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Coppola G, Principessa C, Di Vincenzo F, Puca P, Del Gaudio A, Capobianco I, Bartocci B, Papa A, Cammarota G, Lopetuso LR, Scaldaferri F. Endoscopic Management of Strictures in Crohn's Disease: An Unsolved Case. J Clin Med 2024; 13:4842. [PMID: 39200984 PMCID: PMC11355190 DOI: 10.3390/jcm13164842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/07/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disease associated with a significant burden in terms of quality of life and health care costs. It is frequently associated with several complications, including the development of intestinal strictures. Stricturing CD requires a careful multidisciplinary approach involving medical therapy and surgery, still posing a continuous management challenge; in this context, endoscopic treatment represents a valuable, in-between opportunity as a minimally invasive strategy endorsed by extensive yet heterogeneous evidence and evolving research and techniques. This review summarizes current knowledge on the role of therapeutic endoscopy in stricturing CD, focusing on evidence gaps, recent updates, and novel techniques intended for optimizing efficacy, safety, and tailoring of this approach in the view of precision endoscopy.
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Affiliation(s)
- Gaetano Coppola
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Chiara Principessa
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Federica Di Vincenzo
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Pierluigi Puca
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Angelo Del Gaudio
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Ivan Capobianco
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Bianca Bartocci
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Alfredo Papa
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Giovanni Cammarota
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Loris Riccardo Lopetuso
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Dipartimento di Medicina e Scienze dell’Invecchiamento, Università degli Studi “G. D’Annunzio”, 66100 Chieti, Italy
| | - Franco Scaldaferri
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
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Zhang J, Qian X, Zhu L, Da B, Zhao X, He Q, Wang L, Li Y, Wang Z. Clinical outcomes of serial endoscopic balloon dilation for duodenal Crohn's disease-associated strictures. Surg Endosc 2024:10.1007/s00464-024-10992-8. [PMID: 38914885 DOI: 10.1007/s00464-024-10992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/08/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) is a safe and effective treatment for Crohn's disease (CD)-associated strictures. However, serial EBDs have rarely been reported. This study aimed to evaluate the efficacy and safety of serial EBDs for treating CD-associated duodenal strictures compared with intermittent EBDs. METHODS Patients with CD-associated duodenal strictures who underwent EBD were recruited. The clinical data, stricture characteristics, number of EBDs, dilation diameter, complications, surgical interventions, and follow-up periods were recorded. Patients were divided into a serial dilation group and an intermittent dilation group to analyze the differences in safety and efficacy. RESULTS Forty-five patients with duodenal CD-associated strictures underwent a total of 139 dilations. A total of 23 patients in the serial dilation group underwent 72 dilations, for a median of 3 (range 3 ~ 4) dilations per patient, and 22 patients in the intermittent dilation group underwent 67 dilations, for a median of 3 (range 1 ~ 6) dilations per patient. Technical success was achieved in 97.84% (136/139) of the patients. During the follow-up period, three patients in the intermittent dilation group underwent surgery, and the total clinical efficacy was 93.33% (42/45). No difference in safety or short-term efficacy was noted between the two groups, but serial EBDs exhibited significantly greater clinical efficacy between 6 months and 2 years. No significant difference in recurrence-free survival was observed, but the median longest recurrence-free survival and recurrence-free survival after the last EBD in the serial dilation group were 693 days (range 298 ~ 1381) and 815 days (range 502 ~ 1235), respectively, which were significantly longer than the 415 days (range 35 ~ 1493) and 291 days (range 34 ~ 1493) in the intermittent dilation group (p = 0.013 and p = 0.000, respectively). At the last follow-up, the mean diameter of the duodenal lumen was 1.17 ± 0.07 cm in the serial dilation group, which was greater than the 1.11 ± 0.10 cm in the intermittent dilation group (p = 0.018). We also found that the Simple Endoscopic Score for Crohn's Disease was associated with an increased risk of surgical intervention (HR 2.377, 95% CI 1.125-5.020; p = 0.023) and recurrence at 6 months after the last EBD (HR 0.698, 95% CI 0.511-0.953; p = 0.024), as assessed by univariate analysis. CONCLUSIONS Compared to the intermittent EBDs, serial EBDs for duodenal CD-associated strictures exhibit greater clinical efficacy within two years and could delay stricture recurrence. We suggest that serial EBDs can be a novel option for endoscopic treatment of duodenal CD-associated strictures.
