0016-5107/92/3802-0142$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1992 by the American Society for Gastrointestinal Endoscopy
Endoscopic balloon dilation of colonic and ileo-colonic Crohn's strictures: long-term results Y. Breysem, MD, J. F. Janssens, MD G. Coremans, MD, G. Vantrappen, MD G. Hendrickx, MO, P. Rutgeerts, MD Leuven, Belgium
The long-term effects of endoscopic dilation of colonic or i1eo-colonic Crohn's disease strictures were analyzed. In 18 patients with a Crohn's disease-related low gastrointestinal stricture, the stenosis was dilated using through-the-scope (TTS) balloon catheters. A dilation to a diameter of 18 mm was always attempted. Treatment was successfully carried out in 16 patients, and was followed by immediate symptomatic relief in 14 patients. Long-term success was observed in nine patients. There were no complications. Balloon catheter dilation of a colonic stricture or stricture of an i1eo-colonic anastomosis was found to be safe and effective. This treatment modality can be an alternative to surgery in a selected group of patients. (Gastrointest Endosc 1992;38:142-147)
Chronic idiopathic inflammatory bowel d~sease, especially Crohn's disease, is frequently complicated with low gastrointestinal strictures. Besides medical treatment of active inflammation, there is no specific, conservative approach to this complication. Repetitive surgery with extensive resections leading to short bowel syndrome is often necessary. The introduction of Gruentzig balloon catheters into the endoscopic armentarium has led to a considerable expansion of the possibilities for dilating stenoses in almost all parts of the gastrointestinal tract. 1- 19 There are, however, only sporadic reports of the use of the Gruentzig balloon catheter in patients with stenoses due to Crohn's disease. 19 We report on the long-term results of dilation of low gastrointestinal strictures due to Crohn's disease using an endoscopically placed balloon catheter. We feel that optimal use of this technique may be very beneficial to patients in whom surgery should be avoided. PATIENTS AND METHODS
We carried out through-the-scope (TTS) balloon dilation of colonic or ileo-colonic strictures in 32 patients with Received July 4, 1990. For revision September 17, 1990. Accepted November 26,1991. From the Department of Internal Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. Reprint requests: G. Vantrappen, MD, Department of Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.
142
Crohn's disease. For the present study we defined the longterm effect as the results observed at least 1 year after the first treatment. From February 1986 through April 1990, TTS balloon dilation was performed in 18 patients with Crohn's disease and a low gastrointestinal stricture. All of the patients had a follow-up of at least 1 year. The age of the patients ranged between 17 and 74 years (mean, 40.8 years). There were 13 women and 5 men. Follow-up examinations after dilation varied between 1 and 39 months (mean, 17.2 months). Crohn's disease duration prior to this treatment ranged between 2 and 43 years (mean, 14.9 years). All patients complained of intermittent severe abdominal cramps, abdominal distension, and sometimes absence of stools, all symptoms of partial bowel obstruction. In all patients there was pre-stenotic bowel dilation proximal to the stricture. There was no patient with an acute total obstruction. In all patients, the symptoms were resistant to conventional medical therapy. In eight patients, Crohn's inflammation was considered to be active. These patients had decreased general well being, systemic symptoms, or an abdominal mass. There was also biological activity in these patients with increased erythrocyte sedimentation rate, increased leukocytosis, and hypoalbuminemia. These features were present in addition to abdominal cramping pain due to the stricture. In the other 10 patients, the disease was considered to be quiescent. Endoscopic treatment was preferred over surgery because of multiple resections in the past (14 patients) or the large extent of the disease (4 patients), both requiring extensive resections, with a risk of short bowel. Of the 18 patients, 14 had prior surgery (mean, 1.8 operations/patient) (Table 1). In all operated patients, the stricture was located GASTROINTESTINAL ENDOSCOPY
Table 1. Patients with Crohn's strictures treated with TTS balloon dilation: disease characteristics Location of disease
Disease Patient Age duration (yr)
Previous surgery Small bowel
Large bowel
Disease activity (clinically and biologically)
1
42
6
Right hemicolectomy with Neoterminal Normal re-resection of 40-cm ileum, terminal ileum 10 cm
Inactive
2
46
26
Active
3
29
8
4
17
4
Subtotal colectomy with Neoterminal Rectum resection of terminal ileum, ileum and ileo-sigmoid !Ocm anastomosis Right hemicolectomy with Neoterminal Normal ileum, resection of terminal ileum (cm?) 10cm Resection of ileo-sigmoid fistula Ileitis termi- Normal nal, 15 cm
5
45
16
6
41
9
7
46
9
8
34
8
9
29
9
!O
30
2
11
74
43
12
32
16
13
56
32
14
58
32
