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Jabi O, Lan N, Pokala A, Kiran RP, Shen B. Endoscopic therapy of stoma closure site strictures in ileal pouches is safe and effective. Gastroenterol Rep (Oxf) 2024; 12:goae038. [PMID: 38766493 PMCID: PMC11099542 DOI: 10.1093/gastro/goae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/26/2024] [Accepted: 02/17/2024] [Indexed: 05/22/2024] Open
Abstract
Background Strictures are a common complication after ileal pouch surgery with the most common locations being at the anastomosis, pouch inlet, and stoma closure site. No previous literature has described endoscopic therapy of stoma site stricture. This study aimed to assess the safety and efficacy of endoscopic therapy in the treatment of stoma closure site strictures. Method Patients diagnosed with stoma closure site strictures following ileal pouch surgery who underwent endoscopic treatment at the Center for Colorectal Diseases, Inflammatory Bowel Disease (IBD), and Ileal Pouch between 2018 and 2022 were analysed. Primary outcomes (technical success and surgery-free survival) were compared between endoscopic balloon dilation (EBD) and stricturotomy and/or strictureplasty. Results A total of 30 consecutive eligible patients were analysed. Most patients were female (66.7%) and most patients were diagnosed with IBD (93.3%). Twenty patients (66.7%) had end-to-end anastomosis. A total of 52 procedures were performed, with EBD in 16 (30.8%) and stricturotomy and/or strictureplasty in 36 (69.2%). The mean stricture length was 1.7 ± 1.0 cm. Immediate technical success was achieved in 47 of 52 interventions (90.4%). During a mean follow-up of 12.7 ± 9.9 months, none of the patients underwent surgical intervention for the stricture. Fourteen (46.7%) required endoscopic re-intervention for their strictures with an interval between index and re-interventional pouchoscopy of 8.8 ± 6.3 months. Post-procedural complications were reported in 2 (6.7%) with bleeding and none with perforation. Upon follow-up, 20 (66.7%) patients reported improvement in their symptoms. Conclusion EBD and endoscopic stricturotomy and/or strictureplasty are safe and effective in treating stoma closure site strictures in patients with ileal pouches, providing symptomatic relief in most patients as well as avoiding surgery.
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Affiliation(s)
- Osama Jabi
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Nan Lan
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Akshay Pokala
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Ravi P Kiran
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
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2
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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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3
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Ledder O, Viala J, Serban DE, Urlep D, De Ridder L, Martinelli M, Romano C, Church P, Griffiths C, Oliva S, Basude D, Sharma S, Thomson M. Endoscopic Balloon Dilatation in Pediatric Crohn Disease: An IBD Porto Group Study. J Pediatr Gastroenterol Nutr 2023; 77:62-69. [PMID: 36976584 DOI: 10.1097/mpg.0000000000003783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVE/BACKGROUND Endoscopic balloon dilatation (EBD) has been shown to be effective and safe in adults with stricturing Crohn disease (CD) yet pediatric data is sparse. We aimed to assess efficacy and safety of EBD in stricturing pediatric CD. METHODS International collaboration included 11 centers from Europe, Canada, and Israel. Recorded data included patient demographics, stricture features, clinical outcomes, procedural adverse events, and need for surgery. Primary outcome was surgery-free over 12 months and secondary outcomes were clinical response and adverse events. RESULTS Eighty-eight dilatations were performed over 64 dilatation series in 53 patients. Mean age at CD diagnosis was 11.1 (±4.0) years, stricture length 4 cm [interquartile range (IQR) 2.8-5], and bowel wall thickness 7 mm (IQR 5.3-8). Twelve of 64 (19%) patients underwent surgery in the year following the dilatation series, at a median of 89 days (IQR 24-120; range 0-264) following EBD. Seven of 64 (11%) had subsequent unplanned EBD over the year, of whom two eventually underwent surgical resection. Two of 88 (2%) perforations were recorded, 1 of whom was managed surgically, and 5 patients had minor adverse events managed conservatively. There was a significant improvement in all clinical measures following EBD with weighted pediatric CD activity index-defined remission increasing from 13% at baseline to 44%, 46%, and 61%, and absence of obstructive symptoms in 55%, 53%, and 64% of patients at week 2, 8, and 24 respectively. CONCLUSIONS In this largest study of EBD in pediatric stricturing CD to date, we demonstrated that EBD is effective in relieving symptoms and avoiding surgery. Adverse events rates were low and consistent with adult data.
