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Hudson AS, Wahbeh GT, Zheng HB. Imaging and endoscopic tools in pediatric inflammatory bowel disease: What's new? World J Clin Pediatr 2024; 13:89091. [PMID: 38596437 PMCID: PMC11000065 DOI: 10.5409/wjcp.v13.i1.89091] [Citation(s) in RCA: 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: 10/20/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 03/06/2024] Open
Abstract
Pediatric inflammatory bowel disease (IBD) is a chronic inflammatory disorder, with increasing incidence and prevalence worldwide. There have been recent advances in imaging and endoscopic technology for disease diagnosis, treatment, and monitoring. Intestinal ultrasound, including transabdominal, transperineal, and endoscopic, has been emerging for the assessment of transmural bowel inflammation and disease complications (e.g., fistula, abscess). Aside from surgery, IBD-related intestinal strictures now have endoscopic treatment options including through-the-scope balloon dilatation, injection, and needle knife stricturotomy and new evaluation tools such as endoscopic functional lumen imaging probe. Unsedated transnasal endoscopy may have a role in patients with upper gastrointestinal Crohn's disease or those with IBD with new upper gastrointestinal symptoms. Improvements to dysplasia screening in pediatric patients with longstanding colonic disease or primary sclerosing cholangitis hold promise with the addition of virtual chromoendoscopy and ongoing research in the field of artificial intelligence-assisted endoscopic detection. Artificial intelligence and machine learning is a rapidly evolving field, with goals of further personalizing IBD diagnosis and treatment selection as well as prognostication. This review summarized these advancements, focusing on pediatric patients with IBD.
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Affiliation(s)
- Alexandra S Hudson
- Department of Pediatrics, University of Washington, Seattle, WA 98109, United States
| | - Ghassan T Wahbeh
- Department of Pediatrics, University of Washington, Seattle, WA 98109, United States
| | - Hengqi Betty Zheng
- Department of Pediatrics, University of Washington, Seattle, WA 98109, United States
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Usefulness of Fluoroscopy for Endoscopic Balloon Dilation of Crohn's Disease-Related Strictures. Dig Dis Sci 2022; 67:1295-1302. [PMID: 33740171 DOI: 10.1007/s10620-021-06935-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Fluoroscopy is often used for endoscopic balloon dilation (EBD) of Crohn's disease (CD)-related strictures. However, its benefit remains unclear. AIMS To compare EBD with (EBDF) and without (EBDNF) fluoroscopic guidance in CD patients with strictures. METHODS Single-center, nested, case-control retrospective study of EBD for CD-related strictures. Technical and clinical success and safety outcomes were compared between EBDF and EBDNF. RESULTS A total of 122 strictures in 114 CD patients who underwent EBD from 2010 to 2018 at a single institution were reviewed (44 patients EBDF vs. 70 EBDNF). Esophagogastroduodenoscopy was the approach in 8 strictures, colonoscopy in 86, and deep enteroscopy in 28. There were no significant differences in the rates of technical and clinical success, need for repeat dilation and surgery between the two groups, although the mean maximal endoscopic balloon diameter was larger in the EBDNF group (17.1 ± 1.9 vs. 14.1 ± 2.5; p < 0.001). There was one perforation in EBDF and no serious complications in EBDNF. In multivariate analysis, balloon size < 15 mm (odds ratio [OR] 6.388; 95% CI 1.96-20.79; p = 0.002) and multiple strictures (OR 3.897; 95% CI 1.09-14.01; p = 0.037) were associated with repeat EBD, and age < 50 years (OR 7.178; 95% CI 1.38-37.44; p = 0.019) and small bowel (vs. colon) location (OR 7.525; 95% CI 1.51-37.47; p = 0.014) were associated with the need for surgery after EBD. CONCLUSIONS EBD for CD-related strictures can be performed safely and effectively without fluoroscopic guidance. Balloon size, patient age, stricture location, and multiplicity are associated with clinical success and avoidance of surgery.
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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: 3.7] [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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A protocolized approach to endoscopic hydrostatic versus pneumatic balloon dilation therapy for gastric sleeve stenosis: a multicenter study and meta-analysis. Surg Obes Relat Dis 2020; 16:1543-1553. [DOI: 10.1016/j.soard.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 12/28/2022]
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5
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Gu YB, Zhong J. Endoscopic management of stricturing Crohn's disease. J Dig Dis 2020; 21:351-354. [PMID: 32537911 DOI: 10.1111/1751-2980.12914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
Abstract
The natural history of Crohn's disease (CD) usually begins with primary intestinal inflammation, which progresses gradually to stricturing lesions. Stricture is a complicated, intractable but very common clinical problem in the management of CD. Difficulties remain in treating stricturing CD because of the limited efficacy of drug therapy and relapse of stricturing lesions cannot be completely avoided by surgery. Endoscopic management is a bridging therapy between drug therapy and surgical intervention, mainly including endoscopic balloon dilatation and endoscopic stricturotomy, and has been found to be effective for treating stricturing CD. Its explicit curative effect, less invasiveness and high safety performance make endoscopic management more acceptable by both the physician and patient. Although some patients require repeated endoscopic treatment and ultimately cannot avoid surgery, yet it can significantly delay the time to surgery and improve the quality of life. Physicians carrying out the endoscopic procedure need to be trained for performing this procedure. In this review we summarized the diagnosis and endoscopic treatment of stricturing CD.
