Prolonged avoidance of repeat surgery with endoscopic balloon dilatation of anastomotic strictures in Crohn's disease

Patient-Related Factors Associated With Long-Term Outcomes After Successful Endoscopic Balloon Dilation For Crohn's Disease-Associated Ileo-Colic Strictures: A Systematic Review and Meta-analysis

Background

Successful Crohn's disease (CD) therapy relies on timely and precise management strategies. Endoscopic balloon dilation (EBD) has been applied as a first-line treatment for symptomatic CD-associated strictures due to its minimally invasive nature and the possibility of preserving intestinal length.

Objective

The aim of the present study was to determine patient-related predictive factors associated with the need for surgery for CD-associated ileocolic strictures after technically successful EBD.

Methods

All original studies published before December 2023 that reported the outcomes of patients treated with EBD for ileocolic strictures secondary to CD and described follow-up for at least 1 year were included. The difference in risk of needing surgery was calculated for 8 different patient characteristics (Sex, smoking habit, previous surgery, biologic therapy, steroids, immunosuppressors, nature of the stricture, and endoscopic disease activity).

Results

There were significant differences in the risk of needing surgery after EBD among patients who underwent surgery and patients without a history of surgery (RD: -0.20 [-0.31, -0.08]), patients with endoscopic mucosal activity and patients in remission at the time of EBD (RD: 0.19 [0.04, 0.34]), patients using biologics at the time of EBD and patients not using biologics (RD: -0.09 [-0.16, -0.03]), and patients using steroids and those not using steroids at the time of EBD (RD: 0.16 [0.07, 0.26]).

Conclusions

The use of biologics and endoscopic disease remission at the time of EBD were protective factors against the need for surgery. No previous surgery or use of steroids at the time of EBD was associated with the need for surgery during follow-up.

Endoscopic Balloon Dilation Is Cost-Effective for Crohn's Disease Strictures

BACKGROUND

Endoscopic balloon dilation (EBD) has emerged as an alternative intervention to manage Crohn's disease (CD) strictures. We determined the cost-effectiveness of EBD versus resection surgery for patients with short (< 4-5 cm) primary or secondary/anastomotic small or large bowel strictures.

METHODS

A microsimulation state-transition model analyzed the benefits and risks of EBD and resection surgery for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (2021 $US) and incremental cost-effectiveness ratios (ICER) were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty.

RESULTS

The EBD strategy cost $19,822 and resulted in 6.18 QALYs while the surgery strategy cost $41,358 and resulted in 6.37 QALYs. Surgery had an ICER of $113,332 per QALY, making EBD a cost-effective strategy. The median number of EBDs was 5 in the EBD strategy and 0 in the surgery strategy. The median number of surgeries was 2 in the surgery strategy and 1 in the EBD strategy. Of individuals who initially received EBD, 50.4% underwent subsequent surgery. One-way sensitivity analyses showed that the probabilities of requiring repeated interventions, surgery mortality (< 0.7%), and quality of life after interventions were the most influential model parameters. Probabilistic sensitivity analyses favored EBD in 50.9% of iterations.

CONCLUSIONS

EBD is a cost-effective strategy for managing CD strictures. Differences in patient risk and quality of life after intervention impact cost-effectiveness. Intervention decisions should consider cost-effectiveness, patient risks, and quality of life.

Validation of stricture length, duration and obstructive symptoms as predictors for intervention in ileal stricturing Crohn's disease

BACKGROUND

Risk factors for intervention in terminal ileal (TI) stricturing Crohn's disease (CD) are poorly defined. Novel and rigorous definitions for TI strictures recently became available.

OBJECTIVE

We aimed to describe the rates of symptoms or need for endoscopic balloon dilation (EBD) or surgery as well as risk factors of progression in a well-defined stricturing CD cohort.

METHODS

Consecutive adult patients with non-penetrating stricturing TI CD, as defined by centrally-read magnetic resonance enterography CONSTRICT criteria, were separated into a derivation and validation cohort. Clinical and imaging characteristics were collected following prespecified scoring conventions. Primary outcome was a composite endpoint of EBD or surgery ("intervention"). Multivariable analysis was performed.

