Keywords interventional inflammatory bowel disease - endoscopic balloon dilation - endoscopic
stricturotomy - enteroscopy - colitis-associated neoplasia - endoscopic mucosal resection
- endoscopic submucosal dissection
Introduction
Inflammatory bowel disease (IBD) is on the rise in India with estimated burden of
disease (1.5 million) nearing that of the Unites states.[1 ]
[2 ] Earlier the role of endoscopy in IBD was limited to diagnosis and monitoring of
IBD, dysplasia surveillance, and polypectomy for sporadic adenoma.[3 ] Later endoscopic balloon dilation (EBD) for IBD-related or postoperative strictures
was performed by endoscopists with interest in IBD or IBD specialists with interest
in interventional endoscopy.[3 ] Subsequently, it was shown that endoscopic stricturotomy (ES) is a better modality
for treating IBD related strictures (specially short and anastomotic strictures) than
EBD lowering the risk of future surgery and procedure-related perforation albeit with
an increased risk of bleeding.[4 ] Endoscopic incision therapy with needle knife/insulated tip (IT) knife was shown
to be not only superior to EBD but also noninferior to redo surgery in chronic pouch
anastomotic sinus in ulcerative colitis (UC) and ileocolic anastomotic stricture in
Crohn's disease (CD) thus reducing surgical morbidity.[5 ]
[6 ] Similarly, colectomy was indicated for any grade of dysplasia in UC/colonic CD until
it was recognized that endoscopy resection (endoscopic mucosal resection/ endoscopic
submucosal dissection [EMR/ESD]) for visible dysplasia including high-grade dysplasia
with continued surveillance can avoid colectomy. Almost all of the pouch complications
(leak, stricture, sinus, fistula, CD of pouch and floppy pouch) can be treated endoscopically
along with medical therapy avoiding morbidity of redo pouch surgery or pouch excision.[7 ]
[8 ] The current indications of IIBD include strictures, fistula, sinuses, abscess, leaks,
bleeding, neoplasia, and removing foreign bodies (e.g., retained video capsule endoscope).
Hence, IIBD has emerged as a bridge between medical and surgical management of IBD.
IIBD is not only helpful in treating disease complications (e.g., stricture, fistula,
abscess, and neoplasia) and thus avoiding surgery but also can be very useful in treating
postsurgical recurrence and complications (e.g., pouch strictures, leaks, and sinuses)
given the chronic, disabling nature of IBD.[3 ] Although there is abundant literature from the West on IIBD and recently global
IIBD group has published guidelines on the management of CD-related strictures and
evaluation of altered bowel postsurgery in IBD, there is paucity of published literature
from India on IIBD.[8 ]
[9 ]
[10 ] Hence, we planned to prospectively evaluate the technical and clinical success and
short-term outcomes of IIBD procedures in a high-volume tertiary care center with
a well-established IBD clinic and registry.
Methods
Study Settings and Population
The study was conducted in IBD patients requiring an IIBD procedure (e.g., EBD, and
ES) in a high-volume gastroenterology center in southern India with a well-established
IBD registry of over 6000 patients. The research assistant or the investigator interviewed
all patients to elicit clinical and disease-related details and recorded the procedural
details (e.g., technical success and scope passage after EBD) and enter the anonymized
data onto a web-based platform “google form” that was later exported to Microsoft
Excel for data analysis. Later these patients were followed up physically or telephonically
for evaluating the short-term clinical efficacy and recurrent symptoms. Redo EBD,
rescue therapy, or surgical details on follow-up were also recorded and analyzed.
Interventions
Interventional IBD (IIBD) procedures included (1) EBD or ES for IBD-related strictures
(includes upper gastrointestinal (GI), small bowel, large bowel, anastomotic, and
pouch stricture EBD or stricturotomy), (2) endoscopic resection of colitis-associated
neoplasia (polypectomy/EMR/ESD), (3) endoscopic hemostasis in IBD (hemoclips), and
(4) enteroscopic retrieval of retained capsule endoscope.