Right hemicolectomy with Ileo-colonic resection of 50-em teranastomominal ileum sis Ileitis, 15 cm Total colectomy with ileo- Neoterminal ileum, rectal anastomosis 30 em Ileitis terminal, 20 cm Subtotal colectomy with Neoterminal resection of 25-cm terileum, 30cm minal ileum and ileosigmoid anastomosis Surgical resection of stenotic anastomosis Ileitis terminal, 30 cm Right hemicolectomy with Neoterminal ileum, resection of terminal ileum (cm?) 5cm Partial colectomy Termino-terminal ileosigmoid anastomosis Right hemicolectomy with Neoterminal resection 30-cm termiileum, nal ileum 20 em Second resection of 35-cm neoterminal ileum Ileo-transverse anastomosis with another resection of 20-cm terminal ileum Total colectomy with reIleitis, localized 40 cm section of terminal ileum and ileostomy proximal from ileResection of 20-cm neoterminal ileum ostomy Proctectomy Resection of 30-cm neoterminal ileum Right hemicolectomy with Neoterminal ileum, resection of terminal 15cm ileum (cm?) Total colectomy with ileo.rectal anastomosis Short bowel syndrome
VOLUME 38, NO.2, 1992
Characteristics of the stricture Filiform ileo-colonic anastomosis with a second proximal stricture, each 1 cm in length Ileo-sigmoid anastomosis, 2 cm in length
Active
Filiform stenosis ileo-colonic anastomosis, 6 cm in length
Inactive
Stenosis ileo-cecal valve and terminal ileum, 5 cm in length Short stenosis ileo-colonic anastomosis, 2 cm in length Stricture, 2 cm in length at the ileo-cecal valve Filiform stricture at anastomosis, 5 cm in length
Normal
Inactive
Cecum and rectum Normal
Active Active
Pancolitis
Inactive
Stenotic ileo-cecal valve
Normal
Inactive
Stenotic ileo-sigmoid anastomosis, 2 cm in length
Normal
Active
Stenotic ileo-cecal valve
Normal
Active
Stenotic anastomosis over 2 cm second stenosis in neoterminal ileum, 5 cm in length
Sigmoid anus
Active
Stenosis ileo-colonic anastomosis, 5 cm in length
Inactive
Ileal stenosis, 40 cm proximal from ileostomy, 2 cm in length
Active
Stenosis ileo-rectal anastomosis second stenosis in neoterminal ileum, 10 cm in length
Rectum
143
Table 1-Continued. Disease Patient Age duration (yr) 15
37
12
16
45
6
17
33
5
18
50
6
Location of disease Previous surgery Small bowel Right hemicolectomy with resection of terminal ileum (em?) Surgical reintervention because of stenosis anastomosis Right hemicolectomy with resection of 30-cm terminal ileum Right hemicolectomy with resection of 50-em terminal ileum Surgical repair stenosis ileo-colonic anastomosis Colostomy (anal abscess) Right hemicolectomy with resection of 40-cm terminal ileum
Characteristics of the stricture
Neoterminal Normal ileum, 15 em
Inactive
Stenosis ileo-colonic anastomosis, 3 em in length
Neoterminal Normal ileum, 15 em Neoterminal Sigmoiditis ileum, 50 em
Inactive
Short stenosis ileo-colonic anastomosis, 2 em in length Filiform stenosis ileo-colonic anastomosis, 5 em in length
Neoterminal Normal ileum, 25 em
at the ileo-colonic anastomosis. In the four non-operated patients, the ileo-cecal valve was strictured. There was no change in medication in all patients before and after treatment. All patients were on sulfasalazine or a 5-ASA product, and two patients received metronidazole. In one patient, a low dose of corticosteroids was stopped after therapy. Dilation was carried out using Microvasive (Watertown, Mass.) Rigiflex, TTS balloons. Balloons with a diameter of 12, 15, or 18 mm were available. The balloon section of the catheter has a length of 5 or 8 cm. The balloon is introduced in the stricture under direct visual control. The diameter of the non-inflated balloons of different sizes is the same, so that in most cases the balloon with the largest diameter on inflation was immediately introduced. After correct positioning, the balloon is filled with water under high pressure (Rigiflator Inflator; Microvasive). A pressure of 35 psi was maintained for 2 min. The procedure was repeated three to six times depending on the effect observed. No fluoroscopy was used because the localization and length of the stricture were estimated by radiologic contrast examination and endoscopy before the procedure. Positioning of the dilator can easily be assessed endoscopically. In all instances we tried to obtain dilation sufficient to allow passage of a standard colonoscope. This was occasionally prevented by tortuosity of the stricture. The endoscope could be brought into the stricture, which seemed to have a sufficient diameter, but could not pass the stricture because of angulation. The entire treatment was repeated after a few days if the first procedure was technically not entirely successful and a second therapy seemed possible. In the first two patients, the procedure was carried out under 10 mg of diazepam intravenously. In the other patients, endoscopy with dilation was performed under light general anesthesia using propofol. This allowed the procedure to be repeated until an optimal 144
Large bowel
Disease activity (clinically and biologically)
Active
Active
Long stricture ileo-colonic anastomosis, with large ulcerations, 12 em in length
result was achieved without discomfort for the patient despite a procedure of long duration.
