Symptomatic Strictures Research Articles

Anti-TNF-alpha treatments and obstructive symptoms in Crohn's Disease: A prospective study

BackgroundThe development of symptomatic strictures in Crohn's Disease after anti-Tumour Necrosis Factor-α antibodies is undefined. AimTo assess, in a prospective longitudinal study, the frequency of sub/obstructions in Crohn's Disease patients after treatment with Infliximab or Adalimumab. Changes of small bowel lesions after these biological therapies were searched by ultrasonography. Materials and MethodsFrom January 2007 to October 2008, 36 Crohn's Disease patients with no previous sub/obstructions were treated with either Infliximab (n=13) or Adalimumab (n=23) for ≥12months (mean follow-up duration after the first treatment 23.2±6.8months). Small Intestine Contrast Ultrasonography was performed before and after treatment in 19/36 patients. Sonographic parameters included: bowel wall thickness, lumen diameter, bowel dilation and lesion extent. ResultsSub/obstructions developed in 3/36 patients treated with Infliximab (n=1) or Adalimumab (n=2), all with fibrostricturing Crohn's Disease. Sonographic parameters did not significantly change after treatment. ConclusionsSub/obstructive symptoms may develop in one tenth of Crohn's Disease patients treated with anti-Tumour Necrosis Factor-α antibodies, with no significant sonographic changes of the small bowel lesions.

Fully covered self-expanding metal stents for benign colonic strictures

Uncovered self-expanding metal stents offer effective relief for colonic obstruction. The aim of this study was to determine the effectiveness of fully covered self-expanding metal stents (FCSEMSs) in the treatment of benign colonic strictures. All patients presenting with a symptomatic benign colonic stricture (occlusion or subocclusion) during a 6-year study period were treated with FCSEMSs. The stents were placed and removed 4 - 6 weeks later at one of 10 endoscopy centers. The efficacy of the stent (clinical and radiological signs of colonic decompression within 48 hours), technical success, stent retrieval, safety, and recurrence of symptoms were evaluated during follow-up. Univariate and multivariate analyses were performed to identify variables associated with clinical success, stent migration, and symptom recurrence. The study included 43 patients (24 men, 19 women; mean age 67.6 ± 10.4) with occlusive (n = 18) or subocclusive symptoms (n = 25) due to anastomotic (n = 40), post-ischemic (n = 2), or post-radiation (n = 1) strictures. Insertion was successful in all patients. Clinical success was obtained in 35 patients (81 %). Migration was observed in 27 patients (63 %). The median duration of stenting was 21 days (95 %CI 17.8 - 35.4 days). Multivariate analysis showed that stents more than 20 mm wide migrated significantly less often. Recurrence of obstructive symptoms was observed in 23 patients (53 %), irrespective of migration. No predictive factors for recurrence or clinical efficacy were found. FCSEMSs for treatment of symptomatic benign colonic strictures are safe and effective, despite a high rate of spontaneous migration.

Risk and Prevention of Acute Urinary Retention After Robotic Prostatectomy

Acute urinary retention after catheter removal is a recognized complication following open or robot-assisted radical prostatectomy. We evaluated patient and surgery related risk factors to determine whether acute urinary retention could be prevented. To our knowledge this has not previously been investigated for prostatectomy done by any technique. We reviewed a single surgeon, robot-assisted radical prostatectomy database of patients treated between February 2008 and June 2011 for acute urinary retention after catheter removal, which was routinely performed 3 to 7 days postoperatively. We compared the characteristics of patients with and without acute urinary retention. Of 1,026 patients 25 (2.4%) experienced acute urinary retention. There was no difference between patients with and without acute urinary retention in mean age, body mass index, blood loss or prostate size, and no difference in the frequency of bladder neck reconstruction or nerve sparing. The catheter was removed an average of 4.1 vs 5.7 days postoperatively in patients with vs without acute urinary retention. Of 25 patients with acute urinary retention 22 (88%) underwent catheter removal on postoperative day 3 or 4. Although only 3 of 381 patients (0.8%) had a leak on cystogram on postoperative day 3 or 4, the acute urinary retention rate when the catheter was removed on day 3 or 4 was 5.8% (22 of 381). This was several times higher than the rate in patients who retained the catheter for greater than 4 days (3 of 645 or 0.5%). Acute urinary retention develops infrequently after robotic prostatectomy. No patient related risk factors were identified beyond catheterization time. Although the catheter may be removed after 3 or 4 days with rare leaks, the acute urinary retention risk was much less when the catheter was left in place at least 5 days.

