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Menezes Nascimento Filho H, Kum AST, Bestetti AM, da Silva PHVA, Gallegos MMM, Damião AOMC, Navaneethan U, de Moura EGH. Patient-Related Factors Associated With Long-Term Outcomes After Successful Endoscopic Balloon Dilation For Crohn's Disease-Associated Ileo-Colic Strictures: A Systematic Review and Meta-analysis. CROHN'S & COLITIS 360 2024; 6:otae041. [PMID: 39175792 PMCID: PMC11339545 DOI: 10.1093/crocol/otae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Indexed: 08/24/2024] Open
Abstract
Background Successful Crohn's disease (CD) therapy relies on timely and precise management strategies. Endoscopic balloon dilation (EBD) has been applied as a first-line treatment for symptomatic CD-associated strictures due to its minimally invasive nature and the possibility of preserving intestinal length. Objective The aim of the present study was to determine patient-related predictive factors associated with the need for surgery for CD-associated ileocolic strictures after technically successful EBD. Methods All original studies published before December 2023 that reported the outcomes of patients treated with EBD for ileocolic strictures secondary to CD and described follow-up for at least 1 year were included. The difference in risk of needing surgery was calculated for 8 different patient characteristics (Sex, smoking habit, previous surgery, biologic therapy, steroids, immunosuppressors, nature of the stricture, and endoscopic disease activity). Results There were significant differences in the risk of needing surgery after EBD among patients who underwent surgery and patients without a history of surgery (RD: -0.20 [-0.31, -0.08]), patients with endoscopic mucosal activity and patients in remission at the time of EBD (RD: 0.19 [0.04, 0.34]), patients using biologics at the time of EBD and patients not using biologics (RD: -0.09 [-0.16, -0.03]), and patients using steroids and those not using steroids at the time of EBD (RD: 0.16 [0.07, 0.26]). Conclusions The use of biologics and endoscopic disease remission at the time of EBD were protective factors against the need for surgery. No previous surgery or use of steroids at the time of EBD was associated with the need for surgery during follow-up.
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Affiliation(s)
- Hiram Menezes Nascimento Filho
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Angelo So Taa Kum
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Alexandre Moraes Bestetti
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Megui Marilia Mansilla Gallegos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Adérson Omar Mourão Cintra Damião
- Department of Gastroenterology and Hepatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Udayakumar Navaneethan
- Orlando Health Digestive Health Institute Center for Advanced Endoscopy, Research and Education, Orlando, USA
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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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Endoscopic Balloon Dilation Is Cost-Effective for Crohn's Disease Strictures. Dig Dis Sci 2022; 67:5462-5471. [PMID: 35290570 DOI: 10.1007/s10620-022-07420-z] [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: 12/13/2021] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) has emerged as an alternative intervention to manage Crohn's disease (CD) strictures. We determined the cost-effectiveness of EBD versus resection surgery for patients with short (< 4-5 cm) primary or secondary/anastomotic small or large bowel strictures. METHODS A microsimulation state-transition model analyzed the benefits and risks of EBD and resection surgery for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (2021 $US) and incremental cost-effectiveness ratios (ICER) were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. RESULTS The EBD strategy cost $19,822 and resulted in 6.18 QALYs while the surgery strategy cost $41,358 and resulted in 6.37 QALYs. Surgery had an ICER of $113,332 per QALY, making EBD a cost-effective strategy. The median number of EBDs was 5 in the EBD strategy and 0 in the surgery strategy. The median number of surgeries was 2 in the surgery strategy and 1 in the EBD strategy. Of individuals who initially received EBD, 50.4% underwent subsequent surgery. One-way sensitivity analyses showed that the probabilities of requiring repeated interventions, surgery mortality (< 0.7%), and quality of life after interventions were the most influential model parameters. Probabilistic sensitivity analyses favored EBD in 50.9% of iterations. CONCLUSIONS EBD is a cost-effective strategy for managing CD strictures. Differences in patient risk and quality of life after intervention impact cost-effectiveness. Intervention decisions should consider cost-effectiveness, patient risks, and quality of life.