RESULTS
In 16 of 18 patients dilation was technically successful (Table 2). In two patients dilation was technically impossible: in one the stricture was too long and in the other there were two consecutive strictures, and the proximal stricture could not be reached. After successful dilation it was possible to negotiate the stenosis with the colonoscope in only 11 of 16 patients (68 %). Passage was not possible in the others after therapy due to angulation. It is also possible that the stenosis was not dilated enough so that no splitting of the stricture occurred, and the rigidity of the stricture prevented passage. In three of the five patients where the colonoscope could not pass the stenosis, good symptomatic relief was nevertheless obtained. There was immediate symptomatic relief in 14 of 18 patients (77%) and long-term symptomatic relief (mean followup 25.1 ± 8.6 months) in 8 of 18 patients (44%). There was an inverse correlation between disease activity (endoscopic assessment) and the likelihood of a successful treatment. Of the 16 patients who were successfully dilated technically, 8 had active Crohn's inflammation, and the other 8 patients had inactive disease with a fibrotic stricture. Of the eight patients with inactive disease, seven had a good long-term result. The one patient with a bad outcome underwent surgery and the partial obstruction was found to be the consequence of adhesions, with an open anastomosis. Of the eight patients with persistent disease GASTROINTESTINAL ENDOSCOPY
Table 2. Results of TIS dilation of Crohn's disease-related strictures No. of dilation sessions
Patient
Diameter balloon (F)
1 2 3
36 36-54 36-54
S S
1 3 2
4 5 6
45 45-54 45
S S S
7
36
8 9
10
Endoscope passed after dilation
Follow-up (mo)
Asymptomatic period
Y N Y
32 18 23
32 8 5
1 1 1
Y Y Y
36 39 1
36 39 0
S
2
Y
9
5
45 54
S S
1 3
Y N
25 26
25 2
11
54 54
S S
1 1
Y N
19 19
19 6
12
54
S
3
N
14
1
13 14 15
54 45 54
S S D
1 1 1
Y Y N
16 35 2
16 35 0
16
45
S
1
Y
1
17 18
36 45
S D
1 1
Y N
13 1
Dilation
sa
13 0
Repeated treatment
Second dilation after 6 mo, 5 mo after the second dilation disease reactivation, and steroids were given
Surgery with right hemicolectomy after 1 mo Second dilation after 7 mo Surgery with resection after 9 mo Second dilation after 2 mo, third dilation after4 mo After third dilation satisfactory Second dilation after 7 mo. Persisting angulation, without severe second stenosis Control x-ray not changed. Conservative approach of partial bowel obstruction Second dilation after 5 mo, third dilation after 1 year Surgery with side to side ileo-colonic anastomosis after 14 mo
Persisting partial bowel obstruction Surgery with ileo-transverse anastomosis after 2mo Persisting partial bowel obstruction. After 1 month surgery was done. The anastomosis was passable with a finger. Adhesions were found Persisting partial bowel obstruction. Surgery with ileo-transverse anastomosis after 1 mo
aS, technically successful; D, technically unsuccessful; Y, yes; N, no. activity, there were four patients (50%) with good symptomatic relief and four patients with an unsatisfactory outcome. These results do not reach statistical significance. VOLUME 38, NO.2, 1992
In five patients more than one dilation session was performed. In one patient there was only short symptomatic relief after the first dilation (2 months) and short relief after the second dilation (2 months). How145
ever, after the third dilation session, there was a follow-up of 16 months, during which the patient remained asymptomatic. In two patients, a second dilation gave no relief, and in the two other patients there was immediate relief after the second dilation, but with too short a follow-up period. Surgery was ultimately performed in 5 of 18 patients (27%). A number of technical problems occurred during dilation. Correct positioning of the endoscope in front of the stricture before introduction was often very difficult, e.g., in end to side or side to side anastomoses. In the presence of rigid strictures the balloon was frequently expelled from the stricture on insufflation. The short balloon catheters in particular were not effective. DISCUSSION
Endoscopic dilation of benign colonic and ileo-coIonic stenoses can represent a valid alternative to surgery. Various authors 2- 5, 11, 16-18 have published case reports on endoscopic treatment of strictures using different techniques. Recently, a balloon has been developed (TTS) which can be passed through a standard 2.8-mm channel of a colonoscope and positioned in the stenosis, without the aid of a guidewire. These catheters have made balloon dilation much simpler and quicker, but the endoscopic channel limited passage to balloons up to 54 F in size. The flexibility of balloon catheters makes them ideally suited for tortuous segments of the gastrointestinal tract such as the colon.1, 9, 16, 18 Our study demonstrates that endoscopic dilation of colonic or ileo-colonic strictures can be safely undertaken, even in cases with active Crohn's disease. Balloons exert a radial force on the diseased segment being dilated, in contrast to the longitudinal force applied with conventional dilating methods. Moreover, the fixed diameters and low compliance of the balloons provide a measure of safety against perforation, as overinflation results only in breaking of the balloon. 1 The technique for TTS hydrostatic balloon dilation is not difficult, once the scope is correctly positioned in front of the stricture. It is very important to lubricate the catheter first with silicone spray, since passing the catheter can be difficult when the tip of the scope is kinked. 15 It is also important to use the 8-cm balloon, because shorter balloons have a greater chance to be expelled from the stricture on insufflation. In a survey of the American Society for Gastrointestinal Endoscopy, it was observed that balloons equal or smaller than 40 F were associated with a 50% rate of acute symptomatic relief for colon strictures, whereas balloons that were larger than 51 F led to acute symptomatic relief in approximately 90% of patients. 5 146
