Endoscopic treatment of Crohn-related strictures with a self-expandable stent compared with balloon dilation: a prospective, randomised, controlled study

Pediatric stricturing Crohn's disease

Crohn's disease (CD) is a chronic inflammatory disease of the digestive tract. The incidence of pediatric CD is increasing and is currently 2.5-11.4 per 100000 world-wide. Notably, approximately 25% of children with CD develop stricturing CD (SCD) that requires intervention. Symptomatic stricturing diseases refractory to pharmacological management frequently require non-pharmacological interventions. Non-pharmacological therapeutic strategies include endoscopic balloon dilatation, stricturoplasty, and surgical resection of the strictured segment. However, strictures tend to recur postoperatively regardless of treatment modality. The lifetime risk of surgery in patients with childhood SCD remains at 50%-90%. Thus, new and emerging strategies, advanced diagnostic tools, and minimally invasive approaches are under investigation to improve the outcomes and overall quality of life of pediatric patients with SCD.

Stricturing Crohn's disease: what is the role of endoscopic stenting? A systematic review

BACKGROUND/AIMS

Endoscopic stenting for stricturing Crohn's disease (CD) is an emerging treatment that achieves more persistent dilatation of the stricture over time than endoscopic balloon dilatation (EBD). We aimed to explore the efficacy and safety of stenting for the treatment of CD strictures.

METHODS

A systematic electronic literature search was performed (PROSPERO; no. CRD42022308033). The primary outcomes were technical success, efficacy, complication rate, and the need for further interventions due to reobstruction. The outcomes of partially covered self-expanding metal stents (PCSEMS) with scheduled retrieval after seven days were also analyzed.

RESULTS

Eleven eligible studies were included in the review. Overall, 173 patients with CD were included in this study. Mean percentage of technical success was 95% (range, 80%-100%), short-term efficacy was 100% in all studies, and long-term efficacy was 56% (range, 25%-90%). In patients with a scheduled PCSEMS retrieval, the long-term efficacy was 76% (range, 59%-90%), the mean complication rate was 35% (range, 15%-57%), and the major complication rate was 11% (range, 0%-29%).

CONCLUSION

Endoscopic stenting with scheduled PCSEMS retrieval may be considered a feasible second-line treatment for short CD strictures to postpone surgery. However, larger head-to-head prospective studies are needed to understand the role of stenting as an alternative or additional treatment to EBD in CD.

Systematic Review of Endoscopic Management of Stricture, Fistula and Abscess in Inflammatory Bowel Disease

Background: Interventional inflammatory bowel disease (IIBD) therapies can play a key role in inflammatory bowel disease (IBD) related stricture/fistula/abscess deferring or avoiding invasive surgery. Methods: A total of 112 studies pertaining to IIBD therapy for strictures/fistula/abscess between 2002 and December 2022 were included by searching Pubmed, Medline and Embase with a focus on technical/clinical success, recurrence, re-intervention and complications. Results: IIBD therapy for strictures include endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES) and self-expanding metal stent (SEMS) placement. EBD is the primary therapy for short strictures while ES and SEMS can be used for refractory strictures. ES has higher long-term efficacy than EBD. SEMS is inferior to EBD although it can be useful in long, refractory strictures. Fistula therapy includes endoscopic incision and drainage (perianal fistula)/endoscopic seton (simple, low fistula) and endoscopic ultrasound-guided drainage (pelvic abscess). Fistulotomy can be done for short, superficial, single tract, bowel-bowel fistula. Endoscopic injection of filling agents (fistula plug/glue/stem cell) is feasible although durability is unknown. Endoscopic closure therapies like over-the-scope clips (OTSC), suturing and SEMS should be avoided for de-novo/bowel to hollow organ fistulas. Conclusion: IIBD therapies have the potential to act as a bridge between medical and surgical therapy for properly selected IBD-related stricture/fistula/abscess although future controlled studies are warranted.

Endoscopic Stenting for Inflammatory Bowel Disease Strictures

Strictures are among the most frequent complications in patients with Crohn's disease (CD), usually requiring a combined medical, surgical, and/or endoscopic approach to treatment. Currently, endoscopic balloon dilation (EBD) is the endoscopic treatment of choice, but its effectiveness is not universal, especially in the long term, and it is not free of complications. The technological evolution of stents in recent years has allowed their use in benign diseases of any origin and location, including inflammatory bowel disease (IBD). The current scientific evidence regarding the use of stents in strictures in IBD is limited and it should not be considered the first option in endoscopic treatment. Self-expandable metal stents (SEMS), but no biodegradable stents (BS), can work in cases that are refractory to anterior endoscopic treatment with EBD, in cases in which EBD is not possible, and in cases with strictures of greater length.