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Affiliation(s)
- Juanjuan Zhang
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Xiaoli Qian
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Lin Zhu
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Binlin Da
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Xiaofan Zhao
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Qin He
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Lixin Wang
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Yi Li
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Zhiming Wang
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China.
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Fansiwala K, Spartz EJ, Roney AR, Kwaan MR, Sauk JS, Chen PH, Limketkai BN. Increasing Rates of Bowel Resection Surgery for Stricturing Crohn's Disease in the Biologic Era. Inflamm Bowel Dis 2024:izae113. [PMID: 38795051 DOI: 10.1093/ibd/izae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND The era of biologics is associated with declining rates of surgery for Crohn's disease (CD), but the impact on surgery for stricturing CD is unknown. Our study aimed to assess nationwide trends in bowel resection surgery for obstruction in CD since the introduction of infliximab for CD in 1998. METHODS Using the Nationwide Inpatient Sample, we performed a nationwide analysis, identifying patients hospitalized for CD who underwent bowel resection for an indication of obstruction between 1998 and 2020 (era of biologics). Longitudinal trends in all CD-related resections and resection for obstruction were evaluated. Multivariable logistic regression identified patient and hospital characteristics associated with bowel resection surgery for obstruction. RESULTS Hospitalizations for all CD-related resections decreased from 12.0% of all hospitalizations in 1998 to 6.9% in 2020, while hospitalizations for CD-related resection for obstructive indication increased from 1.3% to 2.0%. The proportion of resections for obstructive indication amongst all CD-related bowel resections increased from 10.8% in 1998 to 29.1% in 2020. In the multivariable models stratified by elective admission, the increasing year was associated with risk of resection for obstructive indication regardless of urgency (nonelective model: odds ratio, 1.01; 95% CI, 1.00-1.02; elective model: odds ratio, 1.06; 95% CI, 1.04-1.08). CONCLUSIONS In the era of biologics, our findings demonstrate a decreasing annual rate of CD-related bowel resections but an increase in resection for obstructive indication. Our findings highlight the effect of medical therapy on surgical rates overall but suggest limited impact of current medical therapy on need of resection for stricturing disease.
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Affiliation(s)
- Kush Fansiwala
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ellen J Spartz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Andrew R Roney
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mary R Kwaan
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Berkeley N Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Cockburn E, Kamal S, Chan A, Rao V, Liu T, Huang JY, Segal JP. Crohn's disease: an update. Clin Med (Lond) 2023; 23:549-557. [PMID: 38065612 PMCID: PMC11298500 DOI: 10.7861/clinmed.2023-0493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Crohn's disease (CD) is a chronic, relapsing and remitting inflammatory bowel disease (IBD) that is increasing in incidence and prevalence globally. Management aims to achieve endoscopic healing, symptom resolution and improvement in quality of life. Therapeutic approaches in CD vary depending on disease phenotype. Thiopurines are important in steroid-sparing maintenance therapy, while anti-tumour necrosis factor agents play a fundamental role, especially in fistulising CD. Suboptimal response to these medications may require escalation to other immunosuppressive and biologic therapies, and surgical intervention is still required in a proportion of patients. Tailoring treatment to target specific patient phenotypes, disease severity and patient wishes is becoming more feasible with the growing array of therapeutic options in CD.
