Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures resulting from Crohn's disease

Surgical and non-surgical risk factors affecting the insufficiency of ileocolic anastomosis after first-time surgery in Crohn’s disease patients

BACKGROUND

Crohn's disease (CD) often necessitates surgical intervention, particularly when it manifests in the terminal ileum and ileocecal valve. Despite undergoing radical surgery, a subset of patients experiences recurrent inflammation at the anastomotic site, necessitating further medical attention.

AIM

To investigate the risk factors associated with anastomotic insufficiency following ileocecal resection in CD patients.

METHODS

This study enrolled 77 patients who underwent open ileocolic resection with primary stapled anastomosis. Patients were stratified into two groups: Group I comprised individuals without anastomotic insufficiency, while Group II included patients exhibiting advanced anastomotic destruction observed endoscopically or those requiring additional surgery during the follow-up period. Surgical and non-surgical factors potentially influencing anastomotic failure were evaluated in both cohorts.

RESULTS

Anastomotic insufficiency was detected in 12 patients (15.6%), with a mean time interval of 30 months between the initial surgery and recurrence. The predominant reasons for re-intervention included stenosis and excessive perianastomotic lesions. Factors associated with a heightened risk of anastomotic failure encompassed prolonged postoperative obstruction, anastomotic bleeding, and clinically confirmed micro-leakage. Additionally, patients in Group II exhibited preoperative malnutrition and early recurrence of symptoms related to CD.

CONCLUSION

Successful surgical outcomes hinge on the attainment of a fully functional anastomosis, optimal metabolic status, and clinical remission of the underlying disease. Vigilant endoscopic surveillance following primary resection facilitates the timely identification of anastomotic failure, thereby enabling noninvasive interventions.

Endoscopic balloon dilation management for benign duodenal stenosis

BACKGROUND AND AIMS

Benign duodenal stenosis (BDS) is most commonly caused by peptic ulcer disease (PUD). Endoscopic balloon dilation (EBD) is the recommended initial management despite limited supporting literature. Our study investigated the etiologic spectrum of BDS and its response to endoscopic dilation.

METHODS

We performed a cohort study of a prospectively maintained database of BDS at our large tertiary academic center between 2002 and 2018. All patients who underwent EBD were analyzed. Dilation was performed using through-the-scope balloons. Technical and clinical successes of initial and repeat EBD were compared. Descriptive statistics, univariate, and multivariate analysis were performed.

RESULTS

The study included 86 patients with 54.7% female gender. Etiologies included 39 patients with PUD (45.3%), 19 patients with Crohn's disease (22.1%), 23 patients had idiopathic etiologies (26.7%), and 5 patients were listed as other etiologies (5.8%). Proximal stricture location (1st part of duodenum) occurred in 66% of females, whereas distal duodenal involvement was seen in 63.6% of males (p value 0.007). Usage of PPI was associated with 3.6 times higher clinical success rate (p value 0.04). Technical (97.4%) and clinical (77.8%) successes for index dilations in PUD were not significantly better than those of non-PUD patients (p values 0.99, 0.52).

CONCLUSION

EBD has both a high technical and clinical success for BDS regardless of etiology and should be considered over initial surgical intervention due to low risk profile. Males tend to have more distal duodenal involvement, and PPI usage is an independent predictor for clinical success.

Futuristic Developments and Applications in Endoluminal Stenting

Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent.

Comparison of Endoscopic Dilation vs Surgery for Anastomotic Stricture in Patients With Crohn's Disease Following Ileocolonic Resection

BACKGROUND & AIMS

It is not clear whether endoscopic balloon dilation (EBD) or surgery is a more effective treatment for ileocolonic anastomosis (ICA) stricture in patients with Crohn's disease. We aimed to compare long-term outcomes of patients who underwent EBD versus surgery for ICA stricture.

METHODS

We performed a retrospective study of adult patients with ICA stricture treated with EBD (n = 176) or surgery (n = 131), from December 1998 through May 2013, at the Cleveland Clinic Foundation. Demographic, clinical, endoscopic, histologic, and radiographic data were collected. Disease duration was defined as the time interval from the diagnosis of Crohn's disease to the treatment for ICA stricture. Data were collected for a median follow-up period of 2.9 years (interquartile range, 0.9-5.7 years). Multivariable analyses were performed to assess risk factors for subsequent surgery.

