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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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2
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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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3
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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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4
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Shen B. Principles, Preparation, Indications, Precaution, and Damage Control of Endoscopic Therapy in Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2022; 32:597-614. [PMID: 36202505 DOI: 10.1016/j.giec.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Interventional inflammatory bowel disease (IBD) or endoscopic therapy for IBD or IBD surgery-associated complications has emerged as a main treatment modality bridging medical and surgical treatment. It delivers therapy more definitive than medical therapy and less invasive than surgical treatment. The main applications of interventional IBD are strictures, fistulas, abscesses, bleeding, foreign bodies, postoperative complications, and colitis-associated neoplasia. The major endoscopic treatment modalities are balloon dilation, stricturotomy, strictureplasty, fistulotomy, sinusotomy, septectomy, banding ligation, incision and drainage, polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection.
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Affiliation(s)
- Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center and New York Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion-Suite 843, New York, NY, USA.
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5
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Toshimori A, Inoue H, Fujiyoshi MRA, Fujiyoshi Y, Nishikawa Y, Tanabe M, Shimamura Y, Ohwada K, Ono M, Ikeda H, Onimaru M. Novel modified side-by-side balloon dilatation method for esophagogastric junction strictures: Single-/double-barrel techniques. Dig Endosc 2022; 34:641-647. [PMID: 34837409 DOI: 10.1111/den.14205] [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: 06/22/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 02/08/2023]
Abstract
Endoscopic balloon dilatation is an established treatment for benign gastrointestinal strictures. In order to dilatate safely, it is necessary to dilatate gradually and preferably under direct endoscopic visualization. However, it is currently difficult to achieve dilatation widths of 20-30 mm with commercial products and of over 30-mm with endoscopic visualization. Therefore, a safe and innovative application technique is needed for patients who need these 20-mm or greater dilatation widths. We have developed two methods that enable more than 20-mm dilatation under direct visualization. (i) Single-barrel method: an endoscopic balloon dilatation catheter was fixed with grasping forceps at the tip of the endoscope and carried into the stomach. The balloon catheter was released from the endoscope to create a retroflexed view. The endoscope and balloon were positioned adjacent to each other at the gastric cardia. The balloon was inflated gradually and the esophagogastric junction was dilatated under direct visualization. (ii) Double-barrel method: the same procedure was repeated with two balloons. Theoretically, we achieved a dilatation of >30-mm in diameter. These modified methods may be helpful for esophagogastric junction strictures, such as esophageal achalasia (serving as an initial endoscopic balloon dilatation prior to using a 30-mm achalasia balloon), or for functional strictures after Nissen fundoplication. In conclusion, our simple, modified method enables safe and gradual dilatation under direct endoscopic visualization. Additionally, combination of the sizes of one or two balloons can achieve various widths of dilatation.
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Affiliation(s)
- Akiko Toshimori
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Yusuke Fujiyoshi
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yohei Nishikawa
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kaori Ohwada
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Masashi Ono
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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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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7
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Muthuvel G, Bartlett MG, Absah I. Case 2: Chronic Feeding Intolerance in a 9-year-old Boy with a Complex Medical History. Pediatr Rev 2020; 41:200-202. [PMID: 32238549 DOI: 10.1542/pir.2017-0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Mark G Bartlett
- Department of Pediatric and Adolescent Medicine and.,Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Imad Absah
- Department of Pediatric and Adolescent Medicine and.,Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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8
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Valdés Del Pino Y, Giordano A, Escapa M, Ricart E, Ordás I, Rodríguez S, Rimola J, Fernández-Esparrach G, Ginès À, Llach J, Panés J, González-Suárez B. Is endoscopic treatment of small bowel strictures effective and safe in patients with Crohn's disease? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:284-289. [PMID: 32216446 DOI: 10.17235/reed.2020.6852/2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION there is very little scientific evidence about the efficacy of endoscopic balloon dilation (EBD) performed with balloon-assisted enteroscopy (BAE) for the treatment of small bowel strictures (SBS) in Crohn's disease (CD). OBJECTIVE to evaluate the efficacy and safety of EBD using BAE in patients with CD and SBS. METHODS a retrospective observational study was performed in a tertiary care medical center in patients with CD and SBS, evaluated by CT enterography or MRI enterography. RESULTS from 2009 to 2019, 205 endoscopic dilations were performed in 80 patients with CD. 17 (21.25 %) had only SBS and 70.6 % were male with a median age of 42.2 (±14.4) years. The mean follow-up was 37.8 ±28.7 months. A total of 39 dilations were performed, 94.1 % were native and less than 5cm long, all strictures were ulcerated. The overall technical success was 82.4 % and clinical success was 88.2 %. During follow-up, 23.5 % of patients required surgery and 29.4 % were re-dilated. The long-term efficacy was 76.5 % and no severe adverse events (AE) were observed. No factors were identified to predict the need for surgery after dilation. CONCLUSIONS SBS can be safely and effectively treated with EBD using BAE, thus reducing the need for surgery in the long term.
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Affiliation(s)
| | - Antonio Giordano
- Unidad de Endoscopia.Servicio de Gastroenterología, Hospital Clínic
| | - Miriam Escapa
- Unidad de Endoscopia.Servicio de Gastroenterología, Hospital Clínic
| | - Elena Ricart
- Unidad de EII. Servicio de Gastroenterología, Hospital Clínic
| | - Ingrid Ordás
- Unidad de EII. Servicio de Gastroenterología, Hospital Clínic
| | | | | | | | - Àngels Ginès
- Unidad de Endoscopia.Servicio de Gastroenterología, Hospital Clínic
| | - Josep Llach
- Unidad de Endoscopia.Servicio de Gastroenterología, Hospital Clínic
| | - Julià Panés
- Unidad de EII. Servicio de Gastroenterología, Hospital Clínic
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9
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Strictures in Crohn's Disease and Ulcerative Colitis: Is There a Role for the Gastroenterologist or Do We Always Need a Surgeon? Gastrointest Endosc Clin N Am 2019; 29:549-562. [PMID: 31078252 DOI: 10.1016/j.giec.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Symptomatic strictures occur more often in Crohn disease than in ulcerative colitis. The mainstay of endoscopic therapy for strictures in inflammatory bowel disease is endoscopic balloon dilation. Serious complications are rare, and risk factors for perforation include active inflammation, use of steroids, and dilation of ileorectal or ileosigmoid anastomotic strictures. This article presents current literature on strictures in inflammatory bowel disease. Focus is placed on the short- and long-term outcomes, complications, and safety of endoscopic balloon dilation for Crohn disease strictures. Adjuvant techniques, such as intralesional injection of steroids and anti-tumor necrosis factor, stricturotomy, and stent insertion, are briefly discussed.