Normally, the immediate result would be considered satisfactory if a standard colonoscope passes easily through the stenosis. However, in our patient group with long-standing Crohn's disease, and multiple resections in the past, we had nearly one third (5 of 16) of the patients in whom dilation was technically successful, but the stenosis could not be passed due to angulation or tortuosity. The chance of a successful dilation is highest in patients with a fibrotic stricture, but without disease activity (80 to 100% success rate). In the patients with active disease, the chance of a good long-term effect was only 50%. The longer the stricture, the more difficult the procedure. The best results after TTS balloon dilation are in short strictures with a length less than 8 em. Technically, an anastomotic stricture is usually easier to dilate than an ileo-cecal stricture. The technique of TTS hydrostatic balloon dilation is new and there are still a lot of factors not known: What are the ideal settings for duration of dilation? How many sessions must be performed? Is elective dilation during follow-up necessary? In our series, insufflation of the TTS balloon was performed for a duration of 2 min. This was repeated three to six times during the same procedure. Other studies deliver the recommended pressure several times with 15- to 60-sec inflation periods. The importance of the duration of inflation is not known. However, it is said that inflation periods longer than 20 sec are often painful. 14 If longer inflation periods would result in a better long-term effect, general anesthesia (e.g., with propofol) for this procedure would be mandatory. One patient was discharged after one treatment. We did not repeat the maneuver if patients were symptom free. Repeat endoscopy, with further dilation after 1 or 2 weeks, was carried out by other authors. 18 In this study, symptoms were the only follow-up parameter, and there was often a discordance between symptomatic response and objective improvement as documented endoscopically or radiographically.5, 16 Nevertheless, these results are encouraging, with a high incidence of immediate relief of symptoms and a reasonable long-term efficacy. Long-term experience will define the limits of this new conservative therapy. We prefer endoscopic balloon dilation rather than stricturoplasty in patients who already have had multiple bowel resections. When there is an unsatisfactory result after endoscopic dilation, stricturoplasty is the treatment of choice.
REFERENCES 1. Siegel JH. Newer developments in gastrointestinal endoscopy.
Pract Gastroenterol 1988;6:52-3. 2. McLean GK, Cooper GS, Hartz WH, et a1. Radiologically guided balloon dilation of gastrointestinal strictures. Part 1. Technique and factors influencing procedural success. Radiology 1987;165:35-40.
GASTROINTESTINAL ENDOSCOPY
3. McLean GK, Cooper GS, Hertz WHo Radiologically guided balloon dilation of gastrointestinal strictures. Part II. Results oflong-term follow-up. Radiology 1987;165:41-3. 4. Siegel JH, Yatto RP. Hydrostatic balloon catheters. A new dimension of therapeutic endoscopy. Endoscopy 1984;16:231-6. 5. Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey. Gastrointest Endosc 1986;32:15-9. 6. Kozarek RA. Endoscopic Gruntzig balloon dilation of gastrointestinal stenoses. J Clin GastroenteroI1984;6:401-7. 7. Gollinger Y, Chemousov AF, Andrew AL, et al. Endoscopic balloon hydrodilation of endoprosthetic treatment of esophageal and esophageal anastomotic strictures. Endoscopy 1989;21:11-4. 8. Cox JC, Winter RK, Moslim JC. Balloon or bougie for dilation of benign oesophageal stricture? An interim report of a randomisedcontrolled trial. Gut 1988;29:1741-7. 9. Graham DY, Tabibian N, Schmertz, JT, et al. Evaluation of the effectiveness of through the scope balloon as dilators of benign and malignant gastrointestinal stenoses. Gastrointest Endosc 1987;33:432-5. 10. Boll WS, Kosloshe AM, Jewell PF. Balloon catheter dilatation of focal intestinal stricture following necrotising enterocolitis. J Pediatr Surg 1985;20:637-9.
VOLUME 38, NO.2, 1992
11. Boll WS, Siegel RS, Goldthorn SF. Colonic strictures in infants following intestinal ischemia. Treatment by balloon catheter dilatation. Radiology 1983;149:469-72. 12. Graham DY, Smith LJ. Balloon dilatation of benign and malignant esophageal strictures. Gastrointest Endosc 1985;31:171-4. 13. Renfrew DL, Smith WL, Pringle KL. Per anal balloon dilatation of a post-necrotizing enterocolitis stricture of the sigmoid colon. Pediatr RadioI1986;16:320-1. 14. Shreden K, Wiig SN, Myrvold HE. Balloon dilatation of rectal strictures. Acta Chir Scand 1987;153:615-7. 15. Schmiindderich W, HarloffM, Riemann JF. Through the scope balloon dilatation of benign pyloric stenoses. Endoscopy 1989;21:7-10. 16. Barroso AO, Ariri E, Jordan G, et al. Repeated balloon dilation of a severe colonic stricture. Gastrointest Endosc 1987;33:3202. 17. Bedogni G, Ricci E, Pedrarolli C, et al. Endoscopic dilation of anastomotic colonic stenosis by different techniques: an alternative to surgery. Gastrointest Endosc 1987;33:21-6. 18. Recci E, Congliaro R, Mortella G, et al. Endoscopic management of colonic stenoses. Endosc Rev 1989;6:9-25. 19. Dobson HM, Robertson DA. Case report: balloon catheter dilatation of a ileocolic stricture. Clin Radiol 1988;39:202-20.