RESULTS

Eighty-six patients (48.8% female, median age 36 years) met selection criteria, 17.4% had prior EBD, 59.3% previously received biologics and 58.1% of strictures were anastomotic. Median follow-up was 63.4 [95% CI: 57, 68.9] months. In the derivation cohort, at 12 and 48 months, 26% and 45% of patients had intervention, respectively. Multivariable analysis showed obstructive symptoms (Hazard ratio [HR] 1.444; 95% CI 1.126-1.852), stricture duration (HR 0.974; 95% CI, 0.954-0.995) and length (HR 1.039; 95% CI, 1.011-1.069) predicted intervention. The concordance index for split-sample validation was 0.74 and 0.67, respectively. Biologics were not associated with intervention. An online risk calculator was constructed.

CONCLUSION

In patients with TI stricturing CD, 26% and 45% required intervention at 1 and 4 years. Obstructive symptoms, stricture duration and length were independent and validated predictors of the need for intervention. These findings are important for clinical practice and aid in the design of future trials for CD strictures.

Medical, Endoscopic and Surgical Management of Stricturing Crohn's Disease: Current Clinical Practice

The development of fibrostenotic intestinal disease occurs in approximately one-third of patients with Crohn's disease and is associated with increased morbidity. Despite introducing new biologic agents, stricturing Crohn's disease remains a significant clinical challenge. Medical treatment is considered the first-line treatment for inflammatory strictures, and anti-TNF agents appear to provide the most considerable benefit among the available medical treatments. However, medical therapy is ineffective on strictures with a mainly fibrotic component, and a high proportion of patients under anti-TNF will require surgery. In fibrotic strictures or cases refractory to medical treatment, an endoscopic or surgical approach should be considered depending on the location, length, and severity of the stricture. Both endoscopic balloon dilatation and endoscopic stricturoplasty are minimally invasive and safe, associated with a small risk of complications. On the other hand, the surgical approach is indicated in patients not suitable for endoscopic therapy. This review aimed to present and analyze the currently available medical, endoscopic, and surgical management of stricturing Crohn's disease.

Usefulness of Fluoroscopy for Endoscopic Balloon Dilation of Crohn's Disease-Related Strictures

BACKGROUND

Fluoroscopy is often used for endoscopic balloon dilation (EBD) of Crohn's disease (CD)-related strictures. However, its benefit remains unclear.

AIMS

To compare EBD with (EBDF) and without (EBDNF) fluoroscopic guidance in CD patients with strictures.

METHODS

Single-center, nested, case-control retrospective study of EBD for CD-related strictures. Technical and clinical success and safety outcomes were compared between EBDF and EBDNF.

RESULTS

A total of 122 strictures in 114 CD patients who underwent EBD from 2010 to 2018 at a single institution were reviewed (44 patients EBDF vs. 70 EBDNF). Esophagogastroduodenoscopy was the approach in 8 strictures, colonoscopy in 86, and deep enteroscopy in 28. There were no significant differences in the rates of technical and clinical success, need for repeat dilation and surgery between the two groups, although the mean maximal endoscopic balloon diameter was larger in the EBDNF group (17.1 ± 1.9 vs. 14.1 ± 2.5; p < 0.001). There was one perforation in EBDF and no serious complications in EBDNF. In multivariate analysis, balloon size < 15 mm (odds ratio [OR] 6.388; 95% CI 1.96-20.79; p = 0.002) and multiple strictures (OR 3.897; 95% CI 1.09-14.01; p = 0.037) were associated with repeat EBD, and age < 50 years (OR 7.178; 95% CI 1.38-37.44; p = 0.019) and small bowel (vs. colon) location (OR 7.525; 95% CI 1.51-37.47; p = 0.014) were associated with the need for surgery after EBD.

CONCLUSIONS

EBD for CD-related strictures can be performed safely and effectively without fluoroscopic guidance. Balloon size, patient age, stricture location, and multiplicity are associated with clinical success and avoidance of surgery.