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Affiliation(s)
| | | | - Andrea Chan
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Tianwei Liu
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Jonathan P Segal
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
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Rodrigues-Pinto E, Ferreira-Silva J, Siersema PD. How to Prevent and Treat the Most Frequent Adverse Events Related to Luminal Dilation and Stenting in Benign Disease. Am J Gastroenterol 2023; 118:1521-1527. [PMID: 36946679 DOI: 10.14309/ajg.0000000000002260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Affiliation(s)
- Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Campbell I, Glinka M, Shaban F, Kirkwood KJ, Nadalin F, Adams D, Papatheodorou I, Burger A, Baldock RA, Arends MJ, Din S. The Promise of Single-Cell RNA Sequencing to Redefine the Understanding of Crohn's Disease Fibrosis Mechanisms. J Clin Med 2023; 12:3884. [PMID: 37373578 PMCID: PMC10299644 DOI: 10.3390/jcm12123884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease with a high prevalence throughout the world. The development of Crohn's-related fibrosis, which leads to strictures in the gastrointestinal tract, presents a particular challenge and is associated with significant morbidity. There are currently no specific anti-fibrotic therapies available, and so treatment is aimed at managing the stricturing complications of fibrosis once it is established. This often requires invasive and repeated endoscopic or surgical intervention. The advent of single-cell sequencing has led to significant advances in our understanding of CD at a cellular level, and this has presented opportunities to develop new therapeutic agents with the aim of preventing or reversing fibrosis. In this paper, we discuss the current understanding of CD fibrosis pathogenesis, summarise current management strategies, and present the promise of single-cell sequencing as a tool for the development of effective anti-fibrotic therapies.
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Affiliation(s)
- Iona Campbell
- Edinburgh Inflammatory Bowel Disease Unit, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
| | - Michael Glinka
- Edinburgh Pathology, Centre for Comparative Pathology, Cancer Research UK Scotland Centre, Institute of Cancer and Genetics, University of Edinburgh, Crewe Road, Edinburgh EH4 2XU, UK
| | - Fadlo Shaban
- Edinburgh Colorectal Unit, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
| | - Kathryn J. Kirkwood
- Department of Pathology, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
| | - Francesca Nadalin
- European Molecular Biology Laboratory, European Bioinformatics Institute, EMBL-EBI, Hinxton, Cambridge CB10 1SD, UK
| | - David Adams
- Experimental Cancer Genetics, Wellcome Sanger Institute, Hinxton, Cambridge CB10 1SA, UK
| | - Irene Papatheodorou
- European Molecular Biology Laboratory, European Bioinformatics Institute, EMBL-EBI, Hinxton, Cambridge CB10 1SD, UK
| | - Albert Burger
- Department of Computer Science, School of Mathematical and Computer Sciences, Heriot-Watt University, Edinburgh EH14 4AS, UK;
| | - Richard A. Baldock
- Edinburgh Pathology, Centre for Comparative Pathology, Cancer Research UK Scotland Centre, Institute of Cancer and Genetics, University of Edinburgh, Crewe Road, Edinburgh EH4 2XU, UK
| | - Mark J. Arends
- Edinburgh Pathology, Centre for Comparative Pathology, Cancer Research UK Scotland Centre, Institute of Cancer and Genetics, University of Edinburgh, Crewe Road, Edinburgh EH4 2XU, UK
| | - Shahida Din
- Edinburgh Inflammatory Bowel Disease Unit, Western General Hospital, NHS Lothian, Edinburgh EH4 2XU, UK
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Arar AM, DeLay K, Leiman DA, Menard-Katcher P. Esophageal Manifestations of Dermatological Diseases, Diagnosis and Management. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:513-528. [PMID: 37287750 PMCID: PMC10243751 DOI: 10.1007/s11938-022-00399-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 06/09/2023]
Abstract
Purpose of Review The purpose of this article is to discuss the diagnosis and treatment of diseases that affect both the skin and the esophagus. Recent Findings The diagnosis of dermatological conditions that affect the esophagus often requires endoscopy and biopsy with some conditions requiring further investigation with serology, immunofluorescence, manometry, or genetic testing. Many conditions that affect the skin and esophagus can be treated successfully with systemic steroids and immunosuppressants including pemphigus, pemphigoid, HIV, esophageal lichen planus, and Crohn's disease. Many conditions are associated with esophageal strictures which are treated with endoscopic dilation. Furthermore, many of the diseases are pre-malignant and require vigilance and surveillance endoscopy. Summary Diseases that affect the skin and esophagus can be grouped by their underlying etiology: autoimmune (scleroderma, dermatomyositis, pemphigus, pemphigoid), infectious (herpes simplex virus, cytomegalovirus, human immunodeficiency virus), inflammatory (lichen planus and Crohn's disease), and genetic (epidermolysis bullosa, Cowden syndrome, focal dermal hypoplasia, and tylosis). It is important to consider primary skin conditions that affect the esophagus when patients present with dysphagia of unknown etiology and characteristic skin findings.