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Affiliation(s)
- Yu Bei Gu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Zhong
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Heriot A, Smart P. Current Status of Segmental Colectomy in Select Crohn's Disease Patients. Clin Colon Rectal Surg 2019; 32:249-254. [PMID: 31275070 DOI: 10.1055/s-0039-1683906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Crohn's disease is a complex disease with a varying clinical and anatomical spectrum. One-third of patients with Crohn's will have disease confined to the colon. In this article, the authors review the surgical treatment options for colonic Crohn's disease including the current status of performing segmental colectomy in colonic Crohn's, the pros and cons of segmental versus subtotal colectomy, and the influence of biologics on recurrence rates following segmental colectomy.
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Affiliation(s)
- Alexander Heriot
- Cancer Surgery, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Philip Smart
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
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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: 35] [Impact Index Per Article: 5.8] [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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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: 5.3] [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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Lopes S, Rodrigues-Pinto E, Andrade P, Afonso J, Baron TH, Magro F, Macedo G. Endoscopic balloon dilation of Crohn’s disease strictures-safety, efficacy and clinical impact. World J Gastroenterol 2017; 23:7397-7406. [PMID: 29151693 PMCID: PMC5685845 DOI: 10.3748/wjg.v23.i41.7397] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/11/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the incidence of anastomotic strictures after intestinal resection in Crohn’s disease (CD), demonstrate long-term efficacy and safety of endoscopic balloon dilation (EBD) in CD strictures and its impact on the diagnosis of subclinical postoperative endoscopic recurrence.
METHODS Retrospective single tertiary center study based on prospectively collected data between 2010 and 2015 including anastomotic and non-anastomotic strictures.
RESULTS 29% of 162 CD patients included developed an anastomotic stricture. 43 patients with anastomotic strictures and 37 with non-anastomotic strictures underwent EBD; technical success was 97.7% and 100%, respectively, however, 63% and 41% needed repeat dilation during the 4.4-year follow-up. Longer periods between surgery and index colonoscopy and higher lactoferrin levels were associated with the presence of stricture after surgery. Calprotectin levels > 83.35 μg/g and current or past history of smoking were associated with a shorter time until need for dilation (HR = 3.877, 95%CI: 1.480-10.152 and HR = 3.041, 95%CI: 1.213-7.627). Anastomotic strictures had a greater need for repeat dilation (63% vs 41%, P = 0.047). No differences were found between asymptomatic and symptomatic cohorts. Disease recurrence diagnosis was only possible after EBD in a third of patients.
CONCLUSION EBD is an effective and safe alternative to surgery, with a good short and long-term outcome, postponing or even avoiding further surgery. EBD may allow to diagnose disease recurrence in patients with no clinical signs/biomarkers of disease activity.
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Affiliation(s)
- Susana Lopes
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
| | - Joana Afonso
- Department of Pharmacology and Therapeutics, University of Porto, Porto 4200-319, Portugal
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC 4200, United States
| | - Fernando Magro
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
- Department of Pharmacology and Therapeutics, University of Porto, Porto 4200-319, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
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Hirai F. Current status of endoscopic balloon dilation for Crohn's disease. Intest Res 2017; 15:166-173. [PMID: 28522945 PMCID: PMC5430007 DOI: 10.5217/ir.2017.15.2.166] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 12/31/2016] [Accepted: 01/02/2017] [Indexed: 12/12/2022] Open
Abstract
The therapeutic target in Crohn's disease (CD) has been raised to the achievement of mucosal healing. Although effective treatments that target cytokines and other molecules has been widely used for CD, intestinal strictures are still a major cause of surgery. Endoscopic balloon dilation (EBD) is known to be an effective and safe intervention for intestinal strictures in CD. Since frequent intestinal resection often results in short bowel syndrome and can decrease the quality of life, EBD can help avoid surgery. EBD with a conventional colonoscope for Crohn's strictures of the colon and ileo-colonic anastomosis has established efficacy and safety. In addition, EBD using balloon-assisted enteroscopy has recently been applied for small bowel Crohn's strictures. Although the evidence is not strong, EBD may become an alternative to surgery in small bowel strictures in CD. EBD and other new methods such as self-expanding stent implantation for Crohn's strictures may be useful and safe; however, it is important to address several issues regarding these interventions and to establish a protocol for combined therapies.
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Affiliation(s)
- Fumihito Hirai
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
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Yamamoto-Furusho J, Bosques-Padilla F, de-Paula J, Galiano M, Ibañez P, Juliao F, Kotze P, Rocha J, Steinwurz F, Veitia G, Zaltman C. Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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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: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [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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Yamamoto-Furusho J, Bosques-Padilla F, de-Paula J, Galiano M, Ibañez P, Juliao F, Kotze P, Rocha J, Steinwurz F, Veitia G, Zaltman C. Diagnóstico y tratamiento de la enfermedad inflamatoria intestinal: Primer Consenso Latinoamericano de la Pan American Crohn's and Colitis Organisation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 82:46-84. [PMID: 27979414 DOI: 10.1016/j.rgmx.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/23/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023]
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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: 89] [Impact Index Per Article: 11.1] [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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Asairinachan A, An V, Daniel ES, Johnston MJ, Woods RJ. Endoscopic balloon dilatation of Crohn's strictures: a safe method to defer surgery in selective cases. ANZ J Surg 2016; 87:E240-E244. [PMID: 27062309 DOI: 10.1111/ans.13500] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/17/2016] [Accepted: 01/23/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic balloon dilatation (EBD) provides a valuable alternative to surgery for strictures in Crohn's disease (CD). Data are lacking regarding the factors that improve the safety and effectiveness of EBD in CD. The aim of this study is to determine the safety and efficacy of EBD and the clinical variables, which are predictive of successful treatment of CD strictures with EBD. METHODS The records of all patients with CD in whom EBD was attempted between 2008 and 2013 were reviewed. Procedures were conducted at a single tertiary referral centre using a Boston Scientific CRE® TTS balloon. Technical success was defined as the ability to traverse the stricture with the endoscope and clinical success as the resolution of obstructive symptoms at review. RESULTS Forty-seven patients with a total of 58 strictures (19 primary and 39 anastomotic strictures) were treated with EBD with median follow-up of 37 months. A total of 161 dilatation procedures were performed, with technical success reported in 139/158 (88%) cases and clinical success reported in 105/137 (76.7%) cases with complete data. Complications occurred in 7/161 dilatations (4.3% dilatations, 15% patients), three patients with perforation, one with acute bleeding and three admitted with abdominal pain. Eighteen of the 47 patients required surgery (38%). Strictures of <50 mm (P = 0.04) and those dilated to a diameter of ≥15 mm (P = 0.031) were less likely to require surgical resection. CONCLUSIONS EBD is safe for both primary and post-surgical strictures. Stricture length and diameter of dilatation are predictive of success. In selected patients, treatment with EBD may reduce or delay the need for surgery.