Therapeutic Endoscopy in Postoperative Pouch Complications

Ileal pouch-anal anastomosis (IPAA) or "J"-pouch as it is commonly referred to, is the treatment of choice in patients with medically refractory ulcerative colitis. IPAA can have infectious, inflammatory, and mechanical complications. Currently, there are no Food and Drug Administration-approved medical therapies for these complications. Surgery that may be eventually required can have significant morbidities due to the complexity of IPAA. Endoscopy is fast emerging as a leading modality of treatment for some of these pouch complications. Endoscopy in adjunct with medical treatment can help manage the majority of pouch-related disorders and improve the outcome.

Efficacy of drug and endoscopic treatment of Crohn's disease strictures: A systematic review

BACKGROUND AND AIMS

Strictures are the commonest complication in Crohn's disease. Surgery and endoscopic dilation are the mainstays of treatment, while drug therapy has often been considered contraindicated. The benefit of nonsurgical treatments, particularly drug and endoscopic therapy, need to be defined.

METHODS

Ovid MEDLINE, Embase, Emcare, PsycINFO, CINAHL and the Cochrane Library (inception until August 30, 2019) were searched. Studies with ≥ 10 patients with Crohn's disease strictures, reporting on outcomes following medication or endoscopic treatment, were included.

RESULTS

Of 3480 records, 85 studies met inclusion criteria and formed the basis of this analysis. Twenty-five studies assessed drug therapy; none were randomized trials. Despite study heterogeneity anti-tumor necrosis factor (TNF) therapy appeared effective, with 50% of patients avoiding surgery after 4 years of follow up. No other drug therapy was of demonstrable benefit. Sixty studies assessed endoscopic therapy including 56 on endoscopic balloon dilation, two assessed needle knife stricturotomy, and two stent insertion. Dilation was equally effective for de novo and anastomotic strictures ≤ 5 cm in length, with most studies reporting a subsequent surgical rate of 30% to 50%. Repeat dilation was required in approximately half of all patients.

CONCLUSIONS

Anti-TNF drug therapy and endoscopic balloon dilation are effective strategies for avoiding surgery in patients with stricturing Crohn's disease. Additional endoscopic therapies require further evaluation. Early data suggest that combining these therapies may provide greater benefit than individual therapies. Optimization of current drug and endoscopic therapy, and the incorporation of newer therapies, are needed for stricturing Crohn's disease.

Surgical treatment of intestinal stricture in inflammatory bowel disease

Fibroblast infiltration and collagen deposition result in structural changes in the bowel wall, and lead to strictures in intestinal inflammatory disease. While strictures can also occur in other contexts, such as malignancy, this review focuses on the surgical treatment of stricture secondary to inflammatory bowel disease. Distinguishing between predominantly inflammation vs established fibrosis as the cause of a stricture can be challenging. While inflammatory strictures may be responsive to medication, predominantly fibrotic strictures usually need surgical intervention. Both endoluminal and extraluminal approaches are described in this review. Endoscopic dilatation of strictures is suitable for short-segment isolated small bowel strictures. Other options are to divide the stricture surgically but preserve the length, performing a strictureplasty or resecting the strictured segment. The mesentery is increasingly recognized as playing a role in stricture recurrence. In a relapsing-remitting disease such as Crohn's disease, the preservation of intestinal length is essential and balance is needed between this and a complete resection to reduce the risk of recurrence. Pre- and postoperative involvement of the multidisciplinary team is essential to improve outcomes in this challenging clinical scenario.

Endoscopic management of strictures in patients with Crohn's disease - A multi-center experience in Taiwan

BACKGROUND/PURPOSE

Inflammatory bowel disease (IBD) is a chronic gastrointestinal (GI) disorder that causes relapsing inflammation and severe mucosal damage in the intestine. Crohn's disease (CD)-related stricturing complications are a major cause of surgery, disability, and reduced quality of life. Endoscopic balloon dilation (EBD) has been shown to reliably delay or prevent surgery in patients with stricturing CD. However, cases of EBD performed for stricture in CD in Taiwan are rare. In this study, we want to evaluate the experiences regarding EBD for stricturing CD in Taiwan.

METHODS

We conducted a retrospective analysis of 9 medical centers in Taiwan. Patients with CD-related strictures who were treated with EBD were included and analyzed.

