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Otero-Piñeiro AM, Floruta C, Maspero M, Lipman JM, Holubar SD, Steele SR, Hull TL. Salvage surgery is an effective alternative for J-pouch afferent limb stricture treatment. Surgery 2023; 174:753-757. [PMID: 37085381 DOI: 10.1016/j.surg.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/15/2023] [Accepted: 03/12/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients requiring surgery for inflammatory bowel disease. A stricture located at the inlet of the afferent limb can lead to small bowel obstruction in a limited number of patients with a pelvic pouch. This paper aims to examine our experience with afferent limb stricture surgical correction when other endoscopic treatment methods have failed to control obstructive symptoms. METHODS All consecutive eligible patients with ileal pouch-anal anastomosis and afferent limb stricture were identified from our institutional review board-approved database from 1990 to 2021. Patients surgically treated with excision and reimplantation/strictureplasty of afferent limb stricture were included in this study. RESULTS Twenty patients met our inclusion criteria. Fifteen (75%) were female, and the overall mean age was 41 ± 10.3 years at afferent limb stricture surgery. The interval from ileal pouch-anal anastomosis formation to surgery for afferent limb stricture was 13.5 ± 6.7 years. Nine (45%) underwent strictureplasty, and 11 (55%) had resection and reimplantation of the afferent limb into the pouch. Before afferent limb stricture surgery, 3 (15%) required a diverting ileostomy for their obstructive symptoms. An additional 12 (60%) had a stoma constructed during afferent limb stricture surgery, and 5 had a strictureplasty and no stoma. Postoperatively, 1 patient (5%) had a leak at the afferent limb stricture repair site. All patients had their ileostomy closed 3.2 (2.99-3.6) months after surgery. Long-term after afferent limb stricture surgery, recurrent small bowel obstruction symptoms recurred in 7 (35%) patients 3.9 (2.6-5.8) years later. CONCLUSION Afferent limb stricture can be treated effectively with salvage surgery. The surgical intervention appears durable and provides an acceptable outcome for their obstructive symptoms.
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Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Crina Floruta
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Marianna Maspero
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Jeremy M Lipman
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Tracy L Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH.
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Solitano V, Dal Buono A, Gabbiadini R, Wozny M, Repici A, Spinelli A, Vetrano S, Armuzzi A. Fibro-Stenosing Crohn's Disease: What Is New and What Is Next? J Clin Med 2023; 12:jcm12093052. [PMID: 37176493 PMCID: PMC10179180 DOI: 10.3390/jcm12093052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/03/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Fibro-stenosing Crohn's disease (CD) is a common disease presentation that leads to impaired quality of life and often requires endoscopic treatments or surgery. From a pathobiology perspective, the conventional view that intestinal fibro-stenosis is an irreversible condition has been disproved. Currently, there are no existing imaging techniques that can accurately quantify the amount of fibrosis within a stricture, and managing patients is challenging, requiring a multidisciplinary team. Novel therapies targeting different molecular components of the fibrotic pathways are increasing regarding other diseases outside the gut. However, a large gap between clinical need and the lack of anti-fibrotic agents in CD remains. This paper reviews the current state of pathobiology behind fibro-stenosing CD, provides an updated diagnostic and therapeutic approach, and finally, focuses on clinical trial endpoints and possible targets of anti-fibrotic therapies.