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Affiliation(s)
- Ashwinna Asairinachan
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Vinna An
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Eric S Daniel
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Michael J Johnston
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Rodney J Woods
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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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: 1.8] [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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Abstract
BACKGROUND Endoscopic balloon dilation and surgery are commonly practiced in stricturing Crohn's disease. Nonetheless, there are still scant data directly comparing these 2 strategies. OBJECTIVE The aim of this study was to compare the short- and long-term outcomes of endoscopic balloon dilation versus surgical resection in symptomatic Crohn's strictures. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a single tertiary center. PATIENTS Seventy-nine patients were identified, 40 in the surgical group and 39 in the endoscopic balloon dilation group (mean age 42.8 ± 13.9 versus 38.5 ± 12.2 years). MAIN OUTCOME MEASURES The outcomes of all patients referred for endoscopic balloon dilation were compared with patients referred to surgery because of stricturing disease between the years 2006 and 2013. The primary outcome was the need for reintervention (either endoscopic balloon dilation or surgery) for symptomatic Crohn's disease during follow-up. RESULTS The proportion of patients who required any reintervention during follow-up was significantly lower in the surgical group versus the endoscopic balloon dilation group (OR = 5.62 (95% CI, 1.66-19.01); p = 0.005). The need for surgery/resurgery during follow-up was also significantly lower in the surgically treated group (OR = 3.53 (95% CI, 1.01-12.29); p = 0.047). Reintervention-free survival and surgery-free survival were both significantly shorter in the endoscopically treated group in a Kaplan-Mayer analysis. The rate of major complications was similar in the endoscopically and surgically treated groups (7.6% versus 7.5%; p = 0.7). LIMITATIONS The small cohort and the retrospective data collection were limitations of this study. CONCLUSIONS In our cohort of patients with fibrostenotic Crohn's disease, a direct comparison showed reduced need for reinterventions with a similar rate of immediate major complications after surgery compared with endoscopic balloon dilation.
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Abstract
Stricture and fistula are common complications of Crohn's disease. Endoscopic balloon dilation and needle-knife stricturotomy has become a valid treatment option for Crohn's disease-associated strictures. Endoscopic therapy is also increasingly used in Crohn's disease-associated fistula. Preprocedural preparations, including routine laboratory testing, imaging examination, anticoagulant management, bowel cleansing and proper sedation, are essential to ensure a successful and safe endoscopic therapy. Adverse events, such as perforation and excessive bleeding, may occur during endoscopic intervention. The endoscopist should be well trained, always be cautious, anticipate for possible procedure-associated complications, be prepared for damage control during endoscopy, and have surgical backup ready. In this review, we discuss the principle, preparation, techniques of endoscopic therapy, as well as the prevention and management of endoscopic procedure-associated complications. We propose that inflammatory bowel disease endoscopy may be a part of training for "super" gastroenterology fellows, i.e., those seeking a career in advanced endoscopy or in inflammatory bowel disease.
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Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches. Inflamm Bowel Dis 2015; 21:2194-213. [PMID: 25985249 DOI: 10.1097/mib.0000000000000403] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [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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20
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Buda A, Okolo PI. Endoscopic treatment of Crohn's complications. Expert Rev Gastroenterol Hepatol 2014; 8:887-95. [PMID: 24849124 DOI: 10.1586/17474124.2014.919850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.
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Affiliation(s)
- Andrea Buda
- Department of Surgical, Gastroenterological and Oncological Sciences, Division of Gastroenterology, University of Padova, 35100, Padova, Italy
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21
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Cash BD, Acosta RD, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Shaukat A, Wang A. The role of endoscopy in the management of constipation. Gastrointest Endosc 2014; 80:563-565. [PMID: 25150599 DOI: 10.1016/j.gie.2014.06.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 06/04/2014] [Indexed: 01/19/2023]
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Hagel AF, Hahn A, Dauth W, Matzel K, Konturek PC, Neurath MF, Raithel M. Outcome and complications of endoscopic balloon dilatations in various types of ileocaecal and colonic stenosis in patients with Crohn's disease. Surg Endosc 2014; 28:2966-72. [PMID: 24853850 DOI: 10.1007/s00464-014-3559-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 04/17/2014] [Indexed: 12/12/2022]
Abstract
AIM We examined the outcome and the complications of endoscopic balloon dilatation (EBD) of ileocaecal and colonic strictures due to Crohn's disease. METHODS We examined 237 dilatation procedures in 77 patients with symptomatic ileocaecal and colonic stenosis regarding outcome, individual perforation risk, the need for further interventions, and other complications within a 10 years observation period. RESULTS In 50 of 77 patients (64.9%), endoscopic dilatation procedures were successful within a median follow-up period of 24 months (25th and 75th percentile 10-38.5 months). Thirty five patients (45.5%) were successfully dilated with only one endoscopic procedure, while the remaining patients required two or more EBDs. Albeit the EBD, 27 patients of the whole cohort (35.1%) underwent surgical repair of the stenosis in due course. Overall complication rate was 7.6%, with postdilatation bleeding in 1.7% and abdominal pain longer than 24 h in 4.2%. Perforation occurred in 4 of 77 patients (5.2%), resulting in a perforation rate of 1.7% per intervention, or, more importantly, for the individual patient in a long-term perforation rate of 5.2% per patient, respectively. DISCUSSION Endoscopic balloon dilatation (EBD) is a safe and effective approach to ileocaecal and colonic stenosis in approximately 65% of Crohn's disease patients. Even in case of recurrence, further endoscopic treatments can be undertaken. The perforation rate depending on the number of interventions is low, but for the individual patient a cumulative per patient perforation risk of 5.2% in the long-term should be considered during patient information and decisions for or against surgical interventions.