EBD procedures were done with wire-guided controlled radial expansion balloon (Boston
scientific, Marlborough, Massachusetts, United States) of various sizes based on tightness
and estimated diameter of the stricture (10–12 mm, 12–15 mm, 15–18 mm, 18–20 mm) with
graded dilations with inflation pressures varying from 3 to 8 atm pressure. Balloon
was inflated for at least 2 minutes and slowly deflated. For mild ooze post-EBD, balloon
tamponade was also done with the same balloon. At the initial session, we at least
tried to dilate upto an extent so that the scope used for dilation can be passed beyond
the stricture postdilation. The patients were asked for repeat intervention after
2 weeks if the dilation goal was not reached (i.e., in terms of the size of the balloon
or improvement in symptoms) at the initial endoscopy. For small bowel strictures not
reachable by endoscope or colonoscope were redilated only if symptoms recur after
initial dilation that is clinically successful. The endpoint for dilation was clinical
(symptomatic relief) and endoscopic success (passage of scope used to dilate the stricture
postdilation). EBD without fluoroscopy was done in majority of the patients requiring
ileocolonic EBD and small-bowel EBD by single-balloon enteroscope with direct visualization
of stricture dilation through the balloon. Fluoroscopy was used for select complicated
colonic strictures, gastroduodenal strictures, and novel motorized spiral enteroscopy
(NMSE)-guided balloon dilation.[11 ]
ES was done using a needle knife/insulted tip knife with Endocut Q (effect—3, cut
duration—1, cut interval—3) as per by global IIBD group consensus.[9 ] Multiple radial incisions were made circumferentially to completely disrupt the
stenotic rim so that scope can be passed after procedure. The incision depth was assessed
using the needle-knife/IT knife length as a comparator.[12 ]
[13 ]
NMSE was done under general anesthesia after 8 hours fasting, whereas single-balloon
enteroscopies were done under propofol sedation.
Resection of ulcerative colitis-associated neoplasia (UCAN) was done using standard
ESD and EMR techniques. Underwater EMR was done in areas of scarring and submucosal
fibrosis that helps with “floating” effects.[14 ] To overcome effects of submucosal fibrosis, traction and water pressure assistance
was used for ESD.[15 ]
[16 ]
Hemostasis was achieved with different hemoclips: EZ clip (Olympus America), Resolution
clip (Boston Scientific), or Medorah clip (Medorah Meditek).
Primary and Secondary Outcome Measures
The primary aim of the study was to evaluate the short-term clinical efficacy of IIBD
procedures. Technical success, recurrent symptoms requiring rescue procedures on short-term
follow-up, and procedure-related adverse events were secondary outcomes. For endoscopic
resection of colitis-associated neoplasia, R0 resection was the primary outcome and
secondary outcome measures were en bloc resection, and residual or recurrent neoplasia
and procedure-related adverse events were the secondary outcomes.
Sampling Strategy
Inclusion Criteria
Patients with confirmed diagnosis of IBD warranting a IIBD procedure were included
in the study.
Exclusion Criteria
1. Patients in whom IBD was ruled out or in cases where diagnostic dilemma persists
(e.g., tuberculosis).
3. Pregnant or breast feeding.
4. Significant comorbidity (significant cardiac or pulmonary illness, chronic liver
or kidney diseases, systemic malignancy, etc.) that precludes IIBD or surgical therapy.
5. Inflammatory and predominantly inflammatory mixed strictures, stricture with complications
(fistula/abscess), and long strictures more than 5 cm.
6. Uncorrected severe anemia (<7 g/dL), low platelets count (<50,000/mm3 ) and ongoing anticoagulant therapy.
Data Collection
For patients, a detailed proforma including demographic details (age, sex, IBD type),
indication of IIBD procedure (stricture, neoplasia, etc.), details of treated lesion
(e.g., number of strictures, location), past history of surgery or IIBD procedure,
procedural details (number of EBD procedures, mode of endoscopy, caliber of dilation,
technical success, scope passage after EBD/ES), clinical improvement postprocedure,
complications (major or minor), histology and R0 resection rates in case of colitis-associated
neoplasia, and short-term clinical improvement were recorded initially. Prior to the
procedure, each case was discussed in institutional dedicated IIBD forum that consisted
of IBD specialists, interventional and small bowel endoscopists, GI surgeon, and interventional
radiologist for careful selection of the cases and reviewing indications and probable
modality to be used. On follow-up, data on symptomatic recurrence (in case of stricture/bleed),
redo procedure, or rescue surgery were also recorded.
Definitions
Stricture was defined according to the European Crohn's and Colitis organization definition
that is narrowing of the intestinal lumen. Based on cross-sectional imaging, stricture
was defined as follows: a combination of a reduction in luminal narrowing more than
50%, an increase in bowel wall thickness more than 25% relative to nonaffected bowel,
and prestricture dilation more than 3 cm. From the clinical perspective, for lesions
detected during an endoscopic examination, an inability to pass an adult colonoscope
through was considered as nonpassable stricture.[17 ] In our study, we considered symptomatic and nonpassable strictures for endoscopic
therapy.