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Affiliation(s)
- Amr M. Arar
- Department of Internal Medicine, University of Colorado School of Medicine - Anschutz Medical Campus, Denver, CO, USA
| | - Kelli DeLay
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine - Anschutz Medical Campus, Denver, CO, USA
| | - David A. Leiman
- Division of Gastroenterology, Duke University Medical Center, Durham NC, USA
- Duke Clinical Research Institute, Durham NC, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine - Anschutz Medical Campus, Denver, CO, USA
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Endoscopic Balloon Dilation Is Cost-Effective for Crohn's Disease Strictures. Dig Dis Sci 2022; 67:5462-5471. [PMID: 35290570 DOI: 10.1007/s10620-022-07420-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) has emerged as an alternative intervention to manage Crohn's disease (CD) strictures. We determined the cost-effectiveness of EBD versus resection surgery for patients with short (< 4-5 cm) primary or secondary/anastomotic small or large bowel strictures. METHODS A microsimulation state-transition model analyzed the benefits and risks of EBD and resection surgery for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (2021 $US) and incremental cost-effectiveness ratios (ICER) were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. RESULTS The EBD strategy cost $19,822 and resulted in 6.18 QALYs while the surgery strategy cost $41,358 and resulted in 6.37 QALYs. Surgery had an ICER of $113,332 per QALY, making EBD a cost-effective strategy. The median number of EBDs was 5 in the EBD strategy and 0 in the surgery strategy. The median number of surgeries was 2 in the surgery strategy and 1 in the EBD strategy. Of individuals who initially received EBD, 50.4% underwent subsequent surgery. One-way sensitivity analyses showed that the probabilities of requiring repeated interventions, surgery mortality (< 0.7%), and quality of life after interventions were the most influential model parameters. Probabilistic sensitivity analyses favored EBD in 50.9% of iterations. CONCLUSIONS EBD is a cost-effective strategy for managing CD strictures. Differences in patient risk and quality of life after intervention impact cost-effectiveness. Intervention decisions should consider cost-effectiveness, patient risks, and quality of life.
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Kim KO. Endoscopic activity in inflammatory bowel disease: clinical significance and application in practice. Clin Endosc 2022; 55:480-488. [PMID: 35898147 PMCID: PMC9329646 DOI: 10.5946/ce.2022.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 04/26/2022] [Indexed: 11/14/2022] Open
Abstract
Endoscopy is vital for diagnosing, assessing treatment response, and monitoring surveillance in patients with inflammatory bowel disease (IBD). With the growing importance of mucosal healing as a treatment target, the assessment of disease activity by endoscopy has been accepted as the standard of care for IBD. There are many endoscopic activity indices for facilitating standardized reporting of the gastrointestinal mucosal appearance in IBD, and each index has its strengths and weaknesses. Although most endoscopic indices do not have a clear-cut validated definition, endoscopic remission or mucosal healing is associated with favorable outcomes, such as a decreased risk of relapse. Therefore, experts suggest utilizing endoscopic indices for monitoring disease activity and optimizing treatment to achieve remission. However, the regular monitoring of endoscopic activity is limited in practice owing to several factors, such as the complexity of the procedure, time consumption, inter-observer variability, and lack of a clear-cut, validated definition of endoscopic response or remission. Although experts have recently suggested consensus-based definitions, further studies are needed to define the values that can predict long-term outcomes.
