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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References

Aim : To evaluate the safety and long-term efficacy of per-endoscopic hydrostatic balloon dilatation in a retrospective series of patients with Crohn's disease.

Methods : Thirty-eight patients had balloon dilatation for intestinal symptomatic strictures which were located as follows: ileo-colonic (26) or colocolic (2) anastomosis, colon (4), ileum (3), proximal jejunum (1) and ileo-caecal valve (5); three patients had two strictures accessible to dilatation. The mean length of the strictures was 2.1 cm (s.d., 0.3 cm).

Results: Thirty-two of the 38 patients were successfully dilated and followed for a median of 22.8 months (0.2–103 months) until surgery or last news. The probabilities of obstructive symptom recurrence were 36% at 1 year and 60% at 5 years. Twelve patients had a second dilatation, and three a third. The probabilities of surgery for stricture were 26% at 1 year and 43% at 5 years. Results were not influenced by age, sex, activity of the disease, passage of the stricture by the colonoscope or concomitant medical therapies. Complications occurred in 9.4% of the 53 dilatation sessions, with only one perforation.

Conclusions : Hydrostatic balloon dilatation is effective for Crohn's symptomatic strictures, and can avoid or postpone surgery, with an acceptable rate of complications.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References

The course of Crohn's disease is often complicated by gastrointestinal strictures. Symptomatic strictures resistant to medical therapy usually require surgery and represent a fifth of surgical indications in patients with Crohn's disease.1 Unfortunately, the disease commonly recurs after resection, sometimes leading to repeated surgery.2 Hydrostatic balloon dilatation through the scope has been proposed as an alternative to surgery in strictures accessible to endoscopy.3, 4 However, there is a paucity of data concerning the long-term results of this endoscopic treatment (Table 1). In this paper, we report our results on the safety and long-term efficacy of hydrostatic balloon dilatation for symptoms of intestinal obstruction and on the need for surgery in a retrospective series of patients with Crohn's disease treated for symptomatic intestinal strictures.

Table 1.  Published series reporting the results of endoscopic balloon dilatation for intestinal Crohn's strictures (case reports were excluded)
ReferenceNo. of patients (no. of dilatations)Stricture location*Success (%)Complications (%) (serious)Follow-up (years)Symptom recurrence (%)Surgery for stricture (%)
  • *

     C, colon; D, duodenum; G, stomach; I, ileum; IC, ileo-colonic; J, jejunum.

  • † 

    Including perforation.

  • ‡ 

    In patients successfully dilated.

  • § 

    Kaplan–Meier analysis.

Williams and Palmer57D, C, IC7101.5–2.0
Blomberg et al.327 (137)667 (7)1.233
Junge and Zuchner610I, C, IC8191.413
Ramboer et al.713 (52) (+ steroid injection)I, C, IC03.90
Couckuyt et al.455 (78)IC9011 (10)2.862 at 5 years38 at 5 years
Matsui et al.85G, D10004.21000
Raedler et al.930 (azathioprine +  budesonide vs. placebo trial)C, IC1.020 vs. 53
Dear and Hunter1022 (71)03.727
Our series38 (53)J, I, C, IC849.4 (2.0)2.760 at 5 years§43 at 5 years§

Patients

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References

The study included 38 consecutive patients (20 males, 18 females), with a mean age of 33.7 ± 9.6 years, who had hydrostatic balloon dilatation for Crohn's disease stricture between 1991 and 2000 in our two academic institutions. Ano-rectal strictures were usually dilated without endoscopy and were not included in this series. The duration of Crohn's disease before dilatation was 10.2 years (s.d., 6.9 years). Previous surgery for Crohn's disease had been performed in 30 of the 38 patients (78%). Seventeen patients (45%) were smokers. The location of the disease was as follows: ileum (15), ileum and colon (18), colon (2), jejunum (1), ileum and jejunum (2). Six patients had ano-perineal disease, six had extra-intestinal manifestations of Crohn's disease and one had both. Disease activity, defined by abdominal pain, diarrhoea, decrease in well-being and biological signs of inflammation,4 was present at the time of dilatation in 21 of the 38 patients (55%). All patients had symptoms of stricture, and were considered for surgery because of resistance to medical treatment: intermittent post-prandial abdominal cramps (n = 28), partial (n = 9) or complete (n = 1) intestinal obstruction. At the time of dilatation, 14 patients (10 steroid-dependent or steroid-resistant) were taking steroids and 13 were taking immunosuppressive therapy (azathioprine 2–2.5 mg/kg per day, n = 12; methotrexate 25 mg/week, n = 1).

