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Endoscopic stricturotomy versus ileocolonic resection in the treatment of ileocolonic anastomotic strictures in Crohn’s disease

  • Nan Lan
    Affiliations
    Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA

    Department of Colorectal Surgery and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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  • Luca Stocchi
    Affiliations
    Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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  • Conor P. Delaney
    Affiliations
    Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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  • Tracy L. Hull
    Affiliations
    Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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  • Bo Shen
    Correspondence
    Reprint requests: Bo Shen, MD, FASGE, The Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute-A31, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195.
    Affiliations
    Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Published:January 30, 2019DOI:https://doi.org/10.1016/j.gie.2019.01.021

      Background and Aims

      Endoscopic stricturotomy (ESt) is a novel technique in the treatment of anastomotic strictures in Crohn’s disease (CD). The aim of this study was to compare the outcome of patients with ileocolonic anastomotic stricture treated with ESt versus ileocolonic resection (ICR).

      Methods

      This historical cohort study included consecutive CD patients with ileocolonic anastomotic stricture treated with ESt or ICR from 2010 to 2017. The primary outcomes were surgery-free survival and postprocedural adverse events.

      Results

      Thirty-five patients treated with ESt and 147 patients treated with ICR were analyzed. Median follow-up was .8 years (interquartile range [IQR], .2-1.7) and 2.2 years (IQR, 1.2-4.4) in the ESt and ICR groups, respectively (P < .001). Subsequent stricture-related surgery was needed in 4 patients (11.3%) receiving ESt and in 15 patients (10.2%) receiving ICR (P = .83). Kaplan-Meier analysis also showed no statistical difference regarding surgery-free survival between the 2 groups (P = .24). Procedure-related major adverse events were documented in 5 of 49 patients (10.2% per procedure) undergoing ESt and 47 patients (31.9%) undergoing ICR (P = .003). Risk factors for decreased surgery-free survival on multivariate analysis included preprocedural corticosteroids (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.0-8.1), multiple strictures (HR, 4.9; 95% CI, 1.7-14.2), and increased disease-related hospitalizations (HR, 4.0; 95% CI, 1.2-13.0).

      Conclusions

      With the limitation of a shorter follow-up, ESt achieved comparable surgery-free survival with a decreased morbidity when compared with ICR.

      Graphical abstract

      Abbreviations:

      CD (Crohn’s disease), CI (confidence interval), EBD (endoscopic balloon dilation), ESt (endoscopic stricturotomy), HR (hazard ratio), IBD (inflammatory bowel disease), ICA (ileocolonic anastomosis), ICR (ileocolonic resection), IQR (interquartile range)
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      References

