The multidisciplinary health care team in the management of stenosis in Crohn’s disease

Figures & data

Table 1 Diagnostic techniques for stenosing Crohn’s disease. Synopsis of main papers cited in this review

Authors	Study type	Number of patients	Main findings	Conclusions
Ha et al^Citation15	Retrospective cohort study	119 Crohn’s disease pts; 133 MRE scans	Positive findings of Crohn’s disease (eg, active inflammation, stricturing, and penetrating disease); more frequent in pts with obstructive symptoms (87.5%) vs other indications (58.1%) (P=0.001) In the subgroup of pts with obstructive symptoms, MRE findings assisted in directing a change of clinical management toward escalation of medical therapy in 55% and surgery in 32.5% pts, respectively Review of surgical resection specimens confirmed MRE findings of disease activity and fibrosis in 92% of cases	MRE provides an effective alternative to CT for evaluating and directing care in Crohn’s disease pts, particularly those presenting with obstructive symptoms
Ripollés et al^Citation16	Prospective cohort study	25 Crohn’s disease pts	Good correlation between the US and pathology scores, for both inflammatory and fibrostenosing strictures Significantly negative association between the color Doppler grade and the pathologic fibrostenotic score	US and CEUS: useful tools for distinguishing inflammatory from fibrostenotic lesions in Crohn’s disease US yields useful information for the management of Crohn’s disease
Patel et al^Citation17	Retrospective cohort review	270 IBD pts; 258 Crohn’s disease pts; 311 enterography studies (291 MRE and 20 CT enterographies)	Active SB disease noted in 73/311 (23.5%) of studies Complications (eg, strictures, perianal fistulas, abscesses, and SB fistulas) noted in 108/311 (34.7%) of studies Endoscopic and enterography defined active disease had an agreement of κ=0.36 in the ileum (n=179) 142/311 (45.7%) enterographies were associated with recommended medication changes within 90 days Surgery or EBD of stricture recommended following 41/311 (13.2%) enterographies	Enterography reveals active disease and complications not evident on endoscopy Enterography should be considered in the initial diagnosis, assessment of disease activity, and monitoring of therapy in pts with IBD

Abbreviations: CT, computed tomography; EBD, endoscopic balloon dilatation; MRE, magnetic resonance enterography; pts, patients; SB, small bowel; vs, versus; US, ultrasound; IBD, inflammatory bowel disease; CEUS, contrast-enhanced ultrasound.

Table 2 Surgical treatments for stenosing Crohn’s disease. Synopsis of the main papers cited in this review

Authors	Study type	Number of patients	Main findings	Conclusions
Futami et al^Citation30	Retrospective pt review	103 pts with obstructive Crohn’s disease 293 strictureplasties (235 Heineke–Mikulicz, 22 Finney, 35 Jaboulay, and one side-to-side isoperistaltic strictureplasty)	No operative mortality Septic complications related to strictureplasty in four pts, reoperation in two pts (1.9%) 5- and 10-year reoperation rates were 45% and 61.9%, respectively, for all pts Further operation for recurrence required in 45 pts (43.7%); 21 pts (20.4%) with recurrence at the site of strictureplasty; 14 pts with re-stricture; seven pts with perforating disease Perforating disease for recurrence: more frequent at the site treated by the Finney or Jaboulay procedure compared with Heineke–Mikulicz	In the long term, strictureplasty is safe and useful for preserving the intestine in the surgical treatment of Crohn’s disease if strictures are carefully selected
Holubar et al^Citation33	Retrospective pt review (Single center; time period: 1997–2008)	92 Crohn’s disease pts who underwent minimal invasive colectomy	Median operative time: 248 (190–292) minutes 15 (16%) conversions: not associated with increased length of stay or with postoperative complications Overall postoperative length of stay: 5 (range, 4–7) days Short-term complications in 34% (reoperation in five pts; obstruction in three, anastomotic leak in two pts) No 30-day mortality	Minimally invasive colectomy in pts with Crohn’s disease colitis can be safely accomplished with reasonable operative times, conversion rates, and excellent postoperative outcomes
Milsom et al^Citation34	Prospective, randomized trial in one surgical department (comparing laparoscopic vs conventional techniques)	60 Crohn’s disease pts	Median length of the incision: 5 cm in the laparoscopic group vs 12 cm in the conventional group Overall recovery of 80% of FEV (1 second) and FVC: median of 2.5 days for laparoscopic vs 3.5 days for conventional (P=0.03) Flatus and first bowel movement returned a median of 3 and 4 days after laparoscopic vs 3.3 and 4 days after conventional surgery, respectively (P=0.21) Median length of stay: 5 days (range, 4–30 days) for laparoscopic, and 6 days range, 4–18 days) for conventional surgery Major complications in one pt in each group. Minor complications in four laparoscopic and eight conventional pts (P<0.05) No mortality Two laparoscopic pts converted to conventional as a result of adhesions or inflammation All pts recovered well, with no clinical recurrences in the follow-up period (median, 20; range, 12–45 months)	Within a single centre experience, laparoscopic techniques offered a faster recovery of pulmonary function, fewer complications, and shorter length of stay compared with conventional surgery for selected pts undergoing ileocolic resection for Crohn’s disease
Maartense et al^Citation35	Prospective, randomized controlled trial	60 Crohn’s disease pts (randomized for laparoscopic- assisted or open surgery)	Conversion rate: three pts(10%) Median operating time longer in laparoscopic compared with open surgery (115 vs 90 minutes; P<0.003) Hospital stay shorter in the laparoscopic group (5 vs 7 days; P=0.008) The number of pts with postoperative morbidity within the first 30 days differed between the laparoscopic and open group (10% vs 33%; P=0.028) No statistically significant difference in QoL between the groups during follow-up Median overall costs during the 3 months’ follow-up were significantly different (higher for open surgery; P=0.042)	Although QoL measured by SF-36 and GIQLI questionnaires was not different for laparoscopic-assisted compared with the open ileocolic resection, morbidity, hospital stay, and costs were significantly lower