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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: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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5
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Liu Q, Zhang X, Ko HM, Stocker D, Ellman J, Chen J, Hao Y, Bhardwaj S, Liang Y, Cho J, Colombel JF, Taouli B, Harpaz N. Constrictive and Hypertrophic Strictures in Ileal Crohn's Disease. Clin Gastroenterol Hepatol 2022; 20:e1292-e1304. [PMID: 34400338 DOI: 10.1016/j.cgh.2021.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Strictures in Crohn's disease (CD) are classically attributed to fibromuscular hypertrophy of the intestinal wall. We have identified and characterized CD-related ileal strictures that result instead from mural constriction (ie, reduced external circumference). METHODS Twenty-four strictures and internal controls from 17 adults with obstructive CD were analyzed by cross-sectional morphometry. RESULTS The stricture-to-control circumference ratios (CRs) ranged from 0.53 to 1.7. Six strictures with CR ≥1.0, designated hypertrophic, had concentrically thickened walls, mean 3-fold increases in cross-sectional area and stainable fibromucular tissue, and high transmural inflammation scores. In contrast, 18 strictures with CR <1.0, designated constrictive, had thin, pliant walls, cross-sectional areas and stainable fibromuscular tissue comparable with control values, and low transmural inflammation scores. Eight mildly constrictive strictures also showed mild fibromuscular mural expansion that fell short of statistical significance. Twelve of 18 constrictive strictures (67%) occurred multiply (2-4 strictures per specimen) in contrast with hypertrophic strictures, all of which occurred singly (P = .01). Constriction correlated quantitatively with circumferential serosal fat wrapping (P = .003) and was associated with myenteric lymphocytic plexitis (P = .02). Disease duration was shortest among subjects with constrictive strictures and correlated with increasing circumference (CR ≤0.8, 6.3 ± 6.2 years; CR >0.8, 8.7 ± 6.4 years; and CR ≥1.00, 13.7 ± 5.0 years, respectively; P = .03). CONCLUSIONS Constrictive ileal strictures in CD differ pathologically and clinically from hypertrophic strictures, featuring little or no fibromuscular mural expansion, frequent multiplicity, and earlier onset. Mesenteric fat wrapping and myenteric plexitis may contribute to their pathogenesis. Pathologic manifestations of constriction and hypertrophy can coexist, suggesting that stricture heterogeneity may be shaped in part by the dynamics of constrictive and hypertrophic processes.
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Affiliation(s)
- Qingqing Liu
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xiaofei Zhang
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Huaibin Mabel Ko
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel Stocker
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jordan Ellman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joyce Chen
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yansheng Hao
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Swati Bhardwaj
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yuanxin Liang
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judy Cho
- Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean Frederic Colombel
- Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bachir Taouli
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noam Harpaz
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
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6
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Takeda T, Kishi M, Takatsu N, Takada Y, Beppu T, Miyaoka M, Hisabe T, Ueki T, Arima H, Hirai F, Yao K. Long-term outcomes of endoscopic balloon dilation for intestinal strictures in patients with Crohn's disease during maintenance treatment with anti-tumor necrosis factor alpha antibodies. Dig Endosc 2022; 34:517-525. [PMID: 34185921 DOI: 10.1111/den.14073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Efficacy of endoscopic balloon dilation (EBD) for intestinal strictures in patients with Crohn's disease (CD) receiving anti-tumor necrosis factor alpha antibodies (anti-TNF) as maintenance therapy is unclear. We investigated the long-term efficacy and safety of EBD for intestinal strictures in patients with CD receiving anti-TNF. METHODS We retrospectively analyzed data from patients with CD who received anti-TNF as maintenance therapy from 2008 to 2017, underwent EBD, and were followed up for ≥6 months. The primary endpoint was the cumulative surgery-free rate. The main secondary endpoints were technical success, repeat EBD rate, risk factors affecting surgical outcomes, and safety. RESULTS Seventy-two patients with CD were assessed. The median observation period after EBD was 50 months. The technical success rate was 67%. The 3- and 5-year cumulative surgery-free rates were 81.1% and 73.5%, respectively. The repeat EBD rate was 74%. Multivariable analyses showed that risk factors affecting surgical outcomes were age at disease onset ≤16 years (hazard ratio 3.69; 95% confidence interval 1.36-10.01; P = 0.011). Serious complications requiring surgery developed in three patients. CONCLUSIONS Endoscopic balloon dilation was an effective and safe short-term treatment and a useful long-term treatment for CD patients with intestinal strictures receiving anti-TNF as maintenance therapy.