RESULTS

In nine medical centers, a total of 26 CD patients (19 male, 7 female, mean disease duration 75.4 ± 65.2 months) underwent 42 EBD procedures during the study period. Among the subjects, an 83.3% (35/42) EBD success rate was seen, but 26.9% (7/26) patients underwent surgery after ineffective EBD. In the surgery group, the the small bowel strictures was high compared with the non-surgery group (p = 0.01). There were no significant differences in disease phenotype, disease duration or history of fistulizing disease. In the surgery group, immunosuppressant use was high, and 5-aminosalicylic acid (5-ASA) use was low compared with the non-surgery group. After EBD, the physicians tended to change the drugs, especially increasing the use of biologic agents.

CONCLUSION

EBD is a safe and effective procedure for CD-related stricture, with a 83.3% success rate in Taiwan.

Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition

Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.

Identification of Endpoints for Development of Antifibrosis Drugs for Treatment of Crohn's Disease

BACKGROUND & AIMS

Intestinal fibrosis is a challenge to management of patients with Crohn's disease (CD); there is an urgent need to expedite development of antifibrosis drugs for this disease. The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) aimed to identify a set of endpoints that can be used to determine efficacy of antifibrosis agents tested in clinical trials of patients with CD.

METHODS

We conducted a systematic review to identify clinical, radiologic, biochemical, endoscopic, and composite endpoints used in assessing activity of fibrostenosing CD and response to treatment, and determined their operational properties. A panel of IOIBD experts performed a consensus process to identify the best endpoints for inclusion in clinical trials, through a 2-round, Delphi-style online survey.

RESULTS

A total of 36 potentially relevant endpoints for intestinal fibrosis were selected and assessed. Forty-eight physicians with expertise in inflammatory bowel disease, from 5 regions (North America, Europe, Middle East, Asia/Pacific, and Latin America), participated in the Delphi consensus process. A core set of 13 endpoints (complete clinical response, long-term efficacy, sustained clinical benefit, treatment failure, radiological remission, normal quality of life, clinical remission without steroids, therapeutic failure, deep remission, complete absence of occlusive symptoms, symptom-free survival, bowel damage progression, and no disability) were rated as critical. Agreement was high among the experts.

CONCLUSIONS

Members of the IOIBD reached expert consensus on a set of endpoints that can be used to assess antifibrosis agents in trials of patients with CD. Studies are needed to clarify methods for measuring these outcomes and validate measurement instruments.

Endoscopic management of Crohn’s strictures

Symptomatic intestinal strictures develop in more than one third of patients with Crohn’s disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.

Endoscopic balloon dilation of Crohn’s disease strictures-safety, efficacy and clinical impact

AIM

To evaluate the incidence of anastomotic strictures after intestinal resection in Crohn’s disease (CD), demonstrate long-term efficacy and safety of endoscopic balloon dilation (EBD) in CD strictures and its impact on the diagnosis of subclinical postoperative endoscopic recurrence.

METHODS

Retrospective single tertiary center study based on prospectively collected data between 2010 and 2015 including anastomotic and non-anastomotic strictures.

RESULTS

29% of 162 CD patients included developed an anastomotic stricture. 43 patients with anastomotic strictures and 37 with non-anastomotic strictures underwent EBD; technical success was 97.7% and 100%, respectively, however, 63% and 41% needed repeat dilation during the 4.4-year follow-up. Longer periods between surgery and index colonoscopy and higher lactoferrin levels were associated with the presence of stricture after surgery. Calprotectin levels > 83.35 μg/g and current or past history of smoking were associated with a shorter time until need for dilation (HR = 3.877, 95%CI: 1.480-10.152 and HR = 3.041, 95%CI: 1.213-7.627). Anastomotic strictures had a greater need for repeat dilation (63% vs 41%, P = 0.047). No differences were found between asymptomatic and symptomatic cohorts. Disease recurrence diagnosis was only possible after EBD in a third of patients.

CONCLUSION

EBD is an effective and safe alternative to surgery, with a good short and long-term outcome, postponing or even avoiding further surgery. EBD may allow to diagnose disease recurrence in patients with no clinical signs/biomarkers of disease activity.