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10
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Lee HW, Park SJ, Jeon SR, Ye BD, Park JJ, Cheon JH, Kim TI, Kim WH. Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Strictures in Patients with Inflammatory Bowel Disease. Gut Liver 2019; 12:530-536. [PMID: 29730904 PMCID: PMC6143444 DOI: 10.5009/gnl17396] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/08/2018] [Accepted: 02/09/2018] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Benign intestinal strictures are common complications in patients with inflammatory bowel disease (IBD). This study aimed to assess the long-term prognosis of endoscopic balloon dilation (EBD) to treat benign strictures in IBD patients. Methods Patients with IBD who had benign strictures and who underwent EBD in four tertiary referral university hospitals between January 2004 and February 2014 were retrospectively reviewed. Technical success was defined as the ability to pass the scope through the stricture after balloon dilation, and clinical success was defined as improved obstructive symptoms. Results Forty-two benign strictures were identified in 30 patients (15 males and 15 females). Technical success was achieved in 26 patients (86.7%) at the first EBD attempt and in all 30 patients (100%) at the second EBD attempt. Clinical success was seen in 28 patients (93.3%). The median follow-up duration was 134.8 months (range, 10.2 to 252.0 months), and recurrence occurred in eight patients (26.7%), who required repeat EBD. The median duration to relapse was 1.7 months (range, 0.2 to 6.3 months). During repeat EBD, perforation occurred in two cases (6.7%), which were both clipped successfully. Finally, only one patient (3.3%) underwent surgery for the relief of recurrent obstructive symptoms during the follow-up period. Conclusions The experience of 10 years shows that EBD is safe and effective for the treatment of benign strictures in IBD patients. Importantly, EBD may allow long-term effective palliation of the symptoms associated with benign intestinal strictures in IBD patients.
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Affiliation(s)
- Hye Won Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Oliva S, Thomson M, de Ridder L, Martín-de-Carpi J, Van Biervliet S, Braegger C, Dias JA, Kolacek S, Miele E, Buderus S, Bronsky J, Winter H, Navas-López VM, Assa A, Chong SKF, Afzal NA, Smets F, Shaoul R, Hussey S, Turner D, Cucchiara S. Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:414-430. [PMID: 30130311 DOI: 10.1097/mpg.0000000000002092] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.
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Affiliation(s)
- Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Lissy de Ridder
- Pediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Javier Martín-de-Carpi
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Christian Braegger
- Division of Gastroenterology and Nutrition, University Children's Hospital, Zurich, Switzerland
| | - Jorge Amil Dias
- Pediatric Gastroenterology Unit, Hospital Sao João, Porto, Portugal
| | - Sanja Kolacek
- Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, "Federico II," University of Naples, Italy
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Harland Winter
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | | | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, affiliated to the Sackler faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sonny K F Chong
- Queen Mary's Hospital for Children, Epsom & St Helier University Hospitals NHS Trust, Carshalton, Surrey
| | - Nadeem Ahmad Afzal
- Department of Paediatric Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Francoise Smets
- Pediatric Gastroenterology and Hepatology Unit, IREC, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Séamus Hussey
- National Children's Research Centre and Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
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12
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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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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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14
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Bessissow T, Reinglas J, Aruljothy A, Lakatos PL, Van Assche G. Endoscopic management of Crohn’s strictures. World J Gastroenterol 2018; 24:1859-1867. [PMID: 29740201 PMCID: PMC5937203 DOI: 10.3748/wjg.v24.i17.1859] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/14/2018] [Accepted: 04/23/2018] [Indexed: 02/06/2023] Open
Abstract
Symptomatic intestinal strictures develop in more than one third of patients with Crohn’s disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.
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Affiliation(s)
- Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Jason Reinglas
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Achuthan Aruljothy
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Peter L Lakatos
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1085, Hungary
| | - Gert Van Assche
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Belgium and University of Leuven, Leuven 3000, Belgium
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15
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Bharadwaj S, Narula N, Tandon P, Yaghoobi M. Role of endoscopy in inflammatory bowel disease. Gastroenterol Rep (Oxf) 2018; 6:75-82. [PMID: 29780594 PMCID: PMC5952948 DOI: 10.1093/gastro/goy006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/04/2018] [Indexed: 12/12/2022] Open
Abstract
Crohn’s disease (CD) and ulcerative colitis (UC) constitute the two most common phenotypes of inflammatory bowel disease (IBD). Ileocolonoscopy with biopsy has been considered the gold standard for the diagnosis of IBD. Differential diagnosis of CD and UC is important, as their medical and surgical treatment modalities and prognoses can be different. However, approximately 15% of patients with IBD are misdiagnosed as IBD unclassified due to the lack of diagnostic certainty of CD or UC. Recently, there has been increased recognition of the role of the therapeutic endoscopist in the field of IBD. Newer imaging techniques have been developed to aid in the differentiation of UC vs CD. Furthermore, endoscopic balloon dilation and stenting have become an integral part of the therapeutic armamentarium of CD stricture management. Endoscopic ultrasound has been recognized as being more accurate than magnetic resonance imaging in detecting perianal fistulae in patients with CD. Additionally, chromoendoscopy may help to detect dysplasia earlier compared with white-light colonoscopy. Hence, interventional endoscopy has become a cornerstone in the diagnosis, treatment and management of IBD complications. The role of endoscopy in the field of IBD has significantly evolved in recent years from small-bowel imaging to endoscopic balloon dilation and use of chormoendoscopy in dysplasia surveillance. In this review article, we discuss the current evidence on interventional endoscopy in the diagnosis, treatment and management of IBD compications.
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Affiliation(s)
- Shishira Bharadwaj
- Department of Gastroenterology/Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Parul Tandon
- Department of Medicine, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
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16
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Lopes S, Rodrigues-Pinto E, Andrade P, Afonso J, Baron TH, Magro F, Macedo G. Endoscopic balloon dilation of Crohn’s disease strictures-safety, efficacy and clinical impact. World J Gastroenterol 2017; 23:7397-7406. [PMID: 29151693 PMCID: PMC5685845 DOI: 10.3748/wjg.v23.i41.7397] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/11/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the incidence of anastomotic strictures after intestinal resection in Crohn’s disease (CD), demonstrate long-term efficacy and safety of endoscopic balloon dilation (EBD) in CD strictures and its impact on the diagnosis of subclinical postoperative endoscopic recurrence.
METHODS Retrospective single tertiary center study based on prospectively collected data between 2010 and 2015 including anastomotic and non-anastomotic strictures.
RESULTS 29% of 162 CD patients included developed an anastomotic stricture. 43 patients with anastomotic strictures and 37 with non-anastomotic strictures underwent EBD; technical success was 97.7% and 100%, respectively, however, 63% and 41% needed repeat dilation during the 4.4-year follow-up. Longer periods between surgery and index colonoscopy and higher lactoferrin levels were associated with the presence of stricture after surgery. Calprotectin levels > 83.35 μg/g and current or past history of smoking were associated with a shorter time until need for dilation (HR = 3.877, 95%CI: 1.480-10.152 and HR = 3.041, 95%CI: 1.213-7.627). Anastomotic strictures had a greater need for repeat dilation (63% vs 41%, P = 0.047). No differences were found between asymptomatic and symptomatic cohorts. Disease recurrence diagnosis was only possible after EBD in a third of patients.