147
Endoscopic balloon dilation of colonic and ileo-colonic Crohn's strictures: long-term results Y. Breysem, MD, J. F. Janssens, MD G. Coremans, MD, G. Vantrappen, MD G. Hendrickx, MO, P. Rutgeerts, MD Leuven, Belgium
The long-term effects of endoscopic dilation of colonic or i1eo-colonic Crohn's disease strictures were analyzed. In 18 patients with a Crohn's disease-related low gastrointestinal stricture, the stenosis was dilated using through-the-scope (TTS) balloon catheters. A dilation to a diameter of 18 mm was always attempted. Treatment was successfully carried out in 16 patients, and was followed by immediate symptomatic relief in 14 patients. Long-term success was observed in nine patients. There were no complications. Balloon catheter dilation of a colonic stricture or stricture of an i1eo-colonic anastomosis was found to be safe and effective. This treatment modality can be an alternative to surgery in a selected group of patients. (Gastrointest Endosc 1992;38:142-147)
Chronic idiopathic inflammatory bowel d~sease, especially Crohn's disease, is frequently complicated with low gastrointestinal strictures. Besides medical treatment of active inflammation, there is no specific, conservative approach to this complication. Repetitive surgery with extensive resections leading to short bowel syndrome is often necessary. The introduction of Gruentzig balloon catheters into the endoscopic armentarium has led to a considerable expansion of the possibilities for dilating stenoses in almost all parts of the gastrointestinal tract. 1- 19 There are, however, only sporadic reports of the use of the Gruentzig balloon catheter in patients with stenoses due to Crohn's disease. 19 We report on the long-term results of dilation of low gastrointestinal strictures due to Crohn's disease using an endoscopically placed balloon catheter. We feel that optimal use of this technique may be very beneficial to patients in whom surgery should be avoided. PATIENTS AND METHODS
We carried out through-the-scope (TTS) balloon dilation of colonic or ileo-colonic strictures in 32 patients with Received July 4, 1990. For revision September 17, 1990. Accepted November 26,1991. From the Department of Internal Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium. Reprint requests: G. Vantrappen, MD, Department of Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.
142
Crohn's disease. For the present study we defined the longterm effect as the results observed at least 1 year after the first treatment. From February 1986 through April 1990, TTS balloon dilation was performed in 18 patients with Crohn's disease and a low gastrointestinal stricture. All of the patients had a follow-up of at least 1 year. The age of the patients ranged between 17 and 74 years (mean, 40.8 years). There were 13 women and 5 men. Follow-up examinations after dilation varied between 1 and 39 months (mean, 17.2 months). Crohn's disease duration prior to this treatment ranged between 2 and 43 years (mean, 14.9 years). All patients complained of intermittent severe abdominal cramps, abdominal distension, and sometimes absence of stools, all symptoms of partial bowel obstruction. In all patients there was pre-stenotic bowel dilation proximal to the stricture. There was no patient with an acute total obstruction. In all patients, the symptoms were resistant to conventional medical therapy. In eight patients, Crohn's inflammation was considered to be active. These patients had decreased general well being, systemic symptoms, or an abdominal mass. There was also biological activity in these patients with increased erythrocyte sedimentation rate, increased leukocytosis, and hypoalbuminemia. These features were present in addition to abdominal cramping pain due to the stricture. In the other 10 patients, the disease was considered to be quiescent. Endoscopic treatment was preferred over surgery because of multiple resections in the past (14 patients) or the large extent of the disease (4 patients), both requiring extensive resections, with a risk of short bowel. Of the 18 patients, 14 had prior surgery (mean, 1.8 operations/patient) (Table 1). In all operated patients, the stricture was located GASTROINTESTINAL ENDOSCOPY
Table 1. Patients with Crohn's strictures treated with TTS balloon dilation: disease characteristics Location of disease
Disease Patient Age duration (yr)
Previous surgery Small bowel
Large bowel
Disease activity (clinically and biologically)
1
42
6
Right hemicolectomy with Neoterminal Normal re-resection of 40-cm ileum, terminal ileum 10 cm
Inactive
2
46
26
Active
3
29
8
4
17
4
Subtotal colectomy with Neoterminal Rectum resection of terminal ileum, ileum and ileo-sigmoid !Ocm anastomosis Right hemicolectomy with Neoterminal Normal ileum, resection of terminal ileum (cm?) 10cm Resection of ileo-sigmoid fistula Ileitis termi- Normal nal, 15 cm
5
45
16
6
41
9
7
46
9
8
34
8
9
29
9
!O
30
2
11
74
43
12
32
16
13
56
32
14
58
32