RESULTS

Patients in the surgery group had a longer median interval from inception (first encounter with patients at either follow-up endoscopy or presentation with obstructive symptoms) until subsequent surgery (4.7 years; interquartile range, 2.2-8.8 vs 1.8 years; interquartile range, 0.4-4.1 years). The average time to surgery delayed by EBD was 6.45 years. Upfront surgery for ICA stricture (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.32-0.76), a longer time for diagnosis to inception (HR, 0.96; 95% CI, 0.93-0.99), a shorter interval from the last surgery to inception (HR, 1.05; 95% CI, 1.01-1.09), only 1 previous resection (HR, 0.41; 95% CI, 0.26-0.66), and the absence of concurrent strictures (HR, 1.68; 95% CI, 0.97-2.9) were associated with a significantly lower risk for subsequent surgery.

CONCLUSIONS

Surgical resection for ICA stricture in patients with Crohn's disease was associated with a lower risk of further surgery than EBD. However, EBD could delay time until need for a second surgery and be attempted first for patients with a lower risk for disease progression. Patients at risk for recurrent disease may benefit from upfront surgical therapy.

A review of endoscopic balloon dilatation techniques for treating Crohn's strictures: time to standardise therapy

Endoscopic balloon dilatation (EBD) is a recognised treatment for symptomatic Crohn's disease strictures. Over 3000 procedure are reported in the literature and yet the long term benefits are unclear. This is largely because of different populations, study designs, techniques, types of strictures, the outcome measures used and follow-up periods. Areas covered: We summarised the techniques reported in the literature based on a systematic review and key factors that may influence outcome: pre-intervention imaging, stricture length and type, balloon size in relation to intestinal lumen diameter, duration of dilatation, frequency of repeat dilatation and instructions on follow-up. Expert commentary: We noted that shorter, non-ulcerated and anastomotic strictures fare better and 2 mins dilatation duration was the commonest technique used without an increased risk of complications. The findings were translated into a standardised protocol and a management pathway to guide clinicians on the therapeutic strategy for Crohn's strictures. To resolve the uncertainty about long-term benefits, future studies should adopt a replicable standardised EBD technique, define degree of fibrosis to decide therapy accordingly, compare it to alternative interventions (strictureplasty or stents) within a randomised controlled trial and apply a validated outcome measure to include intestinal damage and quality of life.

Heterogeneity in endoscopic treatment of Crohn's disease-associated strictures: An international inflammatory bowel disease specialist survey

BACKGROUND

Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards.

METHODS

IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated.

RESULTS

A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001).

CONCLUSIONS

EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.

Endoscopic balloon dilatation of Crohn's strictures: a safe method to defer surgery in selective cases

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.

Clinical Outcomes of Surgery Versus Endoscopic Balloon Dilation for Stricturing Crohn's Disease

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.

Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures

BACKGROUND

Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies.

AIM

To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored.

METHODS

A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics.

RESULTS

Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis.

CONCLUSIONS

Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.

Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease

BACKGROUND

Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear.

METHODS

An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013.

RESULTS

Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028).

CONCLUSION

Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.

Endoscopic therapy in inflammatory bowel diseases (with videos)

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.

[Endoscopic management of luminal stenosis in inflammatory bowel disease]

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.

Endoscopic colonic stents and dilatation

Colonic obstruction is common with malignancy as the most common cause. Endoscopic placement of intraluminal self-expanding stents is a newer option to manage this challenging problem. In benign disease, endoscopic dilatation may play a role whereas stenting can serve as a bridge to surgery. Indications and placement techniques are discussed along with a summary of published results and complications.

Efficacy and safety of endoscopic balloon dilation of symptomatic intestinal Crohn's disease strictures

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.

Endoscopic balloon dilatation without fluoroscopy for treating gastric outlet obstruction because of benign etiologies

BACKGROUND

Benign gastric outlet obstruction (GOO) causes considerable morbidity and conventional treatment has been surgery. Endoscopic balloon dilatation is a minimally invasive treatment modality for GOO but experience with its use is mainly in patients with GOO due to peptic ulcer disease. We report our experience of endoscopic balloon dilatation in benign GOO of various etiologies.

METHODS

Over 4 years, 25 patients with benign GOO were treated by endoscopic balloon dilatation done with through-the-scope controlled radial expansion (CRE) balloon dilators. Dilatation was repeated every 2 weeks with the end point being dilation of 15 mm or the need for surgery. Helicobacter pylori, when present, was eradicated.