CONCLUSION EBD is an effective and safe alternative to surgery, with a good short and long-term outcome, postponing or even avoiding further surgery. EBD may allow to diagnose disease recurrence in patients with no clinical signs/biomarkers of disease activity.
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Affiliation(s)
- Susana Lopes
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
| | - Joana Afonso
- Department of Pharmacology and Therapeutics, University of Porto, Porto 4200-319, Portugal
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC 4200, United States
| | - Fernando Magro
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
- Department of Pharmacology and Therapeutics, University of Porto, Porto 4200-319, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto 4200-319, Portugal
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17
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Abstract
BACKGROUND Endoscopic balloon dilation (EBD) is an effective method for treating stricture-related obstruction in Crohn's disease. We aimed to identify factors predictive of successful avoidance of surgery, including endoscopic features, in patients undergoing balloon dilation. METHODS We performed a retrospective review of patients with symptomatic Crohn's disease-related intestinal strictures undergoing EBD. Clinical, medication use, laboratory, and dilation data, including the minimum and maximum balloon sizes used, and number of balloons used per endoscopic session were collected. Multivariate analysis by Cox proportional hazard regression was used to model future surgical bowel resection. RESULTS In a total of 135 subjects undergoing 292 dilations, multivariate modeling demonstrated that failure to achieve a maximum dilation of 14 mm or more increased the risk of surgery (hazard ratio [HR] 2.88, 95% confidence limit [CL], 1.10-7.53). Although there was no difference in the risk of future surgery between maximum EBD sizes of 14 to 15 mm and 16 to 18 mm, those reaching 16 to 18 mm exhibited a longer interval between subsequent dilations (mean 240 ± 136.7 versus 456 ± 357.3 d, respectively, P = 0.023). Endoscope passage at index dilation was not predictive of future surgery (HR 0.63, 95% CL, 0.31-1.26). Adjusting for covariates of EBD size, stricture location and type, a C-reactive protein >1.5 mg/dL (HR 2.60, 95% CL, 1.12-5.94), and anti-tumor necrosis factor initiation after index EBD (HR 2.39, 95% CL, 1.09-5.25) increased the risk of future surgery. CONCLUSIONS Although dilation calibers larger than 14 to 15 mm were not more protective against future surgery, those reaching 16 to 18 mm underwent maintenance dilation less frequently. The risk of surgery associated with post-EBD anti-tumor necrosis factor initiation suggests that effective therapy is often used too late in the disease course.
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18
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Nishida Y, Hosomi S, Yamagami H, Yukawa T, Nagami Y, Tanaka F, Kamata N, Tanigawa T, Shiba M, Watanabe T, Tominaga K, Fujiwara Y, Arakawa T. Analysis of the Risk Factors of Surgery after Endoscopic Balloon Dilation for Small Intestinal Strictures in Crohn's Disease Using Double-balloon Endoscopy. Intern Med 2017; 56:2245-2252. [PMID: 28794359 PMCID: PMC5635294 DOI: 10.2169/internalmedicine.8224-16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Balloon-assisted endoscopy enables access to and treatment of strictures in the small intestine using endoscopic balloon dilation (EBD); however, the long-term outcomes of EBD have not been sufficiently evaluated. This study evaluated the long-term outcomes of EBD in Crohn's disease to identify the risk factors associated with the need for subsequent surgical intervention. Methods We retrospectively analyzed patients with Crohn's disease who had undergone EBD with double-balloon endoscopy (DBE) for small intestinal strictures at a single center between 2006 and 2015. The long-term outcomes were assessed based on the cumulative surgery-free rate following initial EBD. Results Seventy-two EBD with DBE sessions and 112 procedures were performed for 37 patients during this period. Eighteen patients (48.6%) required surgery during follow-up. Significant factors associated with the need for surgery in a multivariate analysis were multiple strictures (adjusted hazard ratio, 14.94; 95% confidence interval, 1.91-117.12; p=0.010). One patient (6.7%) required surgery among 15 who had single strictures compared to 17 (77.3%) among 22 patients with multiple strictures. Conclusion In a multivariate analysis, the presence of multiple strictures was a significant risk factor associated with the need for surgery; therefore, a single stricture might be a good indication for EBD using DBE for small intestinal strictures in Crohn's disease patients.
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Affiliation(s)
- Yu Nishida
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Tomomi Yukawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Masatsugu Shiba
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Kazunari Tominaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Tetsuo Arakawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
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19
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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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20
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Shen B. Exploring endoscopic therapy for the treatment of Crohn's disease-related fistula and abscess. Gastrointest Endosc 2017; 85:1133-1143. [PMID: 28153572 DOI: 10.1016/j.gie.2017.01.025] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 01/14/2017] [Indexed: 02/07/2023]
Abstract
Fistula and abscess represent penetrating disease phenotypes of Crohn's disease (CD) and can develop in patients with or without prior history of CD-related surgery. While CD fistula and abscess have been traditionally treated with medical and surgical therapy, the role of endoscopic therapy in this particular phenotype of CD is expanding recently, thanks to advanced endoscopic techniques and a better understanding of pathogenesis and natural history of the disease and principle of treatment. The success of endoscopic treatment for inflammatory bowel disease depends on comprehension and appreciation of principles, then techniques, followed by instrument and device. Attempts should be made to temporarily or permanently close the feeding side (or the primary) orifice at the gut, by various forms of clipping. Endoscopic fistulotomy is feasible, particularly for perianal fistula and surgery-associated distal bowel fistula. Perianal abscess can be treated with endoscopic incision and drainage and even seton placement. Endoscopic treatment for fistula and abscess as well as for stricture has become an important part of the multidisciplinary approach to complex CD.