Current status of endoscopic balloon dilation for Crohn's disease

The therapeutic target in Crohn's disease (CD) has been raised to the achievement of mucosal healing. Although effective treatments that target cytokines and other molecules has been widely used for CD, intestinal strictures are still a major cause of surgery. Endoscopic balloon dilation (EBD) is known to be an effective and safe intervention for intestinal strictures in CD. Since frequent intestinal resection often results in short bowel syndrome and can decrease the quality of life, EBD can help avoid surgery. EBD with a conventional colonoscope for Crohn's strictures of the colon and ileo-colonic anastomosis has established efficacy and safety. In addition, EBD using balloon-assisted enteroscopy has recently been applied for small bowel Crohn's strictures. Although the evidence is not strong, EBD may become an alternative to surgery in small bowel strictures in CD. EBD and other new methods such as self-expanding stent implantation for Crohn's strictures may be useful and safe; however, it is important to address several issues regarding these interventions and to establish a protocol for combined therapies.

Mechanisms, Management, and Treatment of Fibrosis in Patients With Inflammatory Bowel Diseases

In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases-associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.

A Pooled Analysis of Efficacy, Safety, and Long-term Outcome of Endoscopic Balloon Dilation Therapy for Patients with Stricturing Crohn's Disease

BACKGROUND

Endoscopic balloon dilation (EBD) is widely used to manage Crohn's disease-associated strictures. However, most studies of the safety and efficacy are small and heterogenous. We performed a combined analysis of published studies and evaluated 676 comprehensive individual participant data sets to determine the overall effects of EBD.

METHODS

Citations from the Embase, MEDLINE, and the Cochrane library from 1991 through 2013 were systematically reviewed, and references of cited articles were assessed for relevant publications. We collected data from studies including ≥15 patients and additionally generated a unique individual patient database containing 676 individual data sets derived from 12 studies. Technical feasibility, short-term and long-term efficacies, and safety were evaluated.

RESULTS

In 1463 patients with Crohn's disease who underwent 3213 EBD procedures, 98.6% of strictures were ileal and 62% anastomotic. The technical success rate of the EBDs was 89.1% with a clinical efficacy of 80.8%. Complications occurred in 2.8% per procedure. After 24 months of follow-up, 73.5% of subjects underwent redilation and 42.9% surgical resection. In a multivariate analysis of 676 individual patients, a stricture length of ≤5 cm was associated with a surgery-free outcome; every 1 cm increase of stricture length increased the hazard of need for surgery by 8% (P = 0.008). Inflammation did not affect outcomes or rate of complications.

CONCLUSIONS

Based on a systematic literature review and analysis of data sets from 676 patients, EBD has a high rate of short-term technical and clinical efficacies, with substantial long-term efficacy and acceptable rates of complication.

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.

Endoscopic Dilatation of Crohn's Anastomotic Strictures is Effective in the Long Term, and Escalation of Medical Therapy Improves Outcomes in the Biologic Era

BACKGROUND AND AIMS

To investigate the long-term efficacy of endoscopic dilatation of Crohn's anastomotic strictures and to identify risk and protective factors associated with the need for repeat dilatation or surgery.

METHODS

A total of 54 patients who had endoscopic balloon dilatations for anastomotic Crohn's strictures between 2004 and 2009, with follow-up until June 2014, were identified from a single tertiary center. The primary end points were repeat dilatation or surgical resection, and the impact of radiology, medical therapy, and endoscopic data on these outcomes was analysed with Cox proportional hazards analysis.

RESULTS

A total of 151 dilatations were performed on patients with a median age of 52 years [interquartile range (IQR), 46-62 years]. The median duration from the first to the second dilatation was 6 years (IQR, 5-7 years). The median disease duration was 28 years (IQR, 19-32 years). At endoscopy, disease activity was reported in 50/54 (92%) cases, with a median Rutgeerts grading of i2 (range, i0-i4). A median of two (IQR 1-9) dilatations was required, with a time to repeat dilatation of 23 months (IQR 7.2-56.9). Escalation of medical therapy was adopted in 22/54 patients (41% of the study population). On multivariate analysis, only combination therapy (anti-TNFα and immunomodulator) was significantly associated with the (decreased) need for repeated dilatation [hazard ratio (HR) 0.23; 95% CI, 0.07-0.67; p = 0.01]. Anastomotic resections were performed in 10 (18%) patients, with a Rutgeerts score of i4 at initial endoscopic balloon dilatation being associated with this outcome (HR 4.55; 95% CI 1.08-19.29; p = 0.04) on multivariate analysis.

