Endoscopic Balloon Dilation of Inflammatory Bowel Disease Strictures

Introduction

Stricture is a common complication in Crohn's disease (CD) and inflammatory bowel disease-related surgeries. The disease phenotype of CD is classified as non-stricturing/non-penetrating (B1), stricturing (B2), or penetrating (B3), by the Montreal Classification. A population-based study showed that 81% of the patients had non-stricturing/non-penetrating disease, 4.6%, had stricturing CD, and 14.0% had penetrating CD, at diagnosis. However, the natural history of CD progresses over time with the majority of patients eventually developing stricturing and/or penetrating complication. Reported cumulative frequencies for the development of either stricture or fistula in CD ranged from 34% to 52% at 5 years, and 40%–70% at 10 years after diagnosis. The majority of the patients would eventually need surgery.

Stricturing CD has been managed with medical, endoscopic and surgical therapies, or combinations. It is believed that pure fibrotic stricture is rare and the inflammatory component of a stricture may be treated by antiinflammatory and immunosuppressive medications. A fibrosis-dominant is usually not amenable to the medical therapy. As a matter of fact, CD patients with dominant stricturing or obstructive symptoms were excluded in the majority of published, large randomized controlled trials in antitumor necrosis (TNF), antiintegrin, or antiinterleukin biologics. Surgical approach, including bowel resection with anastomosis and stricturoplasty, is effective in the management of strictures. However, it is often associated with a high risk of postoperative complications, bowel loss, and disease recurrence.

Between medical and surgical therapy, the emerging endoscopic treatment modalities have recently got the momentum, emerging as a valid option for complications of IBD. In this chapter, we discuss the principle, preparation, and the techniques of endoscopic management for CD-associated stricture and fistula based on current literature and our experiences in a tertiary Endoscopy Center for Inflammatory Bowel Disease (IBD) at the Cleveland Clinic.

Indications

In 2013, we proposed a classification system of IBD-related strictures, based on etiology, length, severity, number, characters, and complexity. IBD-related strictures can be classified into following categories: (1) primary (disease associated) versus secondary (e.g., anastomosis, nonsteroidal antiinflammatory drugs, ischemia); (2) short (≤4 cm) versus long (>4 cm), based on the length; (3) single versus multiple; (4) mild versus moderate versus severe; (5) straight versus angulated; (6) with or without prestenotic bowel dilation; (7) inflammatory versus fibrotic versus mixed; (8) ulcerated versus nonulcerated; and (9) simple versus complex (with concurrent fistula or abscess). For detailed description in the classification of stricture please see Chapter 7 .

The main purpose of proposing this classification is to identify the most suitable lesion to be treated with the best modality. The most suitable strictures for EBD treatment are those: (1) being short (<4 cm); (2) single and straight; (3) with the absence of prestenotic bowel dilation; (4) fibrotic without much concurrent inflammation ( Table 13.1 ).

Techniques

Stricture is a common complication in patient with CD or IBD surgery. The mainstays of endoscopic treatment for CD stricture are EBD and needle-knife stricturotomy (please see a separate Chapter 14 ). The immediate technical success, defined as the successful passage of the endoscope of the treated stricture, was achieved in 45% in earlier small studies to close to 100% in later larger studies. The majority of the patients remained surgery free at the end of follow-up.

Successful performance of EBD requires training of the endoscopist. In addition, the endoscopy team should prepare patient, room setting, equipment, and suppliers. The endoscopist should prepare a roadmap on the nature of the stricture before inserting endoscope, by reviewing history, previous endoscopy and operative reports, and preprocedural abdominal imaging. Patient's bowel preparation is critical. Extreme cautions for aspiration in patients with stricture and partial bowel obstruction should be taken. The technical parts of EBD are discussed as follows:

Retrograde Versus Antegrade Dilation

The through-the-scope (TTS) hydrostatic balloon is most commonly used for the treatment of CD or non-CD–related strictures. There are two fashions of EBD, that is, retrograde and antegrade, which are applied for endoscopically traversable and nontraversable strictures, respectively. Retrograde EBD is always preferred, as the endoscopist can direct visualize the nature of stricture as well as the lumen and mucosa of the bowel segment proximal to the stricture. In retrograde EBD, the scope was pushed through the stricture, often with some resistance, followed by the introduction of the TTS balloon under direct endoscopic view. The scope was withdrawn along with the balloon. Once the balloon's waist is across the stricture, it is inflated. There should be some degree of bleeding after dilation ( Fig. 13.1 ).

EBD for high-grade or angulated strictures, not traversable to the endoscope, can be challenging. One of the concerns is the blind passage of the balloon through the tight stricture may result in barotrauma from the tip of the balloon, potentially leading to perforation. Antegrade, wire-exchange technique may be attempted. The wire-exchange technique will help the blind trauma. The antegrade, wire-exchange technique involves the gentle passage of a soft guidewire equipped in the balloon, by the endoscopy nurse, while the endoscopist holds the endoscope steady, with the tip of the balloon being targeted to the lumen of stricture. If the endoscopy nurse voices no resistance in passing the guidewire through the stricture, the endoscopist can assume that the wire is within the lumen of the bowel. The endoscopist can push the balloon catheter forward, while the endoscopy nurse pulls back. The balloon catheter-wire exchange takes place over the stricture. Once the balloon is secured across the stricture with a finger of the left hand against the console of endoscope, the wire needs to be pushed forward again out of the tip of the balloon, which help to reduce the risk for perforation from the trauma by the tip of the balloon, in case the short balloon slips forward upon insufflation.