-17% of children at presentation and leads to surgery in 20%-50% of cases within ten years of diagnosis. When symptoms develop from these strictures, the treatment in children has primarily been surgical resection. Endoscopic balloon dilation (EBD) has been shown to be a safe and efficacious alternative to surgery in adults, but evidence is poor in the literature regarding its safety and efficacy in children.
AIM To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.
METHODS In a single-center retrospective study, we looked at pediatric patients (ages 0-18) who carry the diagnosis of CD, who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1, 2012 through May 1, 2019. We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype. The type of intervention for patients’ strictures was then identified through procedural and surgical billing codes. We evaluated their demographics, clinical variables, whether they underwent EBD vs surgery or both, and their clinical outcomes.
RESULTS Of the 139 patients with CD, 25 (18%) developed strictures. The initial intervention for a stricture was surgical resection in 12 patients (48%) and EBD in 13 patients (52%). However, 4 (33%) patients whom initially had surgical resection required follow up EBD, and thus 17 total patients (68%) underwent EBD at some point in their treatment process. For those 8 patients who underwent successful surgical resection alone, 4 of these patients (50%) had a fistula present near the stricture site and 4 (50%) had strictures greater than 5 cm in length. All patients who underwent EBD had no procedural complications, such as a perforation. Twenty-two (88%) of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.
CONCLUSION EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.
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Affiliation(s)
- Brianna McSorley
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Robert A Cina
- Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Candi Jump
- Department of Pediatric Gastroenterology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Johanna Palmadottir
- Department of Pediatric Gastroenterology, MUSC Children's Hospital, Charleston, SC 29425, United States
| | - J Antonio Quiros
- Department of Pediatric Gastroenterology and Nutrition, Mount Sinai Kravis Children's Hospital, New York, NY 10029, United States
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Sivasailam B, Manski S, Wentz A, Cross RK. Presence of Obstructive Symptoms and Absence of Perianal Crohn Disease Is Predictive of Surgery After Endoscopic Balloon Dilation. Inflamm Bowel Dis 2021; 27:1230-1236. [PMID: 33165536 DOI: 10.1093/ibd/izaa276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with Crohn disease (CD) often develop strictures that require surgery. Endoscopic balloon dilation (EBD) is an alternative treatment that can be safe and effective. The objective of this study was to assess factors associated with the need for repeat EBD and surgery after initial EBD for stricturing CD. METHODS Patients with stricturing CD who underwent EBD from 2007 to 2017 were identified. Demographic and clinical information was obtained from the electronic medical record. A Cox proportional hazards regression model and Kaplan-Meier curves were generated for variables associated with repeat EBD and surgical resection. RESULTS Ninety-nine patients underwent a total of 240 EBD proedures; 35% had a history of perianal disease, and 63% were on a biologic at the time of initial EBD. Fifty-one percent of patients had obstructive symptoms at the time of initial EBD, and 75% of the EBDs were successful. Complications occurred in 8 EBDs (3.3%). Repeat intervention after EBD was more likely in patients on biologics at baseline EBD (76% vs 54%; P = 0.029). Thirty-three percent of patients had surgical resection at a median of 5 months (interquartile ratio = 2.0-13.0 months) after initial EBD. The presence of obstructive symptoms at the time of EBD was associated with surgical resection (hazard ratio = 3.18; 95% confidence interval, 1.28-7.86). Conversely, a history of perianal disease was negatively associated with surgical resection (hazard ratio = 0.27; 95% confidence interval, 0.10-0.68). CONCLUSIONS Patients on biologic treatment at the time of EBD are more likely to need an intervention in the future. Patients with obstructive symptoms at the time of initial EBD and those without a history of perianal involvement are more likely to undergo surgical intervention.
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Affiliation(s)
- Barathi Sivasailam
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Scott Manski
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Alicia Wentz
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
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Schulberg JD, Wright EK, Holt BA, Wilding HE, Hamilton AL, Ross AL, Kamm MA. Efficacy of drug and endoscopic treatment of Crohn's disease strictures: A systematic review. J Gastroenterol Hepatol 2021; 36:344-361. [PMID: 33150989 DOI: 10.1111/jgh.15330] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Strictures are the commonest complication in Crohn's disease. Surgery and endoscopic dilation are the mainstays of treatment, while drug therapy has often been considered contraindicated. The benefit of nonsurgical treatments, particularly drug and endoscopic therapy, need to be defined. METHODS Ovid MEDLINE, Embase, Emcare, PsycINFO, CINAHL and the Cochrane Library (inception until August 30, 2019) were searched. Studies with ≥ 10 patients with Crohn's disease strictures, reporting on outcomes following medication or endoscopic treatment, were included. RESULTS Of 3480 records, 85 studies met inclusion criteria and formed the basis of this analysis. Twenty-five studies assessed drug therapy; none were randomized trials. Despite study heterogeneity anti-tumor necrosis factor (TNF) therapy appeared effective, with 50% of patients avoiding surgery after 4 years of follow up. No other drug therapy was of demonstrable benefit. Sixty studies assessed endoscopic therapy including 56 on endoscopic balloon dilation, two assessed needle knife stricturotomy, and two stent insertion. Dilation was equally effective for de novo and anastomotic strictures ≤ 5 cm in length, with most studies reporting a subsequent surgical rate of 30% to 50%. Repeat dilation was required in approximately half of all patients. CONCLUSIONS Anti-TNF drug therapy and endoscopic balloon dilation are effective strategies for avoiding surgery in patients with stricturing Crohn's disease. Additional endoscopic therapies require further evaluation. Early data suggest that combining these therapies may provide greater benefit than individual therapies. Optimization of current drug and endoscopic therapy, and the incorporation of newer therapies, are needed for stricturing Crohn's disease.