Procedural success for EBD was defined as ability to perform the EBD procedure. Technical
success (scope passage after EBD/stricturotomy) was assessed as a separate outcome
that was defined as passage of endoscope through the area where EBD/ES was performed.
This included colonoscope for colonic/pouch strictures, endoscope for upper GI and
duodenal strictures, and an enteroscope: motorized spiral or single balloon enteroscope
for small bowel strictures except those in terminal ileum. Short-term clinical efficacy
in EBD/ES was defined as clinical improvement in symptoms (pain/intestinal, gastric
outlet, or colonic obstruction symptoms) after the procedure. Adverse events were
reported as per American Society of Gastrointestinal Endoscopy (ASGE) lexicon for
endoscopic adverse events.[18 ] The adverse events were initially classified as cardiovascular, pulmonary, and procedure
related (perforation/bleeding). For each adverse events, qualifiers such as timing
(intraprocedure, postprocedure <14 days, and delayed >14 days), attribution (definite,
probable, possible, and unlikely), and severity (mild moderate, severe, fatal) were
used.[18 ] Recurrence of symptoms was defined as re-emergence of symptoms for which the procedure
was initially performed. R0 resection for UCAN was defined as histologically free
margin postendoscopic resection. En bloc resection was defined removal of UCAN as
a whole rather than piece-meal removal.
Statistical Analysis
All the data were exported from “google form” to Microsoft Excel and later analyzed
by statistical package for social sciences (SPSS version 26, IBM Corp., Armonk, New
York, United States). Continuous variables are expressed as median (range) and categorical
variables were expressed as number (n) and percentage (%).
Ethical Considerations
The study was approved by the institutional review board (AHF-RAC-09/24/2021). Written
informed consent was taken from each patient and the study conformed to the 1975 Declaration
of Helsinki ethical guidelines mentioning the indication of the procedure, alternative
treatment modalities, and possible adverse events and their management. For all cases
undergoing small bowel endoscopy with anticipated EBD, a prior informed consent was
taken.
Results
Endoscopic Balloon Dilation
Total 44 patients (age: 21–74 years, median: 37, 57% male, CD—41, UC—3) had 56 strictures
and underwent 83 EBD procedures in 63 sessions (10 patients had 2 strictures, one
patient had 3, and 10 had anastomotic strictures) (single stricture × two sessions—6,
single stricture × 3 sessions—2, two strictures x two session—5, two strictures x
three session—1, three strictures × two sessions—1). About 9.1% (4/44) patients had
prior EBD in the same institute prior to initiation of study period ([Table 1 ]). The appropriate endoscope was used as discussed earlier except for two cases:
two proximal jejunal strictures in a patient was dilated using pediatric colonoscope
and a distal ileal stricture that was dilated using a colonoscope with deep ileal
intubation. The mean caliber of balloon dilation was less than 15 mm in pyloroduodenal
strictures, whereas it was equal to or more than 15 mm colonic strictures. Two of
forty-four patients (4.5%) were on biologic therapy (both infliximab). No adverse
events were noted in them post-EBD. The median duration of IBD diagnosis was 36 months
(range: 1–156 months) and the median duration of obstructive symptoms was 6 months
(1–14 months).