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Affiliation(s)
- Oren Ledder
- From the Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jérôme Viala
- Hôpitaux Universitaire Robert-Debré, APHP, Paris, France
| | - Daniela Elena Serban
- 2nd Clinic of Pediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Darja Urlep
- Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Lissy De Ridder
- Erasmus University MC/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Massimo Martinelli
- the Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Claudio Romano
- the Paediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi," University of Messina, Messina, Italy
| | - Peter Church
- the Division of Gastroenterology, Hepatology, and Nutrition, SickKids Hospital, Department of Paediatrics, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Chris Griffiths
- the Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Salvatore Oliva
- the Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, Rome, Italy
| | - Dharam Basude
- University Hospitals Bristol and Weston, United Kingdom
| | - Shishu Sharma
- Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Mike Thomson
- Sheffield Children's Hospital, Sheffield, United Kingdom
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Ledder O, Homan M, Furlano R, Papadopoulou A, Oliva S, Dias JA, Dall'oglio L, Faraci S, Narula P, Schluckebier D, Hauser B, Nita A, Romano C, Tzivinikos C, Bontems P, Thomson M. Approach to Endoscopic Balloon Dilatation in Pediatric Stricturing Crohn Disease: A Position Paper of the Endoscopy Special Interest Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2023; 76:799-806. [PMID: 36867853 DOI: 10.1097/mpg.0000000000003752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Crohn disease (CD) is often complicated by bowel strictures that can lead to obstructive symptoms, resistant inflammation, and penetrating complications. Endoscopic balloon dilatation of CD strictures has emerged as a safe and effective technique for relieving these strictures, which may obviate the need for surgical intervention in the short and medium term. This technique appears to be underutilized in pediatric CD. This position paper of the Endoscopy Special Interest Group of European Society for Pediatric Gastroenterology, Hepatology and Nutrition describes the potential applications, appropriate evaluation, practical technique, and management of complications of this important procedure. The aim being to better integrate this therapeutic strategy in pediatric CD management.
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Affiliation(s)
- Oren Ledder
- From the Juliet Keidan Institute of Paediatric Gastroenterology, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Matjaž Homan
- the Department of Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, University Children's Hospital, University of Ljubljana, Ljubljana, Slovenia
| | - Raoul Furlano
- the Department of Pediatric Gastroenterology, University Children's Hospital Basel, Basel, Switzerland
| | - Alexandra Papadopoulou
- the First Department of Pediatrics, Athens Children's Hospital "Agia Sofia", University of Athens, Athens, Greece
| | - Salvatore Oliva
- the Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Jorge Amil Dias
- the Department of Paediatric Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Luigi Dall'oglio
- the Digestive Endoscopy Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Simona Faraci
- the Digestive Endoscopy, Gastroenterology, Hepatology, and Nutrition Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Priya Narula
- the Department of Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Dominique Schluckebier
- the Department of Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Bruno Hauser
- the Department of Pediatric Gastroenterology, Hepatology and Nutrition, KidZ Health Castle, Vrije Universiteit Brussel (VUB), UZ Brussel, Brussels, Belgium
| | - Andreia Nita
- the Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, United Kingdom
| | - Claudio Romano
- the Department of Pediatric Gastroenterology, University of Messina, Sicily, Italy
| | - Christos Tzivinikos
- the Department of Pediatric Gastroenterology, Al Jalila Children's Hospital, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Patrick Bontems
- the Department of Pediatric Gastroenterology, Queen Fabiola Children's University Hospital, Bruxelles, Belgium
| | - Mike Thomson
- the Department of Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
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5
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Endoscopic Balloon Dilation Is Cost-Effective for Crohn's Disease Strictures. Dig Dis Sci 2022; 67:5462-5471. [PMID: 35290570 DOI: 10.1007/s10620-022-07420-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) has emerged as an alternative intervention to manage Crohn's disease (CD) strictures. We determined the cost-effectiveness of EBD versus resection surgery for patients with short (< 4-5 cm) primary or secondary/anastomotic small or large bowel strictures. METHODS A microsimulation state-transition model analyzed the benefits and risks of EBD and resection surgery for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (2021 $US) and incremental cost-effectiveness ratios (ICER) were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. RESULTS The EBD strategy cost $19,822 and resulted in 6.18 QALYs while the surgery strategy cost $41,358 and resulted in 6.37 QALYs. Surgery had an ICER of $113,332 per QALY, making EBD a cost-effective strategy. The median number of EBDs was 5 in the EBD strategy and 0 in the surgery strategy. The median number of surgeries was 2 in the surgery strategy and 1 in the EBD strategy. Of individuals who initially received EBD, 50.4% underwent subsequent surgery. One-way sensitivity analyses showed that the probabilities of requiring repeated interventions, surgery mortality (< 0.7%), and quality of life after interventions were the most influential model parameters. Probabilistic sensitivity analyses favored EBD in 50.9% of iterations. CONCLUSIONS EBD is a cost-effective strategy for managing CD strictures. Differences in patient risk and quality of life after intervention impact cost-effectiveness. Intervention decisions should consider cost-effectiveness, patient risks, and quality of life.
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Yamamoto H, Yano T, Araki A, Esaki M, Ohtsuka K, Ohmiya N, Oka S, Nakase H, Bamba S, Hirai F, Hosoe N, Matsuda T, Mitsui K, Watanabe K, Ogata H, Katsuki S, Matsumoto T, Fujishiro M, Fujimoto K, Inoue H. Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures (supplement to the Clinical Practice Guidelines for Enteroscopy). Dig Endosc 2022; 34:1278-1296. [PMID: 36073310 DOI: 10.1111/den.14429] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/05/2022] [Indexed: 12/13/2022]
Abstract
Balloon-assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease-associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure-related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline.