RESULTS

Etiology of benign GOO was peptic ulcer (11), corrosive ingestion (7), chronic pancreatitis (4, groove pancreatitis in 1), tuberculosis (2), and Crohn's disease (1). Endoscopic balloon dilatation was successful in 21/25 (84%) patients. Patients required one to six sessions of endoscopic dilatation (mean=2.2±1.2). Corrosive-induced GOO required more dilatation sessions (3.83±0.75) compared to peptic GOO (2.1±0.56; p<0.05). Balloon dilatation was also effective in patients with GOO due to gastroduodenal tuberculosis and Crohn's disease. Patients with chronic pancreatitis-related GOO had poor response to dilatation, with two patients (50%) requiring surgery and the remaining two with recurrence of symptoms requiring repeat dilatation. None of the other patients with successful treatment had recurrence of symptoms. Complication in the form of perforation was noted in two patients (8%).

CONCLUSIONS

Endoscopic balloon dilatation is an effective, safe, and minimally invasive treatment modality for benign gastric outlet obstruction.

Comparison of strictureplasty and endoscopic balloon dilatation for stricturing Crohn's disease--review of the literature

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.

The response of Crohn's strictures to endoscopic balloon dilation

BACKGROUND

Endoscopic balloon dilation has been shown to be an alternative to surgery in the treatment of Crohn's symptomatic strictures.

AIM

To analyse the impact of the type of the strictures -de novo or anastomotic - their location and their length on the outcome of endoscopic balloon dilation.

METHODS

Between December 1999 and June 2008, 55 patients underwent 93 balloon dilations for 74 symptomatic strictures. One stricture was located in the duodenum, 39 strictures were in the terminal ileum, 17 at the ileocoecal anastomosis after a preceding resection and 17 in the colon.

RESULTS

Endoscopic treatment was successful in 76% of the patients during an observation period of 44 (1-103) months. Of the patients, 24% required surgery. All patients who underwent surgery had de novo strictures in the terminal ileum. These strictures were significantly longer compared with the ileal strictures that responded to endoscopic treatment [7.5 (1-25) cm vs. 2.5 (1-25) cm; P = 0.006].

CONCLUSIONS

The long-term success of endoscopic balloon dilation depends on the type of the strictures, their location and their length. Failure of endoscopic treatment was observed only in long-segment strictures in the terminal ileum.

Effective dilation of small-bowel strictures by double-balloon enteroscopy in patients with symptomatic Crohn's disease (with video)

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.

Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn's disease: a prospective study

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.

Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn’s disease: A prospective study

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.

Intraabdominal septic complications following bowel resection for Crohn's disease: detrimental influence on long-term outcome

BACKGROUND

A number of studies deal with factors affecting postoperative recurrence; however, they do not analyze the influence of postoperative morbidity on the long-term outcome. This was the aim of the present study.

MATERIALS AND METHODS

Two hundred eighty-two patients underwent 331 intestinal resections for primary or recurrent Crohn's disease between 1992 and 2005. Closure of ileostomy or colostomy, isolated stricturoplasty, abdominoperineal resection for perianal disease, and reoperations for postoperative complications were excluded. "Surgical recurrence" was defined as a development of stricturing or perforating disease necessitating repeat surgical therapy.

RESULTS

Anastomotic leak, intraabdominal abscess, enterocutaneous fistula (intraabdominal septic complications, IASC) occurred after 46 operations (16%). Four patients died (1.2%). By multivariate analysis, articular disease manifestation (p = 0.03), duration of symptoms leading to surgery (p = 0.009), and weight loss (p = 0.03) were associated with occurrence of postoperative complications. Surgical recurrence occurred following 86 bowel resections, and 36 occurred during the first postoperative year. The following factors were associated with an increased risk of surgical recurrence by multivariate analysis: postoperative IASC (p = 0.0002) and previous bowel resections (p = 0.002). Patients suffering IASC had statistically significantly higher 1-, 2-, 5-, and 10-year surgical recurrence rate (25%, 29%, 50%, and 57%) than patients without IASC (4%, 7%, 19%, and 38%, p = 0.0003).

CONCLUSION

The incidence of the postoperative IASC is predominantly determined by preoperative disease severity. IASC have a detrimental influence on the long-term outcome following intestinal resections in patients with Crohn's disease, leading to increased number of repeat resection surgery.