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Affiliation(s)
- Alexander F Hagel
- Department of Medicine I, University of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany,
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Abstract
INTRODUCTION Stricturing is a common complication of Crohn's disease. Endoscopic balloon dilatation (EBD) offers a valuable alternative to surgical intervention, but there are limited data on factors influencing its safety and efficacy. METHODS A multicenter retrospective audit across 4 U.K. teaching hospitals was performed on the use of EBD for Crohn's strictures between 1998 and 2011. Demographics, smoking status, medications, C-reactive protein, endoscopic findings, and subsequent surgery at follow-up were recorded. Success of EBD was defined as symptomatic improvement without the need for surgery at follow-up. RESULTS Seventy-nine patients (47 women; median age, 48 yr) were identified for this study. Forty-eight (61%) patients had ileocolonic anastomotic strictures, whereas the rest had de novo strictures. In total, 191 EBDs (range, 1-11; median 2) were carried out on 93 strictures (range, 1-5; median 1) over a median duration of 12 months (range, 1-84). There were no serious adverse events. Success at index EBD was 34%, with a further 43% achieving long-term benefit from additional EBDs. Eighteen (23%) patients required surgery. Time to surgery after the first EDB was 2.6 to 71.1 months (median, 12.8 mo). Longer Crohn's disease duration (P = 0.03) and high C-reactive protein (P = 0.008) were associated with an increased need for subsequent surgery. CONCLUSIONS EBD was safe and effective in achieving long-term symptom improvement and avoidance of surgery in most patients. Prospective controlled trials are needed to evaluate the effect of other factors, including Crohn's disease phenotype, and the role of concomitant medication to identify those best suited to EBD.
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24
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Paine E, Shen B. Endoscopic therapy in inflammatory bowel diseases (with videos). Gastrointest Endosc 2013; 78:819-835. [PMID: 24139079 DOI: 10.1016/j.gie.2013.08.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/15/2013] [Indexed: 02/08/2023]
Abstract
Endoscopic therapies are important modalities in the treatment of IBD, adjunct to medical and surgical approaches. These therapeutic techniques are particularly useful in the management of IBD-associated or IBD surgery–associated strictures, fistulas, and sinuses and colitis-associated neoplasia. Although the main focus of endoscopic therapies in IBD has been on balloon stricture dilation and ablation of adenoma-like lesions, new endoscopic approaches are emerging, including needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement, and fistula tract injection. Risk management of endoscopy-associated adverse events is also evolving. The application of endoscopic techniques in novel ways in the treatment of IBD is just beginning and will likely expand rapidly in the near future.
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Affiliation(s)
- Elizabeth Paine
- Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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25
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Annese V, Daperno M, Rutter MD, Amiot A, Bossuyt P, East J, Ferrante M, Götz M, Katsanos KH, Kießlich R, Ordás I, Repici A, Rosa B, Sebastian S, Kucharzik T, Eliakim R. European evidence based consensus for endoscopy in inflammatory bowel disease. J Crohns Colitis 2013; 7:982-1018. [PMID: 24184171 DOI: 10.1016/j.crohns.2013.09.016] [Citation(s) in RCA: 540] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 09/20/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Vito Annese
- Dept. Gastroenterology, University Hospital Careggi, Largo Brambilla 3, 50139 Florence, Italy.
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Gustavsson A, Magnuson A, Blomberg B, Andersson M, Halfvarson J, Tysk C. Smoking is a risk factor for recurrence of intestinal stricture after endoscopic dilation in Crohn's disease. Aliment Pharmacol Ther 2013. [PMID: 23205619 DOI: 10.1111/apt.12176] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic balloon dilation is an efficacious and safe alternative to surgery as treatment of short intestinal strictures in Crohn's disease (CD). Factors predicting outcome of the procedure are not well described. AIM To evaluate whether smoking at diagnosis, treatment with azathioprine, or other clinical variables may affect clinical outcome after endoscopic dilation. The endpoint was requirement of a new intervention such as dilation or surgery with intestinal resection or strictureplasty. METHODS Retrospective study of 83 patients with CD who underwent endoscopic balloon dilation of an intestinal stricture between 1987 and 2009. RESULTS After index dilation 55/83 patients underwent a new intervention. Among current smokers, 31/32 (97%) underwent another intervention compared to 18/33 (55%) among never smokers (adjusted HR: 2.50, 95% CI: 1.14-5.50, P = 0.022). After 5 years, cumulative probability of new intervention was 0.81 in smokers compared to 0.52 in never smokers; difference 0.29 (95% CI: 0.07-0.52, P = 0.01). In 16 patients, therapy with azathioprine was initiated before or shortly after the index dilation; 7/16 underwent a new intervention compared to 48/67 of those without azathioprine (HR: 0.46, 95% CI: 0.21-1.03, P = 0.06). After adjustment for other variables, the association was even weaker (HR: 0.80, 95% CI: 0.29-2.18, P = 0.668). Sex, age at diagnosis, age at first dilation, balloon size, location of stricture, and treatment period did not influence outcome. CONCLUSIONS Smoking doubles the risk of recurrent stricture formation requiring a new intervention after index dilation. Maintenance therapy with azathioprine did not influence the subsequent course and need for a new intervention.