        • Cosnes J.
        • Cattan S.
        • Blain A.
        • et al.
        Long-term evolution of disease behavior of Crohn's disease.
        Inflamm Bowel Dis. 2002; 8: 244-250
        • Li Y.
        • Stocchi L.
        • Shen B.
        • et al.
        Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease.
        Br J Surg. 2015; 102: 1418-1425
        • Rutgeerts P.
        • Geboes K.
        • Vantrappen G.
        • et al.
        Natural history of recurrent Crohn's disease at the ileocolonic anastomosis after curative surgery.
        Gut. 1984; 25: 665-672
        • Bharadwaj S.
        • Fleshner P.
        • Shen B.
        Therapeutic armamentarium for stricturing Crohn's disease: medical versus endoscopic versus surgical approaches.
        Inflamm Bowel Dis. 2015; 21: 2194-2213
        • Wu X.
        • Mukewar S.
        • Kiran R.P.
        • et al.
        Surgical stricturoplasty in the treatment of ileal pouch strictures.
        J Gastrointest Surg. 2013; 17: 1452-1461
        • Tjandra J.J.
        • Fazio V.W.
        Strictureplasty for ileocolic anastomotic strictures in Crohn's disease.
        Dis Colon Rectum. 1993; 36: 1099-1103
        • De Cruz P.
        • Kamm M.A.
        • Hamilton A.L.
        • et al.
        Crohn's disease management after intestinal resection: a randomised trial.
        Lancet. 2015; 385: 1406-1417
        • Van Assche G.
        • Geboes K.
        • Rutgeerts P.
        Medical therapy for Crohn's disease strictures.
        Inflamm Bowel Dis. 2004; 10: 55-60
        • Lamazza A.
        • Fiori E.
        • Sterpetti A.V.
        • et al.
        Self-expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer.
        Colorectal Dis. 2014; 16: O150-O153
        • Shen B.
        • Lian L.
        • Kiran R.P.
        • et al.
        Efficacy and safety of endoscopic treatment of ileal pouch strictures.
        Inflamm Bowel Dis. 2011; 17: 2527-2535
        • Shen B.
        • Fazio V.W.
        • Remzi F.H.
        • et al.
        Endoscopic balloon dilation of ileal pouch strictures.
        Am J Gastroenterol. 2004; 99: 2340-2347
        • Lian L.
        • Stocchi L.
        • Remzi F.H.
        • et al.
        Comparison of endoscopic dilation vs surgery for anastomotic stricture in patients with Crohn's disease following ileocolonic resection.
        Clin Gastroenterol Hepatol. 2017; 15: 1226-1231
        • Katsinelos P.
        • Mimidis K.
        • Paroutoglou G.
        • et al.
        Needle-knife papillotomy: a safe and effective technique in experienced hands.
        Hepatogastroenterology. 2004; 51: 349-352
        • Fukatsu H.
        • Kawamoto H.
        • Harada R.
        • et al.
        Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy.
        Surg Endosc. 2009; 23: 2066-2072
        • Hordijk M.L.
        • Siersema P.D.
        • Tilanus H.W.
        • et al.
        Electrocautery therapy for refractory anastomotic strictures of the esophagus.
        Gastrointest Endosc. 2006; 63: 157-163
        • Lan N.
        • Shen B.
        Endoscopic stricturotomy with needle knife in the treatment of strictures from inflammatory bowel disease.
        Inflamm Bowel Dis. 2017; 23: 502-513
        • Lan N.
        • Shen B.
        Endoscopic stricturotomy vs. balloon dilation in the treatment of anastomotic strictures in Crohn’s disease.
        Inflamm Bowel Dis. 2018; 24: 897-907
        • Lian L.
        • Stocchi L.
        • Shen B.
        • et al.
        Prediction of need for surgery after endoscopic balloon dilation of ileocolic anastomotic stricture in patients with Crohn's disease.
        Dis Colon Rectum. 2015; 58: 423-430
        • Katayama H.
        • Kurokawa Y.
        • Nakamura K.
        • et al.
        Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria.
        Surg Today. 2016; 46: 668-685
        • Paine E.
        • Shen B.
        Endoscopic therapy in inflammatory bowel diseases (with videos).
        Gastrointest Endosc. 2013; 78: 819-835
        • Shen B.
        • Kochhar G.
        • Navaneethan U.
        • et al.
        Role of interventional inflammatory bowel disease in the era of biological therapy: a position statement from the Global Interventional IBD Group.
        Gastrointest Endosc. 2019; 89: 215-237
        • Chen M.
        • Shen B.
        Endoscopic therapy in Crohn's disease: principle, preparation, and technique.
        Inflamm Bowel Dis. 2015; 21: 2222-2240
        • Louis E.
        • Collard A.
        • Oger A.F.
        • et al.
        Behaviour of Crohn's disease according to the Vienna classification: changing pattern over the course of the disease.
        Gut. 2001; 49: 777-782
        • Shen B.
        Damage control: Management of procedure-associated complications.
        in: Shen B. Interventional Inflammatory Bowel Disease. Elsevier, Cambridge, MA2018: 329-351
        • Navaneethan U.
        • Lourdusamy V.
        • Njei B.
        • et al.
        Endoscopic balloon dilation in the management of strictures in Crohn’s disease: a systematic review and meta-analysis of non-randomized trials.
        Surg Endosc. 2016; 30: 5434-5443
        • Gao D.
        • Hu B.
        • Pan Y.
        • et al.
        Feasibility of using wire-guided needle-knife electrocautery for refractory biliary and pancreatic strictures.
        Gastrointest Endosc. 2013; 77: 752-758
        • Samanta J.
        • Dhaka N.
        • Sinha S.K.
        • et al.
        Endoscopic incisional therapy for benign esophageal strictures: technique and results.
        World J Gastrointest Endosc. 2015; 7: 1318-1326
        • Lee J.K.
        • Van Dam J.
        • Morton J.M.
        • et al.
        Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery.
        Am J Gastroenterol. 2009; 104: 575-582
        • Chen M.
        • Shen B.
        Endoscopic needle-knife stricturotomy for nipple valve stricture of continent ileostomy (with video).
        Gastrointest Endosc. 2015; 81: 1287-1288
        • Nyabanga C.T.
        • Veniero J.C.
        • Shen B.
        Rendezvous computed tomography-assisted endoscopic needle-knife stricturotomy for sealed outlet of diverted large bowel.
        Endoscopy. 2015; 47: E625-E626
        • Li Y.
        • Shen B.
        Doppler ultrasound-guided endoscopic needle knife treatment of an anastomotic stricture following subtotal colectomy.
        Endoscopy. 2011; 43: E343
        • Khoury W.
        • Strong S.A.
        • Fazio V.W.
        • et al.
        Factors associated with operative recurrence early after resection for Crohn's disease.
        J Gastrointest Surg. 2011; 15: 1354-1360
        • Vogel J.
        • Moreira A.
        • Baker M.
        • et al.
        CT enterography for Crohn's disease: accurate preoperative diagnostic imaging.
        Dis Colon Rectum. 2007; 50: 1761-1769

      Linked Article

      • Postoperative Crohn’s disease management: still learning and evolving
        Gastrointestinal EndoscopyVol. 90Issue 2
        • Preview
          Despite advancement in the treatment of Crohn’s disease since the introduction of the first biologic in the late 1990s, Crohn’s disease remains a chronic and often relapsing and remitting disease.1 It is estimated that nearly half of patients will require a bowel resection within the first two decades from the time of diagnosis, and an ileocolic resection remains the most common surgical procedure performed.2,3 Postoperative disease recurrence is common, and the management of such adverse events remains a challenging clinical question for clinicians.
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