Terminal Ileal Stricture in Crohn's Disease: Treatment Using a Metallic Enteral Endoprosthesis

Abstract

Enteral strictures are a frequent indication for surgery in Crohn's disease. Postoperative complications are increased in patients with poor preoperative nutritional status, which is common in this patient population. We present a 49-year-old female with longstanding Crohn's disease admitted to our Digestive Health Center with four weeks of increasing abdominal symptoms and radiographic evidence of small-bowel obstruction caused by ileal stricture. Given her poor nutritional status, our team elected to pursue metallic enteral stenting as a bridge to surgical resection. Two Wallstents were placed; luminal patency was subsequently confirmed by a fluoroscopic study. The patient tolerated regular diet and was discharged. When seen in follow-up, she remained asymptomatic and wished to defer surgical intervention indefinitely.

Endoprosthetic management of refractory ileocolonic anastomotic strictures after resection for Crohnʼs disease: Report of nine-year follow-up and review of the literature

“…These results have prompted some authors to conclude that SEMS may be inappropriate for long-term management of CD obstruction and should only be used as a temporary bridge to surgery or in patients with limited life expectancy. 2,9,13,14 The present study, however, suggests a more hopeful outlook, with a mean stent duration over twice as long (24 months), a complication rate of just 20% (n ¼ 1), and an average long-term luminal patency of 34.8 months in the four patients who did not require early reintervention. There were no technical problems, migrations, or late complications.…”

“…6,7 In addition to providing immediate decompression, endoluminal stenting has been shown to improve outcomes and quality of life by reducing the need for emergency surgery and stomas, as well as palliating advanced disease. 2,6,7,9,12 Benign obstruction represents a different challenge, however, and there is no consensus in the scant literature as to whether the same efficacy and safety profiles will hold true. While some studies report failure rates over 60% and a high frequency of complications, particularly in the setting of diverticular disease, 3,9,15,[18][19][20] many authors conclude that for selected patients, endoluminal stenting can be an important treatment option.…”

“…6,8,[18][19][20] From our review of the literature, we identified only nine studies that report on SEMS in CD, in a total of 12 patients and 15 procedures. 2,3,[9][10][11][12][13][14][15] Outcome data are summarized in Table 2. In five patients (45%) the indication for stent placement was anastomotic stricture.…”

“…While initial success rates are high, migration seems to occur more frequently in benign disease 8 and planned surgical removal generally curtails any extended outcome data. 3,9 The literature is particularly scarce regarding inflammatory bowel disease, with only a handful of studies reporting on no more than one to two CD patients each, 2,3,[9][10][11][12][13][14][15] and only three cases with stent durations greater than 1 year. 12,13,15 There is concern that prolonged stenting in CD may lead to more complications such as recurrent inflammation, fistula formation, and perforation.…”

“…[1][2][3] While both resection and strictureplasty can provide immediate symptom relief, recurrence rates are high and repeated interventions often required, resulting in chronic disability, elevated costs of care, and the potential for short bowel syndrome. 4,5 Self-expanding metal stents (SEMS) represent a nonsurgical alternative which has proven very effective in the treatment of malignant obstruction as both a palliative measure and a bridge to surgery.…”