Table 1
Technical and clinical details of patients undergoing endoscopic balloon dilation
(EBD) as interventional inflammatory bowel disease (IIBD) procedure
Gastroduodenal
Small bowel
Ileo-colonic
Postsurgical anastomosis
Pouch
Number of patients (n = 44)
2
15
19
5
3
Number of strictures (n = 56)
4
20
22
5
5
Total sessions of dilation
4 (1 had 3 sessions)
27 (5 had 2 sessions, 2 had 3 sessions)
21 (2 had 2 sessions)
8 (one had 2 sessions and another had 3 sessions)
6 (all had 2 sessions)
Mode of endoscopy
EGD
NMSE[5 ]/SBE[10 ]/pediatric colonoscope[2 ]/colonoscope[2 ]/EGD through ileostomy stoma[1 ]
Colonoscopy (2 postdiversion)
Colonoscopy (5 ileo-transverse, 1 ileo-rectal)
Colonoscopy (3 anal anastomosis, 1 inlet and 1 outlet)
Mean caliber of maximum dilation (mm)
13.5
16.1
15.6
16.3
16.9
Procedural success
100%
Technical success (scope passage postdilation)
2/2 (100%)
10/15 (66.7%)
17/19 (89.4%)
4/5 (80%)
3/3 (100%)
Short term clinical success (after first session of dilation)
1/2 (50%)
13/15 (86.6%)
18/19 (94.7%)
5/5 (100%)
2/3 (66.7%)
Recurrence of symptoms
1/2 (50%)
2/15 (13.3%) (1 repeat EBD, another better with medical management)
5/19 (26.3%)
2/5 (40%)
2/3 (66.7%)
Surgery
0%
0%
1/19 (5.2%)
0%
0%
Repeat dilation
1/2 (50%)
1/15 (6.7%)
4/19 (21%)
2/5 (40%)
2/3 (66.7%)
Complications
0%
1/15 (6.7%) (minor ooze)
2/19 (10.5%) 1 microperforation, 1 pain
0%
1/3 (33%), mild ooze
Rescue endoscopic stricturotomy
1/2 (50%)
0%
0%
0%
0%
Abbreviations: EGD, esophagogastroduodenoscopy; NMSE, novel motorized spiral enteroscopy;
SBE, single-balloon enteroscopy.
Among the strictures, 35 were purely fibrotic stricture, 20 had mixed stricture (with
minimal inflammatory component), and 1 had purely inflammatory stricture. EBD in two
cases avoided surgery: (1) GenEBD (12 mm) in an inflammatory tight sigmoid stricture
(in a newly diagnosed CD), (2) CD-related tight ileocecal stricture presenting with
partial intestinal obstruction (post-antitubercular therapy for 6 months). No complications
occurred in either of the procedures.
Three patients had pouch-related strictures (3 anastomotic strictures [[Fig. 1A–C ]], 1 pouch inlet stricture [[Fig. 1D–F ]], and a stricture at efferent limb). The case with pouch inlet stricture had recurrent
symptom post-EBD and was redilated and later found to have CD of the pouch.
Fig. 1 Stricture therapy in inflammatory bowel disease. (A ) Postileal pouch anastomosis stricture in a case of ulcerative colitis. (B ) Stricture dilated with 18 mm controlled radial expansion (CRE) balloon. (C ) Pouch entered postdilation shows evidence of pouchitis. (D ) Ulcerated stricture at pouch inlet. (E ) Pouch inlet stricture dilated with CRE balloon up to 13.5 mm. (F ) Endoscope negotiable into pouch inlet postdilation showing linear ulceration. (G ) Stricture at site of rectovaginal fistula repair. (H ) Stricture dilated with CRE balloon upto 18 mm. (I ) Passable stricture postdilation. (J ) Stricture at first part of duodenum in case of upper gastrointestinal Crohn's disease—failed
balloon dilation for two sessions. (K ) Endoscopic stricturotomy being performed with insulated tip knife. (L ) Poststricturotomy passable stricture.
Procedural success was achieved in all cases, although technical success (scope passage
after procedure) can be done in 81.8% cases. Short-term clinical efficacy improved
from 88.6% after first session of dilation to 95.4% after maximal dilation. None had
moderate-to-severe complications as per ASGE lexicon for endoscopic adverse events.
A patient with tight rectal stricture (in long standing CD) had microperforation post-EBD
and was managed conservatively and was discharged in next 2 days postprocedure after
contrast study confirmed no extravasation. This patient was subjected to surgery later
due to refractory, long, symptomatic stricture. Among minor complications, two patients
had bleeding post-EBD—both were managed with balloon tamponade; in one case 50% dextrose
was used as local hemostatic agent.[9 ] None of them required transfusion. One patient had pain postprocedure; computed
tomography (CT) showed no leak and hospital stay was not prolonged.
In a short follow-up time (1–8 months, median 5 months), 27.3% patients had recurrent
symptoms among which 22.7% underwent redilation; rest patients were managed with optimization
of medical therapy alone. As mentioned earlier, one patient underwent surgery. One
patient with recurrent symptoms after two unsuccessful EBD sessions underwent ES.