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Affiliation(s)
- Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Division of Gastroenterology, Department of Medicine, Western University, London, ON N6A 4V2, Canada
| | - Arianna Dal Buono
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Roberto Gabbiadini
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marek Wozny
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Department of Endoscopy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Stefania Vetrano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
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3
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Zhang Z, He X, Hu J, Zheng Z, Chen Y, Tang J, Li S, Ke J, Lian L, Lan P, Wu X. Split stoma with delayed anastomosis may be preferred for 2-stage surgical resection in high-risk patients with Crohn's disease. Surgery 2021; 171:1486-1493. [PMID: 34863524 DOI: 10.1016/j.surg.2021.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fecal diversion after bowel resection is a safe and effective procedure in high-risk patients with Crohn's disease, but the better approach between primary anastomosis with protective stoma and split stoma with delayed anastomosis has not yet been investigated. This study aimed to compare the outcomes of these approaches in high-risk patients with Crohn's disease. METHODS A retrospective investigation on consecutive high-risk patients with Crohn's disease was conducted at a tertiary referral hospital from August 2009 to March 2019. The primary outcomes were the overall early postoperative complications and overall anastomosis-related adverse events in an intention-to-treat approach. RESULTS A total of 118 consecutive patients who underwent 121 surgeries (35 procedures with a protective stoma and 86 procedures with a split stoma) were enrolled. After a median follow-up period of 659 days and 728 days, respectively, 25 patients underwent a stoma-reversal procedure in the protective-stoma group, and 54 patients underwent delayed anastomosis in the split stoma group. Overall, early 30-day surgical morbidity and anastomosis-related adverse events were observed in more patients in the protective-stoma group than in the split-stoma group (51.4% [18/35] vs 30.2% [26/86]; P = .028 and 37.1% [13/35] vs 2.3% [2/86]; P < .001, respectively; intention-to-treat analysis). Similar results were found in the per-protocol analysis (44.0% [11/25] vs 20.4% [11/54]; P = .029 and 36.0% [12/25] vs 3.7% [2/54]; P < .001, respectively.) CONCLUSION: Split stoma with delayed anastomosis is associated with a reduction in anastomotic adverse events and overall early surgical complications and thus may be a better surgical option for high-risk patients with Crohn's disease.
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Affiliation(s)
- Zongjin Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaowen He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zheyu Zheng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongle Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jian Tang
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Senmao Li
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Xiaojian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China; Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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Juez Sáez LD, Ocaña J, Ramos D, Die J, García Pérez JC. Management of anastomotic stenosis after ileocecal resection in Crohn's disease with stenotic pattern surgery vs. endoscopic dilation. Surgery vs. endoscopic dilation. Cir Esp 2021; 99:615-617. [PMID: 34332915 DOI: 10.1016/j.cireng.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/08/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Luz Divina Juez Sáez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Juan Ocaña
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Diego Ramos
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Die
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan Carlos García Pérez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Cheung S, Rahman R, Bicknell C, Stoyanov D, Chang PL, Li M, Rolls A, Desender L, Van Herzeele I, Hamady M, Riga C. Comparison of manual versus robot-assisted contralateral gate cannulation in patients undergoing endovascular aneurysm repair. Int J Comput Assist Radiol Surg 2020; 15:2071-2078. [PMID: 33070273 DOI: 10.1007/s11548-020-02247-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/07/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE Robotic endovascular technology may offer advantages over conventional manual catheter techniques. Our aim was to compare the endovascular catheter path-length (PL) for robotic versus manual contralateral gate cannulation during endovascular aneurysm repair (EVAR), using video motion analysis (VMA). METHODS This was a multicentre retrospective cohort study with fluoroscopic video recordings of 24 EVAR cases (14 robotic, 10 manual) performed by experienced operators (> 50 procedures), obtained from four leading European centres. Groups were comparable with no statistically significant differences in aneurysm size (p = 0.47) or vessel tortuosity (p = 0.68). Two trained assessors used VMA to calculate the catheter PL during contralateral gate cannulation for robotic versus manual approaches. RESULTS There was a high degree of inter-observer reliability (Cronbach's α > 0.99) for VMA. Median robotic PL was 35.7 cm [interquartile range, IQR (30.8-51.0)] versus 74.1 cm [IQR (44.3-170.4)] for manual cannulation, p = 0.019. Robotic cases had a median cannulation time of 5.33 min [IQR (4.58-6.49)] versus 1.24 min [IQR (1.13-1.35)] in manual cases (p = 0.0083). Generated efficiency ratios (PL/aorto-iliac centrelines) was 1.6 (1.2-2.1) in robotic cases versus 2.6 (1.7-7.0) in manual, p = 0.031. CONCLUSION Robot-assisted contralateral gate cannulation in EVAR leads to decreased navigation path lengths and increased economy of movement compared with manual catheter techniques. The benefit could be maximised by prioritising robotic catheter shaping over habituated reliance on guidewire manipulation. Robotic technology has the potential to reduce the endovascular footprint during manipulations even for experienced operators with the added advantage of zero radiation exposure.