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Affiliation(s)
| | - Tomonori Yano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akihiro Araki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Motohiro Esaki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kazuo Ohtsuka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Ohmiya
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shiro Oka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroshi Nakase
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shigeki Bamba
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Fumihito Hirai
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naoki Hosoe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Tomoki Matsuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Keigo Mitsui
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenji Watanabe
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Haruhiko Ogata
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | | | | | - Haruhiro Inoue
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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7
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Loras C, Mañosa M, Andújar X, Sánchiz V, Martí-Gallostra M, Zabana Y, Gutiérrez A, Barreiro-de Acosta M. Position Statement. Recommendations of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the treatment of strictures in Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:315-334. [PMID: 34274357 DOI: 10.1016/j.gastrohep.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
Abstract
Despite pharmacological advances, strictures in Crohn's disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.
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Affiliation(s)
- Carme Loras
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España.
| | - Miriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Departamento de Gastroenterología, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Xavier Andújar
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Vicente Sánchiz
- Servicio de Medicina Digestiva. Hospital Clínico Universitario. Valencia, España
| | - Marc Martí-Gallostra
- Departamento de Cirugía Colorectal, General y Digestiva. Hospital Universitari de la Vall d'Hebron. Barcelona, España
| | - Yamile Zabana
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Hospital General Universitario de Alicante, Alicante, España
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Feleshtynskiy Y, Mylianovska A, Pirogovsky V, Dyadyk O. Evaluation of the endoscopic treatment with topical prednisolone administration for intestinal strictures in Crohn’s disease. POLISH JOURNAL OF SURGERY 2021; 94:28-33. [DOI: 10.5604/01.3001.0015.2471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<br><b>Introduction:</b> The prevalence of Crohn’s disease amounts to 5.9 cases per 100,000 population. Complications such as intestinal strictures usually occur within a long course of Crohn’s disease. Intestinal resection for stricture does not prevent a stricture recurrence and the need for repeated resections, which in turn leads to the formation of short intestine syndrome. The advantage of endoscopic balloon dilatation is organ preservation and a quick clinical therapeutic effiect. However, the frequency of recurrences after conventional endoscopic balloon dilatation of the intestinal stricture in Crohn’s disease is still at a relatively high level and amounts to 59%, which justifies the need to improve the endoscopic dilatation technique.</br>
<br><b>Aim:</b> The aim of this study to improve the treatment effectiveness for intestinal strictures in Crohn’s disease using endoscopic balloon dilatation combined with prednisolone injection in the stricture area.</br>
<br><b>Materials and methods:</b> Endoscopic treatment for intestinal strictures in Crohn's disease was performed in 64 patients. Depending on the endoscopic technique, patients were randomized into 2 groups. The first group consisted of 32 (50%) patients who underwent conventional endoscopic balloon dilatation of strictured areas. The second group consisted of 32 (50%) patients in whom an endoscopic balloon dilatation in combination with submucosal injection of prednisolone to the area of stricture after dilatation was performed. Patient groups were comparable in age, sex and length of stricture.</br>
<br><b>Results and conclusions:</b> The results showed that endoscopic balloon dilatation with administration of 40 mg of prednisolone in group II patients was more effective compared to conventional balloon dilatation. The recurrence rate was reduced from 34.4% to 9.3%. The risk of recurrence of intestinal stricture in group I during the first year of observation was found to be 4.5 times higher – HR = 4.5 (1.6–12.9); P = 0.010. The effectiveness of advanced endoscopic balloon dilatation for intestinal strictures was confirmed by colonoscopy with patomorphological examination of the intestinal mucosa 6 months after dilation in patients of both groups.</br>
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Affiliation(s)
| | - Anna Mylianovska
- Department of Endoscopy, Kyiv Regional Hospital, , Kyiv, Ukraine
| | | | - Olena Dyadyk
- Department of Pathology and Topographic Anatomy, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
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9
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Adamina M, Feakins R, Iacucci M, Spinelli A, Cannatelli R, D'Hoore A, Driessen A, Katsanos K, Mookhoek A, Myrelid P, Pellino G, Peros G, Tontini GE, Tripathi M, Yanai H, Svrcek M. ECCO Topical Review Optimising Reporting in Surgery, Endoscopy, and Histopathology. J Crohns Colitis 2021; 15:1089-1105. [PMID: 33428711 DOI: 10.1093/ecco-jcc/jjab011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Diagnosis and management of inflammatory bowel diseases [IBD] requires a lifelong multidisciplinary approach. The quality of medical reporting is crucial in this context. The present topical review addresses the need for optimised reporting in endoscopy, surgery, and histopathology. METHODS A consensus expert panel consisting of gastroenterologists, surgeons, and pathologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. The following topics were covered: in endoscopy: [i] general IBD endoscopy; [ii] disease activity and surveillance; [iii] endoscopy treatment in IBD; in surgery: [iv] medical history with surgical relevance, surgical indication, and strategy; [v] operative approach; [vi] intraoperative disease description; [vii] operative steps; in pathology: [viii] macroscopic assessment and interpretation of resection specimens; [ix] IBD histology, including biopsies, surgical resections, and neoplasia; [x] IBD histology conclusion and report. Statements were developed using a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥ 80% of participants agreed on a recommendation. RESULTS Thirty practice positions established a standard terminology for optimal reporting in endoscopy, surgery, and histopathology. Assessment of disease activity, surveillance recommendations, advice to surgeons for operative indication and strategies, including margins and extent of resection, and diagnostic criteria of IBD, as well as guidance for the interpretation of dysplasia and cancer, were handled. A standardised report including a core set of items to include in each specialty report, was defined. CONCLUSIONS Interdisciplinary high-quality care requires thorough and standardised reporting across specialties. This topical review offers an actionable framework and practice recommendations to optimise reporting in endoscopy, surgery, and histopathology.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Roger Feakins
