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Alimentary Pharmacology & Therapeutics. 2010;31(6):634-639.
Abstract
Background Endoscopic balloon dilation has been shown to be an alternative to surgery in the treatment of Crohn's symptomatic strictures.
Aim To analyse the impact of the type of the strictures –de novo or anastomotic – their location and their length on the outcome of endoscopic balloon dilation.
Methods Between December 1999 and June 2008, 55 patients underwent 93 balloon dilations for 74 symptomatic strictures. One stricture was located in the duodenum, 39 strictures were in the terminal ileum, 17 at the ileocoecal anastomosis after a preceding resection and 17 in the colon.
Results Endoscopic treatment was successful in 76% of the patients during an observation period of 44 (1–103) months. Of the patients, 24% required surgery. All patients who underwent surgery had de novo strictures in the terminal ileum. These strictures were significantly longer compared with the ileal strictures that responded to endoscopic treatment [7.5 (1–25) cm vs. 2.5 (1–25) cm; P = 0.006].
Conclusions The long-term success of endoscopic balloon dilation depends on the type of the strictures, their location and their length. Failure of endoscopic treatment was observed only in long-segment strictures in the terminal ileum.
Introduction
Gastrointestinal strictures are a feared complication of Crohn's disease. Up to one-third of patients develop a stricture from time of diagnosis to 10 years later.[1–3] Symptomatic strictures resistant to medical therapy usually require surgery. Reappearance of symptomatic strictures in up to 40% of the patients within 4 years after surgery may necessitate repeated bowel resections[4] leading to the risk of short bowel syndrome.[5–8] In recent years, endoscopic through the scope (TTS) balloon dilation has offered a therapeutic alternative.[9–11] This procedure has the advantage of being minimally invasive and of preserving intestinal length. Recently published data demonstrate that hydrostatic balloon dilation of Crohn's strictures is safe and effective with immediate success rates ranging from 71% to 100%.[12–20] However, long-term success rates are lower and vary in the different series.[12–20] This variability might be as a result of different rates of de novo and post-operative strictures (59–100%) and their different location in the gastrointestinal tract, which has, to our knowledge, not yet been taken into account.
The aim of the present study was to analyse whether the outcome of dilation of Crohn's strictures depends on the type of the strictures, their location and their length.
Materials and Methods
Patients
Between December 1999 and June 2008, 93 endoscopic balloon dilations were prospectively performed to treat 74 symptomatic strictures in 55 patients [21 males, 34 females, 41 (15–71) years]. All patients had given their written informed consent to the procedure. The history of Crohn's disease was 11 (0–35) years. All patients presented with obstructive symptoms such as abdominal pain, cramps, bloating and vomiting. Prior to endoscopy, the patients received a sonographic and radiological assessment (small bowel enteroclysis or MRI) to confirm the clinically suspected stricture, to exclude intestinal fistulas and angulated strictures and to measure the length of the strictures.
The patients' strictures were located as follows: one in the duodenum, 39 in the terminal ileum or at the ileocoecal valve, 17 at the ileocolonic anastomosis after a preceding resection and 17 in the colon. Six patients had more than one affected location.
The median length of the strictures was 3 (1–25) cm.
In patients with an anastomotic stricture, the median time between the last resection and the first balloon dilation was 70 (17–412) months.
At the time of dilation, 27% of the patients had no treatment of their Crohn's disease, 34% received a systemic or topic steroid therapy, 13% took an immunosuppressive agent. No patient was under treatment with infliximab. Characteristics of the patients are summarized in Table 1 .
Dilation Protocol
Endoscopy was performed under medication with midazolam/pethidin or midazolam/propofol. The act of dilation was carried out under conscious sedation to perceive a possibly imminent perforation by the patient's utterance of pain. At the first dilation, specimens were taken out of the strictures to rule out malignancy. A hydrostatic through the scope balloon with a diameter of 15–18 mm on inflation was used for dilation in all patients (Microvasive Rigiflex, Boston Scientific, Boston, MA, USA). The introduction of the balloon into the stricture was done under visual control. If this was not possible, the balloon was inserted using a guide wire under fluoroscopic control. After reaching the correct position, the balloon was inflated up to a diameter of 15 mm for 1 min. After deflation, another inflation of up to 18 mm was performed and maintained for 1 min. This technique was used to minimize the risk of perforation. In long-segment strictures, segmental dilations were carried out. In unclear situations, a contrast agent (Solutrast 300, Bracco ALTANA GmbH, 78467 Konstanz, Germany) was administered intraluminally.
Analysis
The follow-up data were collected prospectively and analysed retrospectively.
Technical success was defined as the passage of the scope through the stricture after balloon dilation.
Complications were defined as perforation, active bleeding with the need of an endoscopic re-intervention or the transfusion of blood and abdominal pain after balloon dilation.
Data are presented as medians and range. Univariate analysis (Mann–Whitney-Test) was used to compare the characteristics of the strictures. A two-sided P value of <0.05 was considered statistically significant. Kaplan–Meier plots were used to analyse intervals free of surgery.
Abstract
Background Endoscopic balloon dilation has been shown to be an alternative to surgery in the treatment of Crohn's symptomatic strictures.