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Affiliation(s)
- Julien D Schulberg
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Bronte A Holt
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Helen E Wilding
- Library Service, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Amy L Hamilton
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Alyson L Ross
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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11
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Chang CW, Tu CH, Chou JW, Huang TY, Hsu WH, Wang YP, Chen CC, Chung CS, Lin CP, Lin WC, Tai CM, Wang HY, Chen MJ. Endoscopic management of strictures in patients with Crohn's disease - A multi-center experience in Taiwan. J Formos Med Assoc 2020; 119:1500-1505. [PMID: 31917065 DOI: 10.1016/j.jfma.2019.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/11/2019] [Accepted: 12/16/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND/PURPOSE Inflammatory bowel disease (IBD) is a chronic gastrointestinal (GI) disorder that causes relapsing inflammation and severe mucosal damage in the intestine. Crohn's disease (CD)-related stricturing complications are a major cause of surgery, disability, and reduced quality of life. Endoscopic balloon dilation (EBD) has been shown to reliably delay or prevent surgery in patients with stricturing CD. However, cases of EBD performed for stricture in CD in Taiwan are rare. In this study, we want to evaluate the experiences regarding EBD for stricturing CD in Taiwan. METHODS We conducted a retrospective analysis of 9 medical centers in Taiwan. Patients with CD-related strictures who were treated with EBD were included and analyzed. RESULTS In nine medical centers, a total of 26 CD patients (19 male, 7 female, mean disease duration 75.4 ± 65.2 months) underwent 42 EBD procedures during the study period. Among the subjects, an 83.3% (35/42) EBD success rate was seen, but 26.9% (7/26) patients underwent surgery after ineffective EBD. In the surgery group, the the small bowel strictures was high compared with the non-surgery group (p = 0.01). There were no significant differences in disease phenotype, disease duration or history of fistulizing disease. In the surgery group, immunosuppressant use was high, and 5-aminosalicylic acid (5-ASA) use was low compared with the non-surgery group. After EBD, the physicians tended to change the drugs, especially increasing the use of biologic agents. CONCLUSION EBD is a safe and effective procedure for CD-related stricture, with a 83.3% success rate in Taiwan.
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Affiliation(s)
- Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Chia-Hung Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tien-Yu Huang
- Department of Gastroenterology, Tri-Service General Hospital, Taipei, Taiwan
| | - Wen-Hung Hsu
- Department of Gastroenterology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Po Wang
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Cheng Chen
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine,I-Shou University, Kaohsiung, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ching-Pin Lin
- Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Chi-Ming Tai
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine,I-Shou University, Kaohsiung, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan.
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12
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A nationwide, multi-center, retrospective study of symptomatic small bowel stricture in patients with Crohn's disease. J Gastroenterol 2020; 55:615-626. [PMID: 31989252 DOI: 10.1007/s00535-020-01670-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 01/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Small bowel stricture is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilatation (EBD) is a minimally invasive treatment intended to avoid surgery; however, whether EBD prevents subsequent surgery remains unclear. We aimed to reveal the factors contributing to surgery in patients with small bowel stricture and the factors associated with subsequent surgery after initial EBD. METHODS Data were retrospectively collected from surgically untreated CD patients who developed symptomatic small bowel stricture after 2008 when the use of balloon-assisted enteroscopy and maintenance therapy with anti-tumor necrosis factor (TNF) became available. RESULTS A total of 305 cases from 32 tertiary referral centers were enrolled. Cumulative surgery-free survival was 74.0% at 1 year, 54.4% at 5 years, and 44.3% at 10 years. The factors associated with avoiding surgery were non-stricturing, non-penetrating disease at onset, mild severity of symptoms, successful EBD, stricture length < 2 cm, and immunomodulator or anti-TNF added after onset of obstructive symptoms. In 95 cases with successful initial EBD, longer EBD interval was associated with lower risk of surgery. Receiver operating characteristic analysis revealed that an EBD interval of ≤ 446 days predicted subsequent surgery, and the proportion of smokers was significantly high in patients who required frequent dilatation. CONCLUSIONS In CD patients with symptomatic small bowel stricture, addition of immunomodulator or anti-TNF and smoking cessation may improve the outcome of symptomatic small bowel stricture, by avoiding frequent EBD and subsequent surgery after initial EBD.
