P370 Endoscopic balloon dilatation in paediatric stricturing Crohn’s disease: A retrospective collaborative study of the paediatric IBD Porto group of ESPGHAN

Abstract

Background Endoscopic balloon dilatation (EBD) is an effective management strategy in stricturing Crohn’s disease (CD). While adult studies showed a high success rate of improved symptoms and avoiding surgical intervention, very little has been published in children. We thus present a multi-centre retrospective cohort study of EBD in paediatric CD from 9 centres affiliated with the Paediatric IBD Porto group of ESPGHAN. Methods Demographics, imaging, serological data, clinical indices (including the newly-developed modified CD obstructive score (mCDOS)), post-EBD complications and need for surgical intervention were recorded on electronic case report forms. Results Thirty-nine balloon dilatations were performed on 34 children (20 (59%) male, mean age 14.3 ± 3.4 years, median disease duration 3.5 years (IQR 1.1–5.8)). Successful avoidance of surgical intervention was recorded in 26 (76%) children, during a median follow-up period of 24 weeks (IQR 8–24). There was an increase in number of patients in clinical remission (wPCDAI < 12.5) following EBD from 20% pre-dilation to 36% (ns), 53% (p = 0.017) and 57% (p = 0.015) at weeks 2, 8 and 24, respectively. There was a trend to reduced mCDOS, from 5 (IQR 0–15) at baseline to 5 (0–6.25) (ns), 5 (0–5) (p = 0.04), and 0 (0–7.5) (ns), respectively. The stricture was primary in 31 (79%) children (17 in the ileocecal valve (ICV) region, 3 in the terminal ileum, 9 in the colon and 1 in the duodenum), 7 of whom had multiple strictures. Eight (21%) children had an anastomotic stricture. Median stricture length was 3 cm (IQR 2–4.7), bowel wall thickness 7 mm (IQR 5–8) and median pre-stenotic dilatation of 4.5 cm (IQR 4–5). Median maximal dilatation diameter was 15 mm (IQR 12–18) with the successful passage of the colonoscope in 26/39 (67%). There were 3 (8%) post-dilatation complications including one bleed following rectal dilatation (with spontaneous resolution) and 2 perforations (1 duodenal perforation managed conservatively and 1 ICV perforation requiring surgical resection). Conclusion EBD is an effective and safe technique in paediatric stricturing CD with over 75% avoiding surgery by one year and 8% complications. Further data are required to better identify optimal stricture features and dilatation diameter in children.

Approach to Endoscopic Balloon Dilatation in Pediatric Stricturing Crohn Disease: A Position Paper of the Endoscopy Special Interest Group of ESPGHAN

“…The success of dilatation did not difer signiicantly between primary or anastomotic strictures, both in adult ( 12) and pediatric (15) studies.…”

“…The terminal ileum and the ileocecal valve are the most frequent sites of strictures in CD, followed by the colon, and with upper gastrointestinal (GI) and jejunal involvement occurring more infrequently (15,(34)(35)(36). It is important to consider the accessibility of the stricture before considering EBD.…”

“…However, when necessary, multiple strictures can be dilated even in the same session. Indeed, one of the cases in the published pediatric study was a successful dilatation of four individual strictures in close proximity (15) (Video 1).…”

“…Patients in whom these symptoms are not alleviated by appropriate therapies may be referred for surgical resection or stricturoplasty. Both adult (12,14) and pediatric (15,17) data suggest that between 70% and 90% of patients have avoided surgery following EBD. While it may be tempting to assume that there is no significant potential harm in attempting EBD, since even in the event of failure or perforation, surgery would have been required anyway, the likely more complicated surgical course after perforation than primary elective resection must be considered.…”

“…Despite robust adult data and evidence‐based guidelines (14), there remains a significant lack of pediatric data. A recent retrospective collaborative study (15) from European, Canadian, and Israeli pediatric centers affiliated with the inflammatory bowel disease (IBD) interest group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), suggests that EBD may be underutilized in this population.…”