Therapeutic resolution of focal, predominantly anastomotic Crohn’s disease strictures using removable stents: outcomes from a single-center case series in the United Kingdom

Published:February 18, 2020DOI:https://doi.org/10.1016/j.gie.2020.01.053

      Background and Aims

      Intestinal and anastomotic strictures in Crohn’s disease (CD) produce considerable morbidity. The development of surgery-sparing, endoscopic modalities for stricture resolution is essential. Removable stent therapy is emerging as an efficacious and safe means of stricture resolution. We present outcomes from the largest, single-center series of patients with CD undergoing removable self-expanding metal stent (SEMS) therapy to resolve focal intestinal strictures.

      Methods

      Patients with symptomatic CD were assessed with magnetic resonance enterography. Short (≤6 cm), fibrostenotic strictures of the terminal ileum or ileocolonic anastomoses were considered by a multidisciplinary team and put forward for stent therapy. Strictures were examined endoscopically and impassable strictures were treated with SEMSs. The Hanaro HRC-20-080-230 partially covered SEMS was used for all patients. Endoscopically inaccessible or inflammatory strictures were excluded. Stent retrieval was scheduled for 7 days after insertion. Therapeutic benefit was assessed with validated inflammatory bowel disease scoring tools.

      Results

      Twenty-one patients underwent 23 stent episodes, with 2 patients requiring repeat therapy in the follow-up period. Most treated strictures were anastomotic (19 of 21); 2 of 21 were de novo. Of those patients attending follow-up, 81% (13 of 16) reported symptom improvement or resolution; 88% (14 of 16) were in clinical remission at follow-up. Across all stent episodes, only 5 adverse events were noted (2 episodes of stent-related discomfort, 3 asymptomatic stent migrations). There were no direct stent-related adverse events such as perforation, impaction, or bleeding. No patient has required stricture-related surgery in the follow-up period (range, 3-50 months).

      Conclusions

      In this series, removable SEMS therapy for ileal and anastomotic strictures was found to be clinically efficacious. The absence of perforation events and need for stricture-related surgery are noteworthy. These results suggest that the efficacy of stent therapy in this context merits powered, head-to-head investigation with other modalities for stricture resolution.

      Graphical abstract

      Abbreviations:

      AE (adverse event), CD (Crohn’s disease), CDAI (Crohn’s Disease Activity Index), EBD (endoscopic balloon dilatation), ECM (extracellular matrix), HBI (Harvey-Bradshaw Index), IBD (inflammatory bowel disease), MDT (multidisciplinary team), MR (magnetic resonance), SEMS (self-expanding metal stent), TI (terminal ileum)
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      References

        • Rieder F.
        • Zimmermann E.M.
        • Remzi F.H.
        • et al.
        Crohn's disease complicated by strictures: a systematic review.
        Gut. 2013; 62: 1072-1084
        • Satsangi J.
        • Silverberg M.S.
        • Vermeire S.
        • et al.
        The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications.
        Gut. 2006; 55: 749
        • Annese V.
        • Daperno M.
        • Rutter M.D.
        • et al.
        European evidence based consensus for endoscopy in inflammatory bowel disease.
        J Crohns Colitis. 2013; 7: 982-1018
        • 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
        • 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
        • Li C.
        • Kuemmerle J.F.
        Mechanisms that mediate the development of fibrosis in patients with Crohn's disease.
        Inflamm Bowel Dis. 2014; 20: 1250-1258
        • Van Assche G.
        • Geboes K.
        • Rutgeerts P.
        Medical therapy for Crohn's disease strictures.
        Inflamm Bowel Dis. 2004; 10: 55-60
        • Kovacs E.J.
        • DiPietro L.A.
        Fibrogenic cytokines and connective tissue production.
        FASEB J. 1994; 8: 854-861
        • Pinchuk I.V.
        • Mifflin R.C.
        • Saada J.I.
        • et al.
        Intestinal mesenchymal cells.
        Curr Gastroenterol Rep. 2010; 12: 310
        • Cohen R.D.
        • Larson L.R.
        • Roth J.M.
        • et al.
        The cost of hospitalization in Crohn's disease.
        Am J Gastroenterol. 2000; 95: 524
        • Silverstein M.D.
        • Loftus E.V.
        • Sandborn W.J.
        • et al.
        Clinical course and costs of care for Crohn's disease: Markov model analysis of a population-based cohort.
        Gastroenterology. 1999; 117: 49-57
        • 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
        • 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
        • Diagmed
        Product Details - Hanaro Stent Devices 2018.
        (Available at:)
        • Dindo D.
        • Demartines N.
        • Clavien P.-A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205
        • Loras C.
        • Pérez-Roldan F.
        • Gornals J.B.
        • et al.
        Endoscopic treatment with self-expanding metal stents for Crohn's disease strictures.
        Aliment Pharmacol Ther. 2012; 36: 833-839
        • Attar A.
        Stent for Crohn’s disease strictures: which one and when?.
        Endosc Int Open. 2016; 04: E309-E310
        • Karstensen J.G.
        • Christensen K.R.
        • Brynskov J.
        • et al.
        Biodegradable stents for the treatment of bowel strictures in Crohn's disease: technical results and challenges.
        Endosc Int Open. 2016; 4: E296
        • Attar A.
        • Branche J.
        • Coron E.
        • et al.
        P608 New anti-migration extractible metal stents for Crohn's disease strictures: a nationwide GETAID-SFED cohort study.
        J Crohns Colitis. 2017; 11: S389-S390
        • Abbas M.A.
        • Kharabadze G.
        • Ross E.M.
        • et al.
        Predictors of outcome for endoscopic colorectal stenting: a decade experience.
        Int J Colorectal Dis. 2017; 32: 375-382
        • Padwick R.T.
        • Chauhan V.
        • Newman M.
        • et al.
        Endoscopic stenting of acutely obstructing colorectal cancer: a 10-year review from a tertiary referral centre.
        ANZ J Surg. 2016; 86: 778-781
        • Attar A.
        • Maunoury V.
        • Vahedi K.
        • et al.
        Safety and efficacy of extractible self-expandable metal stents in the treatment of Crohn's disease intestinal strictures: a prospective pilot study.
        Inflamm Bowel Dis. 2012; 18: 1849-1854
        • Levine R.A.
        • Wasvary H.
        • Kadro O.
        Endoprosthetic management of refractory ileocolonic anastomotic strictures after resection for Crohn's disease: report of nine-year follow-up and review of the literature.
        Inflamm Bowel Dis. 2012; 18: 506-512
        • Branche J.
        • Attar A.
        • Vernier-Massouille G.
        • et al.
        Extractible self-expandable metal stent in the treatment of Crohn's disease anastomotic strictures.
        Endoscopy. 2012; 44: E325-E326

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