TY - JOUR
AU - MD, Walter A. Koltun,
AB - A clear cause and cure for Crohn's disease (CD) continues to elude caregivers and researchers alike, much to the frustration of these frequently youthful and usually very symptomatic patients. The experienced clinician recognizes that he or she is frequently treating only the complications of CD and not the disease itself. Thus, drugs are used to quell mucosal inflammation and to treat foci of sepsis (fistuli and abscesses) without knowing what is actually causing the inflammation or abscesses. One of the most symptomatic of CD complications is intestinal obstruction brought about by either severe inflammation compromising the lumen of the bowel or a fibrotic stricture, the result of “burnt out” inflammation and scarring. Such bowel obstruction can present as an acute emergency but more often is manifest as recurrent, crampy abdominal pain aggravated by oral intake, especially of high-fiber foods. Twenty percent of CD patients will have small bowel strictures, usually near the terminal ileum, while about another 10% will have colonic strictures.1 Such symptomatic strictures, when inflammatory, should be treated with appropriate antiinflammatory medications. When nonresponsive to medical management or when fixed and fibrotic, surgical resection and anastomosis can provide dramatic relief, especially in the case of ileocolic disease. However, such surgery will commonly be followed by recurrence of disease, initially inflammatory, subsequently fibrotic, precipitating the need for recurrent surgery in ≈50% of patients at 10 years.2,–4 Such recurrence is more a failure of effective medical management than it is of surgery. Regardless, this repetitive cycle of relapsing inflammation, stricturing, and the need for surgical resection can potentially result in short gut with the associated cumulative risk of numerous surgical procedures. In this context the concept of a nonsurgical endoscopic technique to relieve the obstructive symptoms of intestinal stricturing has intuitive appeal. Unfortunately, this attractive first impression must be tempered with some of the realistic problems associated with the technique. Summary of Technique and Outcomes The technique of endoscopic balloon dilatation is widely variable, based largely on the preference and experience of the endoscopist.5 Obviously, the stricture must be reachable, so most are either colonic or ileocolic and not infrequently an anastomotic stricture after previous operative ileocolectomy. Some clinicians dilate using balloon diameters to as large at 25 mm3, but most will dilate only to 18 or 20 mm, citing a lower complication rate. Insufflation is usually held for several (1–4) minutes, and then the balloon is deflated and the process repeated several times until an adequate lumen is appreciated visually. Sometimes successful dilatation is defined by the subsequent passage of the colonoscope (about 13 mm in diameter) through the stricture, but this is inconsistent in the literature and not necessarily associated with a higher symptomatic relief rate. Frequently, an angulated or longer stricture will prohibit the passage of the balloon. This can sometimes be overcome with catheters using a guidewire to cannulate the stricture first, over which the balloon is then passed. The length of the balloon thus, theoretically, restricts the length of the stricture that can be dilated. Although balloons can be up to 8 cm in length, most strictures successfully dilated are much shorter, usually on the order of 2–4 cm, with the longer strictures being associated with technical failures. Thus, longer strictures, angulated strictures, and complex strictures (those associated with fistula tracts) are relative contraindications to successful balloon dilatation and frequently are not even considered for endoscopic treatment. All of the studies summarizing the technique and outcomes of endoscopic balloon dilatation of CD strictures are relatively small and retrospective, and therefore inclined to be favorably inaccurate with regard to results. Recognizing that these are already highly selected patients, some studies then do not even include patients who had a technical failure, or were unable to have the balloon pass through the stricture. Such technical failures can be as high as 21%.6 In addition, “success” may be short-term (immediate relief of symptoms) or long-term, with wide variation in follow-up. Frequently, patients will require multiple, separate sessions of dilatation, either for initial lack of symptom relief or early recurrence. In a study of 32 patients, Sabate et al7 noted that 15 required more than 1 dilatation, while Dear and Hunter8 reported that 30% of 22 patients required repetitive dilatation. Even with these multiple dilatations the long-term success rates are imperfect. At 1 year Sabate et al7 reported only a 64% symptom-free success rate, while at a mean of 29 months Thomas-Gibson et al9 reported only 41% of patients free of symptoms. Morini et al6 reported that at ≈64 months 52.9% of patients had avoided symptomatic recurrence, but this number excludes 9 of the original 43 patients in that study who were technical failures. On an “intent to treat” basis, their success rate falls to 42%. Sabate et al7 reported that 43% of their endoscopically dilated patients needed surgery at 5 years. Roughly speaking, these recurrence rates for endoscopic balloon dilatation are at least double that found after surgery done for stricturing CD.2,–4 Complications of Endoscopic Balloon Dilatation Besides a less than ideal success rate, balloon dilatation also has a concerning complication rate. As mentioned, more vigorous dilatation is associated with higher complication rates. Couckuyt et al5 reported 11 instances of serious complications (perforation, bleeding) in 55 patients dilated with 25-mm balloons, a rate of 20%. Similarly, Blomberg et al,10 using both 18- and 25-mm balloons, had 2 perforations and 2 bleeding episodes in 27 patients, for an overall 15% complication rate. Although Singh et al11 reported a 10% complication rate, this is based on number of dilatations performed29, when in fact their 3 complications were in 17 patients, for a more clinically relevant complication rate of 18%. Morini et al6 reported no serious complications in 34 successfully dilated patients. However, that group used only 18-mm balloons, performed an average of 3 separate dilatation sessions per patient, and 9 of their original 43 patients were unable to be dilated using their more cautious approach. Many other studies also report negligible complication rates, but nearly all are exceedingly small in patient number (under 20). Not all patients suffering such