Right hemicolectomy with Ileo-colonic resection of 50-em teranastomominal ileum sis Ileitis, 15 cm Total colectomy with ileo- Neoterminal ileum, rectal anastomosis 30 em Ileitis terminal, 20 cm Subtotal colectomy with Neoterminal resection of 25-cm terileum, 30cm minal ileum and ileosigmoid anastomosis Surgical resection of stenotic anastomosis Ileitis terminal, 30 cm Right hemicolectomy with Neoterminal ileum, resection of terminal ileum (cm?) 5cm Partial colectomy Termino-terminal ileosigmoid anastomosis Right hemicolectomy with Neoterminal resection 30-cm termiileum, nal ileum 20 em Second resection of 35-cm neoterminal ileum Ileo-transverse anastomosis with another resection of 20-cm terminal ileum Total colectomy with reIleitis, localized 40 cm section of terminal ileum and ileostomy proximal from ileResection of 20-cm neoterminal ileum ostomy Proctectomy Resection of 30-cm neoterminal ileum Right hemicolectomy with Neoterminal ileum, resection of terminal 15cm ileum (cm?) Total colectomy with ileo.rectal anastomosis Short bowel syndrome
VOLUME 38, NO.2, 1992
Characteristics of the stricture Filiform ileo-colonic anastomosis with a second proximal stricture, each 1 cm in length Ileo-sigmoid anastomosis, 2 cm in length
Active
Filiform stenosis ileo-colonic anastomosis, 6 cm in length
Inactive
Stenosis ileo-cecal valve and terminal ileum, 5 cm in length Short stenosis ileo-colonic anastomosis, 2 cm in length Stricture, 2 cm in length at the ileo-cecal valve Filiform stricture at anastomosis, 5 cm in length
Normal
Inactive
Cecum and rectum Normal
Active Active
Pancolitis
Inactive
Stenotic ileo-cecal valve
Normal
Inactive
Stenotic ileo-sigmoid anastomosis, 2 cm in length
Normal
Active
Stenotic ileo-cecal valve
Normal
Active
Stenotic anastomosis over 2 cm second stenosis in neoterminal ileum, 5 cm in length
Sigmoid anus
Active
Stenosis ileo-colonic anastomosis, 5 cm in length
Inactive
Ileal stenosis, 40 cm proximal from ileostomy, 2 cm in length
Active
Stenosis ileo-rectal anastomosis second stenosis in neoterminal ileum, 10 cm in length
Rectum
143
Table 1-Continued. Disease Patient Age duration (yr) 15
37
12
16
45
6
17
33
5
18
50
6
Location of disease Previous surgery Small bowel Right hemicolectomy with resection of terminal ileum (em?) Surgical reintervention because of stenosis anastomosis Right hemicolectomy with resection of 30-cm terminal ileum Right hemicolectomy with resection of 50-em terminal ileum Surgical repair stenosis ileo-colonic anastomosis Colostomy (anal abscess) Right hemicolectomy with resection of 40-cm terminal ileum
Characteristics of the stricture
Neoterminal Normal ileum, 15 em
Inactive
Stenosis ileo-colonic anastomosis, 3 em in length
Neoterminal Normal ileum, 15 em Neoterminal Sigmoiditis ileum, 50 em
Inactive
Short stenosis ileo-colonic anastomosis, 2 em in length Filiform stenosis ileo-colonic anastomosis, 5 em in length
Neoterminal Normal ileum, 25 em
at the ileo-colonic anastomosis. In the four non-operated patients, the ileo-cecal valve was strictured. There was no change in medication in all patients before and after treatment. All patients were on sulfasalazine or a 5-ASA product, and two patients received metronidazole. In one patient, a low dose of corticosteroids was stopped after therapy. Dilation was carried out using Microvasive (Watertown, Mass.) Rigiflex, TTS balloons. Balloons with a diameter of 12, 15, or 18 mm were available. The balloon section of the catheter has a length of 5 or 8 cm. The balloon is introduced in the stricture under direct visual control. The diameter of the non-inflated balloons of different sizes is the same, so that in most cases the balloon with the largest diameter on inflation was immediately introduced. After correct positioning, the balloon is filled with water under high pressure (Rigiflator Inflator; Microvasive). A pressure of 35 psi was maintained for 2 min. The procedure was repeated three to six times depending on the effect observed. No fluoroscopy was used because the localization and length of the stricture were estimated by radiologic contrast examination and endoscopy before the procedure. Positioning of the dilator can easily be assessed endoscopically. In all instances we tried to obtain dilation sufficient to allow passage of a standard colonoscope. This was occasionally prevented by tortuosity of the stricture. The endoscope could be brought into the stricture, which seemed to have a sufficient diameter, but could not pass the stricture because of angulation. The entire treatment was repeated after a few days if the first procedure was technically not entirely successful and a second therapy seemed possible. In the first two patients, the procedure was carried out under 10 mg of diazepam intravenously. In the other patients, endoscopy with dilation was performed under light general anesthesia using propofol. This allowed the procedure to be repeated until an optimal 144
Large bowel
Disease activity (clinically and biologically)
Active
Active
Long stricture ileo-colonic anastomosis, with large ulcerations, 12 em in length
result was achieved without discomfort for the patient despite a procedure of long duration.