- Department of Cellular Pathology, Royal Free Hospital, London, UK
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham, UK.,Division of Gastroenterology, University Hospitals Birmingham NHS Trust, UK
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano,Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Rosanna Cannatelli
- Institute of Translational Medicine, University of Birmingham, Birmingham, UK.,Gastroenterology Unit, Spedali Civili di Brescia, Brescia, Italy
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Ann Driessen
- Department of Pathology, University Hospital Antwerp, University Antwerp, Edegem, Belgium
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Aart Mookhoek
- Department of Pathology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Pär Myrelid
- Department of Surgery, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy.,Colorectal Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Georgios Peros
- Department of Surgery, Cantonal Hospital of Winterthur, Winterthur, Switerland; Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Henit Yanai
- Division of Gastroenterology, IBD Center, Rabin Medical Center, Petah Tikva, Israel
| | - Magali Svrcek
- Department of Pathology, Sorbonne Université, AP-HP, Saint-Antoine hospital, Paris, France
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10
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Upper gastrointestinal tract involvement in Crohn's disease: A case report. Int J Surg Case Rep 2021; 81:105810. [PMID: 33887830 PMCID: PMC8041720 DOI: 10.1016/j.ijscr.2021.105810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/20/2021] [Indexed: 01/25/2023] Open
Abstract
Upper gastrointestinal tract manifestations of Crohn’s disease are unusual. There is limited literature guiding management decisions in affected patients. This case report highlights surgical management in this aspect of Crohn’s disease.
Background Crohn’s disease (CD) is an inflammatory bowel disease that typically affects the distal part of the gastrointestinal tract (GI) such as the terminal ileum and colon. However, it can affect the upper GI tract, potentially resulting in complications such as strictures, but discussion of the management of such effects is limited in the surgical literature. Case presentation A 39 year old male was referred to our department with stricturing upper GI disease 20 years after CD diagnosis. He had a history of intermittent abdominal pain, nausea, frequent vomiting and weight loss. Imaging demonstrated a long stricture in the duodenum with proximal dilatation. There was no evidence of acute inflammatory Crohn’s disease. A Roux-en-Y bypass was performed to successfully relieve the obstructive symptoms. Discussion Proximal obstructive gastrointestinal manifestations of CD are a rare entity and require a full diagnostic workup and treatment in a specialist centre. A variety of systemic treatments, endoscopic procedures and surgical techniques are addressed in this paper. Conclusion Evidence for the optimal treatment of obstructive upper gastrointestinal CD is limited, but careful consideration of the extent of the disease, thorough preoperative planning and weighing up the benefits and risks can lead to a positive outcome for these patients.
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11
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Schulberg JD, Wright EK, Holt BA, Wilding HE, Hamilton AL, Ross AL, Kamm MA. Efficacy of drug and endoscopic treatment of Crohn's disease strictures: A systematic review. J Gastroenterol Hepatol 2021; 36:344-361. [PMID: 33150989 DOI: 10.1111/jgh.15330] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/14/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Julien D Schulberg
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Bronte A Holt
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Helen E Wilding
- Library Service, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Amy L Hamilton
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Alyson L Ross
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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12
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Shi JH, Luo L, Chen XL, Pan YP, Zhang Z, Fang H, Chen Y, Chen WD, Cao Q. Real-world cost-effectiveness associated with infliximab maintenance therapy for moderate to severe Crohn’s disease in China. World J Gastroenterol 2020; 26:6455-6474. [PMID: 33244205 PMCID: PMC7656205 DOI: 10.3748/wjg.v26.i41.6455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/05/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infliximab was the first approved biologic treatment for moderate to severe Crohn’s disease (MS-CD) in China. However, the cost-effectiveness of infliximab maintenance therapy (IMT) for MS-CD relative to conventional maintenance therapy remained unclarified.
AIM To assess the cost-effectiveness of IMT for MS-CD in Chinese patients from the perspective of Chinese public insurance payer.
METHODS A cohort of MS-CD patients managed in a Chinese tertiary care hospital was created to compare IMT with conventional maintenance therapy (CMT) for clinical outcomes and direct medical costs over a 1-year observation time using conventional regression analyses. A decision-analytic model with the generated evidence was constructed to assess the cost-effectiveness of IMT relative to CMT using reimbursed medical costs.
RESULTS Based on the included 389 patients, IMT was associated with significantly higher disease remission chance [odds ratio: 4.060, P = 0.003], lower risk of developing new complications (odds ratio: 0.527, P = 0.010), higher utility value for quality of life (coefficient 0.822, P = 0.008), and lower total hospital costs related to disease management (coefficient -0.378, P = 0.008) than CMT. Base-case cost-effectiveness analysis estimated that IMT could cost Chinese health insurance payers ¥55260 to gain one quality-adjusted life year (QALY). The cost-effectiveness of IMT was mainly driven by the estimate of quality of life, treatment efficacy of maintenance therapy, mortality risk associated with active disease, and unit price of infliximab. The probability that IMT was cost-effective at a willingness-to-pay threshold of three times gross domestic product [2018 Chinese gross domestic product per capita (GDPPC)] was 86.4%.
