Endoscopic Balloon Dilation

Colorectal anastomotic strictures are more likely to occur in the background of CD, surgical resection for diverticular disease, and malignancy. EBD is a safe and widely employed nonsurgical technique in the management of intestinal strictures related to CD. Studies performed have also shown EBD as a safe and effective method for the management of colorectal anastomotic strictures in non-CD patients. ^{, ,} The safety and efficacy of EBD in CD versus non-CD related strictures appear to be comparable. It was previously believed that non–CD-related strictures would respond better to EBD than CD strictures, because of the presence of relapsing inflammation in CD patients. However, in a large study of 90 patients comparing non-CD strictures and CD strictures, the two groups were comparable in terms of technical success rate and cumulative rates of surgery-free interval.

Index dilation procedure may not be sufficient in all cases, with repeat dilation or other endoscopic techniques or surgery needed in a variable proportion of cases. In general, more than 50% of patients will need two or more EBD sessions.

Technique

EBD is usually performed under sedation. Anterograde dilation is done for nontraversable strictures. The balloon sheath is passed with or without a wire across the stenosis. Retrograde dilation (preferred) is performed by passing the scope through the stricture along with the advancement of the balloon sheath, followed by withdrawal of the scope and subsequent insufflation of the balloon. Typically, a graded dilation is performed, and to achieve the greatest efficacy of dilation, a target size of the maximum balloon diameter is 18 to 20 mm. However, this may take multiple sessions. During dilation, the balloon should be secured in place as it tends to slip proximally. Routine use of intra-lesional corticosteroids is not recommended.

Patient Assessment and Consent

A methodical preparation for the procedure is important. The endoscopist must know the patient in detail, including (1) any comorbidities that may affect sedation administration; (2) medications, specifically antithrombotics which can increase the risk of bleeding; and (3) stricture characteristics that can influence technique selection and procedure duration. Consent should include a discussion about the risks and benefits of a potential endoscopic approach, as well as surgery.

Endoscopy Team and Equipment

Endoscopic techniques for stricture management require a team approach. Team members should be able to appreciate the reason for choosing a particular endoscopic technique and adapt and prepare for the given procedure. This includes the endoscopist, nursing staff, and the anesthesiologist, where necessary. The endoscopist and the nursing staff must be familiar with the available endoscopes, and clips including through-the-scope clip (TTSC), over-the-scope clip (OTSC), and hemostatic sprays or gels. EBD should only be performed with carbon dioxide insufflation. This will help as if a perforation does occur, a tension pneumoperitoneum can be avoided and the endoscopist can treat the area of concern effectively and safely with various clips if feasible.

Imaging

In approaching a patient with strictures, several factors are taken under consideration to achieve the maximum efficacy of the endoscopic therapy. All patients should have a preprocedure computerized tomography enterography or magnetic resonance enterography as recommended by the Global Interventional Inflammatory Bowel Disease Group. The length of the strictures, degree of inflammation, and the presence of significant prestenotic dilatation should be considered before planning endoscopic intervention. It is also recommended that patients undergo standard bowel preparation with a polyethylene glycol-based solution and split-dose regimen.

In general, for straight, short-segment strictures (less than 4–5 cm) EBD will result in optimal outcomes. For prestenotic dilatation length of more than 5 cm, and strictures longer than 4 to 5 cm, and multiple or angulated strictures, surgery may be preferred. In case of significant inflammatory changes based on an endoscopic exam (erythema, mucosal friability/spontaneous bleeding, frank ulcerations) medical management may have to be considered first. Fig. 13.1 shows the dilation of ileocolonic anastomotic stricture.

(A) Ileocolonic anastomotic stricture in a patient with Crohn’s disease. (B) Ileocolonic anastomotic stricture in a patient with Crohn’s disease after endoscopic balloon dilation.

Technical Success Rate

Technical success rate is defined as the ability to pass a colonoscope through the stricture after initial dilation. The technical success rate for the first EBD is excellent (86–100%). In a large systematic review of CD involving over 1000 patients, the technical success rate of EBD was 89% with a majority of the strictures (69%) anastomotic. A similar rate of technical success of 86% was shown in a study of 347 CD patients. Another study of 40 patients with colorectal anastomotic strictures reported a technical success rate of 100%. In terms of short-term clinical outcomes, in a systematic review of 12 studies the clinical efficacy of EBD, defined in terms of improvement of symptoms postdilation, was 80.8%. In patients who had a technically successful EBD, 93.3% had improvement in clinical symptoms. Anastomotic strictures appear to be associated with better long-term outcomes after EBD than de novo strictures. However, several other studies have not replicated these findings. ^,