RESULTS
In 16 of 18 patients dilation was technically successful (Table 2). In two patients dilation was technically impossible: in one the stricture was too long and in the other there were two consecutive strictures, and the proximal stricture could not be reached. After successful dilation it was possible to negotiate the stenosis with the colonoscope in only 11 of 16 patients (68 %). Passage was not possible in the others after therapy due to angulation. It is also possible that the stenosis was not dilated enough so that no splitting of the stricture occurred, and the rigidity of the stricture prevented passage. In three of the five patients where the colonoscope could not pass the stenosis, good symptomatic relief was nevertheless obtained. There was immediate symptomatic relief in 14 of 18 patients (77%) and long-term symptomatic relief (mean followup 25.1 ± 8.6 months) in 8 of 18 patients (44%). There was an inverse correlation between disease activity (endoscopic assessment) and the likelihood of a successful treatment. Of the 16 patients who were successfully dilated technically, 8 had active Crohn's inflammation, and the other 8 patients had inactive disease with a fibrotic stricture. Of the eight patients with inactive disease, seven had a good long-term result. The one patient with a bad outcome underwent surgery and the partial obstruction was found to be the consequence of adhesions, with an open anastomosis. Of the eight patients with persistent disease GASTROINTESTINAL ENDOSCOPY
Table 2. Results of TIS dilation of Crohn's disease-related strictures No. of dilation sessions
Patient
Diameter balloon (F)
1 2 3
36 36-54 36-54
S S
1 3 2
4 5 6
45 45-54 45
S S S
7
36
8 9
10
Endoscope passed after dilation
Follow-up (mo)
Asymptomatic period
Y N Y
32 18 23
32 8 5
1 1 1
Y Y Y
36 39 1
36 39 0
S
2
Y
9
5
45 54
S S
1 3
Y N
25 26
25 2
11
54 54
S S
1 1
Y N
19 19
19 6
12
54
S
3
N
14
1
13 14 15
54 45 54
S S D
1 1 1
Y Y N
16 35 2
16 35 0
16
45
S
1
Y
1
17 18
36 45
S D
1 1
Y N
13 1
Dilation
sa
13 0
Repeated treatment
Second dilation after 6 mo, 5 mo after the second dilation disease reactivation, and steroids were given
Surgery with right hemicolectomy after 1 mo Second dilation after 7 mo Surgery with resection after 9 mo Second dilation after 2 mo, third dilation after4 mo After third dilation satisfactory Second dilation after 7 mo. Persisting angulation, without severe second stenosis Control x-ray not changed. Conservative approach of partial bowel obstruction Second dilation after 5 mo, third dilation after 1 year Surgery with side to side ileo-colonic anastomosis after 14 mo
Persisting partial bowel obstruction Surgery with ileo-transverse anastomosis after 2mo Persisting partial bowel obstruction. After 1 month surgery was done. The anastomosis was passable with a finger. Adhesions were found Persisting partial bowel obstruction. Surgery with ileo-transverse anastomosis after 1 mo
aS, technically successful; D, technically unsuccessful; Y, yes; N, no. activity, there were four patients (50%) with good symptomatic relief and four patients with an unsatisfactory outcome. These results do not reach statistical significance. VOLUME 38, NO.2, 1992
In five patients more than one dilation session was performed. In one patient there was only short symptomatic relief after the first dilation (2 months) and short relief after the second dilation (2 months). How145
ever, after the third dilation session, there was a follow-up of 16 months, during which the patient remained asymptomatic. In two patients, a second dilation gave no relief, and in the two other patients there was immediate relief after the second dilation, but with too short a follow-up period. Surgery was ultimately performed in 5 of 18 patients (27%). A number of technical problems occurred during dilation. Correct positioning of the endoscope in front of the stricture before introduction was often very difficult, e.g., in end to side or side to side anastomoses. In the presence of rigid strictures the balloon was frequently expelled from the stricture on insufflation. The short balloon catheters in particular were not effective. DISCUSSION
Endoscopic dilation of benign colonic and ileo-coIonic stenoses can represent a valid alternative to surgery. Various authors 2- 5, 11, 16-18 have published case reports on endoscopic treatment of strictures using different techniques. Recently, a balloon has been developed (TTS) which can be passed through a standard 2.8-mm channel of a colonoscope and positioned in the stenosis, without the aid of a guidewire. These catheters have made balloon dilation much simpler and quicker, but the endoscopic channel limited passage to balloons up to 54 F in size. The flexibility of balloon catheters makes them ideally suited for tortuous segments of the gastrointestinal tract such as the colon.1, 9, 16, 18 Our study demonstrates that endoscopic dilation of colonic or ileo-colonic strictures can be safely undertaken, even in cases with active Crohn's disease. Balloons exert a radial force on the diseased segment being dilated, in contrast to the longitudinal force applied with conventional dilating methods. Moreover, the fixed diameters and low compliance of the balloons provide a measure of safety against perforation, as overinflation results only in breaking of the balloon. 1 The technique for TTS hydrostatic balloon dilation is not difficult, once the scope is correctly positioned in front of the stricture. It is very important to lubricate the catheter first with silicone spray, since passing the catheter can be difficult when the tip of the scope is kinked. 15 It is also important to use the 8-cm balloon, because shorter balloons have a greater chance to be expelled from the stricture on insufflation. In a survey of the American Society for Gastrointestinal Endoscopy, it was observed that balloons equal or smaller than 40 F were associated with a 50% rate of acute symptomatic relief for colon strictures, whereas balloons that were larger than 51 F led to acute symptomatic relief in approximately 90% of patients. 5 146
