Br. J. Surg. 1991, Vol. 78, April, 453-454
A. J. K. Williams and K. R . Palmer Gastro- Intestinal Unit, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK Correspondence to: Dr K. R . Palmer
Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures resulting from Crohn's disease Endoscopic balloon dilatation was undertaken in seven patients who presented with obstructive symptoms resulting f r o m Crohn 's disease. Five patients had strictures f r o m recurrent disease at the site of an ileotransverse anastomosis, one had duodenal stenosis and one a colonic stricture. The procedures were performed under intravenous sedation on one to four occasions (median 2) and were uncomplicated. Sustained improvement over an 18-24-month follow-up period was achieved in jive patients, but dilatation was unsuccessful in two cases. Endoscopic balloon dilatation is a safe and effective option in selected patients with intestinal strictures resulting f r o m Crohn 's disease and may overcome the need.for surgery.
T h e majority of patients w h o develop Crohn's disease undergo a b d o m i n a l surgery a n d , because recurrence is common, many will u n d e r g o multiple operations'.2. The realization t h a t surgery is n o t curative and t h e need t o conserve functional intestine h a v e resulted in t h e concept of a conservative surgical a p p r o a c h t o Crohn's d i s e a ~ e ~T. h~i s. is exemplified by limited intestinal resection a n d t h e use of stricturoplasty. T h e s e operations are usually performed following failed medical treatment w h e n t h e intestinal l u m e n is irreversibly n a r r o w e d by fibrosis resulting f r o m t h e inflammatory process. F i b r o u s strictures elsewhere i n the gastrointestinal tract may be a m e n a b l e t o t r e a t m e n t by endoscopic balloon dilatation which is routinely and successfully used i n the treatment of peptic oesophageal strictures5 and pyloric s t e n o d . T h i s technique might b e extended t o fibrous strictures resulting f r o m Crohn's disease, p e r h a p s overcoming t h e need f o r surgical resection o r stricturoplasty, or a t least allowing delay of a n o p e r a t i o n while awaiting a general i m p r o v e m e n t in t h e patient's condition. T h i s is a r e p o r t of a preliminary experience of endoscopic balloon dilatation for C r o h n ' s strictures.
Patients and methods Endoscopic balloon dilatation was used in the treatment of Crohn's strictures in four men and three women between January 1987 and January 1989. Crohn's disease was diagnosed clinically and radiologically and was confirmed histologically in each case. Five patients underwent dilatation because of recurrent attacks of small bowel obstruction from recurrent Crohn's disease at the site of a previous ileotransverse anastomosis (Figure I ). One patient presented with chronic gastric outflow obstruction and malnutrition caused by duodenal involvement, having had two previous ileal resections for Crohn's disease. The final patient presented with recurrent subacute large bowel obstruction from an isolated stricture in the descending colon, although she also had evidence of inactive ileal Crohn's disease. A11 patients had previously been treated medically, with corticosteroids (all cases), sulphasalazine (four cases), azathioprine (two cases) and/or an elemental diet (three cases), but had failed to achieve sustained remission of their symptoms. All patients had intestinal strictures < 4 cm in length, accessible to the colonoscope or gastroscope. Although the Crohn's disease activity index was not formally measured, all patients were deemed to have inactive disease at the time of endoscopy and none had elevation of C-reactive protein, erythrocyte sedimentation rate or platelet count. Balloon dilatation was performed using the commercially available 'Rigillex' balloon system (Keymed Ltd., Southend, UK). Balloons 18
and 20 mm in diameter were used. Patients with ileocolonic or colonic strictures underwent standard colonoscopic bowel preparation using Pilocax" (Ferring Pharmaceuticals Ltd., Feltham, UK). Following intravenous sedation with midazolam (Hypnoval", Roche Ltd., Welwyn Garden City, UK) and pethidine, colonoscopy was performed using an Olympus ITlOL (Olympus-Keymed, Southend, U K ) colonoscope. The stricture was identified and biopsied and the balloon inserted through the stricture. The balloon was then partially inflated and withdrawn to an optimum position before inflation to its maxium diameter for a period of 1 min. It was deflated and then reinflated for a further 2 min. Radiological screening was not performed routinely. The patient with the duodenal stricture was sedated with midazolam and pethidine and gastroscoped using an Olympus IT10 forward viewing gastroscope. Dilatation was then performed exactly as described for the colonic and ileocolonic strictures. Following endoscopy, patients were fasted for 4 h and observed in hospital for a 24-h period. In two cases the endoscopist felt that the dilatation had been incomplete because he was unable to pass the endoscope into proximal bowel following dilatation. In these instances repeat dilatation was performed. In other cases endoscopic dilatation was repeated following symptom recurrence (Table 1 ). Response to therapy was judged on the basis of symptomatic improvement. The median length of follow-up was 24 months (range 21-27 months).
