Next, I want to introduce our famous professor, the inventor of the balloon assist in teroscopy, Dr. Yamamoto. Dr. Yamamoto is our long-time friend. Every time we have the time to give the lecture, we always learn a lot. I think now in Japan, it's very early, early morning, Dr. Yamamoto, welcome, welcome aboard, and the platform is yours. Thank you for your kind introduction and giving me this opportunity to talk about deep end teroscopy and the management of small bowel structures. Now, can you reach it? Can you treat it? Okay, this is the COI I have, that is Fujifilm company, and okay, the management of the Crohn's disease, the treatment goal of Crohn's disease is control of disease activity. We can't cure Crohn's disease yet. We have to remember it. Therefore, the management goals are improving quality of life by introducing and maintaining remission, and the improvement of prognosis by prevention of relapse and prevention of repeated surgery and short bowel syndrome. This is a famous figure showing a clinical course of Crohn's disease. Patients just feel that relapse and remission of the disease simply repeat. However, during the repetitions, intestinal damage accumulates and gets worse. I want to share my own experienced case. He's a 46-year-old man, and he has been treated for Crohn's disease for 29 years, and he underwent surgery for anal fistula and ileocecal resection for intestinal stenosis 20 years ago. He underwent partial ileal resection for multiple ileal stenosis 13 years ago, and a resection of ileo-ileal anastomosis again due to intestinal obstruction 10 years ago. Then, total parenteral nutrition due to short bowel syndrome. He suffered from repeated catheter infection complicated with candida sepsis and endophthalmitis. He was referred to our hospital with port infection and bilateral thrombotic obstruction of subclavian interjugular vein confluence. So, what were the treatments before transfer? Infliximab started from 10 years ago, and then switched to Adalimab and Ustekinumab. But the problem is he didn't have sufficient evaluation of treatment effect, and short bowel syndrome ensued as a result of repeated surgical resection for multiple small intestinal stenosis. We want to avoid this kind of bad scenario. By the way, what is the intestinal damage? That is complications like strictures and fistula and deformity, and strictures are the most common complications required surgery, and they often occur in the small intestine. So, the small intestinal lesions are most important for patient's prognosis, and small intestinal lesions are often asymptomatic and often diagnosed only after complicated with stricture formation, and even laboratory data such as CRP are often negative with active small intestinal lesions. Therefore, early diagnosis and early treatment are important to prevent complications such as strictures. I want to share a case, a 44-year-old man, and he presented with chronic iron deficiency anemia and black stool. He has had only mild abdominal pain, and this is the initial evaluation by double balloon endoscopy, and he had a stricture at the ileocecal valve, and this is the contrast study. Using a double balloon endoscope, you can use the endoscope balloon to stop, to block the backflow of the contrast, and we can get a good contrast study. By the way, Dr. Hsieh, what do you think? What is your opinion about the treatment strategy for this kind of patient? You know what? In my practice, I already surrendered. Maybe send him for surgery, do the surgical strictureplasty. Okay, because of the tight structure and multiple of them. Multiple of them, yeah, here as well. Yeah. Okay, but actually, we started prednisolone, followed by azathioprine, combined with the elementary diet, and then we check the treatment effect by using double balloon endoscopy, and this time, we could go through the ileocecal valve, and this is about 10 centimeters from the ileocecal valve, and there still be ulceration, longitudinal ulcer, but the long stricture was actually two strictures, and then what we did was we started adalimumab, and then we checked again. Adalimumab was increased to double dosage, and then this time, still a narrowed segment, but the ulcer was healing, but not completely, like this, so we changed to infliximab and double dose, and then we checked again, and this time, we performed endoscopic balloon dilation, and then the endoscope go through the strictures and up to 50 centimeters. We dilated all the strictures up to 15 millimeters. Then, but he had some joint pain and abdominal pain and required budesonide, then we changed to stichingumab and checked the double balloon again, and even got better, but still he had some joint pain and abdominal pain, so we changed to bedrizumab, and this patient, bedrizumab worked very well, and no abdominal pain and no joint pain anymore, and we could examine up to 115 centimeters without any further dilation therapy and no symptoms. So, what I want to say is strictures on image studies could be deceptive, especially at the initial presentation with active disease. We should be careful not to be deceived because the imaging study could just show peristalsis or inflammatory strictures, and only the fibrotic strictures remained, then we can perform dilation therapy. For the evaluation of the