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Affiliation(s)
- Bo Shen
- The Interventional IBD Unit, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
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21
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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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22
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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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Rieder F, Fiocchi C, Rogler G. Mechanisms, Management, and Treatment of Fibrosis in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:340-350.e6. [PMID: 27720839 PMCID: PMC5209279 DOI: 10.1053/j.gastro.2016.09.047] [Citation(s) in RCA: 304] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 02/08/2023]
Abstract
In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases-associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Claudio Fiocchi
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland; Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
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A Pooled Analysis of Efficacy, Safety, and Long-term Outcome of Endoscopic Balloon Dilation Therapy for Patients with Stricturing Crohn's Disease. Inflamm Bowel Dis 2017; 23:133-142. [PMID: 28002130 DOI: 10.1097/mib.0000000000000988] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) is widely used to manage Crohn's disease-associated strictures. However, most studies of the safety and efficacy are small and heterogenous. We performed a combined analysis of published studies and evaluated 676 comprehensive individual participant data sets to determine the overall effects of EBD. METHODS Citations from the Embase, MEDLINE, and the Cochrane library from 1991 through 2013 were systematically reviewed, and references of cited articles were assessed for relevant publications. We collected data from studies including ≥15 patients and additionally generated a unique individual patient database containing 676 individual data sets derived from 12 studies. Technical feasibility, short-term and long-term efficacies, and safety were evaluated. RESULTS In 1463 patients with Crohn's disease who underwent 3213 EBD procedures, 98.6% of strictures were ileal and 62% anastomotic. The technical success rate of the EBDs was 89.1% with a clinical efficacy of 80.8%. Complications occurred in 2.8% per procedure. After 24 months of follow-up, 73.5% of subjects underwent redilation and 42.9% surgical resection. In a multivariate analysis of 676 individual patients, a stricture length of ≤5 cm was associated with a surgery-free outcome; every 1 cm increase of stricture length increased the hazard of need for surgery by 8% (P = 0.008). Inflammation did not affect outcomes or rate of complications. CONCLUSIONS Based on a systematic literature review and analysis of data sets from 676 patients, EBD has a high rate of short-term technical and clinical efficacies, with substantial long-term efficacy and acceptable rates of complication.
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Bálint A, Törőcsik D, Palatka K, Szepes Z, Szűcs M, Tamás F, Nagy F, Farkas K, Fábián A, Bor R, Milassin Á, Rutka M, Molnár T. Prognostic factors, effectiveness and safety of endoscopic balloon dilatation for de novo and anastomotic strictures in Crohn’s disease—A multicenter “real life” study. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1233687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Anita Bálint
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Dalma Törőcsik
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Károly Palatka
- 2nd Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szepes
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Mónika Szűcs
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ferenci Tamás
- Physiological Controls Group, John von Neumann Faculty of Informatics, Óbuda University, Budapest, Hungary
| | - Ferenc Nagy
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Klaudia Farkas
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Anna Fábián
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Renáta Bor
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Ágnes Milassin
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Mariann Rutka
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
| | - Tamás Molnár
- 1st Department of Medicine, University of Szeged, 8-10 Korányi fasor, H6720 Szeged, Hungary
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26
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Arebi N, Hart AL, Thomas-Gibson S. A review of endoscopic balloon dilatation techniques for treating Crohn's strictures: time to standardise therapy. Expert Rev Gastroenterol Hepatol 2016; 10:1101-1107. [PMID: 27411078 DOI: 10.1080/17474124.2016.1212656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endoscopic balloon dilatation (EBD) is a recognised treatment for symptomatic Crohn's disease strictures. Over 3000 procedure are reported in the literature and yet the long term benefits are unclear. This is largely because of different populations, study designs, techniques, types of strictures, the outcome measures used and follow-up periods. Areas covered: We summarised the techniques reported in the literature based on a systematic review and key factors that may influence outcome: pre-intervention imaging, stricture length and type, balloon size in relation to intestinal lumen diameter, duration of dilatation, frequency of repeat dilatation and instructions on follow-up. Expert commentary: We noted that shorter, non-ulcerated and anastomotic strictures fare better and 2 mins dilatation duration was the commonest technique used without an increased risk of complications. The findings were translated into a standardised protocol and a management pathway to guide clinicians on the therapeutic strategy for Crohn's strictures. To resolve the uncertainty about long-term benefits, future studies should adopt a replicable standardised EBD technique, define degree of fibrosis to decide therapy accordingly, compare it to alternative interventions (strictureplasty or stents) within a randomised controlled trial and apply a validated outcome measure to include intestinal damage and quality of life.
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Affiliation(s)
- Naila Arebi
- a Department of Gastroenterology , St. Mark's Hospital , London , UK
| | - Ailsa L Hart
- a Department of Gastroenterology , St. Mark's Hospital , London , UK
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Bettenworth D, Lopez R, Hindryckx P, Levesque BG, Rieder F. Heterogeneity in endoscopic treatment of Crohn's disease-associated strictures: An international inflammatory bowel disease specialist survey. J Gastroenterol 2016; 51:939-48. [PMID: 26831355 DOI: 10.1007/s00535-016-1172-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards. METHODS IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated. RESULTS A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001). CONCLUSIONS EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.
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Affiliation(s)
- Dominik Bettenworth
- Department of Medicine B, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pieter Hindryckx
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Barrett G Levesque
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Rieder F, Latella G, Magro F, Yuksel ES, Higgins PDR, Di Sabatino A, de Bruyn JR, Rimola J, Brito J, Bettenworth D, van Assche G, Bemelman W, d'Hoore A, Pellino G, Dignass AU. European Crohn's and Colitis Organisation Topical Review on Prediction, Diagnosis and Management of Fibrostenosing Crohn's Disease. J Crohns Colitis 2016; 10:873-85. [PMID: 26928961 DOI: 10.1093/ecco-jcc/jjw055] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 01/24/2023]
Abstract
This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focused on prediction, diagnosis, and management of fibrostenosing Crohn's disease [CD]. The objective was to achieve evidence-supported, expert consensus that provides guidance for clinical practice.
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Affiliation(s)
- Florian Rieder
- Department of Pathobiology, Lerner Research Institute, Cleveland, OH, USA Department of Gastroenterology, Hepatology & Nutrition, Lerner Research Institute, Cleveland, OH, USA
| | - Giovanni Latella
- Department of Life, Health and Environmental Sciences, Gastroenterology Unit, University of L'Aquila, L'Aquila, Italy
| | - Fernando Magro
- Department of Pharmacology & Therapeutics, Department of Gastroenterology, Faculty of Medicine University of Porto, Porto, Portugal
| | - Elif S Yuksel
- Department of Gastroenterology, Izmir Ataturk Teaching and Research Hospital-Katip Celebi University, Izmir, Turkey
| | - Peter D R Higgins
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Antonio Di Sabatino
- First Department of Internal Medicine, St Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Jessica R de Bruyn
- Academic Medical Center Amsterdam, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Jordi Rimola
- Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jorge Brito
- Department of Radiology, Centro Hospitalar do Algarve, Lagos, Portugal
| | | | - Gert van Assche
- Division of Gastroenterology, University of Leuven, Leuven, Belgium
| | - Willem Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Andre d'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Gianluca Pellino
- Department of Medicine 1, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Axel U Dignass
- Department of Pathobiology, Lerner Research Institute, Cleveland, OH, USA
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Abstract
The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.