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Affiliation(s)
- Teruyuki Takeda
- IBD Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Masahiro Kishi
- IBD Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Noritaka Takatsu
- IBD Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Yasumichi Takada
- IBD Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Tsuyoshi Beppu
- IBD Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Masaki Miyaoka
- Departments of, Endoscopy, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Takashi Hisabe
- Department of, Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Toshiharu Ueki
- Department of, Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Hisatomi Arima
- Departments of, Preventive Medicine and Public Health, Fukuoka University Facility of Medicine, Fukuoka, Japan
| | - Fumihito Hirai
- IBD Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
- Department of, Gastroenterology, Fukuoka University Facility of Medicine, Fukuoka, Japan
| | - Kenshi Yao
- Departments of, Endoscopy, Fukuoka University Chikushi Hospital, Fukuoka, Japan
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Hayashi Y, Takabayashi K, Hosoe N, Kiyohara H, Kinoshita S, Nanki K, Fukuhara K, Mikami Y, Sujino T, Mutaguchi M, Kawaguchi T, Kato M, Ogata H, Kanai T. Predictors of necessity for endoscopic balloon dilatation in patients with Crohn's disease-related small bowel stenosis. Ann Med 2021; 53:2025-2033. [PMID: 34751600 PMCID: PMC8583773 DOI: 10.1080/07853890.2021.1998597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND AIM In patients with Crohn's disease (CD) and small bowel stenosis, endoscopic balloon dilation (EBD) is considered to be useful in improving stenotic symptoms and avoiding surgery. However, it carries risks such as bleeding and perforation. The aim of this study was to identify the indications for endoscopic intervention in patients with CD and small bowel stenosis. METHODS From November 2007 to March 2020, 143 CD patients with small bowel stenosis were enrolled in this study. We identified the factors associated with not requiring endoscopic intervention during long-term follow-up of these patients. RESULTS Forty of the 143 patients had abdominal symptoms of stenosis and had undergone EBD, whereas the remaining 103 were asymptomatic and had not undergone endoscopic intervention. During long-term follow-up, 95 of those 103 patients never required endoscopic or surgical intervention. Multivariate logistic regression analysis revealed that not consuming an elemental diet (OR 3.18, 95% CI 1.48-6.82; p < .01) and ileocecal valve (ICV) stenosis (OR 0.30, 95% CI 0.11-0.83; p = .02) were independently associated with not requiring EBD. The cumulative emergency hospitalisation-free rate also tended to be higher in patients not consuming an elemental diet or with ICV stenosis. CONCLUSIONS Two factors, namely not consuming an elemental diet and ICV stenosis, predict a long-term intervention-free prognosis in CD patients with small bowel stenosis.Key messagesWhen an endoscopically impassable small bowel stenosis is found in a CD patient, long-term follow-up without endoscopic intervention may be possible if the patient is asymptomatic, is not using an elemental diet, and the stenosis is ICV.
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Affiliation(s)
- Yukie Hayashi
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroki Kiyohara
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Satoshi Kinoshita
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kosaku Nanki
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kayoko Fukuhara
- Center for Preventive Medicine, Keio University Hospital, Tokyo, Japan
| | - Yohei Mikami
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Tomohisa Sujino
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Makoto Mutaguchi
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
| | - Takaaki Kawaguchi
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Motohiko Kato
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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Skamnelos A, Lazaridis N, Vlachou E, Koukias N, Apostolopoulos P, Murino A, Christodoulou D, Despott EJ. The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021. Ann Gastroenterol 2021; 34:599-611. [PMID: 34475730 PMCID: PMC8375652 DOI: 10.20524/aog.2021.0652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/14/2021] [Indexed: 12/11/2022] Open
Abstract
The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.
