Endoscopic Dilation is an Efficacious and Safe Treatment of Intestinal Strictures in Crohn's Disease

A. Gustavsson; A. Magnuson; B. Blomberg; M. Andersson; J. Halfvarson; C. Tysk

Disclosures

Aliment Pharmacol Ther. 2012;36(2):151-158. 

In This Article

Results

Demographics of All Patients

During 1987–2009, 178 patients (94 women) underwent endoscopic balloon dilation due to bowel strictures causing obstructive symptoms. The median (IQR) age at diagnosis of CD was 29 (20–39) and at first dilation 45 (37–56) years. Demographics and clinical characteristics of the patients are shown in Table 1 .

Demographics of Patients From the Primary Catchment Area

In total, 125 (70%) patients resided in the primary catchment area of the hospital. The median age at diagnosis of CD was 31 (22–42) years and at first dilation 46 (38–57) years. Demographics and clinical characteristics of the patients are shown in Table 1 .

Endoscopic Dilation in all Patients

In 178 patients, a total of 776 dilations were made; 155 (20%) were performed on de novo strictures and 621 (80%) on anastomotic strictures. Six hundred twenty-five (81%) procedures were performed in patients with symptomatic strictures, and 151 (19%) dilations in patients with strictures causing no clinical symptoms. Details of strictures and dilation procedures are shown in Table 2 . Data on length of stricture were not accessible retrospectively. In a few dilations, local corticosteroid injection (n = 9) or incision with a papillotome (n = 7) was used as a complement. The dilation procedure was done with sedation with benzodiazepines and/or opioid analgesics in 726 (94%) procedures, general anaesthesia in 11 (1%) and in 37 (5%) procedures no sedation was given (data missing in two patients).

Endoscopic Dilation in Patients From Primary Catchment Area

In 125 patients, a total of 594 dilations were made; 107 (18%) were performed on de novo strictures and 487 (82%) on anastomotic strictures. Four hundred seventy-nine (81%) of procedures were performed in patients with symptomatic strictures and 115 (19%) dilations in patients with strictures causing no obstructive symptoms. Details of strictures and dilation procedures are shown in Table 2 .

Outcome of Endoscopic Dilation in All Patients

Technical success was achieved in 689/776 dilations (89%). Complication rate per procedure was 41/776 (5.3%), which includes 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%) ( Table 3 ). Ten patients underwent surgery due to complications (perforation n = 8, bleeding n = 2). Significantly more complications (20/216, 9.3%) occurred with use of the largest balloon (diameter of 25 mm) compared with use of smaller balloons (diameter of ≤20 mm) (17/489, 3.5%) (P < 0.01). In four complications, the size of the balloon was not known. No difference was found between the two groups with respect to complications requiring surgery [4/216 (1.9%) vs. 4/489 (0.8%) (P = 0.23)]. In two complications requiring surgery, the size of the balloon was not known. Complications did not differ between patients dilated due to de novo (5/155, 3.2%) or anastomotic strictures (36/621, 5.8%) (P = 0.20). There was no procedure-related mortality.

Outcome of Endoscopic Dilation in Patients from Primary Catchment Area

Technical success, analysed in all 125 patients, was achieved in 533/594 dilations (90%) and clinical success in 370 (77%) of 479 dilations performed on strictures causing clinical obstructive symptoms.

Of 125 patients, 83 patients underwent repeated dilations due to recurrent symptomatic strictures only. A subset of 75 patients, with a follow-up of ≥5 years, underwent 246 dilations. The cumulative proportion of patients undergoing no further invention, repeated dilations, or surgery each year during 5-year follow-up after index dilation is shown in Figure 1. No further intervention or one additional dilation only was needed in 60/75 (80%) patients during the first year after the index dilation, and at 3 and 5 years corresponding figures were 43/75 (57%) and 39/75 (52%) (Figure 1). Cumulative proportions of patients undergoing surgery at 1, 3 and 5 years were 13%, 28% and 36%. Time to surgery is shown in Figure 2. Probability of surgery-free survival did not differ between dilations of de novo strictures compared with anastomotic strictures (P = 0,86) (Figure 2). There was no bowel malignancy diagnosed in any patient during follow-up.

Figure 1.

Cumulative proportions of patients undergoing no further invention, repeated dilations or surgery during 5-year follow-up following index dilation. This analysis is restricted to 75 patients having repeated dilations only of strictures causing symptoms of bowel obstruction, and with a follow-up of 5 years or more.

Figure 2.

Kaplan–Meier plot showing probability of surgery-free survival in relation to time after index dilation in patients with anastomotic or de novo strictures (P = 0.86). This analysis is restricted to 83 patients having repeated dilations only of strictures causing symptoms of bowel obstruction.

Among the 83 patients undergoing dilations due to symptomatic stricture only, the indication for surgery was technical failure at the dilation procedure (n = 7), patient's request or doctor's advice due to need of frequent dilations (n = 11), proximal stricture not identified at time of dilation (n = 10), active inflammation (n = 5), complication related to dilation procedure (n = 2) and miscellaneous (n = 8).

Of 125 patients from the primary catchment area, 42 patients had during follow-up repeated dilations of bowel stricture that was clinically asymptomatic. These patients underwent a total of 342 procedures, of which 113 (33%) were performed due to an asymptomatic stricture. This group is very heterogeneous, and analyses of clinical outcome will thus not be possible, except for time to subsequent surgical procedure. During follow-up, 22/42 (52%) patients were operated after 6 (2–10) years.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....