Aim To analyse the impact of the type of the strictures –de novo or anastomotic – their location and their length on the outcome of endoscopic balloon dilation.
Methods Between December 1999 and June 2008, 55 patients underwent 93 balloon dilations for 74 symptomatic strictures. One stricture was located in the duodenum, 39 strictures were in the terminal ileum, 17 at the ileocoecal anastomosis after a preceding resection and 17 in the colon.
Results Endoscopic treatment was successful in 76% of the patients during an observation period of 44 (1–103) months. Of the patients, 24% required surgery. All patients who underwent surgery had de novo strictures in the terminal ileum. These strictures were significantly longer compared with the ileal strictures that responded to endoscopic treatment [7.5 (1–25) cm vs. 2.5 (1–25) cm; P = 0.006].
Conclusions The long-term success of endoscopic balloon dilation depends on the type of the strictures, their location and their length. Failure of endoscopic treatment was observed only in long-segment strictures in the terminal ileum.
Introduction
Gastrointestinal strictures are a feared complication of Crohn's disease. Up to one-third of patients develop a stricture from time of diagnosis to 10 years later.[1–3] Symptomatic strictures resistant to medical therapy usually require surgery. Reappearance of symptomatic strictures in up to 40% of the patients within 4 years after surgery may necessitate repeated bowel resections[4] leading to the risk of short bowel syndrome.[5–8] In recent years, endoscopic through the scope (TTS) balloon dilation has offered a therapeutic alternative.[9–11] This procedure has the advantage of being minimally invasive and of preserving intestinal length. Recently published data demonstrate that hydrostatic balloon dilation of Crohn's strictures is safe and effective with immediate success rates ranging from 71% to 100%.[12–20] However, long-term success rates are lower and vary in the different series.[12–20] This variability might be as a result of different rates of de novo and post-operative strictures (59–100%) and their different location in the gastrointestinal tract, which has, to our knowledge, not yet been taken into account.
The aim of the present study was to analyse whether the outcome of dilation of Crohn's strictures depends on the type of the strictures, their location and their length.
Materials and Methods
Patients
Between December 1999 and June 2008, 93 endoscopic balloon dilations were prospectively performed to treat 74 symptomatic strictures in 55 patients [21 males, 34 females, 41 (15–71) years]. All patients had given their written informed consent to the procedure. The history of Crohn's disease was 11 (0–35) years. All patients presented with obstructive symptoms such as abdominal pain, cramps, bloating and vomiting. Prior to endoscopy, the patients received a sonographic and radiological assessment (small bowel enteroclysis or MRI) to confirm the clinically suspected stricture, to exclude intestinal fistulas and angulated strictures and to measure the length of the strictures.
The patients' strictures were located as follows: one in the duodenum, 39 in the terminal ileum or at the ileocoecal valve, 17 at the ileocolonic anastomosis after a preceding resection and 17 in the colon. Six patients had more than one affected location.
The median length of the strictures was 3 (1–25) cm.
In patients with an anastomotic stricture, the median time between the last resection and the first balloon dilation was 70 (17–412) months.
At the time of dilation, 27% of the patients had no treatment of their Crohn's disease, 34% received a systemic or topic steroid therapy, 13% took an immunosuppressive agent. No patient was under treatment with infliximab. Characteristics of the patients are summarized in Table 1 .
Dilation Protocol
Endoscopy was performed under medication with midazolam/pethidin or midazolam/propofol. The act of dilation was carried out under conscious sedation to perceive a possibly imminent perforation by the patient's utterance of pain. At the first dilation, specimens were taken out of the strictures to rule out malignancy. A hydrostatic through the scope balloon with a diameter of 15–18 mm on inflation was used for dilation in all patients (Microvasive Rigiflex, Boston Scientific, Boston, MA, USA). The introduction of the balloon into the stricture was done under visual control. If this was not possible, the balloon was inserted using a guide wire under fluoroscopic control. After reaching the correct position, the balloon was inflated up to a diameter of 15 mm for 1 min. After deflation, another inflation of up to 18 mm was performed and maintained for 1 min. This technique was used to minimize the risk of perforation. In long-segment strictures, segmental dilations were carried out. In unclear situations, a contrast agent (Solutrast 300, Bracco ALTANA GmbH, 78467 Konstanz, Germany) was administered intraluminally.
Analysis
The follow-up data were collected prospectively and analysed retrospectively.
Technical success was defined as the passage of the scope through the stricture after balloon dilation.
Complications were defined as perforation, active bleeding with the need of an endoscopic re-intervention or the transfusion of blood and abdominal pain after balloon dilation.
Data are presented as medians and range. Univariate analysis (Mann–Whitney-Test) was used to compare the characteristics of the strictures. A two-sided P value of <0.05 was considered statistically significant. Kaplan–Meier plots were used to analyse intervals free of surgery.
They want to put me back on Cimzia even though it didn't work the first time as we have pretty much done everything else at this point. I don't have a lot of hope at this point and now I'm having to wait on the meds because the blood work came back "indeterminite" of possible infection in my lungs. I will be goin in to see an Infectious Disease doctor (at Mayo also) to find out what they can do from here. Boy, I've learned when it rains it sure does pour!
