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Lu C, Baraty B, Robertson HL, Filyk A, Shen H, Fung T, Novak K, Ma C, Panaccione R, Achkar JP, Ouali SE, Bruining D, Jairath V, Feagan B, Rieder F. Systematic review: medical therapy for fibrostenosing Crohn's disease. Aliment Pharmacol Ther 2020; 51:1233-1246. [PMID: 32406116 PMCID: PMC7777136 DOI: 10.1111/apt.15750] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/16/2020] [Accepted: 04/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medical therapy and/or endoscopic balloon dilation with intralesional therapies are options for the treatment of small bowel fibrostenotic Crohn's disease (CD). AIM To perform a systematic review summarising evidence for efficacy of systemic and endoscopic intralesional medical therapy in established small bowel strictures in adult CD patients. METHODS A systematic search of MEDLINE, EMBASE, CENTRAL and Scopus was conducted. Primary outcomes were rates of surgical resection and repeat endoscopic dilation. Pooled event rates from random effects models across studies with 95% confidence intervals were reported. RESULTS Ten studies describing systemic medical therapy and eight studies of intralesional injection were included. One randomised controlled trial each for systemic therapy and intrastricture injection were identified. Only observational studies were found for systemic biologic therapies, which exclusively included tumour necrosis factor (TNF) antagonists, while intralesional therapies all involved corticosteroids except for one study that evaluated infliximab. Pooled event rates for surgical resection after systemic and intralesional therapy were 28.3% (95% CI: 18.2%-41.3%) and 18.5% (95% CI: 8.3%-36.2%), respectively over a median follow-up of 23 months (range 5.5-105.8), and 21.8 months (range 5-47). Risk of repeat endoscopic balloon dilation in those with intralesional therapy was 58.3% (95% CI: 36.6%-77.3%) over a median follow-up of 21.8 months (range 5-47). CONCLUSIONS There are no favoured therapies for patients with stricturing small bowel CD. Data are lacking for ustekinumab and vedolizumab. No endoscopic intralesional medications provided a clear benefit for prevention of repeat EBD or surgery.
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Affiliation(s)
- Cathy Lu
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Brandon Baraty
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Gastroenterology, University of Sydney, Sydney, Australia
| | | | - Alexis Filyk
- Department of Life Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Hua Shen
- Department of Mathematics and Statistics, University of Calgary, AB, Canada
| | - Tak Fung
- Department of Mathematics and Statistics, University of Calgary, AB, Canada
| | - Kerri Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Robarts Clinical Trials Inc., London, Ontario, Canada; Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology & Nutrition; Digestive Diseases and Surgery Institute; Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sara El Ouali
- Department of Gastroenterology, Hepatology & Nutrition; Digestive Diseases and Surgery Institute; Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vipul Jairath
- Robarts Clinical Trials Inc., London, Ontario, Canada; Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London Ontario, Canada
| | - Brian Feagan
- Robarts Clinical Trials Inc., London, Ontario, Canada; Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London Ontario, Canada
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition; Digestive Diseases and Surgery Institute; Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Winder O, Fliss-Isakov N, Winder G, Scapa E, Yanai H, Barnes S, Dekel R, Dotan I, Maharshak N. Clinical outcomes of endoscopic balloon dilatation of intestinal strictures in patients with Crohn's disease. Medicine (Baltimore) 2019; 98:e16864. [PMID: 31464914 PMCID: PMC6736228 DOI: 10.1097/md.0000000000016864] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Intestinal strictures are common complications of Crohn's disease (CD). Endoscopic balloon dilatation (EBD) constitutes an alternative therapy to surgery, but associated factors of procedure success are inconclusive. Therefore, we aimed to evaluate the EBD success rate and its associated factors in CD patients.This is a retrospective cohort study of consecutive EBDs that were conducted between 2006 and 2014 among patients with CD with lower gastrointestinal tract strictures. Patients' and stricture characteristics, short term procedure success and related complications at 1 week follow-up, and long-term clinical endpoints were documented.A total of 138 dilatations were performed on 64 CD patients. The overall dilatation success rate was 84.8%, with no difference between primary or anastomotic strictures, or between first or recurrent dilatation procedures. Long strictures (≥4 cm) were negatively associated with successful EBDs, but not with perforations. A multivariate analysis adjusting for age, sex, smoking, and disease duration revealed that a maximal dilatation diameter of ≥15 mm was positively associated with a successful EBD, while an inflamed stricture was negatively associated with procedure success. Strictures which were both long and inflamed were associated with the lowest EBD success rates compared with other strictures. Only 32.8% of patients required surgery during the follow-up period. Long-term prevention of surgery was negatively associated with stricture length and with a successful EBD.EBD is highly successful in treating intestinal strictures and in prevention of surgery in CD patients. Although EBD of long strictures is safe, it will not prevent surgery in the majority of cases.
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Affiliation(s)
- Ophir Winder
- Department of Gastroenterology and Liver Diseases
- Sackler Faculty of Medicine, Tel Aviv University
| | | | - Gilad Winder
- Department of Gastroenterology and Liver Diseases
| | - Erez Scapa
- Department of Gastroenterology and Liver Diseases
- Sackler Faculty of Medicine, Tel Aviv University
| | - Henit Yanai
- Sackler Faculty of Medicine, Tel Aviv University
- Division of Gastroenterology, Rabin Medical Center, Beilinson Campus, Petah Tikva
| | - Sophie Barnes
- Sackler Faculty of Medicine, Tel Aviv University
- Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Roy Dekel
- Sackler Faculty of Medicine, Tel Aviv University
| | - Iris Dotan
- Sackler Faculty of Medicine, Tel Aviv University
- Division of Gastroenterology, Rabin Medical Center, Beilinson Campus, Petah Tikva
| | - Nitsan Maharshak
- Department of Gastroenterology and Liver Diseases
- Sackler Faculty of Medicine, Tel Aviv University
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