Of the 38 patients, three had two strictures accessible to per-endoscopic dilatation (n = 41 strictures). The location of the strictures was as follows: ileo-colonic anastomosis (n = 26), colocolic anastomosis (n = 2), colon (n = 4), ileum (n = 3), proximal jejunum (n = 1) and ileo-caecal valve (n = 5). The length of the stricture measured on barium X-rays was 2.1 cm (s.d., 0.3 cm) (range, 0.5–7.5 cm), and the diameter of the stricture before dilatation was 6 mm (s.d., 2 mm). The strictures could not be passed by the adult colonoscope (14 mm) before dilatation. Symptom recurrence determined during follow-up was defined by the recurrence of the symptoms of stricture given above.

Hydrostatic dilatation procedures

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References

Colonoscopies with hydrostatic balloon dilatation were performed under general anaesthesia. Microvasive Rigiflex™ through the scope balloons (Boston Scientific Microvasive, MA, USA) were used in all patients. Three types of balloon were used: 50 mm (length) × 18 mm (diameter), 80 mm × 18 mm and 80 mm × 25 mm. Balloons were filled with water to a pressure of 35 psi under visual control and pressure monitoring using the Alliance Integrated Inflation System™ (Boston Scientific, Microvasive, MA, USA). Fluoroscopic control was never used. After filling, the pressure inside the balloon was maintained for at least 2 min, and the dilatation was repeated once or twice, when necessary, after the passage of the adult colonoscope through the stricture was attempted. After the dilatation procedure, 15 patients were given corticosteroids and 18 immunosuppressants (azathioprine, n = 17; methotrexate, n = 1).

Statistical analysis

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References

The probabilities of symptom recurrence after the first dilatation session and of surgery after one or more sessions were estimated using the Kaplan–Meier method. Univariate (log rank test) and multivariate (Cox) analysis were performed to study the influence of the following variables on symptom recurrence and surgery: type of stricture (primary or anastomotic), length and diameter of the stricture, sex, age, activity of the disease, presence of ulcers on the stricture and smoking habits. The results were expressed as the mean or median (range). Probability estimates were given with the 95% confidence interval (95% CI); P < 0.05 was considered to be significant. Although three of the 38 patients had two strictures, the data relating to individual strictures were treated as independent observations.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References

Of the 38 patients, hydrostatic balloon dilatation was technically successful with immediate relief of symptoms in 32 (84%). After dilatation, passage of the stricture was possible with an adult colonoscope in 18 patients (56%). Balloon dilatation failed in six cases because of a too narrow stricture (n = 3, ileo-colonic anastomosis), angulations preventing the passage of the deflated balloon through the stricture (n = 2, ileo-colonic anastomosis and ileo-caecal valve), or failure of the balloon to advance through the endoscope (n = 1, primary ileal stenosis). Three of the six patients were operated on within the following weeks, and the other three were lost to follow-up.

For the 32 patients successfully dilated, the median duration of follow-up after balloon dilatation until surgery or the last news was 22.8 months (0.2–103 months). The probabilities of symptomatic stricture recurrence in these patients were 36% at 1 year, 44% at 2 years and 60% at 5 years (Figure 1). Because of symptom recurrence, 12 patients had a second successful dilatation session, and three a third. The median interval between the first and second dilatation sessions was 4.7 months (1–14 months), and 5.6 months between the second and third sessions. Overall, the success rate of the dilatation technique was 47 of the 53 sessions (89%).

image

Figure 1. Probability of remaining free of symptom recurrence in the 32 patients (pts) successfully dilated after the first session (Kaplan–Meier estimate).

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Surgery was performed in 12 of the 32 successfully dilated patients due to recurrence of obstructive symptoms in 11 and post-dilatation perforation in one. The probabilities of surgery were 26% at 1 year, 38% at 2 years and 43% at 5 years (Figure 2).

image

Figure 2. Probability of remaining free of surgery for stricture in the 32 patients (pts) successfully dilated after the first session (Kaplan–Meier estimate); 12 patients had two and three patients had three dilatation sessions.

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In both the univariate and multivariate analyses, there was no influence of the following variables on symptom recurrence or the need for surgery: age, sex, type of stricture (primary or anastomotic), length or diameter of stricture, disease activity at the time of dilatation, presence of ulcers on the stricture, possibility of passage through the stricture by an adult colonoscope after dilatation, and steroids or immunosuppressive therapy after dilatation. Smoking status showed prognostic value for the need for surgery, but not for symptom recurrence, with a P value of 0.14 in univariate analysis and 0.044 in multivariate analysis (Cox), with a hazard ratio of 4.13 (1.04–17.7).