Endoscopic treatment with self‐expanding metal stents for Crohn's disease strictures

Balloon dilation (with or without steroid injection) is the endoscopic treatment of choice for short strictures in Crohn's disease (CD). The placement of a stent has only rarely been reported in this setting, and it may be a good alternative. To describe the efficacy of temporary placement of a self-expanding metallic stent (SEMS) in the endoscopic treatment of symptomatic strictures in CD. We included 17 CD patients treated with SEMS (4 partially covered SEMS and 21 fully covered SEMS) for symptomatic strictures refractory to medical and/or endoscopic treatment. We placed 25 stents in 17 patients with stenosis (<8 cm), in the colon and in the ileocolonic anastomosis. In two cases, two stents were placed in the same endoscopic procedure. All except three cases had previously been unsuccessfully treated with endoscopic dilatation. The stents were maintained for an average of 28 days (1–112). The treatment was effective in 64.7% of the patients after a mean follow-up time of 60 weeks (5–266). In four cases, removal of the stents was technically difficult due to stent impaction (moderate adverse events-AEs) and one patient had a proximal stent migration requiring delayed surgery (severe AE). The placement of self-expanding metallic stent in Crohn's disease maintained over a period of 4 weeks is a safe, effective treatment for strictures refractory to medical treatment and/or balloon dilatation, and might be an alternative endoscopic

Prolonged avoidance of repeat surgery with endoscopic balloon dilatation of anastomotic strictures in Crohn's disease

Background and aimsThere is a high rate of stricturing post-operative recurrence in Crohn's disease (CD) particularly at sites of surgical anastomosis, and over 50% of these patients will require a repeat resection. Endoscopic dilatation of anastomotic strictures is an alternative to surgical resection in selected patients. We aimed to evaluate the safety and long term efficacy of endoscopic balloon dilatation of symptomatic anastomotic strictures in CD. MethodsRetrospective analysis of a prospectively maintained inflammatory bowel disease database of patients attending a single academic centre (n=1244 patients with CD) who underwent dilatation. ResultsFifty-five dilatations were performed in 31 patients (mean age 43±SD 12, 47% female). Median follow‐up period was 46months (IQR 14–62). Ninety percent of patients had successful initial dilatation and no complications occurred. Six (21%) avoided further dilatations or surgery in the follow-up period. Stricture recurrence was detected in 22 patients; 15 (54%) patients had repeat dilatations and seven (25%) went straight to surgery. Eight (28%) patients were managed with repeat dilatations of the stricture (median dilatations=2 range 2–6) and seven (25%) required surgery despite repeat dilatations. Median time from first dilatation to repeat surgery was 14.5months (IQR 3–28) and to repeat dilatation was 13.8months (IQR 4–28). There was no difference in immunomodulator use, biologic use and smoking status between the groups requiring surgery versus dilatation only. ConclusionEndoscopic balloon dilatation of anastomotic strictures is safe and effective in providing symptomatic relief in CD patients. Forty-five percent of patients had a sustained response to single/serial balloon dilatation with avoidance of further surgical resection for a median interval of 46months. Post-operative medical therapy and smoking status did not predict requirement for recurrent dilatation or surgery.

Possible antistenotic effect of tranilast in a patient with small bowel tuberculosis to prevent intestinal obstruction due to stenosis progression by antituberculous chemotherapy

Small intestinal tuberculosis is a rare disorder of the small intestine. We report the development of deep small bowel tuberculosis in a rheumatoid arthritis patient who was taking methotrexate. The diagnosis of small bowel tuberculosis was ascertained by typical endoscopic findings and production of interferon gamma in the peripheral blood. The patient was successfully treated with antituberculous chemotherapy combined with an antifibrotic agent, tranilast, to suppress the progression of intestinal stenosis toward symptomatic stricture.

