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16 Endoscopic Therapy ofIntestinal Strictures: What Is State oftheArt?
229
a b
Fig. 16.1 Balloon dilation. Syringe gun, manometer and balloon (a). Through the scope (TTS)
balloon (b), and following ination (c). TTS balloon is inserted into the operating channel (d)
Radially expanding balloon dilators are available commercially in several calibers and lengths (Fig.16.1). Balloon dilators are made of low-compliance inatable
thermoplastic polymers which will allow to have a reproducible and uniform expansion of the balloon to its desired maximal size. Dilator diameter is measured in
millimeters or French (Size in millimeters can be converted to French at a ratio of
1:3, e.g. 10mm=30F). The balloons usually range in size from 6 to 20mm diameter. Most balloons allow for sequential expansion and they are marked as singleuse. The balloon is expanded by pressure injection of liquid, mainly water but in
some instances with radiopaque contrast, by using a handle accessory device. The
hydraulic pressure of the balloon is monitored manometrically to gauge the radial
expansion force [41].
Before attempting to perform a dilatation, it is very important to know the length
and complexity of the stricture. If this information can be obtained during the
endoscopy i.e. the stenosis is very short, can easily see through it and the length can
be estimated than no other investigation is required. If this is not the case, further
imaging with either a CT enterography or MR enterography is required to gather
all the required information for a safe procedure. This is preferably done prior to
dilation. In some centers, luminal contrast assisted radioscopy is performed during
the procedure using the balloon catheter to inject contrast uid. As discussed earlier, strictures ≤5cm without any of the mentioned contraindications is amenable
for dilatation.
230
esophagus
abcd
Dilated
Scope
TTS
(balloon)
catheter
Esophageal
stricture
TTS
catheter
inserted
into stricture..
T. Bessissow and G. Van Assche
..balloon
inflated...
Fig. 16.2 Balloon dilatation. Through the scope (TTS) balloon inserted into the endoscopic lumen
(a). TTS balloon passed through the stricture (b). Insufation of balloon to dilate stricture (c).
Dilated stricture (d)
Once the endoscope is passed to the stenosis site, initial selection of the dilator
size is based on an estimation of the diameter of the stenosis (Fig.16.2). The
balloon is then passed through the scope accessory channel with or without a
guidewire which allows direct visualization during the procedure. If a guidewire
is used, it should be rst advanced through the stenosis and the balloon is advanced
over the wire. The balloon is placed across the obstruction and inated under
direct vision and the guidewire is retracted. If the guidewire is not used, the balloon is directly advanced through the stricture and placed across. The balloon is
then inated with a pressure or volume-controlled handles to the desired pressure, representing the chosen balloon diameter. After removal of the balloon, the
dilated stricture is usually examined endoscopically [41]. A three-step ination is
preferred as it is considered to induce more controlled dilation. The diameter of
the balloon will increase with every step of increased pressure. The diameter corresponding with every step is clearly depicted on the balloon catheter. Most centers dilate to a maximum of 18–20 mm. Repeated dilation, with intermittent
deation, during the same procedure can be employed if the rst dilation is judged
to be suboptimal.
..dilated
stricture
16.6 Conclusion
In non-complex strictures that are ≤5cm in length, endoscopic balloon dilatation is
a safe and effective alternative procedure to surgery. The short-term outcomes are
excellent and it can prevent or delay surgery in most patients.
16 Endoscopic Therapy ofIntestinal Strictures: What Is State oftheArt?
231
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38. East JE, Brooker JC, Rutter MD, Saunders BP.A pilot study of intrastricture steroid versus
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T. Bessissow and G. Van Assche
Chapter 17
Resectional Surgery forIntestinal Strictures:
What Is State oftheArt?
KarinA.T.G.M.Wasmann, ChristianneJ.Buskens, PieterJ.Tanis,
andWillemA.Bemelman
Abstract Novel scientic insights and our progressing experience have enlarged
the armamentarium of surgical treatment options for Crohn’s disease. It has become
daily clinical practice to be able to choose between medical or surgical treatment.
The natural course of Crohn’s disease often results in brosis and strictures. Despite
the improvement of medical therapy for Crohn’s disease, to date no medical therapy
for strictures exist. Those patients are destined to dilatation for short strictures but
otherwise undergo stricturoplasty or resectional surgery. This chapter will focus on
the technical aspects of resections for stricturing disease, discussing indications for
surgery, the surgical approach and results of surgery.
Keywords Fibro-inammatory strictures · Pure stenotic strictures · Crohn’s
disease · Ileocolic resection · Single port · Multi port · Anastomosis · Radicality
Mesenteric
17.1 Introduction
The course of Crohn’s disease is described as starting with luminal inammation,
which can progress to irreversible damage of the bowel wall resulting in brotic
ileal strictures and/or stulas [1–5]. According to the natural history of Crohn’s
disease, the majority of patients present with pure inammatory disease at diagnosis
(77%) (Montreal B1) [1]. Others already present with stricturing disease (Montreal
B2), or penetrating disease i.e. stula or abscess (Montreal B3) [6, 7]. In populationbased cohorts up to 36% have complications at diagnosis, including strictures or
penetrating disease [8–10]. Approximately half of the patients with terminal ileitis
will develop a stricture [3, 6]. Although, this could be underestimated as traditionally Montreal and Vienna classication systems score patients according to the
highest level of disease, consequently a stricture is only scored in the absence of
Karin A. T. G. M. Wasmann · C. J. Buskens · P. J. Tanis · W. A. Bemelman (*)
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
e-mail: k.a.wasmann@amc.nl; c.j.buskens@amc.nl; p.j.tanis@amc.nl; w.a.bemelman@amc.
nl
F. Rieder (ed.), Fibrostenotic Inammatory Bowel Disease,
https://doi.org/10.1007/978-3-319-90578-5_17
233© Springer International Publishing AG, part of Springer Nature 2018
234
penetrating disease [6, 7]. Whereas the anatomical location of Crohn’s disease is
mostly stable, behaviour of Crohn’s disease varies substantially during the course of
the disease. As an example, almost a fth of patients clinically evolve to a more
advanced phenotype within 90days [8]. The above described traditional concept
with inammation, complicated by strictures, stulas, and abscesses might be too
simple and rigid, since the natural history of Crohn’s disease is a continuum of
gradual progression towards complicated disease. Within the modern concept of
Crohn’s disease of the terminal ileum emphasizing the progressive nature, the stages
of disease can be divided into bro-inammatory disease, pure brotic disease, stulising disease, and stulising disease with abscess formation. To identify these
phenotypes enterography combined with magnetic-resonance imaging (MRE) is the
preferred choice for preoperative imaging [11–13]. Subclassication into these four
phenotypes can be helpful in standardising timing of surgery, preoperative optimisation, staged surgery, expected morbidity and stoma rates, and prophylactic medical treatment postoperatively. So far, for this staging system only little evidence
exists, but it appears helpful in daily clinical practice [14, 15]. This chapter will
address surgical therapy for stricturing Crohn’s disease, with the focus on the terminal ileum, as its preferred location.
K. A. T. G. M. Wasmann et al.
17.2 Indication forSurgery
Formerly, up to 90% of patients underwent a surgical resection within 15years after
diagnosis, mainly due to complicated Crohn’s disease of the terminal ileum [1, 16–
18]. Surgery is generally considered an invasive and last resort option once all medi-
cal therapies have failed. With the introduction of biologics (in particular anti-tumour
necrosis factor alpha (anti-TNF)) in 1999, the treatment of Crohn’s disease shifted
away from surgery to medical therapy, resulting in a decline in surgical resections
up to 30% over the last decade [19, 20]. The incidence of stricture formation and
surgery for strictures did not seem to decrease in the past decade [21]. Whether a
patient with Crohn’s disease of the terminal ileum should have medical or surgical
therapy depends on many factors: extent of the disease, co-existing other localisations of Crohn’s disease, prior medical treatment, the brotic component of the
disease with or without the presence of prestenotic dilatation. In order to achieve a
tailored treatment approach for each patient, decisions should be made in multidisciplinary teams. The radiology input is vital for decision making, as it can identify
the phenotype correlating with the surgical outcome [22].
17.2.1 Fibro-Inammatory Phenotype
Worldwide, the standard treatment of terminal ileitis in Crohn’s disease is a step-up
medical protocol with the start of anti-inammatory drugs and immunomodulators,
followed by biologics and/or experimental medication. Medical therapy is most
17 Resectional Surgery forIntestinal Strictures: What Is State oftheArt?
235
effective when the disease is still in its inammatory stage of disease [21]. In broinammatory disease, dened as predominant inammatory disease evident by
bowel wall thickening, established indications for surgery include therapy refractory disease, and unacceptable medical therapy side-effects. If patients continue to
have symptoms or persistent inammation under properly dosed anti-TNF, discontinuation of medical treatment and decision to undergo surgery is warranted. The
indication for surgery is also dependent on the extent of the disease: generally, surgery is advised in limited disease (<40cm), because resection of more than 40cm
can result in bile acid diarrhea [23]. Furthermore, additional locations of the disease
should also be taken into account when discussing these patients in the multidisciplinary team (MDT) meeting. If patients have synchronous Crohn’s disease lesions,
e.g. colonic involvement or perineal stula, this would be an argument for (continuation of) medical therapy, as biologics can treat all locations at the same time.
Surgery is effective in all stages but might seem less attractive in the inammatory
stage of the disease, mainly because of the risk of complications like anastomotic
leakage and/or (temporary) ileostomy. However, there are no data, whether the
affected bowel segment, even after mucosal healing was achieved with medical
therapy, still functions normally [24]. Currently, only one head to head comparison
of laparoscopic ileocolic resection versus anti-TNF has been performed in patients
with limited terminal ileitis (<40cm) not responding to immunomodulators, concluding that surgery is a good alternative to anti-TNF.The randomized control trial
(RCT) showed non inferiority of surgery compared to anti-TNF with regard to disease specic quality of life and endoscopic remission rates, and superiority of surgery for general quality of life [25].
17.2.2 Fibrotic Phenotype
Secretion of extracellular matrix (ECM) components, such as collagens and bronectins, is intended to close defects of the bowel wall. So far, it is reported that an
excessive production of ECM driven by the misbalanced inammatory mechanism
of Crohn’s disease causes brotic stenosis [26, 27]. Independently of inammation,
brosis can progress, and once tissue stiffness increases, it can serve as an activator
itself [28]. Medication is less effective when stenosis or perforation has occurred,
and endoscopic balloon dilatation is only applicable for short, isolated strictures
(<4cm) in reach of standard colonoscopy [29]. The absence of inammation on
MRE reliably predicts a pure brotic stricture [30, 31]. However, the great difculty
is the bro-inammatory stricture. With the current diagnostic tools, we are not able
to quantify the relative contribution of brosis to the bro-inammatory stricture
and to the clinical symptoms of the patient. For this reason, a trial of medical therapy is generally started. If the inammation is refractory or the symptoms persist
despite mucosal healing, the patient is sent to the surgeon. This is a pragmatic but
suboptimal strategy, because trial and error consequently cause a delay in appropriate treatment resulting in more extensive disease, loss off quality of life and
increased costs. Prestenotic dilatation is generally considered as a sign of severe
236
brosis requiring surgical management. Pure brotic disease is an established indication for surgery. Also for pure brotic disease the extent of disease should be
taken into account, as it is still not preferable to resect more than 40cm of intestine.
In those cases, stricturoplasty is the preferred treatment.
K. A. T. G. M. Wasmann et al.
17.2.3 Fistulising Disease
Symptomatic stulising disease is an indication for surgery. Clear examples are
enterovesical, enterovaginal and enterocutaneous stula. The phenotype of the disease is likely to reect surgical outcome e.g., stulising disease associated with
abscesses correlate with higher rates of ileostomy, postoperative complications, and
longer hospital stay [32]. Sequential application of new medical therapies has
broadened the spectrum to treat patients with good short-term results, but with the
caveat that surgery might be postponed [33, 34]. Prolonged, partially ineffective
medical therapy might result in healthy nearby organs being included by the inammatory mass resulting in more extensive resections [35]. Furthermore, corticosteroids, immunomodulators and anti-TNF use within 3 months of surgery could
worsen postoperative morbidity [36–38].
17.2.4 Abscess
Intra-abdominal abscesses are caused by perforating disease. Most patients will
require resection of the perforated segment particularly in the presence of a distal
stricture. Other factors indicative for surgery are the development of an abscess
under anti-TNF, involvement of a short segment, and absence of other locations of
Crohn’s disease. The presence of an abscess, anaemia, the use of immunosuppressive medications within 3months of surgery, and perioperative hypalbuminaemia
are associated with increased post-operative complications [32]. Therefore, patients
must be optimised prior to surgery, by improvement of the nutritional status, stopping of the immunomodulating drugs, and starting treatment by percutaneous drainage of the abscess in combination with antibiotics. Also, patients can be planned for
a staged surgery, meaning a resection with stoma in the rst stage and secondly
restoration of continuity with an anastomosis or rstly a stoma only and secondly
resection with anastomosis.
Less often strictures present in the upper gastrointestinal tract, the colon, and the
rectum (see Chap. 20). Crohn’s strictures of the colon are best treated with surgical
resection, because of the high risk for the presence, or development of cancer [39,
40]. Strictures in the stomach or duodenum are uncommon. Duodenal strictures and
strictures of the antrum are preferably treated with stricturoplasty or bypass surgery,
because resection requires extensive surgery [41].
17 Resectional Surgery forIntestinal Strictures: What Is State oftheArt?
237
17.3 Stricturoplasty or Resection
Once surgery is indicated in stricturing Crohn’s disease of the small bowel, the
treatment options are either limited to bowel resection or stricturoplasty [42].
Stricturoplasty can be done in pure brotic strictures as well as in bro- inammatory
strictures. The principle of stricturoplasty is stricture lysis and widening, adapted
from the pyloroplasty procedure. Remarkably, despite leaving the affected bowel in
situ, it has been demonstrated that the mucosa can heal after stricturoplasty, and
recurrences are generally in-between the stricturoplasties rather than at the site of
the stricturoplasty [26, 43, 44]. Accordingly, even though the location of Crohn’s
disease is considered to be stable (see Sect. 17.1), the recurrence is more likely to
develop at a different site [45]. Strong indications for stricturoplasty are (multiple)
short strictures (<10 cm), patients at risk for short-bowel syndrome due to large
strictures (>40cm), prior resectional surgery of more than 100cm, recurrent strictures at the ileocolic anastomotic sites, and strictures within 1year from previous
surgery [40]. Contraindications are strictures associated with perforation, including
abscess and peritonitis, phlegmon and suspicion of carcinoma in the stricture.
Whereas short strictures are easily treated with the Heineke-Mikulicz or Finney
stricturoplasty [46], the longer strictures demand technically more challenging
stricturoplasties. With the Michelassi stricturoplasty, long segments up to 80–100cm
can be treated, resulting in a 40–50cm stricturoplasty [47]. When stricturoplasty
was introduced, concerns were potential increase in septic complications because of
preservation of diseased bowel and suture line through macroscopic disease. The
main drawbacks of surgical therapy are surgical morbidity and recurrence of disease. However, recent data on long-term outcome of ileocolic resections showed an
anastomotic leakage rate of only 3% and a surgical recurrence rate (recurrence
requiring surgery) of less than 20% within 10years [48]. As stricturoplasty and
resection for terminal ileum strictures have different indications, no randomised
control trial exists to compare outcomes of both techniques. However, it is hypothesized that a stricturoplasty over the valve would have the same therapeutic effect as
a surgical resection, with an upcoming RCT to test this hypothesis (see Chap. 20).
So far, a systematic review on stricturoplasties concluded that stricturoplasty is safe
and effective, even in the presence of active disease [45, 49]. The incidence of overall postoperative complications, septic complications, and surgical complications
e.g. anastomotic leak, stula, and abscess are comparable to resection [46, 50].
Eight studies compared recurrence rates after stricturoplasty and resection for strictures in the terminal ileum (Table17.1) [39, 51–57]. Three of these studies found no
signicant difference in the recurrence rate after stricturoplasty and resection [39,
51, 52]. Four of these studies, including patients with multiple lesions, found no
signicant difference after stricturoplasty versus stricturoplasty and resection
[54–57]. One study reported signicant superiority of stricturoplasty versus resection, although this data was not corrected for primary and recurrent disease [53].
One retrospective study with over 500 patients reported more surgical recurrences
238
Table 17.1 Stricturoplasty versus resection for strictures in the terminal ileum
Authors (years) No. of
Sayfan etal. (1989) [51] 82 60 26 26
Broering etal. (2001) [52] 56 86 50 37
Tonelli etal. (2010) [39] 28 120 36 24
Fichera etal. (2006) [53]
Stebbing etal. (1995) [54] 52 50 35 44
Ozuner etal. (1996) [55] 162 42 31 27
Yamamoto etal. (1999) [56] 111 107 47 32
Tonelli and Ficari (2000) [57] Not
a
Studies reporting signicant different recurrence rates
patients
a
79 41 45 70
available
Median follow-up
(months)
48 46 35
K. A. T. G. M. Wasmann et al.
5-year recurrence rate
Stricturoplasty
(%)
Stricturoplasty
(%)
Resection (%)
Stricturoplasty
& resection (%)
at the site of the anastomoses after resection compared to the site of stricturoplasty,
(18% vs 7%, P<0.01) [58]. Conversly, another systematic review concluded that
surgical recurrence after stricturoplasty was more likely than after resection [59].
Additionally, patients undergoing resection had a signicantly longer recurrencefree survival than those undergoing stricturoplasty alone. Disease regression in the
post-stricturoplasty sites has been evaluated based on cytokine production in biopsies, radiologic -, endoscopic-, and histopathologic regression. One study evaluated
cytokine production 1year after stricturoplasty and reported the same concentration
at the post-stricturoplasty site compared to normal mucosa [44]. The hypothesis is
that stricturoplasty, resolving the obstruction and releasing the pressure, results in a
downregulation of the immune system. An important argument for stricturoplasty is
to spare the bowel, and prevent short bowel syndrome. In this respect, it must be
stressed that the most important cause of short bowel is the inadvertent resection of
unaffected small bowel loops during surgery for complications after surgery for
Crohn’s disease. Rarely, the disease is so extensive that it requires long segments of
resection. The disadvantage of stricturoplasty is the risk of developing cancer as the
inamed segment remains in situ, 5 of 1616 patients developed and died of adenocarcinoma in the small bowel arising at the site after a stricturoplasty [47].
17.4 Approach
Over the past two decades, the implementation of laparoscopic surgery and enhanced
recovery programs are the most important achievements in surgery for IBD.In daily
clinical practice, several techniques exist to perform an ileocolic resection, comprising of open surgery, hand assisted laparoscopic surgery, and straight laparoscopic
surgery via multi-port or single port. The extent of what is done laparoscopically