A consensus statement regarding endoscopic therapy of patients with Crohn’s disease-related strictures has been unable to make any strong, grade A recommendations due to a lack of high quality data.

However the consensus statement from the Global Interventional IBD Group is the first step towards urgently needed standardisation in the management of strictures, from pre-procedural preparation through to outcomes measures and the management of adverse events. 

According to the statement, published in The Lancet Gastroenterology and Hepatology, CT or MR enterography, with or without retrograde contrast enema, should be performed before any endoscopic intervention.

This enabled the most accurate assessment of stricture architecture including luminal narrowing, wall thickening and prestenotic dilation.

In other pre-procedural considerations, the strongest evidence was for discontinuation of anti-thrombotic agents and the increased risk of complications with systemic glucocorticoids. However biologics can be safely continued.

Regarding choice of equipment, the statement said preference for the type of endoscope varied among endoscopists. 

However in endoscopic balloon dilation (EBD), the strongest evidence was for graded dilation with balloons that increase in a stepwise fashion to 18-20 mm. 

“Disagreement exists among clinicians regarding the optimal duration of balloon insufflation because there is no consistent evidence on which to base this recommendation,” it said.

The evidence largely supported EBD for primary or anastomotic strictures <4–5 cm in length and for a smaller number of strictures (<4) in close proximity than for multiple strictures (>4). 

It said EBD might also be less effective for strictures with prestenotic luminal dilation.

In other emerging endoscopic treatments with less evidence, endoscopic electroincision can be done in patients with EBD-refractory strictures “in centres with the necessary technical capabilities.”

Fully covered removable metal stents can be used for refractory strictures in selected patients if EBD and endoscopic electroincision are unsuccessful, the consensus statement said.

The Group noted most patients undergoing endoscopic stricture therapy will require repeat interventions.

“In addition to monitoring symptoms, an endoscopic assessment of treatment response is often needed. Therefore, the consensus group suggest that all patients who receive endoscopic treatment undergo a follow-up endoscopy within 1 year to monitor treatment response and receive repeat treatment if needed.”

It noted that while not a perfect criterion, long-term efficacy of endoscopic therapy is defined as surgery-free survival for 1 year after any endoscopic treatment.

The best evidence regarding adverse events was around patients with suspected or frank perforation who should be considered as a medical emergency. Urgent evaluation and a surgical consultation should be done.

Intraprocedural perforations identified at the time of endoscopy might benefit from endoscopic interventions to close the defect.

Practice changing

Director of endoscopy and head of IBD at Concord Hospital  Professor Rupert Leong told the limbic the statement would help encourage further training and skills development in therapeutic endoscopy. 

“We are now quite good at treating the inflammation aspects of CD – we’ve got new drugs available and there are a lot of new trials for new targets. Our weakness is what to do with the fibrosis and the strictures in patients that have the inflammation aspects treated.”

“Their main problems are now from obstruction of the bowel which is traditionally treated surgically with either resection or strictureplasty to conserve the bowel segments.”

He said the expert group led by Professor Bo Shen in New York has provided some useful recommendations such as the size of the balloon and outcome measures. 

“A lot of doctors don’t dilate the structures adequately so he is recommending 18-20mm. He has also defined some endpoints that endoscopists should be aiming for but I don’t think necessarily has been followed before.” 

“One is to be able to traverse the opening with the endoscope after the dilation – that is called technical success – and the other is to avoid surgery at one year which is called long term success.”

Professor Leong who has just returned to Australia after visiting Professor Shen, said the use of endoscopic electroincision in IBD was practice changing.

“Electrocautery is usually reserved for more invasive endoscopic procedures such as in ERCP where you cut into the bile duct sphincter to release a bile duct stone. 

“He [Professor Shen] is now using the same devices to cut into the strictures but also into the sinuses that lead to abscess formation outside the bowel and is one of the complications of Crohn’s disease.”  

He said using the technique to help drain abscesses into the lumen of the bowel would certainly help reduce the need for surgery.

“So I think that is a true advance – a completely new paradigm of treatment using electrocautery which traditionally has not been done in IBD endoscopy at all.”

“His line of thinking in the advantages of electrocautery is the controlled way of opening up the narrowings. When you use a balloon, you traumatically open up the narrowing with no control over where the tear occurs. What electrocautery does is cut the stricture in the direction that is best suited for the patients. You control where the tear will take place and it also controls bleeding as it goes.”

“It’s safe and controlled and in theory is actually going to be a better technique than the traditional technique of balloon dilation.”