Complications occurred in five of the 53 dilatation sessions (9.4%): one intra-peritoneal perforation occurred after a second dilatation session requiring surgery after a 24-h conservative treatment (2%); two cases of fever without evidence of intra- or retro-peritoneal perforation resolving within the following days with antibiotics; one case of haematochezia requiring no blood transfusion; one case of intense abdominal pain resolving within 3 days.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References

In Crohn's disease patients with symptoms of intestinal stricture not responding to medical treatment, surgery with intestinal resection or strictureplasty is usually indicated.11, 12 For strictures accessible to endoscopy, alternative approaches have been proposed, including through the endoscope balloon dilatation3, 5, 13–15 and, more recently, per-endoscopic strictureplasty followed by metallic stent insertion.16, 17

Several studies have reported the results of balloon dilatation (Table 1). The largest study, reported by Leuven's group in Belgium, included 55 patients.4 The reported success rate of dilatation procedures was 90%, a figure very similar to ours (89%). Failures of the technique were represented by too tight strictures or angulations, preventing the passage of the deflated balloon. In our experience, ileo-colonic junction is often of concern, because of the anatomical disposition of the terminal ileum. We did not use balloons smaller than 50 mm × 18 mm, but suggest that, in selected cases, a first passage with a smaller and more flexible balloon could be attempted. Dear et al. performed initial dilatation with a 6- or 12-mm balloon, depending on the diameter of the stricture, before dilatation with an 18-mm balloon.10 In addition, we did not use the wire-guided balloon system because it was not available at the time of this study; this system could reduce the failure rate in the case of angulations.

In our series, the median duration of follow-up was 22.8 months, which was similar to that in the Belgian study.4 The probabilities of symptom recurrence after the first hydrostatic balloon dilatation were also similar: 40% of patients were free of recurrence at 5 years in our series, compared with 38% in the Belgian experience. The probabilities of surgery for stricture were 43% at 5 years in our series and about 40% in the Belgian study. We used the same balloons, but the Belgian authors repeated the dilatation procedure more frequently (2–6 times compared with 0–2 times in our experience). The passage of the colonoscope through the stricture was more often obtained in the Belgian study (73% vs. 56%). Conversely, the rate of perforation was higher in the Belgian series (11% of patients and 8% of procedures) than in ours (3% and 2%, respectively), suggesting that, in our series, the outcomes were as good despite a less aggressive approach.

In the case of symptom recurrence, the dilatation procedure can be repeated,4, 10 but, in contrast with others,3 we did not perform systematic colonoscopy in asymptomatic patients. We have no experience with the local injection of steroids into the stricture, which has been proposed to improve the results of dilatation.7, 18 This has been applied in 13 patients by Ramboer et al.;7 none of the patients required surgery, with a mean duration of follow-up of 3.9 years, but the mean number of dilatation sessions per patient was higher than in our series and in the Belgian study4 (4 vs. 1.3 and 1.4, respectively). In our opinion, steroid injection may be of special interest in patients with ulcerated strictures or in cases of early recurrence after first dilatation.

Because our study was retrospective, we were unable to test the predictive value of steroids or immunosuppressive drugs given after the dilatation procedure, corticosteroid or immunosuppressive therapy being more frequently prescribed post-dilatation in patients with more severe disease. However, a controlled study comparing dilatation without additional treatment with a combination of dilatation with oral budesonide (9 mg) and azathioprine for 1 year showed 1-year recurrence rates of 53% in the placebo group compared with 20% in the budesonide + azathioprine group (P = 0.02).9 In contrast with the study by Couckuyt et al.,4 we found no relationship between the possibility of passage with the colonoscope after dilatation and long-term symptomatic relief. The only statistically significant relation found was between smoking habits and the need for surgery (P = 0.044), but not with the recurrence of symptoms. This was in accordance with recent studies in which an increased risk for surgery was found in patients with smoking habits.19 We performed dilatation in patients with primary and anastomotic strictures, but, as in other studies, most of our patients were dilated for anastomotic strictures. It is reasonable to assume that anastomotic strictures are different from de novo, possibly longer, strictures in Crohn's disease. In our series, there was no statistical difference in terms of the length or diameter between the two groups of strictures; this could explain, together with the small number of patients with primary strictures, why we did not find an influence of the type of stricture on the recurrence of symptoms or need for surgery. However, of the six patients who could not be dilated, two had primary strictures.