Emergent Laparoscopic Left Colectomy for Colonic Perforation After Colonoscopic Dilatation of Stricture Secondary to Ischemic Colitis

Abstract Introduction: Ischemic colitis (IC) is the most common form of bowel ischemia. One of the chronic complications of IC is stricture formation. Symptomatic ischemic strictures can be dilated by colonoscopic techniques. Colonic perforation is an uncommon complication of colonoscopy, which mandates emergent surgical intervention. This is the first report of laparoscopic colectomy for treatment of colonoscopic perforation in a patient with a segmental ischemic stricture. Materials and Methods: A 52-year-old man with chronic constipation underwent diagnostic colonoscopy 4 months back, which revealed a long segment of stricture with normal overlying mucosa at splenic flexure of colon. Histopathologic examination was in favor of benign pathology. After failure of medical treatments in resolving obstructive symptoms, he was scheduled for elective colonoscopic dilatation of stricture. During the procedure the patient developed severe abdominal pain. The gastroenterologist was suspicious of colonic perforat...

OC-080 Reduced circulating FGF19 levels are associated with symptoms of diarrhoea in crohn's disease

IntroductionFGF19 is a polypeptide hormone produced in the ileum which inhibits hepatic synthesis of bile acid and is thought to have roles in regulation of bile acid pool size and...

PWE-180 Clinical and laboratory characteristics and the use of biodegradable stents in eosinophilic oesophagitis: a single centre UK experience

IntroductionEosinophilic Oesophagitis (EoE) is an under recognised condition. There are clues in the history, biochemistry, immunology and gastroscopy to make the diagnosis. Strictures associated with this condition need careful endoscopic...

PWE-240 Incidental diagnosis of inflammatory bowel disease in a British bowel cancer screening cohort: a multi-centre study

IntroductionThe UK Bowel Cancer Screening Programme (BCSP) was launched in 2006 and rolled out in successive waves covering the entire population of England and Wales. It screens individuals aged 60–69...

Outcomes of Endoscopic Realignment of Pelvic Fracture Associated Urethral Injuries at a Level 1 Trauma Center

We examined the success of early endoscopic realignment of pelvic fracture associated urethral injury after blunt pelvic trauma. A retrospective review was performed of patients with pelvic fracture associated urethral injury who underwent early endoscopic realignment using a retrograde or retrograde/antegrade approach from 2004 to 2010 at a Level 1 trauma center. Followup consisted of uroflowmetry, post-void residual and cystoscopic evaluation. Failure of early endoscopic realignment was defined as patients requiring urethral dilation, direct vision internal urethrotomy, posterior urethroplasty or self-catheterization after initial urethral catheter removal. A total of 19 consecutive patients (mean age 38 years) with blunt pelvic fracture associated urethral injury underwent early endoscopic realignment. Twelve cases of complete urethral disruption, 4 of incomplete disruption and 3 of indeterminate status were noted. Mean time to realignment was 2 days and mean duration of urethral catheterization after realignment was 53 days. One patient was lost to followup after early endoscopic realignment. Using an intent to treat analysis early endoscopic realignment failed in 15 of 19 patients (78.9%). Mean time to early endoscopic realignment failure after catheter removal was 79 days. The cases of early endoscopic realignment failure were managed with posterior urethroplasty (8), direct vision internal urethrotomy (3) and direct vision internal urethrotomy followed by posterior urethroplasty (3). Mean followup for the 4 patients considered to have undergone successful early endoscopic realignment was 2.1 years. Early endoscopic realignment after blunt pelvic fracture associated urethral injury results in high rates of symptomatic urethral stricture requiring further operative treatment. Close followup after initial catheter removal is warranted, as the mean time to failure after early endoscopic realignment was 79 days in our cohort.

ENDOSCOPIC MANAGEMENT WITH INSIDE STENT FOR PROXIMAL BENIGN BILIARY STRICTURE AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Endoscopic placement of a plastic stent is the standard drainage for a symptomatic benign biliary stricture. Although a removable fully covered self-expandable metal stent has been applied for distal benign biliary stricture, placement of a plastic stent remains the standard treatment for proximal benign biliary stricture. Placement of a plastic stent above the papilla (inside stent) is an alternative to the conventional method because of its preventive effect against the dysfunction of the stent in patients with proximal benign biliary stricture.