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Affiliation(s)
- Alexandros Skamnelos
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Division of Gastroenterology, University Hospital and Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece (Alexandros Skamnelos, Dimitrios Christodoulou)
| | - Nikolaos Lazaridis
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Genesis Hospital of Thessaloniki, Thessaloniki, Greece (Nikolaos Lazaridis)
| | - Erasmia Vlachou
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Army Share Funds Hospital (NIMTS), Athens, Greece (Erasmia Vlachou, Periklis Apostolopoulos)
| | - Nikolaos Koukias
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott).,Department of Gastroenterology, University Hospital of Patras, Patras, Greece (Nikolaos Koukias)
| | - Periklis Apostolopoulos
- Army Share Funds Hospital (NIMTS), Athens, Greece (Erasmia Vlachou, Periklis Apostolopoulos)
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott)
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital and Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece (Alexandros Skamnelos, Dimitrios Christodoulou)
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and UCL Institute for Liver and Digestive Health, Hampstead, London, United Kingdom (Alexandros Skamnelos, Nikolaos Lazaridis, Erasmia Vlachou, Nikolaos Koukias, Alberto Murino, Edward J. Despott)
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9
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Abstract
Small bowel evaluation is warranted in all newly diagnosed cases of Crohn’s disease (CD) as small bowel is involved in two-thirds of CD patients at diagnosis and the involvement can be discontinuous. Endoscopic evaluation of the small bowel in suspected or established CD can be done by video capsule endoscopy (VCE), device assisted enteroscopy (DAE) (which includes single and double balloon enteroscopy, novel motorized spiral enteroscopy (NMSE) and balloon guided endoscopy (BGE)) and intra-operative enteroscopy (IOE). In suspected CD with a negative ileo-colonoscopy, VCE is the preferred initial diagnostic modality in the absence of obstructive symptoms or known stenosis. VCE should be preceded by cross-sectional imaging or patency capsule testing if obstruction is suspected given with high retention risk. In established cases, small bowel cross-sectional imaging (magnetic resonance or computed tomography enterography) is preferred over VCE as it can assess transmural and extra-luminal involvement. VCE is indicated subsequently if necessary to assess disease extent, unexplained symptoms (e.g., anemia, malnutrition) or mucosal healing. Pan-enteric capsule endoscopy (PCE) and the use of artificial intelligence are the recent developments with VCE. DAE with small bowel biopsy can provide definitive evidence of CD including the extent and severity. A final diagnosis of CD is based on the constellation of clinical, radiologic, histologic and endoscopic features. Newer technologies like NMSE and BGE can help with deeper and faster small bowel evaluation. DAE has also allowed endoscopic treatment of small bowel strictures, small bowel bleeding and retrieval of retained capsule or foreign bodies. Endoscopic balloon dilation (EBD), endoscopic electro-incision, strictureplasty and stenting have shown promising results in CD related small bowel strictures. In conclusion, endoscopic evaluation of the small bowel is rapidly evolving field that has a major role in diagnosis and management of small bowel CD and can alter treatment outcomes in properly selected patients.
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10
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Bettenworth D, Bokemeyer A, Kou L, Lopez R, Bena JF, Ouali SE, Mao R, Kurada S, Bhatt A, Beyna T, Halloran B, Reeson M, Hosomi S, Kishi M, Hirai F, Ohmiya N, Rieder F. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn's disease strictures. Aliment Pharmacol Ther 2020; 52:1104-1116. [PMID: 32813282 PMCID: PMC8052861 DOI: 10.1111/apt.16049] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 05/26/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evidence for endoscopic balloon dilation of small intestinal strictures in Crohn's disease (CD) using balloon-assisted enteroscopy is scarce. AIM To evaluate endoscopic balloon dilation for the treatment of small intestinal CD strictures using balloon-assisted enteroscopy. METHODS Citations in Embase, MEDLINE, and Cochrane were systematically reviewed. In a meta-analysis of 18 studies with 463 patients and 1189 endoscopic balloon dilations, technical success was defined as the ability to dilate a stricture. Individual data were also obtained on 218 patients to identify outcome-relevant risk factors. RESULTS In the pooled per-study analysis, technical success rate of endoscopic balloon dilation was 94.9%, resulting in short-term clinical efficacy in 82.3% of patients. Major complications occurred in 5.3% of patients. During follow-up, 48.3% of patients reported symptom recurrence, 38.8% were re-dilated and 27.4% proceeded to surgery. On the per-patient-based multivariable analysis, that patients with disease activity in the small intestine had lower short-term clinical efficacy (odds ratio 0.32; 95% confidence interval 0.14-0.73, P = 0.007). Patients with concomitant active disease in the small and/or large intestine had an increased risk to proceed toward surgery (hazard ratio 1.85; 95% confidence interval 1.09-3.13, P = 0.02 and hazard ratio 1.77; 95% confidence interval 1.34-2.34, P < 0.001). CONCLUSIONS Balloon-assisted enteroscopy for dilatation of CD-associated small intestinal strictures has high short-term technical and clinical efficacy and low complication rates. However, up to two-thirds of patients need re-dilation or surgery.