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Affiliation(s)
- A Gustavsson
- Department of Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden
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Hashash JG, Regueiro MD. The evolving management of postoperative Crohn's disease. Expert Rev Gastroenterol Hepatol 2012; 6:637-48. [PMID: 23061713 DOI: 10.1586/egh.12.45] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two-thirds to three-quarters of Crohn's disease patients require intestinal surgery for medically refractory disease or complications. Surgery is not a cure and most patients develop recurrent Crohn's disease and require additional intestinal resections. There are a number of medications that have been investigated for preventing and treating recurrence. Risk factors for postoperative disease recurrence help guide the physician in determining the appropriate treatment strategy after Crohn's disease surgery. The approach to Crohn's disease treatment has evolved over the years. No longer should surgery be considered a failure of treatment, rather an important intervention to correct irreversible disease. In combination with a better understanding of postoperative medication strategies, patients with Crohn's disease may achieve longer term remission than previously realized. This review elucidates current understanding of the natural course of postoperative Crohn's disease, monitoring for recurrence, the risk factors for recurrence, and provides insight into an evolving new paradigm for postoperative Crohn's disease treatment.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street-PUH, M2, C-Wing, Pittsburgh, PA 15213, USA.
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Gustavsson A, Magnuson A, Blomberg B, Andersson M, Halfvarson J, Tysk C. Endoscopic dilation is an efficacious and safe treatment of intestinal strictures in Crohn's disease. Aliment Pharmacol Ther 2012; 36:151-8. [PMID: 22612326 DOI: 10.1111/j.1365-2036.2012.05146.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 03/21/2012] [Accepted: 05/02/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bowel strictures are a major cause of morbidity, hospitalisation and surgery in Crohn's disease. AIM We report short- and long-term efficacy and safety of endoscopic balloon dilation of strictures due to Crohn's disease. METHODS Retrospective study of patients who underwent endoscopic balloon dilation between 1987 and 2009. RESULTS We performed 776 dilations, of which 621 (80%) were on anastomotic strictures, in 178 patients (94 women) with Crohn's disease. At first dilation, median (IQR) age of patients was 45 (37-56) years and disease duration 16 (8-22) years. Technical success rate was 689/776 (89%). A subset of 75 patients from the primary catchment area, with >5-year follow-up, underwent a total of 246 dilations. At 1-year follow-up, 60/75 (80%) patients had undergone no further intervention or one additional dilation only. At 3 and 5 years, corresponding figures were 43/75 (57%) and 39/75 (52%). Cumulative proportions of patients undergoing surgery at 1, 3 and 5 years were 13%, 28% and 36%. Complication rate per procedure for all 178 patients was 41/776 (5.3%), bowel perforation (n = 11, 1.4%), major bleeding requiring blood transfusion (n = 8, 1.0%), minor bleeding (n = 10, 1.3%) and abdominal pain or fever (n = 12, 1.5%). Ten patients underwent surgery due to complications (perforation n = 8, bleeding n = 2). There was no procedure-related mortality. CONCLUSIONS Endoscopic balloon dilation is an efficacious and safe alternative to surgical resection of intestinal strictures in Crohn's disease. At 5-year follow-up, 52% of patients required no further or one additional dilation only, whereas 36% had undergone surgical resection. Complication frequency was low.
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Affiliation(s)
- A Gustavsson
- Department of Medicine, Division of Gastroenterology, Örebro University Hospital, Sweden
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Lorenzo-Zúñiga V, García-Planella E, Moreno De Vega V, Domènech E, Boix J. [Endoscopic management of luminal stenosis in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:404-10. [PMID: 22341673 DOI: 10.1016/j.gastrohep.2011.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 11/27/2022]
Abstract
Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.
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Scimeca D, Mocciaro F, Cottone M, Montalbano LM, D'Amico G, Olivo M, Orlando R, Orlando A. Efficacy and safety of endoscopic balloon dilation of symptomatic intestinal Crohn's disease strictures. Dig Liver Dis 2011; 43:121-5. [PMID: 20561831 DOI: 10.1016/j.dld.2010.05.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 04/12/2010] [Accepted: 05/04/2010] [Indexed: 12/11/2022]
Abstract
AIM To evaluate prospectively the clinical efficacy and safety of endoscopic hydrostatic balloon dilation in a consecutive cohort of symptomatic intestinal Crohn's disease strictures. METHODS Between September 2003 and December 2008 we performed endoscopic balloon dilations in 37 Crohn's disease patients with 39 intestinal symptomatic strictures (4 naïve and 35 postoperative). Dilations were performed using a Rigiflex through-the-scope balloon. Clinical success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation, following technical success. Actuarial curves of clinical, endoscopic (redilation) and surgical recurrence were obtained by Kaplan-Meier method. Demographic and disease variables were related to the main outcomes. RESULTS After a mean follow-up of 26.3 months (range, 2-61 months), the long-term global benefit rate was 89% (33/37). The 1-2-3 years cumulative symptom-free rates were respectively: 76%, 55% and 46%. Four patients were operated upon. Technical success predicts a lower rate of surgery. There were no complications related to the endoscopic procedures. CONCLUSIONS Endoscopic balloon dilation of symptomatic Crohn's disease strictures may achieve clinical benefit in many patients and is a valid alternative to surgery in the management of the disease. Dilation may be repeated in recurrent intestinal obstructions and appears safe without morbidity.
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Affiliation(s)
- Daniela Scimeca
- Department of Medicine, Pneumology and Nutrition Clinic, V Cervello Hospital, Palermo University, Palermo, Italy.
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Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature. Int J Colorectal Dis 2010; 25:1149-57. [PMID: 20628881 DOI: 10.1007/s00384-010-1010-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Stricturing Crohn's disease is accompanied by a high-risk for bowel resection and subsequent short bowel syndrome. Strictureplasty (SP) and endoscopic balloon dilatation (EBD) have been developed to prevent, or at least delay, the requirement for resection. The goal of this study was to compare the outcome of these two procedures with regard to complications and disease recurrence. METHODS We conducted a MEDLINE literature search to give a current overview about the safety and efficacy of EBD and SP. RESULTS The initial search yielded 744 articles. Case reports, reviews and meta-analyses were excluded. Finally, 63 articles (SP, 40 articles; EBD, 23 articles) were used for the review. None of the studies compared the two methods directly. A total of 2,532 patients (SP, n = 1,958; EBD, n = 574) were included. The incidence of perioperative complications after SP was 11% and the incidence of major complications was 5%. The median surgical recurrence rate was 24% after a median follow-up of 46 months. The median technical success for EBD was 90%. Major complications occurred in 3% of the cases. According to an intention-to-treat protocol, the median surgical recurrence rate was 27.6%. Per-protocol analysis revealed a median surgical recurrence rate of 21.4% after a median follow-up of 21 months. CONCLUSION Due to the lack of comparable data, there is currently no reliable information on whether one treatment option is superior to the other. Regarding the limited applicability of EBD in strictures of the small bowel, only a controlled trial would provide evidence as a basis for clinical decision making in CD strictures that are potentially treatable by EBD and SP.
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Despott EJ, Gupta A, Burling D, Tripoli E, Konieczko K, Hart A, Fraser C. Effective dilation of small-bowel strictures by double-balloon enteroscopy in patients with symptomatic Crohn's disease (with video). Gastrointest Endosc 2009; 70:1030-6. [PMID: 19640518 DOI: 10.1016/j.gie.2009.05.005] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 05/01/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease (CD)-related small-bowel strictures remain a major cause of morbidity, frequently requiring surgery. OBJECTIVE Assessment of the feasibility and effectiveness of CD small-bowel stricture dilation by DBE. DESIGN Prospective case series. SETTINGS Single, tertiary referral center. METHODS Outcome data on cases of DBE-assisted CD small-bowel stricture dilation were prospectively collected from 2005. Dilation was performed by using controlled radial expansion balloon dilators. A 10-cm visual analogue scale (VAS) was used to assess obstructive symptoms and dietary restriction before DBE stricture dilation and at follow-up. RESULTS A total of 13 DBEs were performed in 11 consecutive patients (mean +/- SD age 46.4 +/- 7.8 years). Eighteen small-bowel stricture dilations were performed in 9 of 11 patients. The mean dilation diameter was 15.4 mm (range 12-20 mm). In 2 cases, stricture dilation was not performed because adhesions made reaching the strictures impossible. One case was complicated by a delayed perforation. In the other 8 patients, stricture dilation was successful; VAS scores improved dramatically and none of the patients has required surgery (mean follow-up 20.5 months; range 2-41 months). During follow-up, 2 patients required repeated dilation (at 6.5 and 13 months, respectively) because of symptom recurrence. Clinical improvements in before and after VAS scores were significant (mean 8.8 vs 1.8, respectively; P < .001). LIMITATIONS Small case series; single tertiary referral center. CONCLUSION DBE-assisted small-bowel stricture dilation for selected patients with CD is potentially of significant benefit and should be considered as a useful and effective alternative to surgery. Larger studies are required to confirm this benefit.
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Affiliation(s)
- Edward J Despott
- The Wolfson Unit for Endoscopy, St. Mark's Hospital and Academic Institute, London, England
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Stienecker K, Gleichmann D, Neumayer U, Glaser HJ, Tonus C. Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn's disease: a prospective study. World J Gastroenterol 2009. [PMID: 19496192 DOI: 10.3748/wjg.15.2623.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
AIM To examine the long-term results of endoscopic treatment in a prospective study conducted over a period of 10 years, 1997 to January 2007. METHODS A total of 25 patients (20 female and five male: aged 18-75 years), with at least one symptom of stricture not passable with the standard colonoscope and with a confirmed scarred Crohn's stricture of the lower gastrointestinal tract, were included in the study. The main symptom was abdominal pain. The endoscopic balloon dilatation was performed with an 18 mm balloon under endoscopic and radiological control. RESULTS Eleven strictures were located in the colon, 13 at the anastomosis after ileocecal resection, three at the Bauhin valve and four in the ileum. Four patients had two strictures and one patient had three strictures. Of the 31 strictures, in 30 was balloon dilatation successful in a single endoscopic session, so that eventually the strictures could be passed easily with the standard colonoscope. In one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart, sufficient dilatation was not possible. This patient therefore required surgery. Improvement of abdominal symptoms was achieved in all cases which had technically successful balloon dilatation, although in one case perforation occurred after dilatation of a recurrent stricture. Available follow-up was in the range of 54-118 mo (mean of 81 mo). The relapse rate over this period was 46%, but 64% of relapsing strictures could be successfully dilated again. Only in four patients was surgery required during this follow-up period. CONCLUSION We conclude from these initial results that endoscopic balloon dilatation, especially for short strictures in Crohn's disease, can be performed with reliable success. Perforation is a rare complication. It is our opinion that in the long-term, the relapse rate is probably higher than after surgery, but usually a second endoscopic treatment can be performed successfully, leading to a considerable success rate of the endoscopic procedure.