Figure 1 Contrast siudy of ileotransverse anasiomoiic recurrence of Crohn's disease in patieni 1 ofTable 1
--
0007-1323/91/040453-02
4 ) 1991 Butterworth-Heinemann Ltd
453
Balloon dilatation for Crohn‘s strictures: A. J. K. Williams and K. R. Palmer
Table 1 Results of endoscopic balloon difutation Patient
Site of stricture
No. of dilatations
1
Ileotransverse anastomosis
2
2
Ileotransverse anastomosis
3
3
Duodenum
4
4
Ileotransverse anastomosis
1
5
Colonic
2
6
Ileotransverse anastomosis
2
7
Ileotransverse anastomosis
1
Results Clinical response is summarized in Table I. Balloon dilatation failed in two patients with ileotransverse anastomotic recurrence because the endoscopist was unable to intubate the stricture. Both patients subsequently underwent a segmental resection. At laparotomy there was no evidence of perforation. Examination of the resected bowel showed particularly tight and tortuous strictures. Dilatation was technically successful in the remaining three patients with anastomotic strictures, although it had to be repeated in one because of recurrent obstructive symptoms. Two patients are asymptomatic 21 and 27 months later, and the other has improved greatly after a single dilatation, with only occasional episodes of abdominal pain and without evidence of intestinal obstruction. The patient with duodenal stenosis improved considerably after four dilatations with 6 kg weight gain, cessation of vomiting and a radiologically confirmed increase in gastric emptying. At 23 months after dilatation he presented with recurrent small bowel disease, eventually leading to a further small bowel resection; at operation a gastroenterostomy was also fashioned. The patient with the colonic stricture has been dilated twice and remains well 23 months later. Balloon dilatation was performed on one to four occasions; the total number of procedures was 15. All patients tolerated the procedure well, although one developed abdominal pain and transient fever 48 h after dilatation of an ileotransverse stricture. This resolved with antibiotic therapy.
Symptoms before dilatation
Symptomatic outcome
Subacute small bowel obstruction occurring every 4-8 weeks Four attacks of small bowel obstruction over previous 6 months Gastric outflow obstruction, weight loss, serum albumin 30 g/l Two attacks of small bowel obstruction Episodic abdominal distension, constipation and colicky abdominal pain Four episodes of small bowel obstruction over 1 year Single episode of small bowel obstruction
Asymptomatic
Technical failure
Weight gain, normal serum albumin, some sensation of abdominal ‘fullness’ only Episodic mild pain and distension Pain free, irregular bowel habit
Symptom free Technical failure
is feasible. While the total number of procedures was relatively few, the technique appears safe and was well tolerated. We have extended our experience to over 30 procedures and have yet to encounter a serious complication. The procedure is sometimes technically demanding; a tortuous endoscope may not freely allow passage of the balloon catheter, strictures may prove difficult to intubate or to broach fully. These factors accounted for two failures. Only a highly selected group of patients are suitable; those with long or multiple strictures and those with lesions inaccessible to endoscopy are clearly unsuitable. Patients with short, fibrous strictures are amenable to this form of therapy and may derive satisfactory improvement. We have not routinely reinvestigated patients following dilatation to minimize radiation risks.
References 1.
2.
3. 4. 5.
Hellers G. Crohn’s disease in Stockholm County 1955-1974. A study of epidemiology, results of surgical treatment and long-term prognosis. Acfa Chir Scund 1979; 4W(Suppl): 31-69. Rutgeerts P, Geboes K , Ventrappen G, Kerremans R, Coenegrachts JL, Coremans G. Natural history of recurrent Crohn’s disease at the ileocolonic anastomosis after curative surgery. Gut 1984; 25: 665-72. Lee ECG. The aim of surgical treatment of Crohn’s disease. Gut 1984; 25: 211-22. Dehn TCB, Kettlewell MGW, Mortensen NJ, Lee ECG, Jewel1 DP. Ten year experience of stricturoplasty for obstructive Crohn’s disease. Br J Surg 1989; 7 6 : 33941. Lindner KD, Ott BJ, Hughes RW. Balloon dilatation of upper digestive tract strictures. Gastroenterology 1985; 89: 545-8. Hogstrom M, Haglund U. A technique for endoscopic balloon dilatation of pyloric stenoses. Endoscopy 1985; 17: 224-5.
Discussion
6.
This preliminary series has shown that endoscopic balloon dilatation of intestinal strictures resulting from Crohn’s disease
Paper accepted 6 October 1990
454
Br. J. Surg., Vol. 78, No. 4, April 1991
A. J. K. Williams and K. R . Palmer Gastro- Intestinal Unit, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK Correspondence to: Dr K. R . Palmer
Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures resulting from Crohn's disease Endoscopic balloon dilatation was undertaken in seven patients who presented with obstructive symptoms resulting f r o m Crohn 's disease. Five patients had strictures f r o m recurrent disease at the site of an ileotransverse anastomosis, one had duodenal stenosis and one a colonic stricture. The procedures were performed under intravenous sedation on one to four occasions (median 2) and were uncomplicated. Sustained improvement over an 18-24-month follow-up period was achieved in jive patients, but dilatation was unsuccessful in two cases. Endoscopic balloon dilatation is a safe and effective option in selected patients with intestinal strictures resulting f r o m Crohn 's disease and may overcome the need.for surgery.
T h e majority of patients w h o develop Crohn's disease undergo a b d o m i n a l surgery a n d , because recurrence is common, many will u n d e r g o multiple operations'.2. The realization t h a t surgery is n o t curative and t h e need t o conserve functional intestine h a v e resulted in t h e concept of a conservative surgical a p p r o a c h t o Crohn's d i s e a ~ e ~T. h~i s. is exemplified by limited intestinal resection a n d t h e use of stricturoplasty. T h e s e operations are usually performed following failed medical treatment w h e n t h e intestinal l u m e n is irreversibly n a r r o w e d by fibrosis resulting f r o m t h e inflammatory process. F i b r o u s strictures elsewhere i n the gastrointestinal tract may be a m e n a b l e t o t r e a t m e n t by endoscopic balloon dilatation which is routinely and successfully used i n the treatment of peptic oesophageal strictures5 and pyloric s t e n o d . T h i s technique might b e extended t o fibrous strictures resulting f r o m Crohn's disease, p e r h a p s overcoming t h e need f o r surgical resection o r stricturoplasty, or a t least allowing delay of a n o p e r a t i o n while awaiting a general i m p r o v e m e n t in t h e patient's condition. T h i s is a r e p o r t of a preliminary experience of endoscopic balloon dilatation for C r o h n ' s strictures.
Patients and methods Endoscopic balloon dilatation was used in the treatment of Crohn's strictures in four men and three women between January 1987 and January 1989. Crohn's disease was diagnosed clinically and radiologically and was confirmed histologically in each case. Five patients underwent dilatation because of recurrent attacks of small bowel obstruction from recurrent Crohn's disease at the site of a previous ileotransverse anastomosis (Figure I ). One patient presented with chronic gastric outflow obstruction and malnutrition caused by duodenal involvement, having had two previous ileal resections for Crohn's disease. The final patient presented with recurrent subacute large bowel obstruction from an isolated stricture in the descending colon, although she also had evidence of inactive ileal Crohn's disease. A11 patients had previously been treated medically, with corticosteroids (all cases), sulphasalazine (four cases), azathioprine (two cases) and/or an elemental diet (three cases), but had failed to achieve sustained remission of their symptoms. All patients had intestinal strictures < 4 cm in length, accessible to the colonoscope or gastroscope. Although the Crohn's disease activity index was not formally measured, all patients were deemed to have inactive disease at the time of endoscopy and none had elevation of C-reactive protein, erythrocyte sedimentation rate or platelet count. Balloon dilatation was performed using the commercially available 'Rigillex' balloon system (Keymed Ltd., Southend, UK). Balloons 18
and 20 mm in diameter were used. Patients with ileocolonic or colonic strictures underwent standard colonoscopic bowel preparation using Pilocax" (Ferring Pharmaceuticals Ltd., Feltham, UK). Following intravenous sedation with midazolam (Hypnoval", Roche Ltd., Welwyn Garden City, UK) and pethidine, colonoscopy was performed using an Olympus ITlOL (Olympus-Keymed, Southend, U K ) colonoscope. The stricture was identified and biopsied and the balloon inserted through the stricture. The balloon was then partially inflated and withdrawn to an optimum position before inflation to its maxium diameter for a period of 1 min. It was deflated and then reinflated for a further 2 min. Radiological screening was not performed routinely. The patient with the duodenal stricture was sedated with midazolam and pethidine and gastroscoped using an Olympus IT10 forward viewing gastroscope. Dilatation was then performed exactly as described for the colonic and ileocolonic strictures. Following endoscopy, patients were fasted for 4 h and observed in hospital for a 24-h period. In two cases the endoscopist felt that the dilatation had been incomplete because he was unable to pass the endoscope into proximal bowel following dilatation. In these instances repeat dilatation was performed. In other cases endoscopic dilatation was repeated following symptom recurrence (Table 1 ). Response to therapy was judged on the basis of symptomatic improvement. The median length of follow-up was 24 months (range 21-27 months).