Abbreviations: CT, computed tomography; FEV, forced expiratory volume; FVC, forced vital capacity; MRE, magnetic resonance enterography; pts, patients; QoL, Quality of Life; vs, versus; SF-36, Short Form (36) Health Survey; GIQLI, Gastrointestinal Quality of Life Index.

Table 3 Endoscopic techniques for diagnosis and treatment of stricturing Crohn’s disease, and synopsis of the main studies cited in this review

Authors	Study type	Number of patients	Main findings	Conclusions
De Angelis et al^Citation6	Prospective cohort study	26 Crohn’s disease pts (27 symptomatic strictures)	46 EBDs performed: technical success of 100% No procedure-related complications EBD success rate after first dilation: 81.5% Surgery avoided in 92.6% of the pts during the entire follow-up Surgical stricture resection required in two pts with no response to treatment (both with ileocecal strictures and fistula) No difference observed between the EBD success rate for naïve and postoperative Crohn’s disease-related strictures (P>0.05)	EBD: safe and effective procedure in the therapeutic management of Crohn’s disease- related strictures of any origin and dimension, in order to prevent surgery
Di Nardo et al^Citation18	Prospective cohort study	30 total, 16 with suspected Crohn’s disease and unspecific upper and lower GI endoscopies; 14 with longstanding Crohn’s disease and previous surgery	WCE: diagnostic of Crohn’s disease in three pts, and suggestive of Crohn’s disease in seven SBE allowed successful dilation of SB strictures in two pts with suspected Crohn’s disease and in three with long-lasting Crohn’s disease No complications occurred	SBE is a useful and safe endoscopic procedure for evaluating the SB in pediatric pts with suspected or established Crohn’s disease SBE: effective in the management of SB strictures SBE can be helpful in redirecting therapy in selected Crohn’s disease pts
Stienecker et al^Citation37	Prospective cohort study	25	Stricture relapses in eleven pts (46%) after a mean of 32 months 13 pts: successfully dilated, remained free of symptoms and stricture relapse over the complete follow-up period of >6.5 years Endoscopic re-dilatation successful in 64% of the pts with relapsing strictures Long-term success rate: 80%	EBD, repeated if necessary, is comparable to surgical treatment Relapse rate after a single balloon dilatation: higher after EBD than after surgical intervention In cases of multiple strictures, only one stricture should be dilated in each session Strictures of more than 5 cm in length should be treated surgically Fistulas originating from the stricture: contraindications for EBD
Chen et al^Citation42	Retrospective cohort study	90, including 30 (33.3%) with non-Crohn’s disease strictures and 60 (66.7%) with Crohn’s disease strictures	Pts with Crohn’s disease strictures were younger than those with non-Crohn’s disease strictures at the time of disease diagnosis (P<0.001) and at the time of the first dilation (P<0.001) No significant differences in characteristics of strictures and their endoscopic treatments between the Crohn’s disease and non-Crohn’s disease groups, except for the percentage of pts who were treated with intralesional corticosteroid injection (25.0% versus 6.7%, respectively, P=0.046) Pts in the two groups had similar technical success rates (94.0% versus 93.9%, respectively, P=1.00) Fewer pts in Crohn’s disease stricture group required emergency room visits due to obstructive symptoms from recurrence of disease (1.7% versus 16.7%, respectively, P=0.02) No procedure-related complications in either of the two groups	The efficacy and safety of EBD in the treatment of Crohn’s disease and non-Crohn’s disease strictures seems to be comparable
Scimeca et al^Citation38	Prospective cohort study	37 Crohn’s disease pts (39 strictures, 72 dilations) (Strictures: 97% post-surgical; 77% at ileocolonic anastomosis sites)	Success rate post first dilation: 51% No complications	Overall success rate of EBD (after subsequent dilations): 89%
Mueller et al^Citation43	Retrospective pt review (study time period: 1999–2008)	55 Crohn’s disease pts 93 EBDs for 74 symptomatic strictures	Endoscopic treatment: successful in 76% of the pts; – 24% of the pts required surgery All pts who underwent surgery had de novo strictures in the TI (significantly longer compared to the ileal strictures that responded to endoscopic treatment) Failure of endoscopic treatment was observed only in long-segment strictures in the TI	The long-term success of EBD depends on the type of the strictures, their location, and their length Statistically significant correlation between the need for surgery and stricture length (P=0.006), with average stricture requiring surgery being 7.5 cm vs 2.5 cm for the strictures amenable to endoscopic therapy