CONCLUSION IMT significantly improved real-world health outcomes and cost the Chinese public health insurance payers less than one GDPPC to gain one QALY in Chinese MS-CD patients.
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Affiliation(s)
- Ji-Hao Shi
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Liang Luo
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Xiao-Li Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Yi-Peng Pan
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Zhou Zhang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Hao Fang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Ying Chen
- Department of Project, Changsha Normin Health Technology Ltd, Changsha 410013, Hunan Province, China
| | - Wen-Dong Chen
- Department of HEOR, Normin Health Consulting Ltd, Toronto L5R 0E9, Ontario, Canada
| | - Qian Cao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
- Inflammatory Bowel Disease Center, Sir Run Run Shaw Hospital, Hangzhou 310016, Zhejiang Province, China
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13
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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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14
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Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group. Lancet Gastroenterol Hepatol 2020; 5:393-405. [PMID: 31954438 DOI: 10.1016/s2468-1253(19)30366-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/09/2019] [Accepted: 09/17/2019] [Indexed: 02/08/2023]
Abstract
Stricture formation is a common complication of Crohn's disease, resulting from the disease process, surgery, or drugs. Endoscopic balloon dilation has an important role in the management of strictures, with emerging techniques, such as endoscopic electroincision and stenting, showing promising results. The underlying disease process, altered bowel anatomy from disease or surgery, and concurrent use of immunosuppressive drugs can make endoscopic procedures more challenging. There is an urgent need for the standardisation of endoscopic procedures and peri-procedural management strategies. On the basis of an extensive literature review and the clinical experience of the consensus group, which consisted of representatives from the Interventional Inflammatory Bowel Disease Group, we propose detailed guidance on all aspects of the principles and techniques for endoscopic procedures in the treatment of inflammatory bowel disease-associated strictures.
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15
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Chen H, Shi J, Pan Y, Zhang Z, Fang H, Chen Y, Chen W, Cao Q. Cost-Effectiveness of Reimbursing Infliximab for Moderate to Severe Crohn's Disease in China. Adv Ther 2020; 37:431-449. [PMID: 31797196 DOI: 10.1007/s12325-019-01150-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To assess the cost-effectiveness of reimbursing infliximab for moderate-to-severe Crohn's disease (MS-CD) in China from the perspective of public insurance payers. METHODS A decision-analytic model with a lifetime time horizon was constructed to simulate the disease progression and direct medical costs in Chinese MS-CD patients under two scenarios: reimbursing infliximab vs. not reimbursing infliximab. A cross-sectional study and literature review were conducted to estimate model variables. The constructed decision-analytic model ran the base case, one-way sensitivity, and probabilistic sensitivity analyses (PSA) to assess the cost-effectiveness of reimbursing infliximab using reimbursed medical costs. RESULTS Base case analysis discounting health benefits and costs estimated that reimbursing infliximab could increase overall survival by 0.604 years, increase total quality-adjusted life years (QALY) by 0.697 QALY, reduce absolute lifetime surgery risk by 13.1%, and increase reimbursed costs by ¥29,409. The incremental cost-effectiveness ratio per gained additional QALY (ICER) based on discounted health benefits and reimbursed medical costs (3% per year) was ¥42,198. The one-way sensitivity analyses identified that the cost-effectiveness of reimbursing infliximab for MS-CD was mainly driven by the treatment efficacies of maintenance therapy, quality of life, and unit price of infliximab. PSA estimated that reimbursing infliximab was associated with a 63.8% chance to be cost-effective under the willingness-to-pay of the 2018 Chinese gross domestic product per capita (GDPPC). CONCLUSION Reimbursing infliximab for MS-CD in Chinese patients was highly attractive, costing Chinese public insurance payers less than the 2018 Chinese GDPPC to gain 1 QALY.
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16
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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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17
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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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18
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Danese S, Bonovas S, Lopez A, Fiorino G, Sandborn WJ, Rubin DT, Kamm MA, Colombel JF, Sands BE, Vermeire S, Panes J, Rogler G, D'Haens G, Peyrin-Biroulet L. Identification of Endpoints for Development of Antifibrosis Drugs for Treatment of Crohn's Disease. Gastroenterology 2018; 155:76-87. [PMID: 29601825 DOI: 10.1053/j.gastro.2018.03.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/20/2018] [Accepted: 03/19/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy.
