Endoscopy for Crohn’s disease-related strictures: can we finally replace the surgeons?

• Main Authors: Nik Muhamad Affendi, Nik Arsyad, Hilmi, Ida Normiha
• Format: Article
• Language: English; English
• Published: Wiley 2024
• Subjects: R Medicine (General)
• Online Access: http://irep.iium.edu.my/114323/7/114323_Endoscopy%20for%20Crohn%E2%80%99s%20disease-related%20strictures.pdf; http://irep.iium.edu.my/114323/13/114323_Endoscopy%20for%20Crohn%E2%80%99s%20disease-related%20strictures_Scopus.pdf; http://irep.iium.edu.my/114323/; https://onlinelibrary.wiley.com/doi/10.1111/jgh.16522
• Institution: Universiti Islam Antarabangsa Malaysia

Despite the advancements in medical therapy, Crohn’s disease (CD) remains an unpredictable disease with a significant proportion of patients developing complications such as stricture, fistula, or even perforation requiring surgical intervention. In particular, stricturing CD remains a significant problem with approximately 50% of CD patients developing a stricture in their lifetime.1 The pathogenesis of stricturing disease in CD is complex involving inflammatory-dependent and independent mechanisms.1 Some patients are asymptomatic, but most will have some form of acute or chronic obstructive symptoms. Patients with acute obstruction usually present with acute abdominal pain, distension, and vomiting while patients with chronic obstruction presents with low-grade abdominal discomfort, postprandial abdominal cramps, distension, borborygmi, and weight loss. Strictures in CD have classically been divided into inflammatory or fibrotic, but in reality, most strictures are a combination of both. The differentiation between predominantly inflammatory and fibrotic strictures is made using a combination of clinical assessment, inflammatory biomarkers, endoscopy, and cross-sectional imaging such as intestinal ultrasound, magnetic resonance imaging, or computed tomography (CT) enterography. Studies have shown that use of biologic therapy can prevent or at least delay the development or progression of strictures,2–5 but are effective only in inflammatory dominant strictures. As a result, an endoscopic or surgical approach is often required in patients with fibrostenotic strictures. Surgery (bowel resection or stricturoplasty) is considered the “definitive” treatment but many of these patients are on immunosuppressive medication and mal- nourished; with a significant risk of developing postoperative complications. In addition, surgery cannot also be considered definitive as the recurrence rate post-surgery remains high and a significant proportion of CD patients require more than one operation. This can result in specific nutritional deficiencies or short gut syndrome if extensive resection is carried out. In view of these issues, there has been renewed interest in endoscopic therapy for CD-related strictures. Previous studies have shown that endoscopic management is effective and has the best outcomes in strictures which are short (4 cm or less), non-angulated and uncomplicated (i.e., no extensive ulcerations, fistulation, abscess, or perforation).6 Current endoscopic therapies include endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES), and the placement of removable or biodegradable self-expanding metallic stent (SEMS). In a recent issue, Partha Pal et al. prospectively looked at re-intervention rates and symptom-free survival at 1 year after endoscopic therapy (ET) versus surgical management of CD-related strictures.7 This retrospective study used propensity score matched analysis found that ET prevented surgery in the majority of patients (> 90%) over the follow-up duration although not surprisingly, re-interventions were more common in ET group. Other outcomes such as symptom-free survival, need for escalation of therapy, and re-operation were comparable to the surgical arm. Al- though the re-intervention rate was higher, repeated procedures were safely carried out using EBD or ES. In this study, EBD was used as the primary ET. This finding is consistent with a previous meta-analysis looking specifically at EBD.6 However, the real question is whether the newer therapies such as ES or stent placement combined with advanced therapy to control inflammation may be able to prevent surgery in the majority of patients altogether. A large study comparing EBD versus ES found that the need for surgery was only 9.5% in the ES group versus 89.5% in the EBD group. In terms of complications, the perforation rate was 1.1% in the EBD group and none in the ES group, but in contrast, there was a higher bleeding rate in the ES group.8 A small study comparing EST and ileo-colonic resection in patients with primary CD-related ileum strictures found that the sub- sequent surgical rates were similar between the two groups with a numerically lower rate of complications in the EST group.9 Al- though at present this procedure is limited to specialized centers, ES shows promise in providing results very similar to surgery. Endoscopic management for IBD has been relatively underdeveloped compared to other conditions but hopefully, this will change over time and may encompass treatment of other complications such as fistulas.10 Nevertheless, the management of CD-related strictures is complex, and many unanswered questions remain. It is essential that each decision is carefully made on an individualized basis and using a multi-disciplinary approach.