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Affiliation(s)
- Sheena Cheung
- Division of Surgery and Cancer, Imperial College London, London, UK
| | - Rafid Rahman
- Division of Surgery and Cancer, Imperial College London, London, UK
| | - Colin Bicknell
- Division of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Danail Stoyanov
- Centre for Medical Image Computing, University College London, London, UK
| | - Ping-Lin Chang
- Centre for Medical Image Computing, University College London, London, UK
| | - Mimi Li
- Division of Surgery and Cancer, Imperial College London, London, UK
| | - Alexander Rolls
- Division of Surgery and Cancer, Imperial College London, London, UK
| | - Liesbeth Desender
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Mohamad Hamady
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Celia Riga
- Division of Surgery and Cancer, Imperial College London, London, UK. .,Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK. .,1003 Queen Elizabeth The Queen Mother Wing (QEQM), St Mary's Hospital, Praed St, Paddington, London, W2 1NY, UK.
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6
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Juez Sáez LD, Ocaña J, Ramos D, Die J, García Pérez JC. Management of anastomotic stenosis after ileocecal resection in Crohn's disease with stenotic pattern surgery vs. endoscopic dilation. Surgery vs. endoscopic dilation. Cir Esp 2020; 99:S0009-739X(20)30267-0. [PMID: 32919700 DOI: 10.1016/j.ciresp.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/22/2020] [Accepted: 08/08/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Luz Divina Juez Sáez
- Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario Ramón y Cajal, Madrid, España.
| | - Juan Ocaña
- Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario Ramón y Cajal, Madrid, España
| | - Diego Ramos
- Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario Ramón y Cajal, Madrid, España
| | - Javier Die
- Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario Ramón y Cajal, Madrid, España
| | - Juan Carlos García Pérez
- Servicio de Cirugía General y del Aparato Digestivo. Hospital Universitario Ramón y Cajal, Madrid, España
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7
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Levin A, Risto A, Myrelid P. The changing landscape of surgery for Crohn's disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lan N, Wu JJ, Wu XR, L T, Shen B. Endoscopic treatment of pouch inlet and afferent limb strictures: stricturotomy vs. balloon dilation. Surg Endosc 2020; 35:1722-1733. [PMID: 32306110 DOI: 10.1007/s00464-020-07562-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 04/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Strictures are common complications after ileal pouch surgery. The aim of this study is to evaluate the efficacy and safety of endoscopic stricturotomy vs. endoscopic balloon dilation (EBD) in the treatment of pouch inlet strictures. METHODS All consecutive ulcerative colitis patients with the diagnosis of pouch inlet or afferent limb strictures treated in our Interventional Inflammatory Bowel Disease Unit (i-IBD) from 2008 to 2017 were extracted. The primary outcomes were surgery-free survival and post-procedural complications. RESULTS A total of 200 eligible patients were included in this study, with 40 (20.0%) patients treated with endoscopic stricturotomy and 160 (80.0%) patients treated with EBD. Symptom improvement was recorded in 11 (42.3%) patients treated with endoscopic stricturotomy and 16 (13.2%) treated with EBD. Subsequent surgery rate was comparable between the two groups (9 [22.5%] vs. 33 [20.6%], P = 0.80) during a median follow-up of 0.6 years (interquartile range [IQR] 0.4-0.8) vs. 3.6 years (IQR 1.1-6.2) in patients receiving endoscopic stricturotomy and EBD, respectively. The overall surgery-free survival seems to be comparable as well (P = 0.12). None of the patients in the stricturotomy group developed pouch failure, while 9 patients (5.6%) had pouch failure in the balloon dilation group (P = 0.17). Procedural bleeding was seen in three occasions (4.7% per procedure) in patients receiving endoscopic stricturotomy and perforation was seen in three occasions (0.8% per procedure) in patients receiving EBD (P = 0.02). In multivariable analysis, an increased length of the stricture (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0-1.8) and concurrent pouchitis (HR 2.5, 95% CI 1.0-5.7) were found to be risk factors for the requirement of surgery. CONCLUSION Endoscopic stricturotomy and EBD were both effective in treating patients with pouch inlet or afferent limb strictures, EBD had a higher perforation risk while endoscopic stricturotomy had a higher bleeding risk.