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Anthony Lopez
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Gionata Fiorino
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | | | - Michael A Kamm
- Departments of Gastroenterology and Medicine, St Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Severine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Julian Panes
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | | | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
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19
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Hirai F, Andoh A, Ueno F, Watanabe K, Ohmiya N, Nakase H, Kato S, Esaki M, Endo Y, Yamamoto H, Matsui T, Iida M, Hibi T, Watanabe M, Suzuki Y, Matsumoto T. Efficacy of Endoscopic Balloon Dilation for Small Bowel Strictures in Patients With Crohn's Disease: A Nationwide, Multi-centre, Open-label, Prospective Cohort Study. J Crohns Colitis 2018; 12:394-401. [PMID: 29194463 DOI: 10.1093/ecco-jcc/jjx159] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/24/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Endoscopic balloon dilation [EBD] is an alternative to surgery for Crohn's strictures. However, there have been no prospective studies of EBD for small bowel strictures in patients with Crohn's disease [CD]. The aim of this study was to clarify the efficacy and safety of EBD using balloon-assisted enteroscopy for small bowel strictures in CD. METHODS This was a nationwide, multi-centre, open-label, prospective cohort study. The subjects were CD patients with at least one symptom [abdominal pain, abdominal bloating, nausea] attributable to small bowel stricture. The primary endpoint related to short-term outcomes was the level of improvement of symptoms evaluated using a 10-cm visual analogue scale [VAS]. Cases in which VAS scores for all symptoms improved 4 weeks after EBD compared with baseline were considered to have short-term symptomatic improvement. Factors related to short-term treatment outcomes and safety were investigated as secondary endpoints. RESULTS A total of 112 patients were enrolled. Seventeen were later excluded because they did not meet the criteria, and the analysis was conducted with the remaining 95 patients. Of these 95 patients, procedure failure occurred in six [6.3%], and short-term symptomatic improvement was achieved in 66 patients [69.5%]. Adverse events were seen in five patients [5%] and all of these improved with conservative treatment. A large dilation diameter of the balloon was a factor contributing to the success of EBD. CONCLUSIONS EBD using balloon-assisted enteroscopy for small bowel strictures in CD patients was shown to be an effective and safe procedure. CLINICAL TRIAL REGISTRY UMIN000005946.
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Affiliation(s)
- Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Zokumyoin, Chikusino, Fukuoka, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science Hospital, Japan
| | - Fumiaki Ueno
- Center for Gastroenterology and Inflammatory Bowel Disease, Ofuna Chuo Hospital, Japan
| | - Kenji Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan.,Department of Intestinal Inflammation Research, Hyogo College of Medicine, Japan
| | - Naoki Ohmiya
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Japan.,Department of Gastroenterology, Fujita Health University, School of Medicine, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Kyoto University, Japan.,Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Japan
| | - Motohiro Esaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yutaka Endo
- Center for Gastroenterology and Inflammatory Bowel Disease, Ofuna Chuo Hospital, Japan.,Department of Gastroenterology, Showa University Fujigaoka Hospital, Japan
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Japan
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Zokumyoin, Chikusino, Fukuoka, Japan
| | - Mitsuo Iida
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan.,Department of Gastroenterology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato Institute Hospital, Kitasato University, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Japan
| | - Yasuo Suzuki
- Internal Medicine, Toho University Sakura Medical Centre, Japan
| | - Takayuki Matsumoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan.,Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Japan
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20
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Kopylov U, Koulaouzidis A, Klang E, Carter D, Ben-Horin S, Eliakim R. Monitoring of small bowel Crohn's disease. Expert Rev Gastroenterol Hepatol 2017; 11:1047-1058. [PMID: 28737951 DOI: 10.1080/17474124.2017.1359541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In recent years, the therapeutic paradigm in Crohn's disease has shifted from a mere symptom-oriented approach, to aiming to healing of the underlying inflammation and prevention of long-term structural complications. Such 'treat-to-target' approach may allow for a more stable disease course with less hospitalizations, lower requirement for surgery and improved quality of life. In Crohn's disease, the small bowel is affected in the majority of patients; frequently, Crohn's involves only the small bowel, which remains inaccessible to conventional ileocolonoscopic techniques. Thus, non-invasive monitoring techniques are crucial for accurate disease assessment. Areas covered: This review addresses the indications and clinical implications of non-invasive small bowel monitoring modalities (magnetic resonance enterography, intestinal ultrasound, capsule endoscopy) in the assessment and management of Crohn's disease. Expert commentary: This review addresses the limitations of the current knowledge and future areas of research, including the possible utilization of transmural healing as an imaging target and the need to establish clear quantitative target values to guide treatment by imaging findings in Crohn's disease.
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Affiliation(s)
- Uri Kopylov
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Anastasios Koulaouzidis
- b Centre for Liver & Digestive Disorders , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Eyal Klang
- c Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Dan Carter
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Shomron Ben-Horin
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Rami Eliakim
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
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21
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Zhang ZM, Deng H, Zhang C, Yu HW, Liu Z, Liu LM, Wan BJ, Zhu MW. Strategies for diagnosis and treatment of benign and malignant colorectal obstruction. Shijie Huaren Xiaohua Zazhi 2017; 25:2597-2604. [DOI: 10.11569/wcjd.v25.i29.2597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colorectal obstruction is one of the most common acute abdominal diseases in surgery department. Because of complex etiological factors, severe condition, and rapid progression, timely diagnosis and proper treatment are necessary for colorectal obstruction. By searching the literature and based on our experience in clinical practice, we performed a comprehensive and systematic analysis of the etiology, diagnosis and treatment of benign and malignant colorectal obstruction, and summarize the main points of diagnosis and treatment of benign and malignant colorectal obstruction as follows: identifying the etiology of benign and malignant colorectal obstruction; flexible application of colonography with meglumine diatrizoate, CT virtual endoscopy, and colonoscopy; preoperative colonoscopic drainage as a bridge to surgery; strict control of surgical indication; precise surgical procedures; and active symptomatic treatment. These measures are of important significance in improving the diagnosis and treatment of benign and malignant colorectal obstruction.