Value of concomitant endoscopic balloon dilation for intestinal stricture during long‐term infliximab therapy in patients with crohn's disease

We assessed the long-term outcome of infliximab (IFX) therapy in patients with Crohn's disease (CD) and investigated the efficacy of concomitant endoscopic balloon dilation (EBD) for intestinal stricture during treatment. The effectiveness of maintenance therapy with IFX was retrospectively evaluated in 185 patients with CD in a single center (median observation period 24 months). IFX effectiveness with and without immunomodulators (IMM) and enteral nutrition (EN), as well as cumulative surgery-free rates, were compared. The efficacy of concomitant EBD in patients with obstructive symptoms and high-level stricture was evaluated. In 185 patients receiving the maintenance therapy, the long-term efficacy rate was 84.9% at 24 months and 79.0% at 48 months. The cumulative surgery-free rate was significantly higher in the maintenance group (P < 0.001). Concomitant IMM and EN did not significantly affect the effectiveness of IFX. IFX was discontinued in only 18 cases (7.3%). Symptomatic high-level stricture occurred in 33 patients (17.8%) in the maintenance group and the cumulative surgery-free rate was significantly higher in the EBD combination compared with the non-EBD group (P < 0.05). If EBD were considered invasive intervention, the actual cumulative surgery rate in the maintenance group was significantly lower compared with the cumulative invasive intervention rate (P < 0.001). Long-term treatment with IFX is highly effective. The surgery-free rate was clearly higher in the maintenance group. Only concomitant EBD for intestinal stricture helped in the avoidance of surgery.

Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos)

Endoscopic placement of fully covered self-expandable metal stents (FCSEMS) has been attempted to manage benign biliary strictures, but currently available FCSEMSs may be associated with unintended complications, including de novo strictures, in patients with normal life expectancy. To evaluate the feasibility of an intraductally placed modified FCSEMS to minimize stent-induced bile duct injury in patients with benign biliary strictures. Prospective observational clinical feasibility study. Tertiary-care academic center. This study involved 21 patients with symptomatic benign biliary strictures in whom conventional endoscopic management failed. Strictured segments were 15 mm above the ampulla of Vater. The modified FCSEMS has convex margins, a lasso, and an anti-migrating waist on the central portion. Stents were placed entirely above the papilla and removed after 3 to 5 months. Success, complications, removability, midterm outcome. FCSEMSs were successfully placed inside the bile duct in all patients. No episodes of pancreatitis, cholangitis, or sepsis were noted during the stenting period. Stent migration occurred in 4 patients (19.0%), but 3 were asymptomatic during follow-up. All stents were removed successfully with rat-tooth forceps without complications. Post-stenting cholangiograms showed improvement of strictures in 20 of 21 patients, without de novo focal stricture. The clinical success rate was 95.2%, with one recurrent stricture. The small number and lack of comparison with other types of FCSEMSs. Temporary intraductal placement of a newly modified FCSEMS effectively improved strictures and prevented potential stent-induced complications in patients with benign biliary strictures. Controlled large-scale trials are needed to confirm the long-term efficacy.

P349 Risk of lymphoma in patients with inflammatory bowel disease: A Korean single-center study

P349 Risk of lymphoma in patients with inflammatory bowel disease: A Korean single-center study

Interventional balloon-enteroscopy

Balloon assisted enteroscopy (BE) expands greatly the therapeutic options in interventional endoscopy; bleeding sites, strictures, polyps, and other small bowel lesions are increasingly been treated by use of BE in the last 10 years. Treatment options for small bowel bleeding include Argon plasma coagulation (APC), injection therapy, and application of TTS metal clips, and thereby bleeding is stopped in most cases. Dilating symptomatic strictures, resecting polyps as seen in Peutz-Jeghers syndrome (PJS), and removing foreign bodies, BE carries most endoscopic treatment techniques to the small bowel. Another new indication field for BE are interventions at the biliary system in patients with surgically modified anatomy such as Roux-Y anastomosis. This review offers a full overview on indications of BE and refers to the practical use of the method for all endoscopic interventions.