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Affiliation(s)
- Nan Lan
- Interventional Inflammatory Bowel Disease Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Jin-Jie Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xian-Rui Wu
- Interventional Inflammatory Bowel Disease Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | | | - Bo Shen
- Interventional Inflammatory Bowel Disease Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
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Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V, Colombo F, Di Candido F, Laureti S, Luglio G, Poggioli G, Rottoli M, Scaringi S, Sciaudone G, Sica G, Sofo L, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease. Tech Coloproctol 2020; 24:421-448. [PMID: 32172396 DOI: 10.1007/s10151-020-02183-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - I Angriman
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, University of Portsmouth, Portsmouth, UK
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Scaringi
- Surgical Unit, Department of Surgery and Translational Medicine, University of Firenze, Florence, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - S Leone
- CEO, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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10
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Lan N, Hull TL, Shen B. Endoscopic stricturotomy and ileo-colonic resection in patients with primary Crohn's disease-related distal ileum strictures. Gastroenterol Rep (Oxf) 2020; 8:312-318. [PMID: 32843979 PMCID: PMC7434583 DOI: 10.1093/gastro/goz071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/25/2019] [Accepted: 10/27/2019] [Indexed: 12/14/2022] Open
Abstract
Background Stricture is a common presentation of Crohn’s disease with the site of prevalence being the distal ileum. This study aimed to compare the efficacy and safety of patients with primary distal ileum stricture treated with endoscopic stricturotomy (ESt) vs ileo-colonic resection (ICR). Methods All consecutive patients with primary distal ileum stricture that were treated with ESt and/or ICR were extracted from the interventional inflammatory bowel disease (i-IBD) unit from 2001 to 2016. All patients with a stricture >5 cm or those with anastomotic strictures were excluded from the study. The primary outcomes were surgery-free survival and post-procedural complications. Results A total of 13 patients receiving ESt and 32 patients receiving ICR were included in this study. Although the length of the stricture is comparable between the two groups (2.4 ± 0.9 vs 3.0 ± 1.1 cm, P = 0.17), patients who received surgery had a more complicated obstruction presented by the high pre-stenosis proximal dilation rate (67.7% vs 9.1%, P = 0.001). All patients in both groups achieved immediate technical success after treatment. The median follow-up durations were 1.8 and 1.5 years in the ESt and ICR groups, respectively. The subsequent surgery rates were similar between the two groups (15.4% vs 18.8%, P = 0.79) and the overall surgery-free survival was also comparable between the two groups (P = 0.98). Post-procedural adverse events were seen in 2/29 ESt procedures (6.9% per procedure) and 8/32 (25.0%) patients receiving ICR (P = 0.05). Conclusions ESt achieved comparable stricture-related surgery-free survival as ICR, while ESt had a numerically lower post-operative complication rate.
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Affiliation(s)
- Nan Lan
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tracy L Hull
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Center for Inflammatory Bowel Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY 10032, USA. Fax. 1 212 305 0267.
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Celentano V. Laparoscopic redo surgery in recurrent ileocolic Crohn's disease: A standardised technique. J Minim Access Surg 2020; 16:90-93. [PMID: 30178767 PMCID: PMC6945328 DOI: 10.4103/jmas.jmas_144_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Despite many advances in the medical management of Crohn's disease (CD), there is still a significant risk of surgical resection for lack of response to medical management or complications during the lifetime of a patient. Laparoscopic surgery offers short-term benefits such as decreased pain, lower wound complication rates, earlier resumption of diet and bowel function, better cosmesis and shorter hospital stays, while reduced post-operative adhesions and lower incisional hernia rate may represent long-term benefits. Methods: A modular, standardised laparoscopic approach can be applied to safely perform laparoscopic redo surgery in the hostile setting of the recurrent CD and to facilitate teaching and training of these advanced procedures. Results: Laparoscopic surgery in CD can be particularly challenging due to multifocal disease with extensive inflammation and a thickened mesentery, the potential for abscesses, fistulas and phlegmons and high conversion rates have been reported in reoperative surgery for recurrent CD with abscesses and adhesions representing the main reasons for conversion. Conclusions: A standardised laparoscopic approach for redo surgery in recurrent CD has been described. Multidisciplinary management of CD is essential and bowel preservation must be the priority.
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Affiliation(s)
- Valerio Celentano
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust; Faculty of Science, University of Portsmouth, Portsmouth, England, United Kingdom
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12
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Pokala A, Shen B. Update of endoscopic management of Crohn's disease strictures. Intest Res 2020; 18:1-10. [PMID: 32013310 PMCID: PMC7000648 DOI: 10.5217/ir.2019.09158] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 12/15/2022] Open
Abstract
One of the most common complications of Crohn's disease (CD) is the formation of strictures. Endoscopy plays a vital role not only in the diagnosis, differential diagnosis, and disease monitoring of CD, but also the delivery of effective treatment. The purpose of this review is to update the endoscopic management of strictures in CD. Endoscopic therapy has provided minimally invasive treatment for CD. Commonly used endoscopic treatment modalities include balloon dilation, endoscopic stricturotomy, endoscopic strictureplasty, and endoscopic stenting. The pros and cons of these endoscopic treatment modalities are discussed.