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Affiliation(s)
- Zong-Ming Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Hai Deng
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Chong Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Hong-Wei Yu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Zhuo Liu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Li-Min Liu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Bai-Jiang Wan
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Ming-Wen Zhu
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
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22
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Klag T, Wehkamp J, Goetz M. Endoscopic Balloon Dilation for Crohn's Disease-Associated Strictures. Clin Endosc 2017; 50:429-436. [PMID: 29017297 PMCID: PMC5642070 DOI: 10.5946/ce.2017.147] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/17/2017] [Indexed: 12/12/2022] Open
Abstract
Management of intestinal strictures associated with Crohn’s disease (CD) is clinically challenging despite advanced medical therapy directed toward mucosal healing to positively influence the natural course of CD-associated complications. Although medical therapy is available for inflammatory strictures, therapy of fibrostenotic strictures is the domain of surgery and endoscopy. Endoscopic balloon dilation (EBD) has been recognized as a well-established first-line procedure in terms of safety and efficacy. Although surgery is a valuable treatment modality for the management of CD-related strictures, EBD can help prevent multiple surgical interventions, which might in the long-term lead to a risk of short bowel syndrome. In this review we discuss requirements, techniques, safety, short- and long-term outcomes, as well as combinations of this procedure with surgical and medical treatment in CD-associated intestinal strictures.
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Affiliation(s)
- Thomas Klag
- Department of Internal Medicine I (Gastroenterology, Hepatology, Infectious Diseases), University Hospital Tübingen, Tübingen, Germany
| | - Jan Wehkamp
- Department of Internal Medicine I (Gastroenterology, Hepatology, Infectious Diseases), University Hospital Tübingen, Tübingen, Germany
| | - Martin Goetz
- Department of Internal Medicine I (Gastroenterology, Hepatology, Infectious Diseases), University Hospital Tübingen, Tübingen, Germany
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23
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Lian L, Stocchi L, Remzi FH, Shen B. Comparison of Endoscopic Dilation vs Surgery for Anastomotic Stricture in Patients With Crohn's Disease Following Ileocolonic Resection. Clin Gastroenterol Hepatol 2017; 15:1226-1231. [PMID: 27816758 DOI: 10.1016/j.cgh.2016.10.030] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/14/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear whether endoscopic balloon dilation (EBD) or surgery is a more effective treatment for ileocolonic anastomosis (ICA) stricture in patients with Crohn's disease. We aimed to compare long-term outcomes of patients who underwent EBD versus surgery for ICA stricture. METHODS We performed a retrospective study of adult patients with ICA stricture treated with EBD (n = 176) or surgery (n = 131), from December 1998 through May 2013, at the Cleveland Clinic Foundation. Demographic, clinical, endoscopic, histologic, and radiographic data were collected. Disease duration was defined as the time interval from the diagnosis of Crohn's disease to the treatment for ICA stricture. Data were collected for a median follow-up period of 2.9 years (interquartile range, 0.9-5.7 years). Multivariable analyses were performed to assess risk factors for subsequent surgery. RESULTS Patients in the surgery group had a longer median interval from inception (first encounter with patients at either follow-up endoscopy or presentation with obstructive symptoms) until subsequent surgery (4.7 years; interquartile range, 2.2-8.8 vs 1.8 years; interquartile range, 0.4-4.1 years). The average time to surgery delayed by EBD was 6.45 years. Upfront surgery for ICA stricture (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.32-0.76), a longer time for diagnosis to inception (HR, 0.96; 95% CI, 0.93-0.99), a shorter interval from the last surgery to inception (HR, 1.05; 95% CI, 1.01-1.09), only 1 previous resection (HR, 0.41; 95% CI, 0.26-0.66), and the absence of concurrent strictures (HR, 1.68; 95% CI, 0.97-2.9) were associated with a significantly lower risk for subsequent surgery. CONCLUSIONS Surgical resection for ICA stricture in patients with Crohn's disease was associated with a lower risk of further surgery than EBD. However, EBD could delay time until need for a second surgery and be attempted first for patients with a lower risk for disease progression. Patients at risk for recurrent disease may benefit from upfront surgical therapy.
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Affiliation(s)
- Lei Lian
- Center for Inflammatory Bowel Diseases, Cleveland Clinic, Cleveland, Ohio; Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Luca Stocchi
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Feza H Remzi
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, Cleveland Clinic, Cleveland, Ohio.
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24
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Kopylov U, Yung DE, Engel T, Vijayan S, Har-Noy O, Katz L, Oliva S, Avni T, Battat R, Eliakim R, Ben-Horin S, Koulaouzidis A. Diagnostic yield of capsule endoscopy versus magnetic resonance enterography and small bowel contrast ultrasound in the evaluation of small bowel Crohn's disease: Systematic review and meta-analysis. Dig Liver Dis 2017; 49:854-863. [PMID: 28512034 DOI: 10.1016/j.dld.2017.04.013] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/07/2017] [Accepted: 04/18/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Capsule endoscopy (CE), magnetic resonance enterography (MRE) and small bowel (SB) intestinal contrast ultrasound (SICUS) are the modalities of choice for SB evaluation. This study aimed to compare the diagnostic yield (DY) of CE to MRE and SICUS in detection and monitoring of SB CD through meta-analysis of the available literature. METHODS We performed a systematic literature search for trials comparing the accuracy of CE, MRE and SICUS for detection of active SB inflammation in patients with suspected and/or established CD. Only prospective studies comparing CE with another additional diagnostic modality were included in the final analysis. Pooled odds ratios (ORs) for the DY of the three modalities were calculated. RESULTS A total of 112 studies were retrieved; following selection, 13 studies were eligible for analysis. The DY of CE for detection of active SB CD was similar to that of MRE (10 studies, 400 patients, OR 1.17; 95% CI 0.83-1.67) and SICUS (5 studies, 142 patients, OR 0.88; 95% CI 0.51-1.53). The outcomes were similar for the subgroups of suspected versus established CD and adult versus pediatric patients. CE was superior to MRE for proximal SB CD (7 studies, 251 patients, OR 2.79; 95% CI 1.2-6.48); the difference vs SICUS was not significant. CONCLUSION CE, MRE and SICUS have similar DY for detection of SB CD in both suspected and established CD. CE is superior to MRE for detection of proximal SB disease, however the risk of capsule retention should be considered.