small intestine, capsule endoscopy and double balloon endoscopy are available, and what are the major roles of endoscopy in Crohn's disease? First, diagnosis and evaluation. For the diagnosis and evaluation, we use a diagnostic double balloon endoscope, and it shows the active ulcer, and after treatment, you can show the, we can show the mucosal healing, and for that purpose, I use a slim double balloon endoscope, that is EN580XP, and this is a very slim endoscope, two meters long, but only 7.5 millimeters outer diameter, and using this slim scope, the pancreatic enzyme like amylase and lipase don't increase, and compared with the therapeutic type, the significant difference in the elevation of the pancreatic enzymes, so that means you can perform double balloon endoscopy gently using the XP rather than therapeutic type. Another role of endoscopy in Crohn's disease is the therapeutic procedure, like endoscopic dilation for small intestinal strictures. For that purpose, we have to use a therapeutic scope with accessory channel of 3.2 millimeter in diameter, and this is the clinical practice guideline for endoscopy from Japan. The indication with the patient with symptoms related to the stricture, or the image it showed, dilation of the bowel proximal to the stricture, and longitudinal length of the stricture should be shorter than five centimeters, and if the stricture is associated with fistula, fissure, abscesses, and deep ulcer or severe adhesion or flexure, that's not a good candidate for balloon dilation. What are the role of the balloon dilation in small intestinal Crohn's disease? This is just the management of the complication of the disease. It is not the treatment of the disease itself, and we want to avoid surgical resection and prevent short bowel syndrome, but there are some misunderstandings in treatment selection in Crohn's disease, I think. Surgical resection is also a management of the complication. It cannot cure the disease, and the endoscopic dilation is not an alternative to surgery. Surgical resection is available anytime, even if endoscopic dilation is selected, and endoscopic dilation is an additional choice rather than an alternative choice to surgery, and redilation for restriction is not a failure of the treatment. Repetitive dilations with acceptable intervals can be considered as a maintenance therapy, and I want to introduce cast food, that is a calibrated, small calibrative transparent food. This is very useful for the balloon dilation because sometimes the insertion of the guide wire could be challenging to the stricture. For example, like this, this stricture, there were inflammatory polyps, so it was difficult to find the opening of the stricture, but using this cap, we could find the stricture and insert the guide wire through the stricture, and even after the dilation, then the insertion of the endoscope through the dilated stricture is easier using this type of cap. The tip of the cap is narrowed down, okay, and it also has a calibrated line, so we can measure the size of the stricture applying this cap, like this. So, you can see the white line and measure the size of the stricture. Smart. And according to the inner diameter of the stricture, we can choose what size of the dilator we should use, and when we use the cast food, I recommend to use it with the water exchange method. Under the water, we can maintain a very good endoscopic view through the cap, this transparent cap. So, even if there is also lesions on the side of the wall, but using this cap, it can be examined very well. And I want to show you a case. This is a 58-year-old man with Crohn's disease, and this is the first stricture was found, 35 centimeters proximal to the ileocecal valve. And using endoscopic enteroclases, we found 10 strictures in the ileum. This is the first one, second one, third one, fourth, fifth, sixth, seventh, eighth, ninth, tenth. If we recheck the segment of this small intestine, it could lead to short bowel syndrome if we repeat them. But of course, we tried balloon dilation. This is the first stricture and dilated. We usually dilate the stricture, try to dilate the stricture up to 13.5 centimeters when we insert the endoscope. And when we come back, if we think that is safe, then increase to 15 millimeters. That is because if we dilate up to 15 millimeters, then the balloon, the withdrawal of the balloon to the accessory channel could become a little bit difficult. So 13.5 millimeters is enough to insert the endoscope and the overtube through the dilated stricture. This is the 10th stricture. And then we check the proximal side with contrast study and no strictures proximal to the 10th stricture. So these are the conclusions. Endoscopic balloon dilation for small intestinal strictures in Crohn's disease is a safe and effective treatment as long as it is performed carefully considering appropriate indications. And combination of optimization of treatment, medical treatment, and endoscopic dilation therapy could provide a favorable long-term outcome avoiding surgery. And evaluation of treatment effect is essential for optimization of medical treatment. Thank you for your attention. you

small bowel structures

Crohn's disease management

complications prevention

endoscopy in diagnosis and treatment

endoscopic balloon dilation