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Affiliation(s)
- Klaus Stienecker
- Department of Visceral Surgery, Herz-Jesu-Hospital Fulda, Buttlarstrasse 74, D-36039 Fulda, Germany
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Stienecker K, Gleichmann D, Neumayer U, Glaser HJ, Tonus C. Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn’s disease: A prospective study. World J Gastroenterol 2009; 15:2623-7. [PMID: 19496192 PMCID: PMC2691493 DOI: 10.3748/wjg.15.2623] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the long-term results of endoscopic treatment in a prospective study conducted over a period of 10 years, 1997 to January 2007.
METHODS: A total of 25 patients (20 female and five male: aged 18-75 years), with at least one symptom of stricture not passable with the standard colonoscope and with a confirmed scarred Crohn’s stricture of the lower gastrointestinal tract, were included in the study. The main symptom was abdominal pain. The endoscopic balloon dilatation was performed with an 18 mm balloon under endoscopic and radiological control.
RESULTS: Eleven strictures were located in the colon, 13 at the anastomosis after ileocecal resection, three at the Bauhin valve and four in the ileum. Four patients had two strictures and one patient had three strictures. Of the 31 strictures, in 30 was balloon dilatation successful in a single endoscopic session, so that eventually the strictures could be passed easily with the standard colonoscope. In one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart, sufficient dilatation was not possible. This patient therefore required surgery. Improvement of abdominal symptoms was achieved in all cases which had technically successful balloon dilatation, although in one case perforation occurred after dilatation of a recurrent stricture. Available follow-up was in the range of 54-118 mo (mean of 81 mo). The relapse rate over this period was 46%, but 64% of relapsing strictures could be successfully dilated again. Only in four patients was surgery required during this follow-up period.
CONCLUSION: We conclude from these initial results that endoscopic balloon dilatation, especially for short strictures in Crohn’s disease, can be performed with reliable success. Perforation is a rare complication. It is our opinion that in the long-term, the relapse rate is probably higher than after surgery, but usually a second endoscopic treatment can be performed successfully, leading to a considerable success rate of the endoscopic procedure.
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Garau MV, Vicens DG, Rigo AL, Méndez ZM, López MJB, Moya SPO, Duran CG, Cantallops JG. [Impacted foreign body in a patient with Crohn's disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:339-42. [PMID: 19457590 DOI: 10.1016/j.gastrohep.2008.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 11/18/2008] [Indexed: 11/30/2022]
Abstract
Crohn's disease is often complicated by intestinal strictures. Symptomatic strictures refractory to medical therapy usually require surgery. Endoscopic balloon dilatation is an alternative to surgery. We report the case of a patient with Crohn's disease with asymptomatic ileocecal stricture, which was identified after intestinal obstruction due to an impacted foreign body. The patient underwent endoscopic dilatation and the foreign body was extracted. We provide a review of the literature on endoscopic balloon dilatation of intestinal strictures in Crohn's disease.
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Affiliation(s)
- Margalida Vanrell Garau
- Servicio de Aparato Digestivo, Hospital Universitario Son Dureta, Palma de Mallorca, Mallorca, España.
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Hoffmann JC, Heller F, Faiss S, von Lampe B, Kroesen AJ, Wahnschaffe U, Schulzke JD, Zeitz M, Bojarski C. Through the endoscope balloon dilation of ileocolonic strictures: prognostic factors, complications, and effectiveness. Int J Colorectal Dis 2008; 23:689-96. [PMID: 18338175 DOI: 10.1007/s00384-008-0461-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS About half of all Crohn's disease (CD) patients undergo surgery at some point, many because of strictures. An alternative possibility is to dilate strictures endoscopically. However, little is known about prognostic factors. PATIENTS AND METHODS Thirty-two patients with primary CD (n=2), radiogenic strictures (n=1), or postoperative strictures (27 because of CD; 2 after resection because of cancer), were planned to undergo colonoscopic dilatation of which 25 patients were dilated (10 men; 15 women; median age 48). Length of stenosis, diameter of stricture, balloon size, smoking status, ulcer in the stricture, passage postdilatation, hemoglobin level, complications, redilatation, and subsequent surgery were recorded. Only patients with at least 6 months follow up were included. RESULTS Five out of 32 patients had no stenosis, marked inflammation, or fistulas adjacent to the stricture. One patient each had a long stricture (8 cm) or a filiform stenosis ruling out dilatation [technical success, 25/27 (92.6%)]. Among these 25 patients, 39 colonoscopies with 51 dilatations were performed. After a single dilatation, 52% were asymptomatic while 48% needed another intervention, half of them surgery. Bleeding without need for transfusion occurred in 3 out of 39 colonoscopies and one perforation required surgery. Significant prognostic factors were smoking and ulcers in the stricture (P<0.05 each). Some ulcers led to intussusception requiring surgery in spite of good dilatation results. CONCLUSION Through the endoscope balloon stricture dilatation is a relatively safe and often effective treatment modality in ileocolonic strictures. The presence of ulcers in the stricture have a worse outcome as do smokers.
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Affiliation(s)
- Jörg C Hoffmann
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Charité, Campus Benjamin Franklin, 12200 Berlin, Germany.