CONCLUSION

Endoscopic balloon dilatation of Crohn's anastomotic strictures is safe and effective in the long term. We demonstrate that active disease predicts for future surgery, while escalation of medical therapy may decrease the need for repeat dilatation.

Endoscopic balloon dilation in the management of strictures in Crohn's disease: a systematic review and meta-analysis of non-randomized trials

BACKGROUND AND AIM

Crohn's disease (CD) is associated with strictures. Endoscopic balloon dilatation (EBD) may prevent or delay the need for surgical resection. The aim of this systematic review was to determine the efficacy and safety of EBD in the management of Crohn's strictures.

METHODS

A comprehensive search of MEDLINE and EMBASE databases from January 1980 to May 2015 was performed. The primary outcome measurements were surgical intervention rates and major adverse events.

RESULTS

A total of 24 studies involving 1163 patients were included in the analysis. The median duration from the initial diagnosis of CD to the first EBD was 10.2-17.0 years. The majority of strictures (69 %) treated were anastomotic, while the remaining strictures were naive (primary). Surgical intervention rate over a median follow-up period of 15-70 months in the reported studies was 27 %. The surgical intervention rate after dilation of anastomotic strictures was 18 % versus 29 % for primary strictures. The risk ratio for the surgical requirement of anastomotic versus primary strictures was [0.88 (95 % confidence interval [CI] 0.59-1.32); p = 0.54]. Stricture length <4 cm was associated with a significantly decreased risk of surgical intervention [risk ratio = 0.48 (95 % CI 0.26-0.90); p = 0.02]. EBD resulted in major adverse events in 4 % of the patients.

CONCLUSIONS

EBD appears to be a safe alternative for surgery in the management of Crohn's strictures. Stricture length <4 cm treated with EBD is associated with a significantly decreased risk of surgical intervention.

Survival and nutritional dependence on home parenteral nutrition: Three decades of experience from a single referral centre

BACKGROUND

Home parenteral nutrition (HPN) is the mainstay of treatment for patients with Type 3 intestinal failure (IF), however long term data on mortality and nutritional outcomes are limited.

OBJECTIVES

To assess the long-term survival and requirements for ongoing HPN in patients receiving treatment at a UK national referral centre for intestinal failure.

METHODS

Patients with IF who received HPN for more than 3 months at this Intestinal Failure Unit between 1978 and 2011 had their clinical records reviewed. SPSS 20 was utilised to perform Cox regression analysis and generate Kaplan Meier curves, with the aim of identifying factors associated with death and the continued need for HPN.

RESULTS

Case notes from 545 patients were reviewed. Overall survival (OS) in patients without malignancy at commencement of IF was 93%, 71%, 59% and 28% at 1, 5, 10 and 20 years after starting treatment. Crohn's disease, mesenteric ischaemia and chronic intestinal pseudo-obstruction were associated with a better OS than scleroderma and radiation enteritis on multivariate analysis. Older age at onset of IF was associated with poor OS, while shorter small bowel length or central line sepsis was not. 15% (25/170) of deaths were due to complications of HPN (central line sepsis = 10, IF-associated liver disease = 15). Continued HPN dependence in survivors was 83%, 63%, 59% and 53% at 1, 5, 10 and 15 years, respectively. Among the 153 patients without malignancy who achieved nutritional independence from HPN, 77 (50.3%) did so after surgical reconstruction of the alimentary tract (HPN duration mean 19 months, range 3-126 months). 76 patients (49.7%) weaned from HPN without undergoing surgical reconstruction.

CONCLUSION

This is the largest reported data set on long-term survival and dependence on HPN and will inform the indications, benefits and risks of treatment in disease specific groups. A significant proportion of patients achieved nutritional autonomy without surgical intervention.

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.

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

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.

Prediction of need for surgery after endoscopic balloon dilation of ileocolic anastomotic stricture in patients with Crohn's disease

BACKGROUND

Endoscopic balloon dilation is used to treat ileocolic anastomotic stricture attributed to recurrent Crohn's disease.

