Safe Treatment of Intestinal Strictures in Crohn's Disease
Safe Treatment of Intestinal Strictures in Crohn's Disease
Background Bowel strictures are a major cause of morbidity, hospitalisation and surgery in Crohn's disease.
Aim We report short- and long-term efficacy and safety of endoscopic balloon dilation of strictures due to Crohn's disease.
Methods Retrospective study of patients who underwent endoscopic balloon dilation between 1987 and 2009.
Results We performed 776 dilations, of which 621 (80%) were on anastomotic strictures, in 178 patients (94 women) with Crohn's disease. At first dilation, median (IQR) age of patients was 45 (37–56) years and disease duration 16 (8–22) years. Technical success rate was 689/776 (89%). A subset of 75 patients from the primary catchment area, with >5-year follow-up, underwent a total of 246 dilations. At 1-year follow-up, 60/75 (80%) patients had undergone no further intervention or one additional dilation only. At 3 and 5 years, corresponding figures were 43/75 (57%) and 39/75 (52%). Cumulative proportions of patients undergoing surgery at 1, 3 and 5 years were 13%, 28% and 36%. Complication rate per procedure for all 178 patients was 41/776 (5.3%), bowel perforation (n = 11, 1.4%), major bleeding requiring blood transfusion (n = 8, 1.0%), minor bleeding (n = 10, 1.3%) and abdominal pain or fever (n = 12, 1.5%). Ten patients underwent surgery due to complications (perforation n = 8, bleeding n = 2). There was no procedure-related mortality.
Conclusions Endoscopic balloon dilation is an efficacious and safe alternative to surgical resection of intestinal strictures in Crohn's disease. At 5-year follow-up, 52% of patients required no further or one additional dilation only, whereas 36% had undergone surgical resection. Complication frequency was low.
Bowel strictures are a major cause of morbidity, hospitalisation and surgery in Crohn's disease (CD). Strictures are caused by transmural inflammation leading to tissue remodelling, mesenchymal cell proliferation and fibrosis, but the underlying cellular and molecular mediators have not yet been elucidated. Any segment of the gastrointestinal tract can be affected, but most commonly the terminal ileum, ileocolonic anastomosis or colon is involved. Traditionally, fibrotic strictures have been treated by surgical resection, as medical treatment is ineffective. The cumulative risk for surgery 10 years after diagnosis of CD is approximately 40–55%. The recurrence risk after resection is high. New endoscopic lesions will be found in a large majority of patients as early as after 1 year, which may in due course cause recurrent clinical symptoms requiring a second surgical procedure in 20–44% of patients after 10 years. In the long-term perspective, multiple resections may be associated with a risk for short-bowel syndrome. Strictureplasty has therefore evolved as a surgical bowel-preserving alternative and has been shown to be as safe and efficient as bowel resection in treating fibrotic strictures in CD.
Endoscopic balloon dilation is a nonsurgical alternative in treatment of fibrotic strictures in CD. It was first described in 1986 and has generally been accepted as an effective and safe treatment for short anastomotic strictures, although the evidence is limited. Most previous studies are retrospective uncontrolled, observational studies with small numbers of patients and short follow-up time. In general, the immediate technical success is high, but the clinical efficacy is variable. A review of 23 publications including between 5 and 59 patients reported a technical success rate of 90%, a rate of major complications like bowel perforation or severe bleeding of 3%, and a surgical recurrence rate of 27.6% after a median follow-up of 21 months. However, the evidence for long-term efficacy is sparse.
The aim of this study is to report a single referral centre experience of short-term and long-term efficacy and safety of endoscopic balloon dilation in treatment of intestinal strictures in CD.
Abstract and Introduction
Abstract
Background Bowel strictures are a major cause of morbidity, hospitalisation and surgery in Crohn's disease.
Aim We report short- and long-term efficacy and safety of endoscopic balloon dilation of strictures due to Crohn's disease.
Methods Retrospective study of patients who underwent endoscopic balloon dilation between 1987 and 2009.
Results We performed 776 dilations, of which 621 (80%) were on anastomotic strictures, in 178 patients (94 women) with Crohn's disease. At first dilation, median (IQR) age of patients was 45 (37–56) years and disease duration 16 (8–22) years. Technical success rate was 689/776 (89%). A subset of 75 patients from the primary catchment area, with >5-year follow-up, underwent a total of 246 dilations. At 1-year follow-up, 60/75 (80%) patients had undergone no further intervention or one additional dilation only. At 3 and 5 years, corresponding figures were 43/75 (57%) and 39/75 (52%). Cumulative proportions of patients undergoing surgery at 1, 3 and 5 years were 13%, 28% and 36%. Complication rate per procedure for all 178 patients was 41/776 (5.3%), bowel perforation (n = 11, 1.4%), major bleeding requiring blood transfusion (n = 8, 1.0%), minor bleeding (n = 10, 1.3%) and abdominal pain or fever (n = 12, 1.5%). Ten patients underwent surgery due to complications (perforation n = 8, bleeding n = 2). There was no procedure-related mortality.
Conclusions Endoscopic balloon dilation is an efficacious and safe alternative to surgical resection of intestinal strictures in Crohn's disease. At 5-year follow-up, 52% of patients required no further or one additional dilation only, whereas 36% had undergone surgical resection. Complication frequency was low.
Introduction
Bowel strictures are a major cause of morbidity, hospitalisation and surgery in Crohn's disease (CD). Strictures are caused by transmural inflammation leading to tissue remodelling, mesenchymal cell proliferation and fibrosis, but the underlying cellular and molecular mediators have not yet been elucidated. Any segment of the gastrointestinal tract can be affected, but most commonly the terminal ileum, ileocolonic anastomosis or colon is involved. Traditionally, fibrotic strictures have been treated by surgical resection, as medical treatment is ineffective. The cumulative risk for surgery 10 years after diagnosis of CD is approximately 40–55%. The recurrence risk after resection is high. New endoscopic lesions will be found in a large majority of patients as early as after 1 year, which may in due course cause recurrent clinical symptoms requiring a second surgical procedure in 20–44% of patients after 10 years. In the long-term perspective, multiple resections may be associated with a risk for short-bowel syndrome. Strictureplasty has therefore evolved as a surgical bowel-preserving alternative and has been shown to be as safe and efficient as bowel resection in treating fibrotic strictures in CD.
Endoscopic balloon dilation is a nonsurgical alternative in treatment of fibrotic strictures in CD. It was first described in 1986 and has generally been accepted as an effective and safe treatment for short anastomotic strictures, although the evidence is limited. Most previous studies are retrospective uncontrolled, observational studies with small numbers of patients and short follow-up time. In general, the immediate technical success is high, but the clinical efficacy is variable. A review of 23 publications including between 5 and 59 patients reported a technical success rate of 90%, a rate of major complications like bowel perforation or severe bleeding of 3%, and a surgical recurrence rate of 27.6% after a median follow-up of 21 months. However, the evidence for long-term efficacy is sparse.
The aim of this study is to report a single referral centre experience of short-term and long-term efficacy and safety of endoscopic balloon dilation in treatment of intestinal strictures in CD.