Endoscopic Stricturotomy
ES was done in a patient with ankylosing spondylitis with duodenal CD with one pyloric
and two duodenal strictures (one in D1, another at D1-D2 junction). The case presented
with symptoms of gastric outlet obstruction and failed EBD (13.5 and 15 mm) twice
in spite of optimization of medical therapy. The benefit of EBD lasted for less than
a month for each session of EBD. Radial incisions were made circumferentially to cut
the fibrotic tissue for pyloric ring and D1 stricture ([Fig. 1J–L ]), whereas D1-D2 stricture dilated with balloon as stricturotomy was not feasible
due to angulation. In the given case, eight radial incisions were made in the duodenal
stricture, although excision of the fibrotic tissue was not performed as the culprit
stricture was at the junction of first and second part of duodenum with high risk
of perforation. For the pyloric ring stricture which was traversable, six incisions
were enough for passing the scope without any resistance. Currently, at 6 months follow-up,
the patient is asymptomatic. Clips as spacers were not applied as described by global
IIBD group as endoscopic stricturoplasty to prevent delayed bleeding or reapposition
of cut margins in stricture.[9 ] No complications were noted postprocedure and the patient is symptom free on a follow-up
of 1 month.
Enteroscopy-Guided Retained Capsule Endoscope Retrieval
All the retained capsules were in the proximal ileum as per capsule endoscopy and
fluoroscopy images. NMSE was used for retrieval of retained capsules in these cases
of CD. In two patients, there were strictures proximal to retained capsule that were
dilated to 15 mm to allow passage of NMSE. The number of strictures were confirmed
using fluoroscopy. In the other two cases, strictures were only distal to retained
capsule that was removed after EBD of downstream strictures ([Fig. 2A–F ]; see [Table 2 ]).
Table 2
Details of patients with Crohn's disease who underwent novel motorized spiral enteroscopy
(NMSE)-guided capsule retrieved and endoscopic balloon dilation of strictures
Age
Sex
Enteroscopy technique
Stricture upstream/downstream to retained capsule
Location
Dilation diameter (mm)
Case 1
29
Male
NMSE
Only downstream
Proximal ileum
12
Case 2
35
Male
NMSE
Upstream[2 ] + downstream
Proximal ileum
15
Case 3
25
Male
NMSE
Only downstream
Proximal ileum
12
Case 4
55
Female
NMSE
Upstream[1 ] + downstream
Proximal ileum
15
Fig. 2 Small bowel interventions in Crohn's disease (CD). (A ) Video capsule endoscope (VCE) image showing impacted food residue impacted in proximal
ileal stricture. (B ) Fluoroscopy image showing position of impacted VCE. (C ) Ulcerated stricture reached with novel motorized spiral enteroscopy and guidewire
negotiated across stricture. (D ) Controlled radial expansion (CRE) balloon dilation was done up to 12 mm given the
ulcerated stricture. (E ) Fluoroscopic image showing disappearance of balloon waist positioned in stricture
and impacted VCE proximally. (F ) Impacted VCE being retrieved with Roth net. (G ) Tight proximal ileal stricture on antegrade single-balloon enteroscopy (SBE). (H ) Stricture being dilated with 18 mm CRE balloon. (I ) Case of CD with recurrent anemia: proximal ileal spurting vessel on SBE. (J ) Two hemoclips applied to achieve hemostasis—no further rebleeding on follow-up.
Endoscopic Resection of Ulcerative Colitis-Associated Neoplasia
Majority of the patients who underwent endoscopic resection for UCAN were middle aged
or elderly with long-standing UC (≥ 8 years) except two patients: one had symptomatic
(2 cm) rectal inflammatory polyp and a case of broad-based vascular polyps in sigmoid
colon. The later turned out to be low-grade dysplasia on histology ([Fig. 3G–I ]). Two cases had high-grade dysplasia—one was treated with ESD ([Fig. 3A–C ]) and other with EMR (possibility of high-grade dysplasia not anticipated during
resection as the lesion was JNET type 2A on narrow band imaging—NBI) ([Fig. 3D–F ]). In the later, follow-up colonoscopy showed small residual lesion at resection
site that was resected using underwater EMR. R0 resection was achieved in all cases
except one. The details of endoscopic resection for UCAN have been summarized in [Table 3 ]. All the lesions were visible on white light endoscopy, whereas case 2 (flat lesion)
was better appreciated only on virtual chromoendoscopy (NBI).