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13
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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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14
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Dalzell AM, Ba'Ath ME. Paediatric inflammatory bowel disease: review with a focus on practice in low- to middle-income countries. Paediatr Int Child Health 2019; 39:48-58. [PMID: 30900526 DOI: 10.1080/20469047.2019.1575056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Inflammatory bowel disease (IBD) should be considered in any child with a persistently altered bowel habit. Growth failure may be a consequence and there may also be extra-intestinal manifestations. Oesophago-gastroduodenoscopy and colonoscopy and conventional histopathology are the diagnostic tools of choice in IBD. The identification and management of children with IBD in resource-poor settings is difficult and there are few data on its prevalence in low- and middle-income countries. The main challenges are a lack of resources and infrastructure including trained personnel in settings where there are other priorities for maintaining the health and wellbeing of children. The identification and management of children with inflammatory bowel conditions often depends on the enthusiasm, skill and commitment of a few dedicated individuals. Abbreviations: ADA: Adalimumab; CD: Crohn disease; ECCO: European Crohn's and Colitis Organisation; EEN: exclusive enteral nutrition; ESPGHAN: European Society for Paediatric Gastroenterology Hepatology and Nutrition; FMT: faecal microbiota transplantation; GDP: gross domestic product; HIC: high-income countries; IBD: inflammatory bowel disease; IBDU: inflammatory bowel disease unclassified; IC: ileocolonoscopy; IFX: infliximab; IPAA: ileal pouch anal anastomosis; LMIC: low- and middle-income countries; MH: mucosal healing; OGD: oesophago-gastroduodenoscopy; PCDAI: Paediatric Crohn's Disease Activity Index; PIBD: paediatric inflammatory bowel disease; PUCAI: Paediatric Ulcerative Colitis Activity Index; UC: ulcerative colitis; UGIT: upper gastrointestinal tract; VEO-IBD: very early-onset IBD; WLE: white light endoscopy; 5-ASA: 5 aminosalicylic acid; 6-MP: 6-mercaptopurine.
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15
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Oliva S, Thomson M, de Ridder L, Martín-de-Carpi J, Van Biervliet S, Braegger C, Dias JA, Kolacek S, Miele E, Buderus S, Bronsky J, Winter H, Navas-López VM, Assa A, Chong SKF, Afzal NA, Smets F, Shaoul R, Hussey S, Turner D, Cucchiara S. Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:414-430. [PMID: 30130311 DOI: 10.1097/mpg.0000000000002092] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.
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Affiliation(s)
- Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Lissy de Ridder
- Pediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Javier Martín-de-Carpi
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Christian Braegger
- Division of Gastroenterology and Nutrition, University Children's Hospital, Zurich, Switzerland
| | - Jorge Amil Dias
- Pediatric Gastroenterology Unit, Hospital Sao João, Porto, Portugal
| | - Sanja Kolacek
- Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, "Federico II," University of Naples, Italy
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Harland Winter
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | | | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, affiliated to the Sackler faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sonny K F Chong
- Queen Mary's Hospital for Children, Epsom & St Helier University Hospitals NHS Trust, Carshalton, Surrey
| | - Nadeem Ahmad Afzal
- Department of Paediatric Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Francoise Smets
- Pediatric Gastroenterology and Hepatology Unit, IREC, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Séamus Hussey
- National Children's Research Centre and Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
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16
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Danese S, Bonovas S, Lopez A, Fiorino G, Sandborn WJ, Rubin DT, Kamm MA, Colombel JF, Sands BE, Vermeire S, Panes J, Rogler G, D'Haens G, Peyrin-Biroulet L. Identification of Endpoints for Development of Antifibrosis Drugs for Treatment of Crohn's Disease. Gastroenterology 2018; 155:76-87. [PMID: 29601825 DOI: 10.1053/j.gastro.2018.03.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/20/2018] [Accepted: 03/19/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Intestinal fibrosis is a challenge to management of patients with Crohn's disease (CD); there is an urgent need to expedite development of antifibrosis drugs for this disease. The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) aimed to identify a set of endpoints that can be used to determine efficacy of antifibrosis agents tested in clinical trials of patients with CD. METHODS We conducted a systematic review to identify clinical, radiologic, biochemical, endoscopic, and composite endpoints used in assessing activity of fibrostenosing CD and response to treatment, and determined their operational properties. A panel of IOIBD experts performed a consensus process to identify the best endpoints for inclusion in clinical trials, through a 2-round, Delphi-style online survey. RESULTS A total of 36 potentially relevant endpoints for intestinal fibrosis were selected and assessed. Forty-eight physicians with expertise in inflammatory bowel disease, from 5 regions (North America, Europe, Middle East, Asia/Pacific, and Latin America), participated in the Delphi consensus process. A core set of 13 endpoints (complete clinical response, long-term efficacy, sustained clinical benefit, treatment failure, radiological remission, normal quality of life, clinical remission without steroids, therapeutic failure, deep remission, complete absence of occlusive symptoms, symptom-free survival, bowel damage progression, and no disability) were rated as critical. Agreement was high among the experts. CONCLUSIONS Members of the IOIBD reached expert consensus on a set of endpoints that can be used to assess antifibrosis agents in trials of patients with CD. Studies are needed to clarify methods for measuring these outcomes and validate measurement instruments.
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Affiliation(s)
- Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy.
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Anthony Lopez
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Gionata Fiorino
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | | | - Michael A Kamm
- Departments of Gastroenterology and Medicine, St Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Severine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Julian Panes
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | | | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
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17
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Bessissow T, Reinglas J, Aruljothy A, Lakatos PL, Van Assche G. Endoscopic management of Crohn's strictures. World J Gastroenterol 2018; 24:1859-1867. [PMID: 29740201 PMCID: PMC5937203 DOI: 10.3748/wjg.v24.i17.1859] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/14/2018] [Accepted: 04/23/2018] [Indexed: 02/06/2023] Open
Abstract
Symptomatic intestinal strictures develop in more than one third of patients with Crohn's disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.