Figure 1 Contrast siudy of ileotransverse anasiomoiic recurrence of Crohn's disease in patieni 1 ofTable 1
--
0007-1323/91/040453-02
4 ) 1991 Butterworth-Heinemann Ltd
453
Balloon dilatation for Crohn‘s strictures: A. J. K. Williams and K. R. Palmer
Table 1 Results of endoscopic balloon difutation Patient
Site of stricture
No. of dilatations
1
Ileotransverse anastomosis
2
2
Ileotransverse anastomosis
3
3
Duodenum
4
4
Ileotransverse anastomosis
1
5
Colonic
2
6
Ileotransverse anastomosis
2
7
Ileotransverse anastomosis
1
Results Clinical response is summarized in Table I. Balloon dilatation failed in two patients with ileotransverse anastomotic recurrence because the endoscopist was unable to intubate the stricture. Both patients subsequently underwent a segmental resection. At laparotomy there was no evidence of perforation. Examination of the resected bowel showed particularly tight and tortuous strictures. Dilatation was technically successful in the remaining three patients with anastomotic strictures, although it had to be repeated in one because of recurrent obstructive symptoms. Two patients are asymptomatic 21 and 27 months later, and the other has improved greatly after a single dilatation, with only occasional episodes of abdominal pain and without evidence of intestinal obstruction. The patient with duodenal stenosis improved considerably after four dilatations with 6 kg weight gain, cessation of vomiting and a radiologically confirmed increase in gastric emptying. At 23 months after dilatation he presented with recurrent small bowel disease, eventually leading to a further small bowel resection; at operation a gastroenterostomy was also fashioned. The patient with the colonic stricture has been dilated twice and remains well 23 months later. Balloon dilatation was performed on one to four occasions; the total number of procedures was 15. All patients tolerated the procedure well, although one developed abdominal pain and transient fever 48 h after dilatation of an ileotransverse stricture. This resolved with antibiotic therapy.
Symptoms before dilatation
Symptomatic outcome
Subacute small bowel obstruction occurring every 4-8 weeks Four attacks of small bowel obstruction over previous 6 months Gastric outflow obstruction, weight loss, serum albumin 30 g/l Two attacks of small bowel obstruction Episodic abdominal distension, constipation and colicky abdominal pain Four episodes of small bowel obstruction over 1 year Single episode of small bowel obstruction
Asymptomatic
Technical failure
Weight gain, normal serum albumin, some sensation of abdominal ‘fullness’ only Episodic mild pain and distension Pain free, irregular bowel habit
Symptom free Technical failure
is feasible. While the total number of procedures was relatively few, the technique appears safe and was well tolerated. We have extended our experience to over 30 procedures and have yet to encounter a serious complication. The procedure is sometimes technically demanding; a tortuous endoscope may not freely allow passage of the balloon catheter, strictures may prove difficult to intubate or to broach fully. These factors accounted for two failures. Only a highly selected group of patients are suitable; those with long or multiple strictures and those with lesions inaccessible to endoscopy are clearly unsuitable. Patients with short, fibrous strictures are amenable to this form of therapy and may derive satisfactory improvement. We have not routinely reinvestigated patients following dilatation to minimize radiation risks.
References 1.
2.
3. 4. 5.
Hellers G. Crohn’s disease in Stockholm County 1955-1974. A study of epidemiology, results of surgical treatment and long-term prognosis. Acfa Chir Scund 1979; 4W(Suppl): 31-69. Rutgeerts P, Geboes K , Ventrappen G, Kerremans R, Coenegrachts JL, Coremans G. Natural history of recurrent Crohn’s disease at the ileocolonic anastomosis after curative surgery. Gut 1984; 25: 665-72. Lee ECG. The aim of surgical treatment of Crohn’s disease. Gut 1984; 25: 211-22. Dehn TCB, Kettlewell MGW, Mortensen NJ, Lee ECG, Jewel1 DP. Ten year experience of stricturoplasty for obstructive Crohn’s disease. Br J Surg 1989; 7 6 : 33941. Lindner KD, Ott BJ, Hughes RW. Balloon dilatation of upper digestive tract strictures. Gastroenterology 1985; 89: 545-8. Hogstrom M, Haglund U. A technique for endoscopic balloon dilatation of pyloric stenoses. Endoscopy 1985; 17: 224-5.
Discussion
6.
This preliminary series has shown that endoscopic balloon dilatation of intestinal strictures resulting from Crohn’s disease
Paper accepted 6 October 1990
454
Br. J. Surg., Vol. 78, No. 4, April 1991