Table 3
Procedural details of patients with ulcerative colitis who underwent endoscopic resection
for visible colonic polypoidal lesions
Age (years)
Sex
Duration of UC
Diagnosis
Modality of resection
Bx
En bloc resection
Ro resection
Treatment of residual or recurrent neoplasia
Case 1
54
Female
12 years
Recurrent large laterally spreading tumor rectum (3 cm) (JNET 2B)
ESD
HGD
En bloc
Yes
NA
Case 2
49
Male
10 years
Flat lesion (Paris IIb, JNET 2A) (2 cm)
EMR
Foci of HGD
Piecemeal
No, R1 resection
Underwater EMR
Case 3
66
Male
8 years
Subpedunculated lesion (Isp), JNET 2A (1 cm)
EMR
LGD
En bloc
Yes
NA
Case 4
26
Male
5 years
Broad based vascular polyps (Paris Isp) sigmoid colon (JNET 2A) (1.5–2 cm)
EMR
LGD
Piecemeal
Yes
NA
Case 5
69
Male
29 years
Sessile polyp in transverse colon (JNET 2A) (1 cm)
EMR
LGD
En bloc
Yes
NA
Case 6
62
Male
8 years
Rectum (Paris IIa, JNET 2A) (1.5 cm)
Band EMR
LGD
En bloc
Yes
NA
Case 7
25
Male
2 years
Symptomatic rectal inflammatory polyp (Paris Is, JNET 1) (1.5 cm)
EMR
Hyperplastic/inflammatory polyp
Piecemeal
Yes
NA
Abbreviations: EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection;
HGD, high-grade dysplasia; JNET, Japanese NBI (narrowband imaging) expert team classification;
LGD, low-grade dysplasia; NA, not available; UC, ulcerative colitis.
Fig. 3 Endoscopic management of ulcerative colitis-associated neoplasia. (A ) Recurrent large laterally speeding tumor rectum in case of ulcerative colitis (UC).
(B ) Postendoscopic submucosal dissection (ESD). (C ) Specimen post en bloc resection (3 cm in size)-biopsy showed high-grade dysplasia
(ESD). (D ) Flat lesion in rectum in a case of UC. (E ). Postsubmucosal injection. (F ) Endoscopic mucosal resection (EMR) done: Biopsy showed foci of high-grade dysplasia.
(G ) Broad-based vascular polyps in sigmoid colon. (H ) Narrow band imaging showed regular surface and vascular pattern. (I ) Post-EMR site biopsy showed tubular adenoma with low-grade dysplasia.
Endoscopic Hemostasis
Endoscopic hemostasis was done in three cases ([Table 4 ]). The first case presented with a history of recurrent anemia; CT showed proximal
ileal wall thickening suggestive of CD. During single-balloon enteroscopy (SBE), active
spurt was noted that was controlled with hemoclips ([Fig. 2I–J ]). He was treated with medical therapy and on follow-up of 6 months had no recurrence
of bleeding.
Table 4
Details of cases who underwent endoscopic hemostasis as interventional inflammatory
bowel disease (IIBD) procedure
Age
Sex
Indication
Endoscope used
Hemostasis technique
Hemostasis achieved
Rebleeding
Case 1
36
Male
Crohn's disease with recurrent anemia—active ooze in proximal ileum
Single-balloon enteroscopy
Clips[2 ]
Yes
No
Case 2
34
Female
Ulcerative colitis rectal ulcer bleeding
Colonoscopy
Sclerotherapy
Yes
No
Case 3
40
Male
Acute severe ulcerative colitis with bleeding—visible vessel
Colonoscopy
Clips
Yes
Yes, mild—managed conservatively with standard of care
Second case of UC presented with bleeding per rectum, although stool frequency was
under control. Sigmoidoscopy showed persistent ooze from a rectal ulcer near anal
verge. Injection sclerotherapy using 3% polidocanol was successful in controlling
the bleeding. Hemoclip was not used due to close proximity from anal verge. There
was no recurrence of hematochezia with continued medical therapy on 4 months follow-up.
Third case had bleeding from a visible vessel in acute severe ulcerative colitis that
was managed with hemoclips. However, there was rebleeding during same admission from
an adjacent ulcer. However, he later responded to medical therapy (intravenous steroids)
and colectomy was avoided.
Discussion
In this prospective study, the first from our country of over 50 patients with IBD,
endoscopic interventions were found to be useful in CD-related/anastomotic/pouch-related
strictures, colitis-associated neoplasia, retained capsule retrieval due to CD-related
strictures, and hemostasis for bleedings. Majority of the patients underwent EBD for
strictures with excellent short-term clinical efficacy with recurrent symptoms in
nearly one quarter of patients. The impact of EBD on patient management was profound
as most of the patients could be salvaged from surgery. Ileostomy could be closed
in all patients with strictures in diverted colon. Redo pouch surgery or pouch excision
could be avoided in all patients with pouch-related strictures. Retained capsule endoscope
retrieval was successful in all cases with additional therapeutic EBD and tissue diagnosis
for CD with motorized spiral enteroscopy. Endoscopic hemostasis was feasible with
acceptable rebleeding rates. Endoscopic resection (EMR/ESD) was successful in treating
UCAN with 83.3% R0 resection rates. Residual lesion in a case treated subsequently
with endoscopic therapy as well. The long-term results of stricture and colitis-associated
neoplasia management in these patients are underway.