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Navaneethan U, Lourdusamy V, Njei B, Shen B. Endoscopic balloon dilation in the management of strictures in Crohn's disease: a systematic review and meta-analysis of non-randomized trials. Surg Endosc 2016; 30:5434-5443. [PMID: 27126619 DOI: 10.1007/s00464-016-4902-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 04/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Crohn's disease (CD) is associated with strictures. Endoscopic balloon dilatation (EBD) may prevent or delay the need for surgical resection. The aim of this systematic review was to determine the efficacy and safety of EBD in the management of Crohn's strictures. METHODS A comprehensive search of MEDLINE and EMBASE databases from January 1980 to May 2015 was performed. The primary outcome measurements were surgical intervention rates and major adverse events. RESULTS A total of 24 studies involving 1163 patients were included in the analysis. The median duration from the initial diagnosis of CD to the first EBD was 10.2-17.0 years. The majority of strictures (69 %) treated were anastomotic, while the remaining strictures were naive (primary). Surgical intervention rate over a median follow-up period of 15-70 months in the reported studies was 27 %. The surgical intervention rate after dilation of anastomotic strictures was 18 % versus 29 % for primary strictures. The risk ratio for the surgical requirement of anastomotic versus primary strictures was [0.88 (95 % confidence interval [CI] 0.59-1.32); p = 0.54]. Stricture length <4 cm was associated with a significantly decreased risk of surgical intervention [risk ratio = 0.48 (95 % CI 0.26-0.90); p = 0.02]. EBD resulted in major adverse events in 4 % of the patients. CONCLUSIONS EBD appears to be a safe alternative for surgery in the management of Crohn's strictures. Stricture length <4 cm treated with EBD is associated with a significantly decreased risk of surgical intervention.
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Affiliation(s)
- Udayakumar Navaneethan
- Center for Interventional Endoscopy, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
| | - Vennisvasanth Lourdusamy
- Center for Interventional Endoscopy, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.,Department of Internal Medicine, Brandon Regional Hospital, Brandon, FL, USA
| | - Basile Njei
- Section of Digestive Diseases, Yale University, New Haven, CT, USA
| | - Bo Shen
- Department of Gastroenterology, The Cleveland Clinic, Cleveland, OH, USA
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31
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Current challenges in the surgical management of Crohn's disease: a systematic review. Am J Surg 2016; 212:345-51. [PMID: 27182048 DOI: 10.1016/j.amjsurg.2015.12.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/19/2015] [Accepted: 12/02/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Crohn's disease is a chronic inflammatory disorder, and the broad variability in phenotypic presentations makes the treatment of this disease a true multidisciplinary approach. We sought to review the current recommendations regarding the surgical management of Crohn's disease. DATA SOURCE A Systematic literature review of surgical techniques was performed from 1979 through 2015. We evaluated 30 articles focusing on findings over the past 5 years. CONCLUSIONS Crohn's is a complex disease with no surgical cure. Invasive techniques vary from strictureplasty to resection and percutaneous drainage of penetrating disease when indicated. There is a paucity of well-controlled randomized studies evaluating these surgical techniques, and therefore, we continue to rely on smaller studies and historical data. The surgical goals are to minimize postoperative complications while preserving intestinal length and slowing the progression to clinical recurrence. The evidence discussed is one strategy against this complex pathology.
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32
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Asairinachan A, An V, Daniel ES, Johnston MJ, Woods RJ. Endoscopic balloon dilatation of Crohn's strictures: a safe method to defer surgery in selective cases. ANZ J Surg 2016; 87:E240-E244. [PMID: 27062309 DOI: 10.1111/ans.13500] [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] [Received: 11/29/2015] [Revised: 01/17/2016] [Accepted: 01/23/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic balloon dilatation (EBD) provides a valuable alternative to surgery for strictures in Crohn's disease (CD). Data are lacking regarding the factors that improve the safety and effectiveness of EBD in CD. The aim of this study is to determine the safety and efficacy of EBD and the clinical variables, which are predictive of successful treatment of CD strictures with EBD. METHODS The records of all patients with CD in whom EBD was attempted between 2008 and 2013 were reviewed. Procedures were conducted at a single tertiary referral centre using a Boston Scientific CRE® TTS balloon. Technical success was defined as the ability to traverse the stricture with the endoscope and clinical success as the resolution of obstructive symptoms at review. RESULTS Forty-seven patients with a total of 58 strictures (19 primary and 39 anastomotic strictures) were treated with EBD with median follow-up of 37 months. A total of 161 dilatation procedures were performed, with technical success reported in 139/158 (88%) cases and clinical success reported in 105/137 (76.7%) cases with complete data. Complications occurred in 7/161 dilatations (4.3% dilatations, 15% patients), three patients with perforation, one with acute bleeding and three admitted with abdominal pain. Eighteen of the 47 patients required surgery (38%). Strictures of <50 mm (P = 0.04) and those dilated to a diameter of ≥15 mm (P = 0.031) were less likely to require surgical resection. CONCLUSIONS EBD is safe for both primary and post-surgical strictures. Stricture length and diameter of dilatation are predictive of success. In selected patients, treatment with EBD may reduce or delay the need for surgery.
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Affiliation(s)
- Ashwinna Asairinachan
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Vinna An
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Eric S Daniel
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Michael J Johnston
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Rodney J Woods
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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34
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Abstract
BACKGROUND Endoscopic balloon dilation and surgery are commonly practiced in stricturing Crohn's disease. Nonetheless, there are still scant data directly comparing these 2 strategies. OBJECTIVE The aim of this study was to compare the short- and long-term outcomes of endoscopic balloon dilation versus surgical resection in symptomatic Crohn's strictures. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted at a single tertiary center. PATIENTS Seventy-nine patients were identified, 40 in the surgical group and 39 in the endoscopic balloon dilation group (mean age 42.8 ± 13.9 versus 38.5 ± 12.2 years). MAIN OUTCOME MEASURES The outcomes of all patients referred for endoscopic balloon dilation were compared with patients referred to surgery because of stricturing disease between the years 2006 and 2013. The primary outcome was the need for reintervention (either endoscopic balloon dilation or surgery) for symptomatic Crohn's disease during follow-up. RESULTS The proportion of patients who required any reintervention during follow-up was significantly lower in the surgical group versus the endoscopic balloon dilation group (OR = 5.62 (95% CI, 1.66-19.01); p = 0.005). The need for surgery/resurgery during follow-up was also significantly lower in the surgically treated group (OR = 3.53 (95% CI, 1.01-12.29); p = 0.047). Reintervention-free survival and surgery-free survival were both significantly shorter in the endoscopically treated group in a Kaplan-Mayer analysis. The rate of major complications was similar in the endoscopically and surgically treated groups (7.6% versus 7.5%; p = 0.7). LIMITATIONS The small cohort and the retrospective data collection were limitations of this study. CONCLUSIONS In our cohort of patients with fibrostenotic Crohn's disease, a direct comparison showed reduced need for reinterventions with a similar rate of immediate major complications after surgery compared with endoscopic balloon dilation.