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Affiliation(s)
| | | | | | | | | | | | - Ren Mao
- Cleveland, OH, USA,Guangzhou, China
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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: 8] [Impact Index Per Article: 2.0] [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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Morita Y, Bamba S, Inatomi O, Takahashi K, Imai T, Murata M, Ohno M, Sasaki M, Tsujikawa T, Andoh A. Prototype single-balloon enteroscopy with passive bending and high force transmission improves depth of insertion in the small intestine. Intest Res 2020; 18:229-237. [PMID: 32252502 PMCID: PMC7206344 DOI: 10.5217/ir.2019.09150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background/Aims We retrospectively analyzed Crohn’s disease (CD) patients with small intestinal strictures who underwent single-balloon enteroscopy (SBE) to ascertain whether prototype SBEs with a passive bending mechanism and high force transmission insertion tube had better insertability in the small intestine than a conventional SBE. Methods Among 253 CD patients who underwent SBE, we identified 94 CD patients who had undergone attempted endoscopic balloon dilatation (EBD) for small intestinal stenosis for inclusion in this study. We analyzed whether the type of scope used for their initial procedure affected the cumulative surgery-free rate. For the insertability analysis, patients who underwent SBE at least twice were divided into 3 groups according to the type of scope used: conventional SBE only, prototype SBE only, and both conventional and prototype SBEs. For each group, depth of insertion, procedure time, and number of EBDs were compared in the same patient at different time points. Results The success rate of EBD was 88.3%. The 5- and 10-year cumulative surgery-free rate was 75.7% and 72.8%, respectively. Cox regression analysis indicated that the factors contributing to surgery were long stricture (≥2 cm), EBD failure, and elevated Crohn’s Disease Activity Index, but not the type of scope used for EBD. The prototype SBEs significantly improved the depth of insertion (P=0.03, Wilcoxon’s signed-rank test). Conclusions In CD patients with small intestinal stenosis, the prototype SBEs with a passive bending mechanism and high force transmission insertion tube did not improve long-term EBD outcome but did improve deep insertability. (Clinical Trial Registration No. UMIN000037102)
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Affiliation(s)
- Yasuhiro Morita
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Shigeki Bamba
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | | | - Takayuki Imai
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Masaki Murata
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Masashi Ohno
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Masaya Sasaki
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Tomoyuki Tsujikawa
- Department of Comprehensive Internal Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Otsu, Japan
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Strictures in Crohn's Disease and Ulcerative Colitis: Is There a Role for the Gastroenterologist or Do We Always Need a Surgeon? Gastrointest Endosc Clin N Am 2019; 29:549-562. [PMID: 31078252 DOI: 10.1016/j.giec.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Symptomatic strictures occur more often in Crohn disease than in ulcerative colitis. The mainstay of endoscopic therapy for strictures in inflammatory bowel disease is endoscopic balloon dilation. Serious complications are rare, and risk factors for perforation include active inflammation, use of steroids, and dilation of ileorectal or ileosigmoid anastomotic strictures. This article presents current literature on strictures in inflammatory bowel disease. Focus is placed on the short- and long-term outcomes, complications, and safety of endoscopic balloon dilation for Crohn disease strictures. Adjuvant techniques, such as intralesional injection of steroids and anti-tumor necrosis factor, stricturotomy, and stent insertion, are briefly discussed.
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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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