Safety and Efficacy of Endoscopic Dilatation of Strictures in Crohn s Disease Vinna An, Ashwinna Asairinachan, Michael Johnston, James Keck, Paul Salama, Steven Brown, Rodney Woods Department of Colorectal Surgery St Vincents Hospital Melbourne 0 1
Crohn s Strictures Vienna Classification of Crohn s Strictures constant luminal narrowing as demonstrated by radiologic, endoscopic or surgical examination combined with prestenotic dilatation and/or obstructive symptoms without evidence of penetrating disease. 1 Up to 80% of patients will require surgical intervention 2 1. Gasche, C., et al., A simple classification of Crohn's disease: report of the Working Party for the World Congresses of Gastroenterology, Vienna 1998. Inflamm Bowel Dis, 2000. 6(1): p. 8-15. 2. Greenstein, A.J., et al., Reoperation and recurrence in Crohn's colitis and ileocolitis Crude and cumulative rates. N Engl J Med, 1975. 293(14): p. 685-90.
Endoscopic Balloon Dilatation Technical success rates 86-90% 3, 4, 5 Long term efficacy 68% 4 Complication rate 2-10% 3, 4, 5 At 5 years 36% of patients required surgery 4, 6 3. Gustavsson, A., et al., Endoscopic dilation is an efficacious and safe treatment of intestinal strictures in Crohn's disease. Aliment Pharmacol Ther, 2012. 36(2): p. 151-8. 4. Hassan, C., et al., Systematic review: Endoscopic dilatation in Crohn's disease. Alimentary Pharmacology & Therapeutics, 2007. 26(11-12): p. 1457-64. 5. Ajlouni, Y., J.H. Iser, and P.R. Gibson, Endoscopic balloon dilatation of intestinal strictures in Crohn's disease: safe alternative to surgery. J Gastroenterol Hepatol, 2007. 22(4): p. 486-90. 6.Singh, V.V., P. Draganov, and J. Valentine, Efficacy and safety of endoscopic balloon dilation of
Study Aim Determine the technical and clinical success rates Complication rates Predictors of technical and clinical success, complications and need for surgery
Methodology Retrospective review of all patients attending St Vincents Hospital Melbourne between January 2008 and June 2013 with Diagnosis of Crohn s Disease Undergoing EBD of stricture both primary and anastomotic Boston Scientific Controlled Radial Expansion (CRE) TTS Balloon Dilator Distension time 1 minute Sequential increase in diameter Extent of dilatation at clinician discretion 12 Proceduralists 4 Colorectal Surgeons 8 Gastroenterologists
Data Collection Demographics Prior Surgery Dilatation Length of stricture on imaging where available Or on clinical estimate where imaging is not available Diameter of dilatation Technical Success Defined as the ability to traverse the stricture with the scope post dilatation Clinical Success Resolution of obstructive symptoms at post procedural review Complication rates Requiring admission or intervention
Demographic Data
Stricture Characteristics
Outcomes of Dilatation
Patients Requiring Surgery
Factors Predictive of Surgery
Factors Predictive of Surgery - Multivariate Analysis The only factors significant after binary logistic regression Clinical success at last dilatation Steroid therapy Stricture length and complication variables were accounted for by clinical success and were not included on the final analysis as a result. Date
Predictors of Clinical Success Patients with stricture lengths <50mm : 3.6 x more likely Patients dilated to 15mm or more: 1.8 x more likely
Impact of Anti TNF Agents = 22 = 24 p=0.74
Impact of Smoking on Strictures = 18 = 29 p=0.72
Discussion Technical, clinical success and complications rates comparable to the literature Surgical resection rate of 31.9% Longer strictures >50mm 8 out of 18 patients who had technical success did not improve clinically 44.4% Stricture length significant factor in clinical success and subsequent requirement for surgery
Limitations Retrospective series Selection bias Missing data Small complication numbers Difficult to draw meaningful conclusions Multiple operators No standardised procedure Heterogeneity in technique Endpoint of EBD is variable and at clinicians discretion Short study period with relatively short follow-up (median 14 months)
Conclusions EBD is safe for both primary and post-surgical strictures in Crohn s disease 32(68%) of patients successfully treated with EBD alone by the end of study period Is a viable approach to successfully treating strictures if: Strictures 50mm in length Dilatation to >15mm diameter Patient not requiring steroid therapy for control of disease May be considered as an adjunctive therapy to defer the need for surgery in a subset of patients with longer strictures.
References 1. Gasche, C., et al., A simple classification of Crohn's disease: report of the Working Party for the World Congresses of Gastroenterology, Vienna 1998. Inflamm Bowel Dis, 2000. 6(1): p. 8-15. 2. Greenstein, A.J., et al., Reoperation and recurrence in Crohn's colitis and ileocolitis Crude and cumulative rates. N Engl J Med, 1975. 293(14): p. 685-90. 3. Gustavsson, A., et al., Endoscopic dilation is an efficacious and safe treatment of intestinal strictures in Crohn's disease. Aliment Pharmacol Ther, 2012. 36(2): p. 151-8. 4. Hassan, C., et al., Systematic review: Endoscopic dilatation in Crohn's disease. Alimentary Pharmacology & Therapeutics, 2007. 26(11-12): p. 1457-64. 5. Ajlouni, Y., J.H. Iser, and P.R. Gibson, Endoscopic balloon dilatation of intestinal strictures in Crohn's disease: safe alternative to surgery. J Gastroenterol Hepatol, 2007. 22(4): p. 486-90. 6. Singh, V.V., P. Draganov, and J. Valentine, Efficacy and safety of endoscopic balloon dilation of symptomatic upper and lower gastrointestinal Crohn's disease strictures. Journal of Clinical Gastroenterology, 2005. 39(4): p. 284-90. 7. Dear, K.L. and J.O. Hunter, Colonoscopic hydrostatic balloon dilatation of Crohn's strictures. Journal of Clinical Gastroenterology, 2001. 33(4): p. 315-8. Acknowledgements Statistical analysis performed by Ms Anna To, University of Melbourne
Surgery vs EBD Alone
Type of Anastomosis