Normally, the immediate result would be considered satisfactory if a standard colonoscope passes easily through the stenosis. However, in our patient group with long-standing Crohn's disease, and multiple resections in the past, we had nearly one third (5 of 16) of the patients in whom dilation was technically successful, but the stenosis could not be passed due to angulation or tortuosity. The chance of a successful dilation is highest in patients with a fibrotic stricture, but without disease activity (80 to 100% success rate). In the patients with active disease, the chance of a good long-term effect was only 50%. The longer the stricture, the more difficult the procedure. The best results after TTS balloon dilation are in short strictures with a length less than 8 em. Technically, an anastomotic stricture is usually easier to dilate than an ileo-cecal stricture. The technique of TTS hydrostatic balloon dilation is new and there are still a lot of factors not known: What are the ideal settings for duration of dilation? How many sessions must be performed? Is elective dilation during follow-up necessary? In our series, insufflation of the TTS balloon was performed for a duration of 2 min. This was repeated three to six times during the same procedure. Other studies deliver the recommended pressure several times with 15- to 60-sec inflation periods. The importance of the duration of inflation is not known. However, it is said that inflation periods longer than 20 sec are often painful. 14 If longer inflation periods would result in a better long-term effect, general anesthesia (e.g., with propofol) for this procedure would be mandatory. One patient was discharged after one treatment. We did not repeat the maneuver if patients were symptom free. Repeat endoscopy, with further dilation after 1 or 2 weeks, was carried out by other authors. 18 In this study, symptoms were the only follow-up parameter, and there was often a discordance between symptomatic response and objective improvement as documented endoscopically or radiographically.5, 16 Nevertheless, these results are encouraging, with a high incidence of immediate relief of symptoms and a reasonable long-term efficacy. Long-term experience will define the limits of this new conservative therapy. We prefer endoscopic balloon dilation rather than stricturoplasty in patients who already have had multiple bowel resections. When there is an unsatisfactory result after endoscopic dilation, stricturoplasty is the treatment of choice.
REFERENCES 1. Siegel JH. Newer developments in gastrointestinal endoscopy.
Pract Gastroenterol 1988;6:52-3. 2. McLean GK, Cooper GS, Hartz WH, et a1. Radiologically guided balloon dilation of gastrointestinal strictures. Part 1. Technique and factors influencing procedural success. Radiology 1987;165:35-40.
GASTROINTESTINAL ENDOSCOPY
3. McLean GK, Cooper GS, Hertz WHo Radiologically guided balloon dilation of gastrointestinal strictures. Part II. Results oflong-term follow-up. Radiology 1987;165:41-3. 4. Siegel JH, Yatto RP. Hydrostatic balloon catheters. A new dimension of therapeutic endoscopy. Endoscopy 1984;16:231-6. 5. Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenoses: a national survey. Gastrointest Endosc 1986;32:15-9. 6. Kozarek RA. Endoscopic Gruntzig balloon dilation of gastrointestinal stenoses. J Clin GastroenteroI1984;6:401-7. 7. Gollinger Y, Chemousov AF, Andrew AL, et al. Endoscopic balloon hydrodilation of endoprosthetic treatment of esophageal and esophageal anastomotic strictures. Endoscopy 1989;21:11-4. 8. Cox JC, Winter RK, Moslim JC. Balloon or bougie for dilation of benign oesophageal stricture? An interim report of a randomisedcontrolled trial. Gut 1988;29:1741-7. 9. Graham DY, Tabibian N, Schmertz, JT, et al. Evaluation of the effectiveness of through the scope balloon as dilators of benign and malignant gastrointestinal stenoses. Gastrointest Endosc 1987;33:432-5. 10. Boll WS, Kosloshe AM, Jewell PF. Balloon catheter dilatation of focal intestinal stricture following necrotising enterocolitis. J Pediatr Surg 1985;20:637-9.
VOLUME 38, NO.2, 1992
11. Boll WS, Siegel RS, Goldthorn SF. Colonic strictures in infants following intestinal ischemia. Treatment by balloon catheter dilatation. Radiology 1983;149:469-72. 12. Graham DY, Smith LJ. Balloon dilatation of benign and malignant esophageal strictures. Gastrointest Endosc 1985;31:171-4. 13. Renfrew DL, Smith WL, Pringle KL. Per anal balloon dilatation of a post-necrotizing enterocolitis stricture of the sigmoid colon. Pediatr RadioI1986;16:320-1. 14. Shreden K, Wiig SN, Myrvold HE. Balloon dilatation of rectal strictures. Acta Chir Scand 1987;153:615-7. 15. Schmiindderich W, HarloffM, Riemann JF. Through the scope balloon dilatation of benign pyloric stenoses. Endoscopy 1989;21:7-10. 16. Barroso AO, Ariri E, Jordan G, et al. Repeated balloon dilation of a severe colonic stricture. Gastrointest Endosc 1987;33:3202. 17. Bedogni G, Ricci E, Pedrarolli C, et al. Endoscopic dilation of anastomotic colonic stenosis by different techniques: an alternative to surgery. Gastrointest Endosc 1987;33:21-6. 18. Recci E, Congliaro R, Mortella G, et al. Endoscopic management of colonic stenoses. Endosc Rev 1989;6:9-25. 19. Dobson HM, Robertson DA. Case report: balloon catheter dilatation of a ileocolic stricture. Clin Radiol 1988;39:202-20.
147