Recurrence

Recurrence rates of EBD for colorectal strictures vary based on the duration of follow-up. Previous studies have shown a recurrence rate of (12.5–69%). In one of the largest studies on EBD for colorectal anastomotic strictures, a recurrence of 11%, 22%, and 25% at 1-, 3-, and 5-year follow-ups. Ding et al. in their study of 54 CD patients with anastomotic strictures showed that repeat EBD was required in almost 69% of the patients. The use of combination medical therapy was found to significantly decrease the need for repeat dilatation in Crohn’s anastomotic strictures. A stricture length of >40 mm was found to be a significant predictor for further dilatation. Recurrent strictures are usually managed with repeat EBD. In some cases, other alternative modes or a combination of techniques or even surgical resection may be needed. Atreja et al. in their study on anastomotic strictures in CD showed that EBD delayed the need for surgery by an average of 6.45 years.

Surgical Resection Rates

Subsequent surgical resection rates in those who have undergone EBD for colorectal anastomotic strictures were estimated to be around 18–35%. In a large systemic review, the need for surgical intervention after EBD of colorectal strictures from CD has been estimated to be around 27% over a median follow-up of 15 to 70 months. Another large single-center study from Cleveland Clinic documented a surgical rate of 35.7% (median follow-up of 3.9 years) in CD patients with ileocolonic anastomotic strictures, initially treated with EBD. A study from the UK on EBD for colorectal anastomotic strictures demonstrated a surgical resection rate of up to 18%.

Adverse Events

Perforation and bleeding are the two major adverse events seen with EBD in the management of anastomotic colorectal strictures. Other adverse events including fistula/abscess are more likely to be related to the underlying disease process than direct procedure-related. Overall adverse event rates were 1.5% to 15.7% on follow-up. Overall perforation rates were 0.4% to 2.7% ( Table 13.1 ). No studies recorded direct procedure-related mortality.