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35
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Morar PS, Faiz O, Warusavitarne J, Brown S, Cohen R, Hind D, Abercrombie J, Ragunath K, Sanders DS, Arnott I, Wilson G, Bloom S, Arebi N. Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures. Aliment Pharmacol Ther 2015; 42:1137-48. [PMID: 26358739 DOI: 10.1111/apt.13388] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/16/2015] [Accepted: 08/11/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. AIM To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. METHODS A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. RESULTS Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. CONCLUSIONS Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.
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Affiliation(s)
- P S Morar
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
| | - J Warusavitarne
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
| | - S Brown
- Sheffield Teaching Hospitals, Sheffield, UK
| | - R Cohen
- University College Hospital, London, UK
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - J Abercrombie
- NIHR Nottingham Digestive Disease Biomedical Research Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Ragunath
- NIHR Nottingham Digestive Disease Biomedical Research Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - I Arnott
- Departments of Gastroenterology and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - G Wilson
- Departments of Gastroenterology and Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - S Bloom
- University College Hospital, London, UK
| | - N Arebi
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital, London, UK
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Irani S, Kozarek RA. Techniques and principles of endoscopic treatment of benign gastrointestinal strictures. Curr Opin Gastroenterol 2015; 31:339-50. [PMID: 26247823 DOI: 10.1097/mog.0000000000000200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio. RECENT FINDINGS Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition. SUMMARY Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches. Inflamm Bowel Dis 2015; 21:2194-213. [PMID: 25985249 DOI: 10.1097/mib.0000000000000403] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.
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Abstract
Stricture and fistula are common complications of Crohn's disease. Endoscopic balloon dilation and needle-knife stricturotomy has become a valid treatment option for Crohn's disease-associated strictures. Endoscopic therapy is also increasingly used in Crohn's disease-associated fistula. Preprocedural preparations, including routine laboratory testing, imaging examination, anticoagulant management, bowel cleansing and proper sedation, are essential to ensure a successful and safe endoscopic therapy. Adverse events, such as perforation and excessive bleeding, may occur during endoscopic intervention. The endoscopist should be well trained, always be cautious, anticipate for possible procedure-associated complications, be prepared for damage control during endoscopy, and have surgical backup ready. In this review, we discuss the principle, preparation, techniques of endoscopic therapy, as well as the prevention and management of endoscopic procedure-associated complications. We propose that inflammatory bowel disease endoscopy may be a part of training for "super" gastroenterology fellows, i.e., those seeking a career in advanced endoscopy or in inflammatory bowel disease.
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Malgras B, Pautrat K, Dray X, Pasquier P, Valleur P, Pocard M, Soyer P. Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease. Dig Dis Sci 2015; 60:1152-68. [PMID: 25381203 DOI: 10.1007/s10620-014-3421-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.
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Affiliation(s)
- Brice Malgras
- Department of Surgery, Laiboisiere Hospital, Paris 7 University and AP-HP, 2 rue Ambroise Paré, 75475, Paris Cedex 10, France,
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Prediction of need for surgery after endoscopic balloon dilation of ileocolic anastomotic stricture in patients with Crohn's disease. Dis Colon Rectum 2015; 58:423-30. [PMID: 25751799 DOI: 10.1097/dcr.0000000000000322] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic balloon dilation is used to treat ileocolic anastomotic stricture attributed to recurrent Crohn's disease. OBJECTIVE The purpose of this work was to investigate long-term outcomes after dilation of ileocolic anastomotic stricture and to identify risk factors associated with the need for subsequent surgical intervention. DESIGN This was a retrospective study based on chart review of an electronic medical chart system. SETTINGS The study was conducted at a tertiary care center. PATIENTS All of the eligible patients with ileocolic anastomotic stricture attributed to recurrent Crohn's disease treated with endoscopic dilation between December 1998 and May 2013 were evaluated. Patients with concurrent enterocutaneous fistula or abdominal or pelvic abscess were excluded. MAIN OUTCOME MEASURES The main outcome measure was the need for subsequent salvage surgery because of stricture-related symptoms. RESULTS A total of 185 patients with Crohn's disease (45.9% women; mean age, 43.1 years; symptomatic strictures in 80%) underwent 462 endoscopic dilations of ileocolic anastomosis (median per-patient dilations, 2; range, 1-3). During a mean follow-up of 3.9 years, 27 patients (14.6%) required hospitalization without surgery for stricture-related symptoms, and 66 patients (35.7%) required subsequent salvage surgery. Specific medical management, type of anastomosis, and endoscopic intralesional steroid injection had no impact on the risk of needing surgery. Significant factors associated with the need for surgery on multivariable analysis were symptomatic disease (HR, 3.54 [95% CI, 1.41-8.93]), longer time interval from last surgery (HR, 1.05 [95% CI, 1.01-1.10]), and radiographic proximal bowel dilation (HR, 2.36 [95% CI, 1.38-4.03]). A nomogram estimating the need for surgery was created with a concordance index of 0.67. LIMITATIONS The study was limited by its retrospective design. CONCLUSIONS Although endoscopic dilation is a valid option for ileocolic anastomotic stricture attributed to recurrent Crohn's disease, the need for surgery is common. The nomogram can identify patients who might benefit from upfront surgery.
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Gasparetto M, Angriman I, Guariso G. The multidisciplinary health care team in the management of stenosis in Crohn's disease. J Multidiscip Healthc 2015; 8:167-79. [PMID: 25878504 PMCID: PMC4388000 DOI: 10.2147/jmdh.s38729] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Stricture formation is a common complication of Crohn’s disease (CD), occurring in approximately one-third of all patients with this condition. Our aim was to summarize the available epidemiology data on strictures in patients with CD, to outline the principal evidence on diagnostic imaging, and to provide an overview of the current knowledge on treatment strategies, including surgical and endoscopic options. Overall, the unifying theme of this narrative review is the multidisciplinary approach in the clinical management of patients with stricturing CD. Methods A Medline search was performed, using “Inflammatory Bowel Disease”, “stricture”, “Crohn’s Disease”, “Ulcerative Colitis”, “endoscopic balloon dilatation” and “strictureplasty” as keywords. A selection of clinical cohort studies and systematic reviews were reviewed. Results Strictures in CD are described as either inflammatory or fibrotic. They can occur de novo, at sites of bowel anastomosis or in the ileal pouch. CD-related strictures generally show a poor response to medical therapies, and surgical bowel resection or surgical strictureplasty are often required. Over the last three decades, the potential role of endoscopic balloon dilatation has grown in importance, and nowadays this technique is a valid option, complementary to surgery. Conclusion Patients with stricturing CD require complex clinical management, which benefits from a multidisciplinary approach: gastroenterologists, pediatricians, radiologists, surgeons, specialist nurses, and dieticians are among the health care providers involved in supporting these patients throughout diagnosis, prevention of complications, and treatment.
