Issue 19

Clinical Question

Does therapeutic endoscopic dilatation for anastomotic strictures provide long-lasting benefits for patients with stricturing Crohn’s disease (CD)?

Editor’s Bottom Line

Endoscopic balloon dilation appears to be effective for anastomotic strictures in CD, with low rates of complication.

Reference

Ding NS, Yip WM, Choi CH, et al. Endoscopic Dilatation of Crohn’s Anastomotic Strictures is Effective in the Long Term, and Escalation of Medical Therapy Improves Outcomes in the Biologic Era. J Crohns Colitis. 2016 Oct;10(10):1172–8. https://www.ncbi.nlm.nih.gov/pubmed/26971054

Synopsis

Patients with CD who underwent endoscopic dilatation for treatment of an anastomotic stricture between 2004 and 2009 were enrolled and followed until 2014. “Through-the-scope” balloons were used with dilatations in 3 mm increments each lasting 60 seconds. An endoscopist blinded to the outcomes retrospectively graded the dilatation and adjacent disease activity using a modified Rutgeerts score based upon images (i0=no lesions; i1≤aphthous lesions; i2=recurrence; i3=diffuse ileitis; i4=large ulcers at anastomotic site and diffuse inflammation). Following treatment, passage of the scope through the dilated stricture was considered therapeutic success. Therapy escalation was defined as initiation of thiopurines or biologics within 6 months of first dilatation; combination therapy comprised thiopurines and a biologic.

The 54 patients enrolled (median age=52 years; median disease duration=28 years) required a median of 2 dilatations (total=151) with a median interval of 6 years between the first two dilatations. The median Rutgeerts score for 92% of the endoscopies was i2. Repeat dilatations (median=2) were required by 69% of patients within a median time of 23 months between procedures. Therapeutic success was achieved in 89% of dilatations. Medical therapy was escalated in 41%. On multivariate analysis, only combination therapy decreased risk for repeat dilatation with a hazard ratio (HR) of 0.23 (P=0.01). 10 patients required anastomotic resection which was associated with a score of i4 at initial dilatation (HR 4.55, P=0.04). One perforation occurred but was noticed within 24 hours of the procedure and required resection.

Details

Study Design: Retrospective cohort study
Funding: None
Allocation: n/a
Setting: Single centre, London, UK
Level of Evidence: 2b (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.