Gustavsson et al^Citation44	Retrospective cohort study	178 Crohn’s disease pts (776 dilations, of which 621 [80%] were on anastomotic strictures)	Cumulative proportions of pts undergoing surgery at 1, 3, and 5 yrs: 13%, 28%, and 36%, respectively Complication rate per procedure for all 178 pts: 41/776 (5.3%); bowel perforation (n=1, 1.4%); major bleeding requiring blood transfusion (n=8, 1.0%); minor bleeding (n=10, 1.3%); abdominal pain or fever (n=12, 1.5%) Ten pts underwent surgery due to complications (perforation, n=8, bleeding n=2) No procedure-related mortality	EBD: efficacious and safe alternative to surgical resection of intestinal strictures in Crohn’s disease At 5-year follow-up, 52% of pts required no further or one additional dilation only; 36% had undergone surgical resection Low complication frequency
East et al^Citation45	Prospective cohort study (pilot study comparing local quadrantic injection of triamcinolone [40 mg total dose] after EBD of Crohn’s disease ileocolonic anastomotic strictures vs saline placebo)	13 Crohn’s disease pts (seven treated with steroids, six with placebo)	Re-dilatation in one of six pts in the placebo group and in five of seven pts in the steroid group (P=0.06)	A single treatment of intrastricture triamcinolone injection did not reduce the time to re-dilatation after EBD of Crohn’s disease ileocolonic anastomotic strictures, and there was a trend toward a worse outcome
Di Nardo et al^Citation47	Prospective, randomized, double-blind, controlled trial	29 pediatric pts with stricturing Crohn’s disease (randomized to receive intrastricture injection of CS [n=15] or placebo [n=14] after EBD)	Re-dilatation required in one of the 15 pts receiving CS vs five of the 14 placebo pts Surgery needed in four of the placebo pts, but in none of those receiving CS The two groups statistically differed in the time free of re-dilatation (P=0.04), as well as for time free of surgery after EBD (P=0.02), which were worse in the placebo group compared to the CS group	In stricturing pediatric Crohn’s disease, intralesional CS injection after EBD is an effective strategy for reducing the need both for re-dilatation and surgery
Thienpont et al^Citation48	Retrospective cohort study	138 237 dilatations	Immediate success of a first dilatation: 97% Complication rate: 5% Recurrent obstructive symptoms led to new dilatation in 46% or surgery in 24% after a median follow-up of 5.8 yrs	Long term efficacy of EBD of Crohn’s disease outweighs the complication risk
Levine et al^Citation49	Retrospective review (all pts undergoing endoluminal stenting for Crohn’s disease strictures from 2001–2010)	Five	100% rate of technical and 80% rate of clinical success Mean follow-up: 28 months Mean long-term luminal patency: 34.8 months One complication involving re-obstruction, required surgical intervention No mortality	Endoluminal stenting of Crohn’s disease strictures is a safe and effective alternative to surgery which can provide lasting benefit in selected pts
Attar et al^Citation50	Prospective cohort study	Eleven (quiescent Crohn’s disease pts except for obstructive symptoms associated with intestinal stenosis of less than 50 mm length on enterography)	Stent placement: technically successful in ten pts Obstructive symptoms: relieved in six out of ten pts Two pts needed surgery related to the procedure Six downstream migrations Only one pt could have the stent extracted as scheduled on day 28 and remained symptom-free after 73 months of follow-up	Though stenting appears an effective technique in treating symptomatic Crohn’s disease intestinal strictures, the procedure is associated with a prohibitively high rate of spontaneous migrations and complications

Abbreviations: CS, corticosteroids; CT, computed tomography; EBD, endoscopic balloon dilatation; GI, gastrointestinal; MRE, magnetic resonance enterography; pts, patients; SB, small bowel; TI, terminal ileum; vs, versus; WCE, wireless capsule endoscopy; yrs, years; SBE, single balloon enteroscopy.

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