The main indications of IIBD include stricture, bleeding, fistula/abscess/sinuses,
surgical leaks, colitis-associated neoplasia, and foreign body (e.g., retained capsule)
removal.[19 ] Endoscopic stricture management can be done by EBD ([Fig. 1G–H ]; [Fig. 2G–H ]), ES, endoscopic stricturoplasty (stricturotomy with placement of clips as spacers),
and stent placement. Endoscopic fully covered self expanding metal stent placement
was shown to be inferior to EBD in a recent randomized controlled trial (RCT) with
nearly half requiring reintervention at 1 year (compared with 19% in EBD arm).[20 ] Although EBD and ES have not been compared in a randomized manner, the technical
success (100%) and immediate symptomatic improvement (73%) were higher with ES compared
with EBD (90 and 45%, respectively, p = 0.25 and 0.08, respectively). No perforation occurred with ES, whereas 14% had
bleeding requiring transfusion. Need for additional endoscopic therapy and surgery
was lower with ES (29 and 10%, respectively) compared with EBD (34 and 60%, p = 0.85 and 0.03, respectively).[4 ] The reported technical success rates of EBD for gastroduodenal, small bowel, and
ileocecal strictures according to meta-analysis (18 studies, 463 patients, 1189 EBDs)
were 100, 95, and 90%, respectively.[21 ] Clinical success rates of EBD gastroduodenal, small bowel, and ileocecal strictures
were 87, 82.3, and 80.8%, respectively. Recurrent symptoms occur in nearly 48% for
small bowel and ileocecal strictures, whereas 70% for gastroduodenal strictures had
recurrent symptoms. Surgery is required in close to 30% cases. Redilation rates in
small bowel strictures were 38.8%. Complication rates were higher for small bowel
structures (5.3%) These included studies had variable follow-up time. Roughly half
had recurrent symptoms and two third required surgery.[21 ] High short-term efficacy and lower complication rates in our study could be due
to careful selection of cases in IIBD forum prior to deciding on mode of therapy.
Lower reprocedure rate could be attributed to very short follow-up time. The technical
success rate in small bowel strictures was lower compared with clinical success as
scope passage through stricture may be technically difficult in small bowel specially
with large diameter motorized spiral entersocope.
However, we performed ES in only one case refractory to EBD, although many of the
endoscopists performing these procedures were expert third space endoscopists. This
could be due to less experience with the procedure compared with EBD. Stricture therapy
in CD is, however, moving from EBD to ES in the current era.[19 ] Results from well-designed future RCT and gaining experience with the procedure
may result in higher use of this modality.
Pouch-related strictures were successfully treated in three patients along with medical
management for pouchitis in three patients in our study. Among pouch-related complications,
pouch strictures, floppy pouch complex, acute and chronic anastomotic leak, or sinuses
were amenable to endoscopic therapy.[7 ]
The next most common indication of IIBD after strictures in our cohort was colitis-associated
neoplasia. Endoscopically visible lesions with no deep submucosal invasion can be
successfully resected endoscopically with EMR or ESD.[22 ]
[23 ] Resection of a nonlifting, fibrotic adenoma in descending colon using full thickness
resection device has recently been reported.[24 ] Underwater EMR and traction or water pressure-assisted ESD can help in resecting
UCAN in the presence of submucosal fibrosis.[14 ]
[15 ]
[16 ] Compared with non-UC patients, ESD in UC is associated with lower rate of R0 resection
(71 vs. 93%) probability due to technical difficulties arising from scarring and severe
submucosal fibrosis that can be present in nearly 70% patients.[25 ]
[26 ] Similarly underwater EMR may help overcoming submucosal fibrosis by “floating” effect.[14 ] In our small series, R0 resection was noted in 83.3% cases. We did follow-up colonoscopy
in only one patient who had R1 resection. Long-term effects are needed to be studied
as local recurrence; metachronous tumor and additional surgery can be required post-ESD
in 5, 6, and 10%, respectively, in a recent meta-analysis.[26 ] Bleeding and perforations have been reported in 8 and 6%, respectively, in the same
study.[26 ] Results of ESD in UCAN are best for those with polypoidal lesion, noninvasive pit/vascular
pattern without surface ulceration, distinct borders, and appropriate lifting on submucosal
injection.[27 ] ESD has higher R0 resection rates than EMR for equal to or more than 11 mm lesions
(94 vs. 55%) and nonpolypoidal lesions (100 vs. 55%).[28 ] We performed ESD in only one case as most of the other lesions were smaller and
easily liftable on submucosal incision. As the evidences are emerging, newer guidelines
and practices may change over the next few years for UCAN.