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Affiliation(s)
- Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Jason Reinglas
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Achuthan Aruljothy
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Peter L Lakatos
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1085, Hungary
| | - Gert Van Assche
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Belgium and University of Leuven, Leuven 3000, Belgium
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18
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Bharadwaj S, Narula N, Tandon P, Yaghoobi M. Role of endoscopy in inflammatory bowel disease. Gastroenterol Rep (Oxf) 2018; 6:75-82. [PMID: 29780594 PMCID: PMC5952948 DOI: 10.1093/gastro/goy006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/04/2018] [Indexed: 12/12/2022] Open
Abstract
Crohn’s disease (CD) and ulcerative colitis (UC) constitute the two most common phenotypes of inflammatory bowel disease (IBD). Ileocolonoscopy with biopsy has been considered the gold standard for the diagnosis of IBD. Differential diagnosis of CD and UC is important, as their medical and surgical treatment modalities and prognoses can be different. However, approximately 15% of patients with IBD are misdiagnosed as IBD unclassified due to the lack of diagnostic certainty of CD or UC. Recently, there has been increased recognition of the role of the therapeutic endoscopist in the field of IBD. Newer imaging techniques have been developed to aid in the differentiation of UC vs CD. Furthermore, endoscopic balloon dilation and stenting have become an integral part of the therapeutic armamentarium of CD stricture management. Endoscopic ultrasound has been recognized as being more accurate than magnetic resonance imaging in detecting perianal fistulae in patients with CD. Additionally, chromoendoscopy may help to detect dysplasia earlier compared with white-light colonoscopy. Hence, interventional endoscopy has become a cornerstone in the diagnosis, treatment and management of IBD complications. The role of endoscopy in the field of IBD has significantly evolved in recent years from small-bowel imaging to endoscopic balloon dilation and use of chormoendoscopy in dysplasia surveillance. In this review article, we discuss the current evidence on interventional endoscopy in the diagnosis, treatment and management of IBD compications.
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Affiliation(s)
- Shishira Bharadwaj
- Department of Gastroenterology/Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Parul Tandon
- Department of Medicine, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
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19
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de’Angelis N, Di Saverio S, Chiara O, Sartelli M, Martínez-Pérez A, Patrizi F, Weber DG, Ansaloni L, Biffl W, Ben-Ishay O, Bala M, Brunetti F, Gaiani F, Abdalla S, Amiot A, Bahouth H, Bianchi G, Casanova D, Coccolini F, Coimbra R, de’Angelis GL, De Simone B, Fraga GP, Genova P, Ivatury R, Kashuk JL, Kirkpatrick AW, Le Baleur Y, Machado F, Machain GM, Maier RV, Chichom-Mefire A, Memeo R, Mesquita C, Salamea Molina JC, Mutignani M, Manzano-Núñez R, Ordoñez C, Peitzman AB, Pereira BM, Picetti E, Pisano M, Puyana JC, Rizoli S, Siddiqui M, Sobhani I, ten Broek RP, Zorcolo L, Carra MC, Kluger Y, Catena F. 2017 WSES guidelines for the management of iatrogenic colonoscopy perforation. World J Emerg Surg 2018; 13:5. [PMID: 29416554 PMCID: PMC5784542 DOI: 10.1186/s13017-018-0162-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/09/2018] [Indexed: 12/13/2022] Open
Abstract
Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45-60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator's level of experience, and surgical device availability. Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers' clinical judgment for individual patients, and they may need to be modified based on the medical team's level of experience and the availability of local resources.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, and University of Paris Est, UPEC, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | | | - Osvaldo Chiara
- General Surgery and Trauma Team, Niguarda Hospital, Milan, Italy
| | | | - Aleix Martínez-Pérez
- Department of General and Digestive Surgery, University Hospital Dr Peset, Valencia, Spain
| | - Franca Patrizi
- Unit of Gastroenterology and Endoscopy, Maggiore Hospital, Bologna, Italy
| | - Dieter G. Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter Biffl
- Acute Care Surgery at The Queen’s Medical Center, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Francesco Brunetti
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, and University of Paris Est, UPEC, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Federica Gaiani
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, Parma, Italy
| | - Solafah Abdalla
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, and University of Paris Est, UPEC, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Aurelien Amiot
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor Hospital, AP-HP, and University of Paris Est, UPEC, Creteil, France
| | - Hany Bahouth
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Giorgio Bianchi
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, and University of Paris Est, UPEC, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Daniel Casanova
- Unit of Digestive Surgery and Liver Transplantation, University Hospital Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | | | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, CA USA
| | | | | | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Pietro Genova
- Department of General and Oncological Surgery, University Hospital Paolo Giaccone, Palermo, Italy
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Jeffry L. Kashuk
- Assia Medical Group, Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew W. Kirkpatrick
- Department of Surgery, Critical Care Medicine and the Regional Trauma Service, Foothills Medical Center, Calgari, AB Canada
| | - Yann Le Baleur
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor Hospital, AP-HP, and University of Paris Est, UPEC, Creteil, France
| | - Fernando Machado
- Department of Emergency Surgery, Hospital de Clínicas, School of Medicine, UDELAR, Montevideo, Uruguay
| | - Gustavo M. Machain
- Il Cátedra de Clínica Quirúgica, Hospital de Clínicas, Facultad de Ciencias Medicas, Universidad National de Asuncion, Asuncion, Paraguay
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynecologic, Regional Hospital, Limbe, Cameroon
| | - Riccardo Memeo
- Unit of General Surgery and Liver Transplantation, Policlinico di Bari “M. Rubino”, Bari, Italy
| | - Carlos Mesquita
- Unit of General and Emergency Surgery, Trauma Center, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
| | - Juan Carlos Salamea Molina
- Department of Trauma and Emergency Center, Vicente Corral Moscoso Hospital, University of Azuay, Cuenca, Ecuador
| | | | - Ramiro Manzano-Núñez
- Department of Surgery and Critical Care, Universidad del Valle, Fundacion Valle del Lili, Cali, Colombia
| | - Carlos Ordoñez
- Department of Surgery and Critical Care, Universidad del Valle, Fundacion Valle del Lili, Cali, Colombia
| | - Andrew B. Peitzman
- Department of Surgery, UPMC, University of Pittsburg, School of Medicine, Pittsburg, USA
| | - Bruno M. Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Edoardo Picetti
- Department of Anesthesiology and Intensive Care, University Hospital of Parma, Parma, Italy
| | - Michele Pisano
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Juan Carlos Puyana
- Critical Care Medicine, University of Pittsburg, School of Medicine, Pittsburg, USA
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Mohammed Siddiqui
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, and University of Paris Est, UPEC, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Iradj Sobhani
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor Hospital, AP-HP, and University of Paris Est, UPEC, Creteil, France
| | - Richard P. ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luigi Zorcolo
- Department of Surgery, Colorectal Surgery Unit, University of Cagliari, Cagliari, Italy
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
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Lauro A, D'Amico F, Gondolesi G. The current therapeutic options for Crohn's disease: from medical therapy to intestinal transplantation. Expert Rev Gastroenterol Hepatol 2017; 11:1105-1117. [PMID: 28805088 DOI: 10.1080/17474124.2017.1367665] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Crohn's disease (CD) has an annual incidence per 100.000 person-year of 20.2 in North America and 12.7 in Europe, and the purpose of this review is to evaluate its medical management, from diagnosis to transplant. Pharmacologic manipulation with nutritional care aims to achieve and maintain remission, but more than half of patients will undergo an intestinal resection, very often repeated over time. They could experience short bowel syndrome (SBS) requiring total parenteral nutrition (TPN). Intestinal transplantation (ITx) represents an alternative in case of irreversible intestinal failure (IF) with life-threatening TPN complications. Patient survival after ITx is 79%, 53% and 43% at 1, 3 and 5 years respectively, with no differences among ITx for other disorders. Areas covered: The research discussed medical therapy with nutritional support, evaluating the role of endoscopy, surgery and transplant in CD. A systematic literature review was conducted using the PubMed search engine up to May 31th, 2017 without restriction of the language. The decision on paper's eligibility was reached by consensus between the 3 screening authors. Expert commentary: CD treatment is mainly medical, leaving endoscopy and surgery for a complex course. ITx represents a therapeutic option if TPN complications with IF arise.
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Affiliation(s)
- Augusto Lauro
- a Liver and Multiorgan Transplant Unit , St. Orsola University Hospital , Bologna , Italy
| | - Francesco D'Amico
- b Hepatobiliary Surgery and Liver Transplant Unit , University Hospital of Padua , Padua , Italy
| | - Gabriel Gondolesi
- c Intestinal Failure, Rehabilitation and Transplantation Unit , Fundación Favaloro University Hospitals , Buenos Aires , Argentina
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21
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Allocca M, Bonifacio C, Fiorino G, Spinelli A, Furfaro F, Balzarini L, Bonovas S, Danese S. Efficacy of tumour necrosis factor antagonists in stricturing Crohn's disease: A tertiary center real-life experience. Dig Liver Dis 2017; 49:872-877. [PMID: 28416240 DOI: 10.1016/j.dld.2017.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Stenosis is the most common complication of Crohn's disease (CD). Long-term outcome of patients receiving tumour necrosis factor (TNF) antagonists for such disease complication is poorly understood. METHODS 51 CD patients (from July 2006 to November 2015) who had a diagnosis of small bowel or colonic stenosis, diagnosed by colonoscopy and/or MRI enterography, and were treated with TNF antagonists (adalimumab or infliximab) were enrolled. The primary outcome was to assess the rate of success of TNF antagonists on avoiding abdominal surgery for stricturing CD patients. RESULTS 20 patients (39.2%) underwent surgery during the follow-up period. The overall incidence of abdominal surgery was 1.8 per 100 person-months at risk, while the median time to surgery was 37.9 months. The univariable and multivariable Cox's proportional hazards analysis of baseline parameters indicated that disease location (colonic vs ileal, HR: 28.2, 95% CI: 2.45-324, p=0.007; ileocolonic vs ileal, HR: 3.38, 95% CI: 1.09-10.5, p=0.035), prestenotic dilatation (per 1-mm increase, HR: 1.08, 95% CI: 1.01-1.15, p=0.022) and the existence of non-perianal fistula (HR: 9.77, 95% CI: 2.99-31.9, p<0.001) are independent risk factors for abdominal surgery. CONCLUSIONS In stricturing CD, anti-TNFs are effective in up to about two-thirds of the patients.
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Affiliation(s)
| | | | - Gionata Fiorino
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | | | - Federica Furfaro
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | | | - Stefanos Bonovas
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy
| | - Silvio Danese
- IBD Center, Gastroenterology, IRCCS Humanitas, Rozzano, Milan, Italy.
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22
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Yamamoto H, Ogata H, Matsumoto T, Ohmiya N, Ohtsuka K, Watanabe K, Yano T, Matsui T, Higuchi K, Nakamura T, Fujimoto K. Clinical Practice Guideline for Enteroscopy. Dig Endosc 2017; 29:519-546. [PMID: 28370422 DOI: 10.1111/den.12883] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.
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Affiliation(s)
| | - Haruhiko Ogata
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
| | - Takayuki Matsumoto
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Naoki Ohmiya
- Japan Gastroenterological Endoscopy Society
- Japanese Association for Capsule Endoscopy
| | - Kazuo Ohtsuka
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Kenji Watanabe
- Japanese Society of Gastroenterology
- Japanese Association for Capsule Endoscopy
| | - Tomonori Yano
- Japan Gastroenterological Endoscopy Society
- Japanese Association for Capsule Endoscopy
| | - Toshiyuki Matsui
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Kazuhide Higuchi
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
| | - Tetsuya Nakamura
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
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23
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Belza C, Fitzgerald K, Amaral J, Steinberg K, Avitzur Y, Wales PW. Use of balloon dilatation for management of postoperative intestinal strictures in children with short bowel syndrome. J Pediatr Surg 2017; 52:760-763. [PMID: 28190552 DOI: 10.1016/j.jpedsurg.2017.01.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Children with short bowel syndrome (SBS) often require numerous operations to optimize intestinal function. Postoperative intestinal strictures are a complication that inhibits enteral feeding advancement and prolongs parenteral nutrition dependency, often requiring reoperation. Our objective was to review our experience with fluoroscopic balloon dilatation to treat intestinal strictures. METHODS A retrospective cohort study of intestinal failure patients with SBS was completed. Patients who had radiologically diagnosed intestinal strictures and treated with fluoroscopic guided balloon dilatation were included [n=6]. Data related to demographics, anatomy, surgical procedures, and dilatation procedures were collected. Descriptive summary statistics were employed. RESULTS 98 intestinal failure patients were recruited between 2011 and 2015. Five of 98 patients (5.1%) [2 males; median age 4.4months] underwent fluoroscopy guided balloon dilatation of 6 strictures. Balloon dilatation was successful in 4/6 (67%). The median number of dilatations was 2 per patient (range=1-3). Median time to feed initiation postdilatation was 3days. One patient developed an anastomotic leak after dilatation that required antibiotics, but no reoperation. CONCLUSION Four of six (67%) postoperative bowel strictures in 5 patients with SBS were successfully treated with fluoroscopically guided balloon dilatation. Balloon dilatation is less invasive than reoperation, preserves bowel length and reduces time to reinitiation of enteral feeding. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Kevin Fitzgerald
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Karen Steinberg
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.
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Jain D, Mahmood E, Singhal S. Biodegradable Stents: An Evolution in Management of Benign Intestinal Strictures. J Clin Gastroenterol 2017; 51:295-299. [PMID: 27749637 DOI: 10.1097/mcg.0000000000000725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Benign intestine strictures secondary to postoperative narrowing or inflammatory bowel disease can be managed surgically or conservatively. Some patients may not be suitable surgical candidates and some patients may choose not to have repeat surgery. Biodegradable (BD) stents offer a prolonged dilatory effect before gradual degradation and obviates the need of a second procedure for stent removal. BD stents have high technical success rates (mean, 94.4%; median, 100%; range, 86% to 100%) but widely variable clinical success rates (range, 45% to 100%). Stent migration is the most commonly reported complication (mean, 22.2%; range, 0% to 36%). In the future, with better understanding of the factors contributing to stent migration, improvement in present stent design and better anchoring techniques, the stent migration rate is expected to decrease and improve clinical outcome. The role of prophylactic BD stent placement to prevent stricture development postintestine surgery is an intriguing idea and needs to be explored. As of now, the use of BD stents is a reasonable option for patients with dilatation resistant intestinal strictures who are unfit for surgery or refuse to have surgical treatment.