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Affiliation(s)
- Uri Kopylov
- Gastroenterology Department, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Israel.
| | - Diana E Yung
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Tal Engel
- Gastroenterology Department, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Sanju Vijayan
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Ofir Har-Noy
- Gastroenterology Department, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Lior Katz
- Gastroenterology Department, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy
| | - Tomer Avni
- Department of Medicine E, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Robert Battat
- McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Rami Eliakim
- Gastroenterology Department, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Shomron Ben-Horin
- Gastroenterology Department, Sheba Medical Center, Ramat-Gan, and Sackler School of Medicine, Tel-Aviv University, Israel
| | - Anastasios Koulaouzidis
- Centre for Liver & Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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25
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Belza C, Fitzgerald K, Amaral J, Steinberg K, Avitzur Y, Wales PW. Use of balloon dilatation for management of postoperative intestinal strictures in children with short bowel syndrome. J Pediatr Surg 2017; 52:760-763. [PMID: 28190552 DOI: 10.1016/j.jpedsurg.2017.01.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Children with short bowel syndrome (SBS) often require numerous operations to optimize intestinal function. Postoperative intestinal strictures are a complication that inhibits enteral feeding advancement and prolongs parenteral nutrition dependency, often requiring reoperation. Our objective was to review our experience with fluoroscopic balloon dilatation to treat intestinal strictures. METHODS A retrospective cohort study of intestinal failure patients with SBS was completed. Patients who had radiologically diagnosed intestinal strictures and treated with fluoroscopic guided balloon dilatation were included [n=6]. Data related to demographics, anatomy, surgical procedures, and dilatation procedures were collected. Descriptive summary statistics were employed. RESULTS 98 intestinal failure patients were recruited between 2011 and 2015. Five of 98 patients (5.1%) [2 males; median age 4.4months] underwent fluoroscopy guided balloon dilatation of 6 strictures. Balloon dilatation was successful in 4/6 (67%). The median number of dilatations was 2 per patient (range=1-3). Median time to feed initiation postdilatation was 3days. One patient developed an anastomotic leak after dilatation that required antibiotics, but no reoperation. CONCLUSION Four of six (67%) postoperative bowel strictures in 5 patients with SBS were successfully treated with fluoroscopically guided balloon dilatation. Balloon dilatation is less invasive than reoperation, preserves bowel length and reduces time to reinitiation of enteral feeding. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Kevin Fitzgerald
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Karen Steinberg
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.
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26
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Hirai F. Current status of endoscopic balloon dilation for Crohn's disease. Intest Res 2017; 15:166-173. [PMID: 28522945 PMCID: PMC5430007 DOI: 10.5217/ir.2017.15.2.166] [Citation(s) in RCA: 21] [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: 12/29/2016] [Revised: 12/31/2016] [Accepted: 01/02/2017] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Fumihito Hirai
- Inflammatory Bowel Disease Center, Fukuoka University Chikushi Hospital, Fukuoka, Japan
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27
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Kumar AS, Lee JK. Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions. Clin Colon Rectal Surg 2017; 30:136-144. [PMID: 28381945 DOI: 10.1055/s-0036-1597312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists.
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Affiliation(s)
- Anjali S Kumar
- Colorectal Surgery Program, Virginia Mason Medical Center, Seattle, Washington
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28
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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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29
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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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30
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Kopylov U, Carter D, Eliakim AR. Capsule Endoscopy and Deep Enteroscopy in Irritable Bowel Disease. Gastrointest Endosc Clin N Am 2016; 26:611-27. [PMID: 27633591 DOI: 10.1016/j.giec.2016.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In approximately one-third of Crohn's disease patients, the disease is confined to the small bowel, inaccessible to the reach of standard endoscopy. Thorough and complete evaluation of the small bowel is crucial in such patients for the initial diagnosis, prognostication, and disease monitoring. Video capsule endoscopy and device-assisted enteroscopy have revolutionized the ability to visualize the small-bowel mucosa. This article reviews the literature pertaining to the use of capsule endoscopy and deep enteroscopy in established Crohn's disease, including the major indications, applications, and safety issues.
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Affiliation(s)
- Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer 5265601, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv 6910302, Israel.
| | - Dan Carter
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer 5265601, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv 6910302, Israel
| | - Abraham Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer 5265601, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv 6910302, Israel
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