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Affiliation(s)
- Kyeong Ok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Loras C, Mañosa M, Andújar X, Sánchiz V, Martí-Gallostra M, Zabana Y, Gutiérrez A, Barreiro-de Acosta M. Position Statement. Recommendations of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the treatment of strictures in Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:315-334. [PMID: 34274357 DOI: 10.1016/j.gastrohep.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
Abstract
Despite pharmacological advances, strictures in Crohn's disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.
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Affiliation(s)
- Carme Loras
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España.
| | - Miriam Mañosa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Departamento de Gastroenterología, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Xavier Andújar
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Vicente Sánchiz
- Servicio de Medicina Digestiva. Hospital Clínico Universitario. Valencia, España
| | - Marc Martí-Gallostra
- Departamento de Cirugía Colorectal, General y Digestiva. Hospital Universitari de la Vall d'Hebron. Barcelona, España
| | - Yamile Zabana
- Departamento de Gastroenterología, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España
| | - Ana Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Madrid, España; Hospital General Universitario de Alicante, Alicante, España
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Zhang J, Li Y, Diao Y, Da B, Wang Z. Long-Term Outcome of Endoscopic Balloon Dilation for Duodenal Crohn's Disease-Associated Strictures. Dig Dis Sci 2021; 66:3570-3577. [PMID: 33159272 DOI: 10.1007/s10620-020-06675-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Duodenal Crohn's disease (CD) is rare and may present with obstructive symptoms, and few reports have focused on endoscopic balloon dilation (EBD) for duodenal CD-associated strictures. AIMS To evaluate the efficacy and safety of EBD for duodenal CD-associated strictures. METHODS Patients with duodenal CD-associated strictures who underwent EBD were recruited. The clinical date, stricture characteristics, number of EBDs, dilation diameter, complications, surgical interventions, and follow-up periods were recorded. Patients were also divided into a serial dilation group and a nonserial dilation group to analyze the efficacy and safety of serial EBD for duodenal strictures. RESULTS A total of 54 patients with duodenal CD-associated strictures underwent a total of 153 dilations. Technical success was achieved in 98.69% (151/153) of cases. The short-term efficacy at 1 month and 2 months was 100%. At a median follow-up period of 223 days (range 30-866), 11 patients underwent surgery, and the total clinical efficacy was 79.63% (43/54). No difference in the safety or efficacy was noted between the serial dilation group and the nonserial dilation group. The median surgery-free survival of 507 days (range 170-857) and the median recurrence-free survival of 215 days (range 30-866) in the serial dilation group were significantly longer than those in the nonserial dilation group (185.5 days (range 73-275) and 124 days (range 30-699), respectively). CONCLUSIONS EBD is a safe and effective treatment for duodenal CD-associated strictures. Serial dilations could delay recurrence and surgical intervention but did not change the long-term outcome or prevent surgery.
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Affiliation(s)
- Juanjuan Zhang
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Yi Li
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Yanqing Diao
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Binlin Da
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Zhiming Wang
- Research Institute of General Surgery, Jinling Hospital, No. 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China.
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Lowenfeld L, Michelassi F. Managing Stricturing Crohn's Disease: Resect? Strictureplasty? Dilate? J Laparoendosc Adv Surg Tech A 2021; 31:881-889. [PMID: 34265212 DOI: 10.1089/lap.2021.0099] [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: 10/20/2022] Open
Abstract
Crohn's disease (CD) is a pan-intestinal disease of the gastrointestinal tract characterized by inflammatory, penetrating, and fibrostenotic phenotypes. Fibrostenotic stricture formation, without inflammatory or penetrating disease, is a common complication in CD, primarily affecting the small intestine and leading to small bowel obstruction. Because there is no medical therapy that prevents or reverses stricturing disease, endoscopic and surgical treatments are the mainstays of treatment, indicated to palliate symptoms and treat the complications. Endoscopic approaches include dilation, stricturotomy, and endoscopic stenting. Surgical options include resection, intestinal bypass, and various strictureplasty techniques. In this article, we will focus on the treatment of stricturing CD: specifically, the considerations important in choosing between different treatment options and technical tips to deal with complicated disease.