NMSE-guided retired capsule retrieval in CD-related strictures was successful in all
patients with therapeutic EBD for strictures with symptomatic relief. Tissue diagnosis
of CD was obtained additionally in three out of four cases in whom CD was diagnosed
postcapsule endoscopy. Enteroscopy-guided biopsy was suggestive of CD in two cases
(chronic inflammation with architectural distortion with or without granuloma), whereas
in one case it was nonspecific. However, treatment as per probable CD based on imaging
and EBD resulted in symptomatic remission in the later. NMSE has high total enteroscopy
rates (nearly 70%) with ease for therapeutic intervention due to wide inner diameter
of channel (3.2 mm) compared with balloon-assisted enteroscopy.[29 ] In this study, 23% patients underwent therapeutic procedures.[29 ] NMSE-assisted capsule retrieval after all bowel stricture dilation has been reported
earlier.[30 ] However, we performed SBE-assisted EBD in almost all parts of small bowel ([Table 1 ]). Hence, both modalities of enteroscopy may be effective for IIBD-related small
bowel interventions with NMSE scoring over SBE except in cases not fit for general
anesthesia, pediatric patients, or postoperative patients with adhesions that may
preclude spiral enteroscopy progression.
Endoscopic hemostasis was reported in UC-related bleeding with rebleeding in a case
of acute severe colitis in whom later colectomy could be avoided with continued medical
therapy. SBE-guided hemostasis using hemoclips have been reported for proximal ileal
bleeding. Enteroscopy-assisted hemostasis has been reported earlier.[31 ]
[32 ]
IIBD is still an evolving field and its application has several challenges. IIBD is
still not widely accepted due to paucity of prospective and comparative data. The
skills of an IIBD specialist should include understanding the underlying disease process
and anatomy (e.g., postoperative) and advanced endoscopy skills. Training in IIBD
is still not available in India. Learning curve for procedures like ES and ESD (in
fibrotic colon) is high. Managing the adverse events like significant bleeding and
perforation endoscopically needs advanced endoscopic skills. Moreover, surgical and
interventional radiology backup to manage complications may not be present in all
the centers. The lack of specific codes for IIBD procedures is another challenge that
the endoscopist faces.
Our study has several important implications. IIBD can have an important role stricture
management in de novo or postsurgical anastomotic strictures in CD with excellent
short-term efficacy. The advantage is preservation of bowel length in CD. In UC, endoscopic
resection techniques can effectively treat UCAN with high R0 resection rates avoiding
colectomy. Moreover, IIBD can effectively treat pouch strictures averting need for
redo surgery or pouch excision. Careful case selection with multidisciplinary IIBD
team can avoid or manage complications of IIBD procedures effectively. The long-term
efficacy needs to be studied in future.
There are few limitations of the current study. It is a single, tertiary center study
with expert endoscopists performing IIBD procedures. So, the results may not be applicable
universally. Another limitation is very short follow-up time in the cohort. The relatively
small numbers limit the ability to study predictors of success of EBD. Moreover, we
have not used an objective score to evaluate improvement in symptoms (e.g., CD obstruction
score). However, none of earlier studies on EBD have used such scoring except for
one studying effect of adalimumab on symptomatic small bowel stricture.[21 ]
[33 ]
In conclusion, IIBD has an ever-expanding role in the treatment of IBD-related complications
as well as postsurgical adverse events serving as a bridge between medical and surgical
management. IIBD procedures are safe and have excellent short-term efficacy. These
complex diseases and associated complications require knowledge of the disease, postsurgical
anatomy, understanding of the principles, and indications of IIBD as well as the technical
skills of therapeutic endoscopy. Unfortunately, there is paucity of personnel trained
in IIBD as well as literature from India, where incidence of IBD is rising dramatically.
