Biodegradable stents: another big step in the field of non-surgical therapy for fibrostenotic Crohn’s disease

We read with interest the article by Rejchrt et al. entitled “Biodegradable stents for the treatment of benign stenoses of the small and large intestines” [1]. The authors successfully inserted biodegradable stents transanally in 10 of 11 patients with fibrostenotic Crohn’s disease. The authors reported that seven of these patients were symptom-free after stent insertion and that all of them remained asymptomatic after full biodegradation of the stents, which took place within a period of 4 months. However, a high rate of early stent migration in 30 % of cases was also reported.

In general, balloon dilation is the first step in the treatment of isolated (typically < 4 cm) intestinal and colonic stenosing Crohn’s disease or of Crohn’s disease with anastomotic strictures with no or minimal signs of inflammation. According to some authors it is unacceptable not to offer endoscopic dilation as an option in the treatment of stenosing Crohn’s disease, because the overall success of through-the-scope balloon dilation ranges from 50 % to 85 % in these cases [2]. The addition of intra-lesional long-acting steroids further improves this rate and decreases the necessity for further endoscopic procedures in the long term [3]. In the present report, we noticed that four patients had never been treated with a previous balloon dilation and that none of the patients had received steroid injections as an adjunct to balloon dilation. Therefore, the authors cannot suggest that all of their cases had refractory stenoses or strictures that were resistant to other therapies.

A further point is that only five patients had signs of bowel obstruction and it is not clear from the text what kinds of symptoms were present in the remaining patients. This is important due to the fact that two of the patients with no signs of bowel obstruction had stenosis before stent insertion leading to 12-mm openings at the anastomotic sites. These were the cases in which the patients developed stent migration. It is possible that these cases had no overt signs or symptoms of bowel obstruction and were not in need of any kind of treatment such as balloon dilation and/or stent insertion. However, we accept the success of biodegradable stents in the other patients in this study, who were more appropriately selected for treatment with this new technology. Nevertheless, we also believe that the authors should have demonstrated the degree of resolution of stenosis by a repeat colonoscopic examination.

Although endoluminal stenting with biodegradable polymers will definitely be utilized in the therapy of fibrostenosing Crohn’s disease, these polymers can cause obstructing hyperplastic reactions [4] and, furthermore, the stent costs in excess of US$2000. Thus, we need to correctly define the strictures refractory to or unsuitable for other cheaper and easily applicable non-surgical therapies, such as endoscopic balloon dilation with or without intra-lesional steroid injection. Subsequent to such a determination, biodegradable stents can be a good treatment alternative for such cases.

• References

• 1 Rejchrt S, Kopacova M, Brozik J et al. Biodegradable stents for the treatment of benign stenoses of the small and large intestines. Endoscopy 2011; 43: 911-917
• 2 Hassan C, Zullo A, De Francesco V et al. Systematic review: endoscopic dilatation in Crohn’s disease. Aliment Pharmacol Ther 2007; 26: 1457-1464
• 3 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: 252-255
• 4 Orive-Calzada A, Alvarez-Rubio M, Romero-Izquierdo S et al. Severe epithelial hyperplasia as a complication of a novel biodegradable stent. Endoscopy 2009; 41 (02) E137-138