Table 13.1

Endoscopic Balloon Dilation in the Management of Colorectal Strictures

Study	Total Patients (n)	Etiology of Colorectal Anastomotic Strictures	Technical Success	Recurrence Rates	Adverse Events	Need for Other Modalities of Management During Follow Up
Biraima et al.	76	Diverticular disease (45%); neoplasia (35%); IBD (3%) others (17%)	97%	11% at 1 yr; 22% at 2 years; 25% at 5 yr follow-up	1.3%—perforation 14.4%—minor bleeding	1 patient required stent; another patient required colostomy
Ding et al.	54	All were Crohn’s patients with anastomotic strictures	89%	Repeat endoscopic dilatation was required in 69% of the patients, with a median time to first repeat dilatation of 23 months	1 patient had perforation	18% needed surgical resection ultimately
Delaunay-Tardy et al.	27	Colon carcinoma (40.7%), colorectal adenoma (8.5%), complicated diverticular disease (51.8%)	96.3%	59.3% of the patients needed repeat procedures	1 patient (1.9%) had bowel perforation	Surgery was necessary for 3 patients. 3 patients were treated with a self-expanding metal stent.
Chan et al.	40	Malignancy (92.5%) IBD (5%) Diverticular disease (2.5%)	100%	5 patients (12.5%) developed restenosis and underwent repeat balloon dilation during median follow-up period was 56 months	1 patient (2.5%) had micro perforation managed conservatively	None
Lian et al.	185	All were CD patients with ileo-colic anastomotic stricture	90.8%	47/185 patients (25.4%) had failure of initial or repeated EBD and needed surgery	2.7% perforation rate. 5.9% developed fistula or abscess	35.7% underwent salvage surgery because of failure of nonoperative management
Lee et al.	30	IBD strictures—both CD and UC (19% anastomotic)	86.7%	recurrence in 8 (26.7%) who needed repeat EBD	2 pts (6.7%) had perforation during repeat EBD	1 patient needed surgery for recurrent obstructive symptoms during follow up
Ajlouni et al.	37	All were CD (31 anastomotic and 52 primary strictures)	90%	8 patients (21.6%) needed at least a second dilation	1 pt developed abscess needing surgery.	2 patients eventually needed surgery for recurrent obstruction and 1 needed surgery for abscess
Andújar et al.	187	All were IBD (41% anastomotic strictures)	79.5%	49.7% requiring more than one dilation	Overall adverse event rate was 8.8% (35/400 dilations) including perforations 1.3% (5/400)	Surgical resection was required in 20.9% (39/187)
Mueller et al.	55	CD symptomatic strictures (23% anastomotic strictures)	95%	Successful in 76% of the patients during an observation period of 44 (1–103) months	Perforation rate 1.8% per patient and 1.1% per procedure	24% required surgery
Stienecker et al.	25	CD strictures (13/31 strictures were ileocolonic anastomotic strictures)	96.7%	Relapse rate over a mean follow-up of 81 months was 46%, but 64% of relapsing strictures could be successfully dilated again. Long-term success rate of balloon dilation was 80% over a mean follow-up period of 81 months	Perforation in 1 patient during second dilation	In 4 patients was surgery required during the follow-up period
Bhalme et al.	79	48-ileocolonic anastomotic strictures, 31-denovo strictures	95%	43% (34 patients) achieved long-term symptomatic relief from further episodes of EBDs	No major events 4% (3 patients) with minor adverse event (2 minor bleeding and 1 vasovagal syncope)	18 (23%) patients required surgery
Gustavsson et al.	178	CD, 80% of dilations were for anastomotic strictures	89%	At 5-year follow-up, 52% of patients had required no further intervention or 1 additional dilation only	Overall 41/776 (5.3%), bowel perforation (n = 11, 1.4%), major bleeding (n = 8, 1.0%), minor bleeding (n = 10, 1.3%) and abdominal pain or fever (n = 12, 1.5%)	Cumulative proportions of patients undergoing surgery at 1, 3 and 5 years were 13%, 28%, and 36%
Ferlitsch et al.	46	All were CD, 23 Ileocolonic anastomosis, 16-nonanastomotic/surgically untreated. 7 patients did not undergo dilation	95%	2 patients developed recurrent symptoms needing surgery within 1 year. During long term follow-up (median 21 months), repeat interventions were needed in 24/39(62%)	Perforation—3%	Surgery was needed in 33% of cases during a median follow up of 21 months
Sivasailam et al.	99	All were CD with 51.5% anastomotic strictures, rest were ileal, colonic or anorectal strictures	75%	52% needed atleast 1 subsequent dilation at a median of 2 months, and 40% required more than 1 repeat dilation	3.3%	33% needed surgical intervention at a median of 5 months
Chang et al.	26	All CD strictures.	83.3%	6 pts developed recurrence of strictures	2.4%	26.9%—7/26 pts underwent surgery
Winder et al.	64	All were CD, 50% were anastomotic strictures	84.7%	–	5% (6 perforations and 1 major bleeding)	32.8% needed surgery during follow-up of 1–9 years
Shivashankar et al.	273	All CD with 52.1% anastomotic and 47.9% de novo strictures	91.3%	41.8% (114 patients) needed second dilation	2.1% (6/286 procedures—4 perforations, 1 bleeding, 1 abdominal pain)	30% (82 pts) needed surgery during 5 year follow up
Reutemann et al.	135	All CD, 38.5% were anastomotic	74%	In those needing surgery, 25.8% required 2 dilations, and 12.4% required 3 or more; In those who avoided surgery, 25.8% needed 2 and 12.4% needed more than 3 dilations	0.74%—1 perforation	38 pts (28.1%) underwent surgery with a median time to surgery of 14.7 months
Lian et al.	176	All were CD- ileocolonic anastomotic strictures	90.3%	–	1.1%	51.7% (91 patients) needed surgery during a median follow up of 1.8 years
Chen and Shen 13	90	66.7% CD 33.3% Non-CD	94%	Additional endoscopic and/or surgical intervention were required in 58 patients (64.4%)	0%	25 patients (27.8%) needed surgery during a mean follow-up of 50 months
Atreja et al.	128	All CD, 47.9% anastomotic strictures	83%	58.6%—58 patients needed more than 2 dilations 94 patients (73.4%) needed surgery or repeat dilation	3.1% per pt and 0.93% per procedure Total 3 perforations, 1 major bleeding	32.8%—42 patients underwent surgery during follow up
Endo et al.	30	All CD	93.6%	60.5% required repeat EBD	10.6%	37% needed surgery during follow up of 26 months
De’Angelis et al.	26	All CD	100%	13 patients (50%) required repeat dilation	0%	2 patients needed surgical interventions
Van Assche et al.	138	All were CD	97.1%	46% (64/138) needed repeat dilation	5.1% of all dilation	24% needed surgery during follow up-median 5.8 years

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