complications of balloon dilatation require surgery. Specifically, bleeding can frequently be conservatively managed. However, it is the extremely self-confident (foolhardy?) physician who will not immediately operate on a bowel perforation in these usually immunosuppressed and relatively malnourished patients. Having been called to do so more than once myself, it is a challenge for the surgeon to successfully salvage these individuals and then safely return their gastrointestinal tract to continuity. Even a single perforation in a larger series represents a serious, life-threatening complication that if successfully corrected still requires inordinate clinical effort and usually multiple operations. Such a complication calls into question at least the pre-endoscopy selection criteria for the performance of balloon dilatation. These patients are sick to start with, and bowel perforation is a seriously morbid complication. A salient, though underappreciated advantage of surgery versus endoscopic dilatation is the delivery of a specimen. Even with open strictureplasty there is the advantage of clearly visualizing the area in question and then performing a biopsy if there are any suspicious characteristics. The issue, of course, is malignancy, and the concern that a malignant stricture is being managed as a benign one with repetitive balloon dilatations that delay definitive operative care. Such malignancy occurring in CD is generally speaking rare, but has been clearly described as masquerading as a recurrent stricture at the site of previous surgery.12,–14 One must be especially suspicious of the colonic stricture.15 There is clearly the ability to perform simultaneous biopsy with balloon strictureplasty, but such is rarely stressed or reported as routine in the literature.16 One can appreciate the reluctance of the endoscopist to be yet more invasive when already concerned about possible perforation with balloon dilatation alone. Again, our group's experience with several patients whose malignant strictures were first managed conservatively (with and without balloon dilatation) makes one reevaluate very carefully a nonoperative approach in these patients. Miscellaneous Conditions Although the majority of endoscopic balloon dilatations are done in the ileocolic area after previous resection, it can also be selectively performed for other miscellaneous strictures. Duodenal and proximal small bowel dilatations via an upper endoscopy approach have been successfully performed, but are difficult to specifically evaluate due to the small number of such described cases. Many of the same caveats mentioned above generally apply to these sites as well. A special circumstance, however—namely, the patient with a terminal ileum to pouch stricture after ileal pouch anal anastomosis (IPAA)—bears specific mention. Some ulcerative colitis patients appear to be more Crohn's-like in their disease characteristics after IPAA than before, and a pouch inlet stricture is a recognized phenomenon in these patients, analogous to an ileocolic stricture with the pouch being the “neo-colon.” Again, studies are small, follow-up is short, and patients frequently require repetitive dilatations; however, such patients appear to benefit from endoscopic balloon intervention.17 The risk/benefit ratio in this circumstance is somewhat different than the Crohn's patient with straightforward recurrent ileocolic disease, however. Specifically, surgical correction of such an IPAA stricture is difficult and pouch excision with conversion of the patient to a permanent ileostomy is a significant risk, if not probability. The advantage of an endoscopic, nonoperative approach therefore is greater, by virtue of possibly avoiding this very adverse consequence of surgical intervention. The Surgical Alternative A major argument for the performance of endoscopic balloon dilatation promulgated in the literature is the avoidance of repetitive surgeries and, by inference, short gut. But in fact, inflammatory bowel disease (IBD) clinicians recognize that it is not the patient with the discrete 2 or 3 cm stricture that gets short gut or represents an undue surgical risk. It is the patient with extensive small bowel disease, with numerous sequential or continuous areas of stricturing disease. However, such a patient is not in any way a candidate for endoscopic balloon dilatation. Thus, the “short gut argument” is fallacious. What is the best, modern surgical option for a patient with a discrete ileocolic stricture, such as would be a candidate for endoscopic dilatation? It would be a laparoscopic resection and anastomosis, which would take about 2 hours and get the patient out of the hospital in about 4 days.18,–20 Even when converted to open (5%–20% of the time), such an operation still provides excellent immediate relief of symptoms and an ≈50% operative recurrence rate at 10 years.2,–4 The major complication rate in the elective circumstance is ≈5%.21 This is the procedure and the data that need to be compared to the results of endoscopic balloon dilatation described above. Summary and Conclusion It is clear that endoscopic balloon dilatation of ileocolic and other intestinal strictures are possible in the Crohn's patient. However, patients need to be highly and carefully selected in order to maximize technical success and minimize complications. Recommended criteria for balloon dilatation include 1) short stricture; 2) minimal inflammation; 3) no evidence of fistula or angulation of stricture; 4) no evidence of cancer; 5) stricture easily reachable by scope; and 6) preferably a single dominant, symptomatic stricture. Other factors that facilitate successful dilatation include the need for sophisticated technology (types of catheters), fluoroscopy, anesthesia, and, finally, surgical backup. In the aggregate, it will be the rare patient and/or endoscopy facility that will comfortably satisfy all these criteria. Then, even when successfully completed, a third to a half of patients will require repetitive dilatation, increasing complications and costs, and still having a 50% need for surgical operation at 5 years. Clearly, the use of endoscopic balloon dilatation in CD has a very limited role. It must be carefully weighed against a more definitively successful, more widely applicable, and probably safer surgical resection. 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TI - Dangers associated with endoscopic management of strictures in IBD
JF - Inflammatory Bowel Diseases
DO - 10.1002/ibd.20090
DA - 2007-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/dangers-associated-with-endoscopic-management-of-strictures-in-ibd-isVujRrmEC
SP - 359
EP - 361
VL - 13
IS - 3
DP - DeepDyve
ER -