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Affiliation(s)
- Lea Lowenfeld
- Division of Colon and Rectal Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Fabrizio Michelassi
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
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Jeon SR, Kim JO, Byeon JS, Yang DH, Ko BM, Goong HJ, Jang HJ, Park SJ, Kim ER, Hong SN, Im JP, Kim SE, Koo JS, Eun CS, Chang DK. Enteroscopy in Crohn's Disease: Are There Any Changes in Role or Outcomes Over Time? A KASID Multicenter Study. Gut Liver 2021; 15:375-382. [PMID: 32616680 PMCID: PMC8129664 DOI: 10.5009/gnl20023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/17/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background/Aims Although balloon-assisted enteroscopy (BAE) enables endoscopic visualization of small bowel (SB) involvement in Crohn's disease (CD), there is no data on the changes in outcomes over time. We therefore investigated the changes in BAE use on CD patients over different time periods in terms of its role and clinical outcomes. Methods We used a multicenter enteroscopy database to identify CD patients with SB involvement who underwent BAE (131 procedures, 116 patients). We compared BAE-related factors and outcomes between the first period (70 procedures, 60 patients) and the second period (61 procedures, 56 patients). The specific cutoff point for dividing the two periods was 2007, when BAE guidelines were introduced. Results Initial diagnosis of SB involvement in CD was the most common indication for BAE during each period (50.0% vs 31.1%, p=0.034). The largest change was in the number of BAE uses for stricture evaluation and/or treatment, which increased significantly in the latter period (2.9% vs 21.3%, p=0.002). The diagnostic yield in patients with suspected CD was 90.7% in the first period and 95.0% in the second (p=0.695). More endoscopic interventions were performed in the second period than in the first (5.1% vs 17.6%, p=0.041). Enteroscopic success rates were high throughout (100% in the first period vs 80.0% in the second period, p>0.999). In the first and second periods, therapeutic plans were adjusted in 62.7% and 61.4% of patients, respectively. Conclusions The overall clinical indications, outcomes, and effectiveness of BAE were constant over time in CD patients with SB involvement, with the exception that the frequency of enteroscopic intervention increased remarkably.
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Affiliation(s)
- Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jin-Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Bong Min Ko
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hyeon Jeong Goong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hyun Joo Jang
- Department of Internal Medicine, Hallym University College of Medicine, Hwaseong, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Ran Kim
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Noh Hong
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University College of Medicine and Liver Research Institute, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ja Seol Koo
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Chang Soo Eun
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
| | - Dong Kyung Chang
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
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Cicero G, Mazziotti S. Crohn's disease at radiological imaging: focus on techniques and intestinal tract. Intest Res 2020; 19:365-378. [PMID: 33232590 PMCID: PMC8566824 DOI: 10.5217/ir.2020.00097] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/02/2020] [Indexed: 11/05/2022] Open
Abstract
Over recent years, inflammatory bowel diseases have become an issue of increased attention in daily clinical practice, due to both a rising incidence and improved imaging capability in detection. In particular, the diagnosis of Crohn's disease is based on clinical picture, laboratory tests and colonoscopy with biopsy. However, colonoscopic evaluation is limited to the mucosal layer. Thus, imaging modalities play a pivotal role in enriching the clinical picture, delivering information on intestinal and extraintestinal involvement. All the imaging modalities can be employed in evaluation of Crohn's disease patients, each of them with specific strengths as well as limitations. In this wide selection, the choice of a proper diagnostic framework can be challenging for the clinician. Therefore, the aim of this work is to offer an overview of the different imaging techniques, with brief technical details and diagnostic potential related to each intestinal tract.
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Affiliation(s)
- Giuseppe Cicero
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Silvio Mazziotti
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
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