Interventional inflammatory bowel disease: endoscopic therapy of complications of Crohn's disease

Endoscopic therapy for inflammatory bowel diseases (IBD) or IBD surgery-associated complications or namely interventional IBD has become the main treatment modality for Crohn’s disease, bridging medical and surgical treatments. Currently, the main applications of interventional IBD are (i) strictures; (ii) fistulas and abscesses; (iii) bleeding lesions, bezoars, foreign bodies, and polyps; (iv) post-operative complications such as acute and chronic anastomotic leaks; and (v) colitis-associated neoplasia. The endoscopic treatment modalities include balloon dilation, stricturotomy, strictureplasty, fistulotomy, incision and drainage (of fistula and abscess), sinusotomy, septectomy, banding ligation, clipping, polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The field of interventional IBD is evolving with a better understanding of the underlying disease process, advances in endoscopic technology, and interest and proper training of next-generation IBD interventionalists.

Endoscopic Stenting in Crohn's Disease-related Strictures: A Systematic Review and Meta-analysis of Outcomes

BACKGROUND

Crohn's disease (CD) is a chronic progressive condition that is complicated by intestinal or colonic stricture in nearly 30% of cases within 10 years of the initial diagnosis. Endoscopic balloon dilation (EBD) is associated with a risk of perforations and recurrence rates of up to 60% at 5 years. Endoscopic stenting has been used as an alternative to EBD, but data on its safety and efficacy are limited. We conducted a systematic review and meta-analysis to assess the outcomes of endoscopic stenting in CD-related strictures.

METHODS

A systematic and detailed search was run in January 2022 with the assistance of a medical librarian for studies reporting on outcomes of endoscopic stenting in CD-related strictures. Meta-analysis was performed using random-effects model, and results were expressed in terms of pooled proportions along with relevant 95% confidence intervals (CIs).

RESULTS

Nine studies with 163 patients were included in the final analysis. Self-expanding metal stents (SEMS) including both partial and fully covered were used in 7 studies, whereas biodegradable stents were used in 2 studies. Pooled rate of clinical success and technical success was 60.9% (95% CI, 51.6-69.5; I2 = 13%) and 93% (95% CI, 87.3-96.3; I2 = 0%), respectively. Repeat stenting was needed in 9.6% of patients (95% CI, 5.3-16.7; I2 = 0%), whereas pooled rate of spontaneous stent migration was 43.9% (95% CI, 11.4-82.7; I2 = 88%). Pooled incidence of overall adverse events, proximal stent migration, perforation, and abdominal pain were 15.7%, 6.4%, 2.7%, and 17.9%, respectively. Mean follow-up period ranged from 3 months to 69 months.

DISCUSSION

Endoscopic stenting in CD-related strictures is a safe technique that can be performed with technical ease, albeit with a limited clinical success. Postprocedure abdominal pain and proximal stent migration are some of the common adverse events reported.

Intestinal strictures in Crohn's disease: a 2021 update

Intestinal strictures remain one of the most intractable and common complications of Crohn's disease (CD). Approximately 70% of CD patients will develop fibrotic strictures after 10 years of CD diagnosis. Since specific antifibrotic therapies are unavailable, endoscopic balloon dilation and surgery remain the mainstay treatments despite a high recurrence rate. Besides, there are no reliable methods for accurately evaluating intestinal fibrosis. This is largely due to the fact that the mechanisms of initiation and propagation of intestinal fibrosis are poorly understood. There is growing evidence implying that the pathogenesis of stricturing CD involves the intricate interplay of factors including aberrant immune and nonimmune responses, host-microbiome dysbiosis, and genetic susceptibility. Currently, the progress on intestinal strictures has been fueled by the advent of novel techniques, such as single-cell sequencing, multi-omics, and artificial intelligence. Here, we perform a timely and comprehensive review of the substantial advances in intestinal strictures in 2021, aiming to provide prompt information regarding fibrosis and set the stage for the improvement of diagnosis, treatment, and prognosis of intestinal strictures.

Futuristic Developments and Applications in Endoluminal Stenting

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