Endoscopic dilation of anastomotic colonic stenosis by different techniques: an alternative to surgery?☆

A majority of patients with Crohn's disease (CD) eventually develop disease-associated complications, such as stricture and fistula. The stricture is characterized by progressive luminal narrowing with inflammatory and fibrosing components and clinically with obstructive symptoms. Various antiinflammatory and immunosuppressive medications have been used in treating inflammatory and fistulizing CD. The efficacy and safety of biological agents in treating Crohn's stricture have been a concern CD. Rapid tissue healing from potent biological agents may trigger or exacerbate stricture. On the other hand, strictures have been one of main indications for surgical intervention. In the majority of patients, surgery is not a cure. Disease recurrence is common at the anastomotic site and bowel segment above the anastomosis. The progressive nature of the disease with repetitive cycle of inflammation and fibrosis results in recurrent stricture and repeated surgery, with a risk of short bowel syndrome. Surgical stricturoplasty and endoscopic balloon dilation and recently endoscopic stricturotomy have emerged as valid alternatives. There are pros and cons of each treatment modality. The choice among the treatment options is determined by the nature of stricture, disease, systemic conditions of individual patient, and local expertise in endoscopy versus surgery.

In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases−associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.

Background and aims

There is a high rate of stricturing post-operative recurrence in Crohn's disease (CD) particularly at sites of surgical anastomosis, and over 50% of these patients will require a repeat resection. Endoscopic dilatation of anastomotic strictures is an alternative to surgical resection in selected patients. We aimed to evaluate the safety and long term efficacy of endoscopic balloon dilatation of symptomatic anastomotic strictures in CD.

Retrospective analysis of a prospectively maintained inflammatory bowel disease database of patients attending a single academic centre (n = 1244 patients with CD) who underwent dilatation.

Fifty-five dilatations were performed in 31 patients (mean age 43 ± SD 12, 47% female). Median follow‐up period was 46 months (IQR 14–62). Ninety percent of patients had successful initial dilatation and no complications occurred. Six (21%) avoided further dilatations or surgery in the follow-up period. Stricture recurrence was detected in 22 patients; 15 (54%) patients had repeat dilatations and seven (25%) went straight to surgery. Eight (28%) patients were managed with repeat dilatations of the stricture (median dilatations = 2 range 2–6) and seven (25%) required surgery despite repeat dilatations. Median time from first dilatation to repeat surgery was 14.5 months (IQR 3–28) and to repeat dilatation was 13.8 months (IQR 4–28). There was no difference in immunomodulator use, biologic use and smoking status between the groups requiring surgery versus dilatation only.

Endoscopic balloon dilatation of anastomotic strictures is safe and effective in providing symptomatic relief in CD patients. Forty-five percent of patients had a sustained response to single/serial balloon dilatation with avoidance of further surgical resection for a median interval of 46 months. Post-operative medical therapy and smoking status did not predict requirement for recurrent dilatation or surgery.

Stricturing Crohn's disease (CD) occurs in 12–54% of the CD patient population and is associated with significant morbidity and impaired quality of life.

The detailed pathophysiology of stricture formation has not been fully elucidated, but is primarily associated with luminal narrowing secondary to inflammation and the fibrosis that ensues during mucosal healing. The diagnosis of stricturing disease is based on clinical signs and symptoms along with imaging modalities. The advantages and shortcomings of each imaging modality are discussed.

Treatment options are based on the differentiation between inflammatory versus fibrous-predominant strictures; whereas the former can potentially be managed with conservative medical treatment, the latter necessitates a mechanical solution through endoscopy or surgery. Indications, contra-indications and success rates of the different therapeutic approaches are discussed.

Endoscopy plays an integral role in the diagnosis, management, and surveillance of inflammatory bowel disease (IBD). Because there is no single pathognomonic test that establishes the diagnosis of IBD, endoscopy is useful in establishing the diagnosis, excluding other etiologies, distinguishing Crohn’s disease from ulcerative colitis, defining the patterns, extent, and activity of mucosal inflammation, and obtaining mucosal tissue for histologic evaluation. In established IBD, endoscopy helps define the extent and severity of involvement, which in turn influences medical and surgical decisions, aids in targeting medical therapies, and allows for the management of IBD-related complications. Furthermore, endoscopy plays a key role in the surveillance of patients with long-standing colitis who are at increased risk for dysplasia and the development of colorectal cancer.

Benign colonic strictures are uncommon but not rare in endoscopic practice. Strictures of the colon develop as a consequence of numerous disorders. Colonic strictures typically are asymptomatic or cause chronic obstructive symptoms. Nonsurgical methods, particularly dilatation and occasionally endoscopic stent placement or laser therapy, are currently available options in the treatment of benign colonic stricture. Surgical treatment is reserved for those who fail endoscopic remediation or are not candidates for endoscopic treatment.