OBJECTIVE

The purpose of this work was to investigate long-term outcomes after dilation of ileocolic anastomotic stricture and to identify risk factors associated with the need for subsequent surgical intervention.

DESIGN

This was a retrospective study based on chart review of an electronic medical chart system.

SETTINGS

The study was conducted at a tertiary care center.

PATIENTS

All of the eligible patients with ileocolic anastomotic stricture attributed to recurrent Crohn's disease treated with endoscopic dilation between December 1998 and May 2013 were evaluated. Patients with concurrent enterocutaneous fistula or abdominal or pelvic abscess were excluded.

MAIN OUTCOME MEASURES

The main outcome measure was the need for subsequent salvage surgery because of stricture-related symptoms.

RESULTS

A total of 185 patients with Crohn's disease (45.9% women; mean age, 43.1 years; symptomatic strictures in 80%) underwent 462 endoscopic dilations of ileocolic anastomosis (median per-patient dilations, 2; range, 1-3). During a mean follow-up of 3.9 years, 27 patients (14.6%) required hospitalization without surgery for stricture-related symptoms, and 66 patients (35.7%) required subsequent salvage surgery. Specific medical management, type of anastomosis, and endoscopic intralesional steroid injection had no impact on the risk of needing surgery. Significant factors associated with the need for surgery on multivariable analysis were symptomatic disease (HR, 3.54 [95% CI, 1.41-8.93]), longer time interval from last surgery (HR, 1.05 [95% CI, 1.01-1.10]), and radiographic proximal bowel dilation (HR, 2.36 [95% CI, 1.38-4.03]). A nomogram estimating the need for surgery was created with a concordance index of 0.67.

LIMITATIONS

The study was limited by its retrospective design.

CONCLUSIONS

Although endoscopic dilation is a valid option for ileocolic anastomotic stricture attributed to recurrent Crohn's disease, the need for surgery is common. The nomogram can identify patients who might benefit from upfront surgery.

Magnetic resonance enterography in post-operative inflammatory bowel disease

OBJECTIVE

To describe the role of magnetic resonance enterography (MRE) in patients with inflammatory bowel disease (IBD), and to review the expected post-operative appearance, as well as, potential surgical complications in this unique patient population.

CONCLUSION

MRE compares favorably to CT Enterography (CTE) in terms of overall diagnostic accuracy and may provide better functional assessment of the small bowel through cine-MRI, diffusion-weighted imaging and dynamic contrast-enhancement. In the post-operative population, MRE provides critical information including: normal post-surgical anatomy, chronic strictures vs. active inflammation and disease/treatment-related complications. The post-operative IBD patient undergoes frequent repeated imaging and MRE may significantly reduce cumulative radiation dose while providing similar or improved diagnostic accuracy compared to CTE. MRE should be considered as an alternative imaging modality in this population.

Endoscopic and medical management of fibrostenotic Crohn's disease

Crohn's disease (CD) is a disease characterized by acute inflammation at diagnosis which evolves toward a more fistulizing and fibrostenotic disease phenotype over time. This leads to a high risk of bowel resections and ultimately short bowel with diarrhea and malabsorption, which represents a major part of the burden inflicted by CD. Bowel-conserving endoscopic and surgical procedures have therefore been developed. Specific antifibrotic medical therapies are currently lacking. Through-the-scope endoscopic balloon dilation has been described in several cohorts as an alternative to surgical resection or stricturoplasty in selected patients. Efficacy of endoscopic dilation is high, with an immediate success rate of 78% (between 73 and 100%), defined as the ability to pass with the scope through the stricture. However, symptomatic recurrence is frequent, with need for new dilatation in 41% and need for surgery in 42%, with a mean interval of 15 months. Adjunctive techniques such as local steroid or anti-TNF injections or stenting have not been conclusively proven to be of added benefit. We usually reserve endoscopic dilation for patients with short strictures (<5 cm) and nonpenetrating disease, preferably at the ileocolonic anastomosis. Similar to other interventions in endoscopy, endoscopic dilation has an intrinsic risk of complications which can be estimated at 2%. Balloon size and patient selection can serve to increase safety.

Endoscopic treatment of Crohn's complications

The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.

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.