Through the endoscope balloon dilation of ileocolonic strictures: prognostic factors, complications, and effectiveness

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.

Systematic review: Endoscopic dilatation in Crohn's disease

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.

Endoscopic balloon dilatation of intestinal strictures in Crohn's disease: safe alternative to surgery

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.

Advances in gastrointestinal endoscopic techniques

An increasing number of techniques for endoscopic diagnosis and treatment is being described. Endoscopic surgeons should be familiar with these techniques. Although many of the diagnostic techniques, other than marking, do not have widespread clinical application, the therapeutic techniques that were described in this article are being used successfully in increasing numbers of appropriately selected patients. Additional experience and technologic advances will refine the endoscopic therapy that is available to patients with colorectal diseases.

Endoscopic treatment of strictures in Crohn's disease

Patients with Crohn's disease often develop (recurring) intestinal stenosis. This is a result of continuous activation of fibrogenic cells by ongoing inflammation. Surgery is usually needed and consists of intestinal resection or strictureplasty. Medical therapy has not proven to be successful. Over the years endoscopic treatment has become more important. Uncomplicated stenosis, with a maximal length of 4 cm, can be treated by balloon dilatation. Indications, procedure and results are discussed. More recently, local corticosteroid injection in addition to balloon dilatation has been studied, but it remains to be seen whether long-term prevention of re-stenosis occurs. Other endoscopic therapies and new developments are also discussed in this chapter.

Long-term outcome of endoscopic pneumatic dilatation in Crohn's disease

BACKGROUND

To avoid multiple surgeries in stenosing Crohn's disease, pneumatic endoscopic dilatation has been introduced. The present study evaluated the long-term clinical outcome in Crohn's disease patients after endoscopic dilatation for ileal or neoileal strictures.

PATIENTS AND METHODS

All Crohn's disease patients who underwent pneumatic dilatation of ileal or ileo-colonic strictures between January 1988 and December 2001 were invited to return for a clinical check-up in June 2002. Clinical, endoscopic and radiological reports were reviewed. Symptomatic relief from sub-occlusive symptoms without requiring surgery was considered as a positive outcome, whereas the requirement of surgery was regarded as an unfavourable outcome. Possible predictors of favourable outcome were analysed.

RESULTS

Endoscopic dilatation was technically successful in 34/43 (79%) Crohn's disease patients, with a mean number of dilatations per patient of 3 +/- 3.13. During a mean follow-up of 63.7 +/- 44.6 months, a positive long-term outcome was observed in 18 (52.9%) patients, whereas surgery was necessary in the remaining 16 cases. The risk of surgery was distinctly higher within 2 years post-dilatation than in the next 2 years (26.4% versus 8.3%, respectively; P = 0.078). No clear clinical, endoscopic or radiological predictive factors for a successful outcome were identified.

CONCLUSIONS

Endoscopic pneumatic dilatation is an effective and safe procedure to be applied to patients with stenosing Crohn's disease, offering a very long-term benefit in a sub-group of patients.

Hydrostatic balloon dilatation of Crohn's strictures

AIM

To evaluate the safety and long-term efficacy of per-endoscopic hydrostatic balloon dilatation in a retrospective series of patients with Crohn's disease.

METHODS

Thirty-eight patients had balloon dilatation for intestinal symptomatic strictures which were located as follows: ileo-colonic (26) or colocolic (2) anastomosis, colon (4), ileum (3), proximal jejunum (1) and ileo-caecal valve (5); three patients had two strictures accessible to dilatation. The mean length of the strictures was 2.1 cm (s.d., 0.3 cm).

RESULTS

Thirty-two of the 38 patients were successfully dilated and followed for a median of 22.8 months (0.2-103 months) until surgery or last news. The probabilities of obstructive symptom recurrence were 36% at 1 year and 60% at 5 years. Twelve patients had a second dilatation, and three a third. The probabilities of surgery for stricture were 26% at 1 year and 43% at 5 years. Results were not influenced by age, sex, activity of the disease, passage of the stricture by the colonoscope or concomitant medical therapies. Complications occurred in 9.4% of the 53 dilatation sessions, with only one perforation.

CONCLUSIONS

Hydrostatic balloon dilatation is effective for Crohn's symptomatic strictures, and can avoid or postpone surgery, with an acceptable rate of complications.