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Affiliation(s)
- Marco Gasparetto
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
| | - Imerio Angriman
- Department of Surgery, Gastroenterology and Oncology, Padua University, Padova, Italy
| | - Graziella Guariso
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
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Thienpont C, Van Assche G. Endoscopic and medical management of fibrostenotic Crohn's disease. Dig Dis 2014; 32 Suppl 1:35-8. [PMID: 25531351 DOI: 10.1159/000367824] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Crohn's disease (CD) is a disease characterized by acute inflammation at diagnosis which evolves toward a more fistulizing and fibrostenotic disease phenotype over time. This leads to a high risk of bowel resections and ultimately short bowel with diarrhea and malabsorption, which represents a major part of the burden inflicted by CD. Bowel-conserving endoscopic and surgical procedures have therefore been developed. Specific antifibrotic medical therapies are currently lacking. Through-the-scope endoscopic balloon dilation has been described in several cohorts as an alternative to surgical resection or stricturoplasty in selected patients. Efficacy of endoscopic dilation is high, with an immediate success rate of 78% (between 73 and 100%), defined as the ability to pass with the scope through the stricture. However, symptomatic recurrence is frequent, with need for new dilatation in 41% and need for surgery in 42%, with a mean interval of 15 months. Adjunctive techniques such as local steroid or anti-TNF injections or stenting have not been conclusively proven to be of added benefit. We usually reserve endoscopic dilation for patients with short strictures (<5 cm) and nonpenetrating disease, preferably at the ileocolonic anastomosis. Similar to other interventions in endoscopy, endoscopic dilation has an intrinsic risk of complications which can be estimated at 2%. Balloon size and patient selection can serve to increase safety.
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Buda A, Okolo PI. Endoscopic treatment of Crohn's complications. Expert Rev Gastroenterol Hepatol 2014; 8:887-95. [PMID: 24849124 DOI: 10.1586/17474124.2014.919850] [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: 11/08/2022]
Abstract
The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.
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Affiliation(s)
- Andrea Buda
- Department of Surgical, Gastroenterological and Oncological Sciences, Division of Gastroenterology, University of Padova, 35100, Padova, Italy
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Abstract
BACKGROUND Endoscopy-associated perforation (EAP) is a dreaded adverse event with significant morbidity and even mortality. Whether EAP in patients with inflammatory bowel disease (IBD) is associated with worse outcomes is not known. We aimed to assess the frequency of perforations in patients undergoing lower gastrointestinal (GI) endoscopies and compare the risk factors and perforation-associated complications (PAC) in patients with IBD with those without IBD. METHODS In this case-control study, we identified patients with lower GI EAP from January 2002 to June 2011. PAC was defined as EAP-associated death, colectomy with ileostomy, and bowel resection with/without diverting ostomy. Twenty-nine demographic, clinical, endoscopic, and surgical features were evaluated in univariable and multivariable analyses. RESULTS A total of 217,334 lower GI endoscopies were performed (IBD, N = 9518 and non-IBD, N = 207,816). Eighty-four patients with EAP were included. The rate of perforation was 18.91 per 10,000 and 2.50 per 10,000 procedures for IBD and non-IBD endoscopy, respectively. PAC occurred in 59 patients (70.2%) with death in 4 (4.8%) and bowel resection with or without ostomy in 55 (65.5%) (total colectomy with ileostomy, n = 3; resection with diversion and secondary anastomosis, n = 28; and resection with primary anastomosis, n = 24). On multivariable analysis, the use of systemic corticosteroids at the time of endoscopy was associated with 13 times greater risk for PAC (13.5 [95% confidence interval, 1.3-1839.7] P = 0.007), whereas IBD was not found to be associated with an increased risk for PAC (0.69 [95% confidence interval, 0.23-2.1] P = 0.52). CONCLUSIONS Patients with IBD have a higher frequency of EAP than those without IBD. Endoscopists need to be cautious while performing a lower GI endoscopy in patients taking systemic corticosteroids.
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Hendel J, Karstensen JG, Vilmann P. Serial intralesional injections of infliximab in small bowel Crohn's strictures are feasible and might lower inflammation. United European Gastroenterol J 2014; 2:406-12. [PMID: 25360319 DOI: 10.1177/2050640614547805] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/07/2014] [Accepted: 07/18/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Crohn's disease can cause strictures throughout the gastrointestinal tract. Endoscopic balloon dilatation is a well-established treatment, but recurrence is seen in up to three out of four cases. Infliximab is playing an increasingly important role in the modern systemic treatment of severe Crohn's disease. Combining the anti-inflammatory effects of infliximab with the proven effect of endoscopic balloon dilatation could possibly improve outcome. In small studies, intralesional injections in perianal fistulas have been effective and endoscopic injection therapy in colonic strictures is feasible. OBJECTIVE We wanted to assess whether serial intralesional injection of infliximab in small bowel strictures is feasible and reduces local inflammation. METHODS We included six patients with Crohn's disease and inflammatory small bowel strictures. They were treated with endoscopic serial balloon dilatation. Subsequent to each dilatation, 40 mg infliximab was injected submucosally. A modified simplified endoscopic score for Crohn's disease was used for the involved area before the initial treatment and at the final follow-up after six months. Complications and development of symptoms were registered. RESULTS Balloon dilatation and serial injection of infliximab were accomplished in five out of six patients. One patient completed the serial balloon dilatations and follow-up but received only one infliximab injection. The modified simplified endoscopic score for Crohn's disease decreased in all patients. There were no adverse events registered and all patients described themselves as feeling well. CONCLUSIONS Combining balloon dilatation of strictures with serial intralesional injection of infliximab in Crohn's disease of the small bowel is feasible and seems successful in reducing inflammation.
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Affiliation(s)
- Jakob Hendel
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
| | | | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark
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Hirai F, Beppu T, Takatsu N, Yano Y, Ninomiya K, Ono Y, Hisabe T, Matsui T. Long-term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease. Dig Endosc 2014; 26:545-51. [PMID: 24528293 DOI: 10.1111/den.12236] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Endoscopic balloon dilation (EBD) is an alternative to surgery for small bowel strictures of patients with Crohn's disease (CD). However, little is known about the long-term efficacy of EBD. The aim of the present study was to clarify the long-term outcome of EBD for small bowel strictures in patients with CD. METHODS Subjects comprised 65 patients with CD who underwent EBD for small intestinal strictures and were followed up for at least 6 months. All subjects had obstructive symptoms as a result of small bowel strictures. Short-term success was defined as technical success and the disappearance of obstructive symptoms. The short-term success rate of EBD, its safety profile, the cumulative surgery-free rate and the cumulative redilation-free rate were investigated. RESULTS Short-term success rate was 80.0% (52/65). Complications were encountered in six of the 65 patients (9.2%). Seventeen patients (26.2%) underwent surgery during the observation period of this study. Cumulative surgery-free rate after initial EBD was 79% at 2 years and 73% at 3 years, respectively. EBD successful cases showed significantly higher surgery-free rates than unsuccessful cases (P < 0.0001). In 52 of the successful cases, the cumulative redilation-free rate after initial EBD was 64% at 2 years and 47% at 3 years, respectively. CONCLUSION EBD for small bowel strictures secondary to CD provides not only short-term success but also long-term efficacy. However, the high redilation rate is one of the clinical problems of this procedure.