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Affiliation(s)
- Akshay Pokala
- Interventional IBD Center, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- Interventional IBD Center, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
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Lan N, Stocchi L, Delaney CP, Hull TL, Shen B. Endoscopic stricturotomy versus ileocolonic resection in the treatment of ileocolonic anastomotic strictures in Crohn's disease. Gastrointest Endosc 2019; 90:259-268. [PMID: 30710508 DOI: 10.1016/j.gie.2019.01.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic stricturotomy (ESt) is a novel technique in the treatment of anastomotic strictures in Crohn's disease (CD). The aim of this study was to compare the outcome of patients with ileocolonic anastomotic stricture treated with ESt versus ileocolonic resection (ICR). METHODS This historical cohort study included consecutive CD patients with ileocolonic anastomotic stricture treated with ESt or ICR from 2010 to 2017. The primary outcomes were surgery-free survival and postprocedural adverse events. RESULTS Thirty-five patients treated with ESt and 147 patients treated with ICR were analyzed. Median follow-up was .8 years (interquartile range [IQR], .2-1.7) and 2.2 years (IQR, 1.2-4.4) in the ESt and ICR groups, respectively (P < .001). Subsequent stricture-related surgery was needed in 4 patients (11.3%) receiving ESt and in 15 patients (10.2%) receiving ICR (P = .83). Kaplan-Meier analysis also showed no statistical difference regarding surgery-free survival between the 2 groups (P = .24). Procedure-related major adverse events were documented in 5 of 49 patients (10.2% per procedure) undergoing ESt and 47 patients (31.9%) undergoing ICR (P = .003). Risk factors for decreased surgery-free survival on multivariate analysis included preprocedural corticosteroids (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.0-8.1), multiple strictures (HR, 4.9; 95% CI, 1.7-14.2), and increased disease-related hospitalizations (HR, 4.0; 95% CI, 1.2-13.0). CONCLUSIONS With the limitation of a shorter follow-up, ESt achieved comparable surgery-free survival with a decreased morbidity when compared with ICR.
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Affiliation(s)
- Nan Lan
- Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Luca Stocchi
- Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Conor P Delaney
- Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy L Hull
- Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Shen
- Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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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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15
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Role of interventional inflammatory bowel disease in the era of biologic therapy: a position statement from the Global Interventional IBD Group. Gastrointest Endosc 2019; 89:215-237. [PMID: 30365985 DOI: 10.1016/j.gie.2018.09.045] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 09/29/2018] [Indexed: 02/08/2023]
Abstract
Interventional (or therapeutic) inflammatory bowel disease (IBD) endoscopy has an expanding role in the treatment of disease and surgical adverse events. Endoscopic therapy has been explored and used in the management of strictures, fistulas/abscesses, colitis-associated neoplasia, postsurgical acute or chronic leaks, and obstructions. The endoscopic therapeutic modalities include balloon dilation, stricturotomy, stent placement, fistulotomy, fistula injection and clipping, sinusotomy, EMR, and endoscopic submucosal dissection. With a better understanding of the disease course of IBD, improved long-term impact of medical therapy, and advances in endoscopic technology, we can foresee interventional IBD becoming an integrated part of the multidisciplinary approach to patients with complex IBD.