In our series, complications were rare, only one intra-peritoneal perforation being observed requiring surgery. In the literature, the perforation rate is in the range 0–15%.3, 4, 6–8, 10 We also observed one case of haematochezia that required no blood transfusion; this complication is reported in 0–1.5% in the literature.3

We conclude that hydrostatic balloon dilatation is simple, technically feasible in most patients selected for the procedure, can avoid or delay surgery in the majority of patients and is relatively safe. In our opinion, this endoscopic approach to Crohn's stricture should be attempted before surgery in every case when it appears technically feasible. Short, anastomotic, ileo-colonic strictures are probably the best indication. However, for patients with Crohn's stricture treated by endoscopic dilatation, there is a need for the prospective collection of data and for randomized studies to assess the effect of steroid injection, as well as the influence of concurrent or subsequent medical therapy, on outcome.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Hydrostatic dilatation procedures
  7. Statistical analysis
  8. Results
  9. Discussion
  10. References
  • 1
    Michelassi F, Balestracci T, Chappell R, et al. Primary and recurrent Crohn's disease. Experience with 1379 patients. Ann Surg 1991; 214: 2308.
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    Krupnick AS, Morris JB. The long-term results of resection and multiple resections in Crohn's disease. Semin Gastrointest Dis 2000; 11: 4151.
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    Blomberg B, Rolny P, Jarnerot G. Endoscopic treatment of anastomotic strictures in Crohn's disease. Endoscopy 1991; 23: 1958.
  • 4
    Couckuyt H, Gevers AM, Coremans G, et al. Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's strictures: a prospective long term analysis. Gut 1995; 36: 57780.
  • 5
    Williams AJ, Palmer KR. Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures resulting from Crohn's disease. Br J Surg 1991; 78: 4534.
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    Junge U, Zuchner H. [Endoscopic balloon dilatation of symptomatic strictures in Crohn's disease]. Dtsch Med Wochenschr 1994; 119: 137782.
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    Ramboer C, Verhamme M, Dhondt E, et al. Endoscopic treatment of stenosis in recurrent Crohn's disease with balloon dilation combined with local corticosteroid injection. Gastrointest Endosc 1995; 42: 2525.
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    Matsui T, Hatakeyama S, Ikeda K, et al. Long-term outcome of endoscopic balloon dilation in obstructive gastroduodenal Crohn's disease. Endoscopy 1997; 29: 6405.
  • 9
    Raedler A, Peters I, Schreiber S. Treatment with azathioprine and budesonide prevents reoccurrence of ileocolonic stenoses after endoscopic dilatation in Crohn's disease. Gastroenterology 1997; 112: A1067(Abstract).
  • 10
    Dear KL, Hunter JO. Colonoscopic hydrostatic balloon dilatation of Crohn's strictures. J Clin Gastroenterol 2001; 33: 3158.
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    Tjandra JJ, Fazio VW. Strictureplasty for ileocolonic anastomotic strictures in Crohn's disease. Dis Colon Rectum 1993; 36: 1099103.
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    Fazio VW, Tjandra JJ, Lavery IC, et al. Long-term follow-up of strictureplasty in Crohn's disease. Dis Colon Rectum 1993; 36: 35561.
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    Kirtley DW, Willis M, Thomas E. Balloon dilation of recurrent terminal ileal Crohn's stricture. Gastrointest Endosc 1987; 33: 399400.
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    Brower RA. Hydrostatic balloon dilation of a terminal ileal stricture secondary to Crohn's disease. Gastrointest Endosc 1986; 32: 3840.
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    Breysem Y, Janssens JF, Coremans G, et al. Endoscopic balloon dilation of colonic and ileo-colonic Crohn's strictures: long-term results. Gastrointest Endosc 1992; 38: 1427.
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    Matsuhashi N, Nakajima A, Suzuki A, et al. Long-term outcome of non-surgical strictureplasty using metallic stents for intestinal strictures in Crohn's disease. Gastrointest Endosc 2000; 51: 3435.
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    Matsuhashi N, Nakajima A, Suzuki A, et al. Nonsurgical strictureplasty for intestinal strictures in Crohn's disease: preliminary report of two cases. Gastrointest Endosc 1997; 45: 1768.
  • 18
    Lavy A. Steroid injection improves outcome in Crohn's disease strictures. Endoscopy 1994; 26: 366.
  • 19
    Cosnes J, Carbonnel F, Beaugerie L, et al. Effects of cigarette smoking on the long-term course of Crohn's disease. Gastroenterology 1996; 110: 42431.