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Affiliation(s)
- Deepanshu Jain
- *Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, PA †Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, TX
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Rieder F, Fiocchi C, Rogler G. Mechanisms, Management, and Treatment of Fibrosis in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:340-350.e6. [PMID: 27720839 PMCID: PMC5209279 DOI: 10.1053/j.gastro.2016.09.047] [Citation(s) in RCA: 354] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 02/08/2023]
Abstract
In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases-associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Claudio Fiocchi
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland; Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
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26
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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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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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28
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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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29
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Keihanian S, Moss AC. Crohn’s disease stricture evaluation and management. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016; 18:136-144. [DOI: 10.1016/j.tgie.2016.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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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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31
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Rueda Guzmán A, Wehkamp J, Kirschniak A, Naumann A, Malek NP, Goetz M. Endoscopic balloon dilatation of Crohn's-associated intestinal strictures: High patient satisfaction and long-term efficacy. United European Gastroenterol J 2016; 4:794-799. [PMID: 28408997 DOI: 10.1177/2050640616628515] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/13/2015] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Stricture formation is a common long-term complication of Crohn's disease. Endoscopic balloon dilatation offers a bowel-sparing treatment option, but long-term outcome and its association with patient-, stricture-, and procedure-related factors is only poorly understood. Patient satisfaction with endoscopic balloon dilatation is largely unknown. METHODS We performed a retrospective review of all endoscopic balloon dilatation for Crohn's disease-related strictures between January 2005 and January 2013. Long-term outcome, complication rates and predictive factors were evaluated. Patient satisfaction was assessed using a questionnaire and telephone interviews. RESULTS A total of 118 balloon dilatations were performed for 69 strictures in 46 patients. One patient was excluded from further analysis due to malignancy. Median time from diagnosis of Crohn's disease to symptomatic stricture formation was 19 years. Technical success, defined as passage of the endoscope after dilatation, was reportedly obtained in 95 of 106 procedures (89.6%). Two perforations occurred, one of which could be managed conservatively. No episodes of severe bleeding were recorded (procedure-related complication rate: 2/118; 1.7%). During a median follow-up of 4.8 years (range 0.4-8.7), 55.6% (25/45) of patients were able to avoid surgery. Of the patients, 35.6% (16/45) did not need any further intervention, 40.0% (18/45) underwent more than one dilatation, and 24.4% (11/45) were operated after the first dilatation. The percentage of patients who were satisfied with the procedure and would again opt for balloon dilation as first line therapy was 83.3% (35/42). None of the risk factors examined in this study correlated with the necessity for subsequent surgery. DISCUSSION Endoscopic balloon dilatation is a safe and effective first line therapy for Crohn's disease-related strictures. No technical, stenosis-, or patient-related factor reliably predicted sustained dilatation success. Patient satisfaction was high.
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Affiliation(s)
| | - Jan Wehkamp
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Andreas Kirschniak
- Allgemeine, Viszeral- und Transplantationsmedizin, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Aline Naumann
- Institut für Klinische Epidemiologie und angewandte Biometrie, Universität Tübingen, Germany
| | - Nisar P Malek
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Martin Goetz
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
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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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Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches. Inflamm Bowel Dis 2015; 21:2194-213. [PMID: 25985249 DOI: 10.1097/mib.0000000000000403] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.
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Malgras B, Pautrat K, Dray X, Pasquier P, Valleur P, Pocard M, Soyer P. Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease. Dig Dis Sci 2015; 60:1152-68. [PMID: 25381203 DOI: 10.1007/s10620-014-3421-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.
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Affiliation(s)
- Brice Malgras
- Department of Surgery, Laiboisiere Hospital, Paris 7 University and AP-HP, 2 rue Ambroise Paré, 75475, Paris Cedex 10, France,
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Gasparetto M, Angriman I, Guariso G. The multidisciplinary health care team in the management of stenosis in Crohn's disease. J Multidiscip Healthc 2015; 8:167-79. [PMID: 25878504 PMCID: PMC4388000 DOI: 10.2147/jmdh.s38729] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Stricture formation is a common complication of Crohn’s disease (CD), occurring in approximately one-third of all patients with this condition. Our aim was to summarize the available epidemiology data on strictures in patients with CD, to outline the principal evidence on diagnostic imaging, and to provide an overview of the current knowledge on treatment strategies, including surgical and endoscopic options. Overall, the unifying theme of this narrative review is the multidisciplinary approach in the clinical management of patients with stricturing CD. Methods A Medline search was performed, using “Inflammatory Bowel Disease”, “stricture”, “Crohn’s Disease”, “Ulcerative Colitis”, “endoscopic balloon dilatation” and “strictureplasty” as keywords. A selection of clinical cohort studies and systematic reviews were reviewed. Results Strictures in CD are described as either inflammatory or fibrotic. They can occur de novo, at sites of bowel anastomosis or in the ileal pouch. CD-related strictures generally show a poor response to medical therapies, and surgical bowel resection or surgical strictureplasty are often required. Over the last three decades, the potential role of endoscopic balloon dilatation has grown in importance, and nowadays this technique is a valid option, complementary to surgery. Conclusion Patients with stricturing CD require complex clinical management, which benefits from a multidisciplinary approach: gastroenterologists, pediatricians, radiologists, surgeons, specialist nurses, and dieticians are among the health care providers involved in supporting these patients throughout diagnosis, prevention of complications, and treatment.