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Affiliation(s)
- Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
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Hagel AF, Hahn A, Dauth W, Matzel K, Konturek PC, Neurath MF, Raithel M. Outcome and complications of endoscopic balloon dilatations in various types of ileocaecal and colonic stenosis in patients with Crohn's disease. Surg Endosc 2014; 28:2966-72. [PMID: 24853850 DOI: 10.1007/s00464-014-3559-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 04/17/2014] [Indexed: 12/12/2022]
Abstract
AIM We examined the outcome and the complications of endoscopic balloon dilatation (EBD) of ileocaecal and colonic strictures due to Crohn's disease. METHODS We examined 237 dilatation procedures in 77 patients with symptomatic ileocaecal and colonic stenosis regarding outcome, individual perforation risk, the need for further interventions, and other complications within a 10 years observation period. RESULTS In 50 of 77 patients (64.9%), endoscopic dilatation procedures were successful within a median follow-up period of 24 months (25th and 75th percentile 10-38.5 months). Thirty five patients (45.5%) were successfully dilated with only one endoscopic procedure, while the remaining patients required two or more EBDs. Albeit the EBD, 27 patients of the whole cohort (35.1%) underwent surgical repair of the stenosis in due course. Overall complication rate was 7.6%, with postdilatation bleeding in 1.7% and abdominal pain longer than 24 h in 4.2%. Perforation occurred in 4 of 77 patients (5.2%), resulting in a perforation rate of 1.7% per intervention, or, more importantly, for the individual patient in a long-term perforation rate of 5.2% per patient, respectively. DISCUSSION Endoscopic balloon dilatation (EBD) is a safe and effective approach to ileocaecal and colonic stenosis in approximately 65% of Crohn's disease patients. Even in case of recurrence, further endoscopic treatments can be undertaken. The perforation rate depending on the number of interventions is low, but for the individual patient a cumulative per patient perforation risk of 5.2% in the long-term should be considered during patient information and decisions for or against surgical interventions.
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Affiliation(s)
- Alexander F Hagel
- Department of Medicine I, University of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany,
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Gill RS, Kaffes AJ. Small bowel stricture characterization and outcomes of dilatation by double-balloon enteroscopy: a single-centre experience. Therap Adv Gastroenterol 2014; 7:108-14. [PMID: 24790641 PMCID: PMC3968817 DOI: 10.1177/1756283x13513995] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There is little data on the role of balloon enteroscopy and small bowel strictures. We aim to characterize the diagnostic role of double balloon enteroscopy (DBE) in small bowel strictures and document the outcomes of dilatation. METHODS This is a retrospective review from a single tertiary referral centre DBE database from July 2004 to September 2012. All patients with suspected strictures in the small bowel undergoing DBE were included. The position of the small bowel strictures considered for dilatation was determined by diagnostic imaging, i.e. CT enterography, MR enterography or capsule endoscopy in the workup before DBE. Endpoints included stricture description, dilatation parameters and response to treatment. Main outcome measurements were the safety and efficacy of DBE and dilatation. RESULTS From our DBE database of 594 patients, a total of 32 patients underwent 44 DBE procedures for suspected or known strictures. Stricture aetiology included Crohn's disease (CD), nonsteroidal anti-inflammatory drugs (NSAIDs), surgical, Beçhets disease and one unknown. A total of 17 patients did not undergo dilatation as the strictures were ulcerated, nonobstructing or of uncertain aetiology. From the total of 25 dilatations in 15 patients that were attempted, 8/15 (53%) patients had 1 dilatation, 5 patients had 2 dilatations, 1 had 3 dilatations and 1 had 4 dilatations. The mean dilatation diameter was 14 mm. Three patients underwent surgery post-dilatation (2 for perforation). Mean follow up was 16 months. CONCLUSION DBE is a useful method in determining the need for dilatation by assessing for active ulceration. Dilatation is effective in the 10-18 mm range, however perforation does occur.
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Affiliation(s)
- Raghubinder S Gill
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Hospital, Sydney, NSW, Australia
| | - Arthur J Kaffes
- Gastroenterology Consultant, A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Hospital, Camperdown, Sydney, NSW 2050, Australia
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Mosli M, Al Beshir M, Al-Judaibi B, Al-Ameel T, Saleem A, Bessissow T, Ghosh S, Almadi M. Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties. Saudi J Gastroenterol 2014; 20:81-101. [PMID: 24705146 PMCID: PMC3987157 DOI: 10.4103/1319-3767.129473] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 12/30/2013] [Indexed: 12/14/2022] Open
Abstract
Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.
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Affiliation(s)
- Mahmoud Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Mohammad Al Beshir
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
| | - Bandar Al-Judaibi
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Turki Al-Ameel
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Abdulaziz Saleem
- Department of Surgery, McGill University and McGill University Health Centre, Montreal, Canada
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Talat Bessissow
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
| | - Subrata Ghosh
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Majid Almadi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
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Abstract
INTRODUCTION Stricturing is a common complication of Crohn's disease. Endoscopic balloon dilatation (EBD) offers a valuable alternative to surgical intervention, but there are limited data on factors influencing its safety and efficacy. METHODS A multicenter retrospective audit across 4 U.K. teaching hospitals was performed on the use of EBD for Crohn's strictures between 1998 and 2011. Demographics, smoking status, medications, C-reactive protein, endoscopic findings, and subsequent surgery at follow-up were recorded. Success of EBD was defined as symptomatic improvement without the need for surgery at follow-up. RESULTS Seventy-nine patients (47 women; median age, 48 yr) were identified for this study. Forty-eight (61%) patients had ileocolonic anastomotic strictures, whereas the rest had de novo strictures. In total, 191 EBDs (range, 1-11; median 2) were carried out on 93 strictures (range, 1-5; median 1) over a median duration of 12 months (range, 1-84). There were no serious adverse events. Success at index EBD was 34%, with a further 43% achieving long-term benefit from additional EBDs. Eighteen (23%) patients required surgery. Time to surgery after the first EDB was 2.6 to 71.1 months (median, 12.8 mo). Longer Crohn's disease duration (P = 0.03) and high C-reactive protein (P = 0.008) were associated with an increased need for subsequent surgery. CONCLUSIONS EBD was safe and effective in achieving long-term symptom improvement and avoidance of surgery in most patients. Prospective controlled trials are needed to evaluate the effect of other factors, including Crohn's disease phenotype, and the role of concomitant medication to identify those best suited to EBD.
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