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Lan N, Stocchi L, Ashburn JH, Hull TL, Steele SR, Delaney CP, Shen B. Outcomes of Endoscopic Balloon Dilation vs Surgical Resection for Primary Ileocolic Strictures in Patients With Crohn's Disease. Clin Gastroenterol Hepatol 2018; 16:1260-1267. [PMID: 29505909 DOI: 10.1016/j.cgh.2018.02.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/19/2018] [Accepted: 02/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Few studies have compared endoscopic balloon dilation (EBD) with ileocolic resection (ICR) in the treatment of primary ileocolic strictures in patients with Crohn's disease (CD). METHODS We performed a retrospective study to compare postprocedure morbidity and surgery-free survival among 258 patients with primary stricturing ileo(colic) CD (B2, L1, or L3) initially treated with primary EBD (n = 117) or ICR (n = 258) from 2000 through 2016. Patients with penetrating disease were excluded from the study. We performed multivariate analyses to evaluate factors associated with surgery-free survival. RESULTS Postprocedural complications occurred in 4.7% of patients treated with EBD and salvage surgery was required in 44.4% of patients. Factors associated with reduced surgery-free survival among patients who underwent EBD included increased stricture length (hazard ratio, 2.0; 95% CI, 1.3-3.3), ileocolonic vs ileal disease (hazard ratio, 10.9; 95% CI, 2.6-45.4), and decreased interval between EBD procedures (hazard ratio, 1.2; 95% CI, 1.1-1.4). There were no significant differences in sex, age, race, or CD duration between EBD and ICR groups. Patients treated with ICR were associated with more common postoperative adverse events (32.2%; P < .0001), but a reduced need for secondary surgery (21.7%; P < .0001) and significantly longer surgery-free survival (11.1 ± 0.6 vs 5.4 ± 0.6 y; P < .001). CONCLUSIONS In this retrospective study, we found that although EBD is initially successful with minimal adverse events, there is a high frequency of salvage surgery. Initial ICR is associated with a higher morbidity but a longer surgery-free interval. The risks and benefits should be balanced in selecting treatments for individual patients.
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Affiliation(s)
- Nan Lan
- Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Luca Stocchi
- Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio.
| | - Jean H Ashburn
- Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Tracy L Hull
- Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Conor P Delaney
- Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Bo Shen
- Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio
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Lan N, Shen B. Endoscopic Stricturotomy Versus Balloon Dilation in the Treatment of Anastomotic Strictures in Crohn's Disease. Inflamm Bowel Dis 2018; 24:897-907. [PMID: 29546384 DOI: 10.1093/ibd/izx085] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current treatment modalities for anastomotic stricture in Crohn's disease (CD) include endoscopic balloon dilation (EBD) and surgery. We recently published a case series of inflammatory bowel disease patients treated with the novel endoscopic stricturotomy (ES). The aim of this case-control study was to compare the efficacy and safety of ES versus conventional EBD in the treatment of anastomotic strictures in CD patients. METHODS All eligible patients with CD anastomotic stricture who were treated with ES or EBD were included. The primary outcomes were surgery-free survival and post-procedural complications. RESULTS A total of 185 patients were studied, including 21 treated with ES since 2009, and 164 treated with EBD since 1998. The immediate technical success after therapy was achieved in 100% of patients treated with ES and 89.5% of patients with EBD. Symptomatic and endoscopic improvement rates were higher in those treated with ES than EBD. Subsequent surgery was needed in 2 (9.5%) patients with ES and 55 (33.5%) with EBD (P = 0.03), during a median of 0.8 (interquartile range [IQR]:0.1-1.6) year and 4.0 (IQR: 0.8-6.9) years, respectively. Five procedure-associated perforation (1.1% per procedure) occurred in the EBD group and none in the ES group. In contrast, 4 procedure-associated, transfusion-required bleeding (8.8% per procedure) occurred in the ES group and none in the EBD group. CONCLUSIONS ES appears to be more effective in treating CD patients with anastomotic stricture than EBD. Although ES may have a lower risk for perforation, the procedure needs to be perfected to reduce its bleeding risk.
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Affiliation(s)
- Nan Lan
- Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute, the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bo Shen
- Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute, the Cleveland Clinic Foundation, Cleveland, Ohio
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Shen B. Interventional IBD: The Role of Endoscopist in the Multidisciplinary Team Management of IBD. Inflamm Bowel Dis 2018; 24:298-309. [PMID: 29361105 DOI: 10.1093/ibd/izx058] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Indexed: 12/13/2022]
Abstract
Inflammatory bowel disease (IBD) has been traditionally managed by IBD medical doctors or IBDologists and colorectal surgeons. Complications related to IBD and IBD surgery, such as stricture, fistula, and abscess, are common. For the past decade, endoscopic therapy has emerged as a valid treatment option for those complications. Endoscopic therapy provides more effective therapy for those structural complications than medical treatment, while being a less invasive approach than surgery. Endoscopic therapy plays a growing role in bridging medical and surgical therapies and is becoming an important component in the multidisciplinary approach to complex IBD. In fact, endoscopic therapy has become the treatment of choice for anastomotic stricture and anastomotic sinus. The role of endoscopic resection of colitis-associated neoplasia is currently being explored. Interventional IBD is intellectually and technically challenging. We are calling for proper teaching and training of our next generation of IBD interventionists.