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Affiliation(s)
- Marco Gasparetto
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
| | - Imerio Angriman
- Department of Surgery, Gastroenterology and Oncology, Padua University, Padova, Italy
| | - Graziella Guariso
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
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Chang CW, Wong JM, Tung CC, Shih IL, Wang HY, Wei SC. Intestinal stricture in Crohn's disease. Intest Res 2015; 13:19-26. [PMID: 25691840 PMCID: PMC4316217 DOI: 10.5217/ir.2015.13.1.19] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 09/15/2014] [Accepted: 09/17/2014] [Indexed: 12/13/2022] Open
Abstract
Crohn's disease (CD) is a disease with chronic inflammation of unknown etiology involving any part of the gastrointestinal tract. The incidence and prevalence of CD are increasing recently in Asia. Half of the CD patients will have intestinal complications, such as strictures or fistulas, within 20 years after diagnosis. Twenty-five percentage of CD patients have had at least one small bowel stricture and 10% have had at least one colonic stricture and lead to significant complications. Most of these patients will require at least one surgery during their lifetime. Early diagnosis and evaluation with adequate managements for the patients can prevent disability and mortality of these patient. Here, we reviewed the current incidence of CD with stricture, the etiology of stricture, and how to diagnose and manage the stricture.
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Affiliation(s)
- Chen-Wang Chang
- Department of Gastroenterology, Mackay Memorial Hospital, Taipei; Mackay Junior College of Medicine, Nursing and Management, Taipei; Mackay Medical College, New Taipei, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chien-Chih Tung
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Horng-Yuan Wang
- Department of Gastroenterology, Mackay Memorial Hospital, Taipei; Mackay Junior College of Medicine, Nursing and Management, Taipei; Mackay Medical College, New Taipei, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
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Thienpont C, Van Assche G. Endoscopic and medical management of fibrostenotic Crohn's disease. Dig Dis 2014; 32 Suppl 1:35-8. [PMID: 25531351 DOI: 10.1159/000367824] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Crohn's disease (CD) is a disease characterized by acute inflammation at diagnosis which evolves toward a more fistulizing and fibrostenotic disease phenotype over time. This leads to a high risk of bowel resections and ultimately short bowel with diarrhea and malabsorption, which represents a major part of the burden inflicted by CD. Bowel-conserving endoscopic and surgical procedures have therefore been developed. Specific antifibrotic medical therapies are currently lacking. Through-the-scope endoscopic balloon dilation has been described in several cohorts as an alternative to surgical resection or stricturoplasty in selected patients. Efficacy of endoscopic dilation is high, with an immediate success rate of 78% (between 73 and 100%), defined as the ability to pass with the scope through the stricture. However, symptomatic recurrence is frequent, with need for new dilatation in 41% and need for surgery in 42%, with a mean interval of 15 months. Adjunctive techniques such as local steroid or anti-TNF injections or stenting have not been conclusively proven to be of added benefit. We usually reserve endoscopic dilation for patients with short strictures (<5 cm) and nonpenetrating disease, preferably at the ileocolonic anastomosis. Similar to other interventions in endoscopy, endoscopic dilation has an intrinsic risk of complications which can be estimated at 2%. Balloon size and patient selection can serve to increase safety.
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Raghu Subramanian C, Triadafilopoulos G. The gates of hell: Crohn's disease isolated to the pylorus and ileo-cecal valve. Dig Dis Sci 2014; 59:1108-11. [PMID: 24549833 DOI: 10.1007/s10620-014-3066-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/05/2014] [Indexed: 12/12/2022]
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Modha K, Navaneethan U. Advanced therapeutic endoscopist and inflammatory bowel disease: Dawn of a new role. World J Gastroenterol 2014; 20:3485-3494. [PMID: 24707131 PMCID: PMC3974515 DOI: 10.3748/wjg.v20.i13.3485] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 12/16/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Endoscopy plays a key role in the diagnosis and treatment of patients with inflammatory bowel disease (IBD). Colonoscopy has been traditionally used in the diagnosis of IBD and helps in determination of an important end point in patient management, “mucosal healing”. However, the involvement of an advanced endoscopist has expanded with innovations in therapeutic and newer imaging techniques. Endoscopists are increasingly being involved in the management of anastomotic and small bowel strictures in these patients. The advent of balloon enteroscopy has helped us access areas not deemed possible in the past for dilations. An advanced endoscopist also plays an integral part in managing ileal pouch-anal anastomosis complications including management of pouch strictures and sinuses. The use of rectal endoscopic ultrasound has been expanded for imaging of perianal fistulae in patients with Crohn’s disease and appears much more sensitive than magnetic resonance imaging and exam under anesthesia. Advanced endoscopists also play an integral part in detection of dysplasia by employing advanced imaging techniques. In fact the paradigm for neoplasia surveillance in IBD is rapidly evolving with advancements in endoscopic imaging technology with pancolonic chromoendoscopy becoming the main imaging modality for neoplasia surveillance in IBD patients in most institutions. Advanced endoscopists are also called upon to diagnose primary sclerosing cholangitis (PSC) and also offer options for endoscopic management of strictures through endoscopic retrograde cholangiopancreatography (ERCP). In addition, PSC patients are at increased risk of developing cholangiocarcinoma with a 20% lifetime risk. Brush cytology obtained during ERCP and use of fluorescence in situ hybridization which assesses the presence of chromosomal aneuploidy (abnormality in chromosome number) are established initial diagnostic techniques in the investigation of patients with biliary strictures. Thus advanced endoscopists play an integral part in the management of IBD patients and our article aims to summarize the current evidence which supports this role and calls for developing and training a new breed of interventionalists who specialize in the management of IBD patients and complications specific to those patients.
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