Endoscopic balloon dilatation of Crohn's strictures: a safe method to defer surgery in selective cases

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Excerpt

Gastrointestinal strictures are a well‐known complication of Crohn's disease (CD). The Vienna classification describes strictures as ‘constant luminal narrowing (radiological, endoscopic and surgical) with pre‐stenotic dilatation or obstructive signs without penetrating disease, at any time in the course of the disease’.1 Intestinal strictures develop anywhere along the gastrointestinal tract, and are found in up to 12% of patients with CD.2
Chronic transmural inflammation of the intestinal wall leads to fibrosis and narrowing of the bowel lumen, commonly at the terminal ileum and surgical anastomoses.3 Several cellular markers such as tumour necrosis factor alpha (TNF‐α) have been identified to be key players in this process, but the actual pathogenesis and mechanisms of intestinal fibrosis remain unknown.4 Disease duration and clinical severity of CD are important predictive factors of stricture formation, which often presents as postprandial abdominal bloating or frank intestinal obstruction.3
Whilst TNF‐α blockade agents are effective in treating the inflammatory component of CD, they may be less effective for the treatment of fibrostenotic disease.4 Surgical options include segmental bowel resection or strictureplasty. The cumulative 10‐year risk for surgery after diagnosis of CD is up to 80%.5 Unfortunately, 10–30% of these patients require reoperations for recurrence at 5 years and up to 50% at 20 years.5 Furthermore, 10% of reoperations are for recurrences at previous sites of surgery.6 These surgical interventions are not without risk. Anastomotic leaks, fistula and abscess formation occur in approximately 4% of patients post‐strictureplasty.6 Additionally, multiple resections may result in short gut syndrome and dependence on parenteral nutrition with its associated complications.
Endoscopic balloon dilatation (EBD) was first described in CD in 1986, using a combination of dilatation during endoscopy and laparotomy, and was initially reserved for those refusing surgery.7 Over the years, EBD has been gaining favourability as a method to defer surgery in CD. A large prospective study in 2012 revealed that EBD could be the sole treatment method for stricturing CD in 64% of their patients, avoiding the need for surgery.8 A systematic review comparing 13 studies found a technical success rate of 86% and long‐term clinical efficacy of 58% with a low procedural complication rate of 2%.5 Despite this, there is insufficient evidence regarding the long‐term success rates, and knowledge regarding patient and disease factors that predict successful dilatation.
Our study looks at the safety and efficacy of EBD in stricturing CD, and the clinical variables that predict its success.
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