Therapeutic options in the management of strictures in Crohn's disease

Intestinal strictures are a commonly encountered problem in patients with Crohn's disease. Endoscopic management with hydrostatic balloon dilation is an effective alternative to surgery in patients with endoscopically accessible lesions that are shorter than 7-8 cm. Endoscopic balloon dilation is the preferred initial modality in anastomotic strictures. The presence of inflammation near the stricture should not be considered a contraindication to dilation, and intralesional steroid injection should be considered in these patients with inflammation present in the area of the stricture. Further technological developments in endoscopes and balloon dilators may allow for broader application of these techniques.

Colonoscopic hydrostatic balloon dilatation of Crohn's strictures

Recurrent strictures cause considerable morbidity among many patients with Crohn's disease. We present a retrospective review of the outcome of patients who underwent endoscopic hydrostatic balloon dilatation of Crohn's strictures in our hospital over the past 7 years. All patients were under observation at Addenbrooke's Hospital, Cambridge. An initial assessment of all strictures was made radiologically, and any patient with active disease was treated before consideration of endoscopic dilatation. Dilatation was carried out with Microvasive Rigiflex balloons. Outcome after dilatation was assessed by review at subsequent clinic visits. Sixteen of 22 patients had resolution of their obstructive symptoms after dilatation, although one third of patients required more than two dilatations over the follow-up period. Six of 22 patients had persisting symptoms after endoscopic treatment, requiring surgery. There were no complications noted after any of the 71 dilatations that were performed. We conclude that hydrostatic balloon dilatation is a safe and effective alternative to surgery in the management of Crohn's strictures within the reach of the colonoscope.

Inflammatory bowel disease. 2: Medical and surgical treatment

The first article in this three-part series reviewed the aetiology, treatment and concept of participation in inflammatory bowel disease. This article provides a brief overview of current trends in the medical and surgical treatment of inflammatory bowel disease. The discussion of medical management will include the most common drugs utilized for symptom control, their modes of action, routes of administration and side-effects. In addition, the role of nutritional support, both as an adjunctive and a primary therapy, will be considered. The options for, and consequences of, definitive surgical intervention in the event of failed medical management of both ulcerative colitis and Crohn's disease will be examined.

Controversies in Crohn's disease

Despite recent advances in the medical therapy of Crohn's disease, surgery continues to play a central role in the treatment of the disease. The strategy for surgical management of Crohn's disease continues to evolve. This chapter reviews many of the controversies surrounding surgical palliation of complications of Crohn's disease. Included is a discussion of indications for strictureplasty in treatment of intractable intestinal obstruction. Factors influencing long-term outcome with sphincter-saving resection in the treatment of Crohn's colitis are reviewed. Experience with definitive treatment of anal Crohn's disease and repair of rectovaginal fistulas is examined. Finally, recent experience supporting ileocolic resection when acute Crohn's ileitis is identified during laparotomy for right lower quadrant pain is critically evaluated. These controversial aspects of the surgical treatment of Crohn's disease reflect an improved understanding of the natural history of the disease as well as refinement in surgical techniques and better definition of criteria for surgical intervention.

Strictureplasty with a pedunculated jejunal patch in Crohn's disease of the duodenum

Surgical treatment for duodenal stenosis caused by Crohn's disease is only indicated in symptomatic duodenal obstruction when conservative treatment has failed. Previously described operative procedures include strictureplasty for short stenoses and bypass or resectional procedures, if duodenal stenosis is extensive. In this case of an extensive duodenal Crohn's stenosis, we performed a strictureplasty of the duodenum with a pedunculated jejunal patch. Thus, duodenal passage could be well preserved, and the patient has remained asyptomatic during a follow-up of more than 9 months.

Management and causes of acute large-bowel obstruction

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.

Endoscopic balloon dilatation of duodenal strictures in Crohn's disease

Endoscopic balloon dilatation of oesophageal and colonic strictures is now widely performed. Duodenal strictures due to Crohn's disease represent a difficult clinical problem as surgical intervention is a major undertaking and recurrences are common. We describe endoscopic balloon dilatation in three patients with obstructive symptoms from duodenal strictures due to Crohn's disease. The procedure appeared safe, was well tolerated and resulted in an excellent symptomatic response. This method is particularly suitable for short duodenal strictures and avoids the need for surgical intervention in this difficult group of patients.