WEO NEWSLETTER AND CONTENTS

WEO NEWSLETTER AND CONTENTS

Safety and efficacy of extractible self-expandable metal stents in the treatment of Crohnʼs disease intestinal strictures: A prospective pilot study

Endoscopic management of Crohn's disease (CD) intestinal strictures with balloon dilation is effective; however, recurrences are frequent and require further dilations or surgery. The use of extractible metallic stents may be as effective as balloon dilation with fewer recurrences. The aim was to investigate in a prospective pilot study the feasibility and clinical effectiveness of the use of extractible stents in the treatment of CD intestinal strictures. In two tertiary referral centers, quiescent CD patients except for obstructive symptoms associated with intestinal stenosis of less than 50 mm length on enterography were eligible for transitory stent placement, initially planned to be retrieved after 8 weeks, which was secondarily reduced to 4 weeks after patient 3. Eleven patients (six males, five females, median age 34 years [range 18-66]) were prospectively included. The sites of intestinal stenosis were an ileocolonic anastomosis, an ileosigmoidic anastomosis, and the surgically untreated terminal ileum in eight, one, and two patients, respectively. Stent placement was technically successful in 10 patients. Obstructive symptoms were relieved in 6 out of 10 patients. Two patients needed surgery related to the procedure. Six downstream migrations were observed. Only one patient could have the stent extracted as scheduled on day 28 and remains symptom-free after 73 months of follow-up. Even if stenting appears an effective technique in treating symptomatic CD intestinal strictures, the procedure is associated with a prohibitively high rate of spontaneous migrations and complications.

Endoscopic Treatment of Benign Colorectal Striture. A Retrospective Study

Purpose: Endoscopic balloon dilation and electroincision have proven to be an alternative to surgery in the treatment of symptomatic colorectal strictures. The aim of this study was to analyze its efficacy and safety at our Institution. Methods: This study is to retrospectively investigate the results of endoscopic balloon dilation and electroincision for symptomatic stenotic benign colorectal lesions, whether they be anastomotic or not. All patients underwent dilation by using through-the-scope balloon dilation(TTS) or needle knife electrosurgery stenotomy. Student t test was applied in order to analyze means and chi-square was used to compare frequency. P value <0.05 was considered significant. Colonoscopies were performed under light sedation. Results: Forty-four patients from 2001 to 2010 with benign colorectal strictures were enrolled in this study. Sixteen were male and 28 female, the youngest being 32 and the oldest 84. Mean age was 60+/-13for the whole group. No difference between ages of male and female, 64+/-10 and 58+/-14 P>0.05 was observed. Twenty-eight (71%)out of 39 patients with anastomotic stricture and 4 (80%) out of 5 without bowel resection were successfully treated P>0.05. Failure was mostly related to long-segment stricture, being 2 (16%) for short and 10 (83%) for long P<0.01. Twelve were submitted to radiation therapy before the endoscopic procedure, 7 of them (58%) had successful outcome P>0.05. There were two (4%) perforations treated through surgery. No casualties. Five (11%) and 39 (88%) were submitted to electroincision and TTS dilatation, respectively. Conclusion: Endoscopic treatment is an alternative to surgery when we are dealing with a benign stricture of the colon. Besides, no statistical difference was obtained, it seems that previous radiation therapy had made the procedure more difficult. In our study, long segment stricture was the worst problem to be solved.

Risk of recurrence after surgery for chronic radiation enteritis

Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE. Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality, reoperation for recurrent enteritis and risk factors for reoperation were analysed. Of 107 patients (94 women; 87·8 per cent) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76·6 per cent). Forty-nine ileocaecal resections (45·8 per cent) were performed. Overall and surgical morbidity rates were 74·8 per cent (80 patients) and 28·0 per cent (30) respectively. Fourteen patients (13·1 per cent) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54 per cent respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2·72, 95 per cent confidence interval 1·57 to 4·86), anastomotic leakage (OR 2·53, 1·54 to 4·42) and male sex (OR 3·57, 1·82 to 7·29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4·48, 2·52 to 8·31). Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis.