Endoscopic Balloon Dilation Size and Avoidance of Surgery in Stricturing Crohnʼs Disease

Abstract

BACKGROUND Endoscopic balloon dilation (EBD) is an effective method for treating stricture-related obstruction in Crohn’s disease (CD). We aimed to identify factors predictive of successful avoidance of surgery, including endoscopic features, in patients undergoing balloon dilation. METHODS We performed a retrospective review of patients with symptomatic CD-related intestinal strictures undergoing EBD. Clinical, medication use, laboratory, and dilation data, including the minimum and maximum balloon sizes used, and number of balloons used per endoscopic session were collected. Multivariate analysis by Cox proportional hazard regression was used to model future surgical bowel resection. RESULTS In a total of 135 subjects undergoing 292 dilations, multivariate modeling demonstrated that failure to achieve a maximum dilation of 14mm or more increased the risk of surgery (HR 2.88, 95%CL 1.10,7.53). While there was no difference in the risk of future surgery between maximum EBD sizes of 14–15mm and 16–18mm, those reaching 16–18mm exhibited a longer interval between subsequent dilations (mean 240±136.7 vs. 456±357.3 days, respectively, p=0.023). Endoscope passage at index dilation was not predictive of future surgery (HR 0.63 95%CL 0.31, 1.26). Adjusting for covariates of EBD size, stricture location and type, a CRP>1.5mg/dL (HR 2.60, 95%CL 1.12, 5.94) and anti-TNF initiation following index EBD (HR 2.39, 95%CL 1.09, 5.25) increased the risk of future surgery. CONCLUSIONS While dilation calibers larger than 14–15mm were not more protective against future surgery, those reaching 16–18mm underwent maintenance dilation less frequently. The risk of surgery associated with post-EBD anti-TNF initiation suggests effective therapy is often employed too late in the disease course.

Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group

“…budesonide) and systemically active corticosteroids was mentioned in the majority of cited studies. 8,9,10,11,13,14,15,28,29,30 However, the impact of steroid use on efficacy and adverse events was not specified in those studies. IBD patients undergoing colonoscopy, especially EBD, exhibited a higher risk for procedure-associated perforation than non-IBD or non-intervention controls.…”

“…Concurrent or prior use of biological agents ranged from 5.6% to 86.3% patients. 8,9,10,11,14,15,21,22,26,28,29,30,47 No published data exist associating the efficacy or adverse events of EBD with concurrent biological agent use (Recommendation Table 3-1-9).…”

“…Various definitions of "graded dilation" have been used in the current literature. 8,9,10,11,13,14,15,21,22,26,28,29 Graded dilation is normally performed with controlled radial expansion balloons, with inflation and partial or complete deflation in between each size.…”

“…A goal of the size 18-20 mm should pursued, as shown in foundational studies, even with multiple sessions of ET (Recommendation Table 3 -2-3). 8,9,10,11,15,21,22,26,27,28,29,30 The efficacy of EBD may be tied with balloon size employed, 14 although a pooled analysis failed to correlate balloon size and surgery-free survival. 54 No literature exists correlating balloon size and complication risk, but the consensus group cautioned that balloon size may yet impact procedure-associated complication risks.…”

Crohn's disease associated strictures

“…With regard to EBD technique, the maximum balloon diameter recorded in the studies ranged from 15 to 25 mm, but an increased caliber of dilation neither resulted in increased rates of clinical efficacy nor reduced the need for redilation or surgery . In a recent retrospective review of patients with symptomatic CD‐related strictures undergoing EBD, Reutemann and colleagues found that although there was no difference in the risk of future surgery between maximum EBD sizes of 14 to 15 mm and 16 to 18 mm, those reaching 16 to 18 mm exhibited a longer interval between subsequent dilations (mean 240 ± 136.7 vs 456 ± 357.3 days, respectively, P = 0.023) . Moreover, dilating strictures up to 25 mm had a higher than average complication rates.…”