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Affiliation(s)
- Bo Shen
- The Interventional IBD Unit, Digestive Disease and Surgery Institute, the Cleveland Clinic Foundation, Cleveland, Ohio
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Endoscopic Stricturotomy with Needle Knife in the Treatment of Strictures from Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:502-513. [PMID: 28296818 DOI: 10.1097/mib.0000000000001044] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fibrotic strictures in patients with inflammatory bowel disease (IBD) are often not amenable to medical therapy. Therapy with endoscopic balloon dilation usually requires frequent repeat treatments. Therefore, we developed the novel needle knife stricturotomy (NKSt) for the treatment of strictures in the patients with IBD. The aim of this study was to evaluate the efficacy and safety of NKSt. METHODS Data of patients with strictures treated with NKSt in our Interventional IBD Unit at the Cleveland Clinic were extracted from the registry. The primary and secondary outcomes were surgery-free survival and procedure-related complications. RESULTS A total of 85 patients were included in this study. Multiple strictures were noticed in 30 (35.3%) patients at inception, giving a total of 127 strictures treated. The median length of the treated strictures was 1.5 cm (interquartile range: 1.0-2.0) and 52 (41.6%) were endoscopically nontraversable. The immediate success with passage of the scope through the stricture after NKSt therapy was achieved in all patients. During the median follow-up of 0.9 years (interquartile range: 0.3-1.8) and a median of 2.0 treatment (interquartile range: 1.0-3.0), 13 (15.3%) patients required stricture-related surgery. There were 77 (60.6%) patients who required additional NKSt, endoscopic balloon dilation, or both after the inception of NKSt. In a total of 272 NKSt procedures performed, 10 (3.7%) adverse events occurred, including 9 with delayed bleeding and one hospitalization due to perforation. CONCLUSIONS Endoscopic NKSt is effective and safe for treating the primary and secondary IBD-related strictures, which may provide an alternative for endoscopic balloon dilation and surgical intervention.
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Toh JWT, Stewart P, Rickard MJFX, Leong R, Wang N, Young CJ. Indications and surgical options for small bowel, large bowel and perianal Crohn's disease. World J Gastroenterol 2016; 22:8892-8904. [PMID: 27833380 PMCID: PMC5083794 DOI: 10.3748/wjg.v22.i40.8892] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
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Guo F, Huang Y, Zhu W, Wang Z, Cao L, Chen A, Guo Z, Li Y, Gong J, Li J. Efficacy and Safety of Endoscopic Balloon Dilation for Upper Gastrointestinal Strictures of Crohn's Disease. Dig Dis Sci 2016; 61:2977-2985. [PMID: 27401273 DOI: 10.1007/s10620-016-4242-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Few articles focused on endoscopic balloon dilation (EBD) in the management of Crohn's strictures in the upper gastrointestinal (GI) tract. AIMS The purpose of this study was to evaluate the long-term efficacy and safety of EBD for Crohn's strictures in the upper GI tract and to determine early predictors of response and surgical intervention. METHODS All eligible patients who underwent EBD for Crohn's strictures in the upper GI tract were retrospectively reviewed. The long-term success was defined as the recovery of normal diets without surgical intervention over the follow-up period. In order to seek early predictors, patients who achieved long-term success were compared with those who didn't. RESULTS A total of 67 dilations of upper GI strictures were performed between June 2011 and March 2015 on 24 patients (mean age 25.6 ± 6.7, 20 male) with Crohn's disease. Technical success was achieved in 62 of 67 dilations (92.5 %) with a complication rate of 3 %. After the median follow-up period of 23.0 months (range 6.2-51.2 months), nine patients underwent surgical intervention, nine patients were still depending on tube feeding; in the meantime, only six (25 %) patients achieved long-term success. Additionally, patients who remained 1 month intervention-free (55.6 vs. 5.9 %, P = 0.015) were more likely to achieve long-term success. CONCLUSIONS EBD was a safe procedure, but not a potent therapy for Crohn's upper GI strictures. Meanwhile, 1-month response could serve as an early predictor of the long-term response.
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Affiliation(s)
- Feilong Guo
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Yuhua Huang
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China.
| | - Zhiming Wang
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Aoxue Chen
- National Clinical Research Center of Kidney Disease, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
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