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Anton Decker G, Pasha SF, Leighton JA. Utility of Double Balloon Enteroscopy for the Diagnosis and Management of Crohn’s Disease. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2008. [DOI: 10.1016/j.tgie.2007.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Hassan C, Zullo A, De Francesco V, Ierardi E, Giustini M, Pitidis A, Taggi F, Winn S, Morini S. Systematic review: Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther 2007; 26:1457-64. [PMID: 17903236 DOI: 10.1111/j.1365-2036.2007.03532.x] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic dilatation for Crohn's disease has been evaluated only in some small and heterogeneous studies. AIM To evaluate any association between the main clinical variables and endoscopic variables and the efficacy and safety of endoscopic dilatation in Crohn's disease. METHODS A Medline search regarding pneumatic dilatation in Crohn's disease was performed. Several technical and clinical variables were extracted from each study to build up a descriptive, pool-data analysis. Data on individual patients were extracted from suitable studies to create a simulated population upon which a multivariate statistical analysis was performed. RESULTS Thirteen studies enrolling 347 Crohn's disease patients were reviewed. Endoscopic dilatation was mainly applied to postsurgical strictures, being technically successful in 86% of the cases. Long-term clinical efficacy was achieved in 58% of the patients. Mean follow-up was as long as 33 months, corresponding to 800 patient years of follow-up. Major complication rate was 2%, being higher than 10% in two series. At multivariate analysis, a stricture length < or = 4 cm was associated with a surgery-free outcome (OR: 4.01; 95% CI: 1.16-13.8; P < 0.028). CONCLUSIONS Endoscopic dilatation is an effective and safe treatment for short strictures caused by Crohn's disease, impacting substantially on the natural history of these patients.
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Affiliation(s)
- C Hassan
- Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.
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Strong SA, Koltun WA, Hyman NH, Buie WD. Practice parameters for the surgical management of Crohn's disease. Dis Colon Rectum 2007; 50:1735-46. [PMID: 17690937 DOI: 10.1007/s10350-007-9012-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Scott A Strong
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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Abstract
Despite advances in medical treatment, most patients who have Crohn's disease of the small intestine need surgery at some point during the course of their disease. Surgery is currently indicated for intractable disease and complications of the disease (strictures, abscesses, fistulas, hemorrhage). There is increasing interest in nonsurgical and minimal access strategies of dealing with complicated disease, however. These new approaches may enable postponement of surgery to a more favorable time, or conversion of a two-stage procedure involving a stoma to a one-stage resection with anastomosis. A continuing challenge is prevention of disease recurrence postoperatively.
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Affiliation(s)
- Keith R Gardiner
- Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland, UK.
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Ajlouni Y, Iser JH, Gibson PR. Endoscopic balloon dilatation of intestinal strictures in Crohn's disease: safe alternative to surgery. J Gastroenterol Hepatol 2007; 22:486-90. [PMID: 17376038 DOI: 10.1111/j.1440-1746.2006.04764.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Endoscopic balloon dilatation (EBD), a non-surgical treatment option for intestinal strictures in Crohn's disease, appears to be applied infrequently, possibly due to the perceived risk of perforation and early recurrence. This study aimed to determine the outcomes of EBD by a single endoscopist using a defined technique. METHODS The records of all patients with Crohn's disease in whom EBD was attempted over a 12-year period were examined to determine the rate of technical success, complications and outcome. A stricture was defined as that which prevented passage of the 14 mm diameter colonoscope. Technical success was defined as the ability to traverse the stricture postdilatation. Patients were selected on the colonoscopic appearance of the stricture and dilatation was performed using through-the-endoscope balloons. Antibiotics were given during and for 7 days postdilatation. RESULTS EBD was attempted on 83 strictures (31 anastomotic and 52 primary) in 37 patients (15 males) and was successful in 75 (90%) of 31 patients. A single dilatation only was required in 21 patients who had a median follow-up of 20 months (range 6-122 months). Recurrent symptomatic stricture requiring dilatation (eight patients) or surgery (two patients) occurred 8 (1-112) months after the initial dilatation. The only complication occurred in one patient where an intra-abdominal fistula and abscess were probably related to the dilatation. CONCLUSION EBD of intestinal strictures associated with Crohn's disease has a low complication rate and leads to prolonged clinical benefit. It should be considered as a real alternative to surgery.
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Affiliation(s)
- Yousef Ajlouni
- IBD Clinic, Box Hill Hospital, Melbourne, Victoria, Australia
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Koltun WA. Dangers associated with endoscopic management of strictures in IBD. Inflamm Bowel Dis 2007; 13:359-61; discussion 362-3. [PMID: 17206622 DOI: 10.1002/ibd.20090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Walter A Koltun
- Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA.
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Van Assche G, Vermeire S, Rutgeerts P. Endoscopic therapy of strictures in Crohn's disease. Inflamm Bowel Dis 2007; 13:356-8; discussion 362-3. [PMID: 17230480 DOI: 10.1002/ibd.20091] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Gert Van Assche
- Division of Gastroenterology, Leuven University Hospital, Leuven, Belgium.
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Hoffmann JC. Interdisziplinäres Vorgehen bei Stenosen und Fisteln bei Morbus Crohn. Visc Med 2006. [DOI: 10.1159/000097992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Qureshi W, Adler DG, Davila RE, Egan J, Hirota WK, Jacobson BC, Leighton JA, Rajan E, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO. ASGE guideline: guideline on the use of endoscopy in the management of constipation. Gastrointest Endosc 2005; 62:199-201. [PMID: 16046978 DOI: 10.1016/j.gie.2005.04.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Affiliation(s)
- J O Hunter
- Gastroenterology Research Unit, Box 262, Addenbrooke's Hospital, Cambridge CB2 2QQ, England, UK.
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