So I think we'll go to the last presentation for this evening. It's a pleasure to introduce Dr. Nayanthara Kolhaprabhu from Mayo Clinic. She's an Associate Professor of Medicine and a gastroenterologist who specializes in endoscopic therapy and IPD. We welcome her to talk on the role of endoscopic balloon dilation, how to do it more effectively, and how effective is it in the treatment of strictures. Welcome, Nayanthara. All right. Well, thank you to the SGE and Bo and Uday for having me at the symposium. I've been listening all evening. It's been fabulous. And my goal today is to go over endoscopic balloon dilation and go through some practical examples and maybe some tips and tricks. These are my disclosures. So today we'll talk briefly about the epidemiology of strictures so that you can potentially anticipate them, talk about the management and when you should consider dilation of strictures, and then also about the tips and tricks of dilation, and then we'll briefly go over the outcomes. And so remember that most Crohn's disease presents as inflammatory initially, but up to 20 percent can have a stricture at diagnosis. Sometimes this can be associated with internal fistulizing disease, and more recent imaging data has shown that up to 95 percent of internal fistulae are associated with stricturing, probably the stricturing being the underlying etiology of that fistula forming. Also, as disease progresses at about five years, over 50 percent of patients with Crohn's disease can require surgery. With our current medical therapy, it hopefully would be less over time, but it's still quite significant. The most common site is in the small bowel and at the ileocolonic area, but about five to 10 percent can occur at the upper GI tract, most commonly at the pylorus and the duodenum, but remember esophageal Crohn's does exist, and about 10 to 15 percent can occur in the colon, the commonest site being the left colon or the sigmoid area. Another important point to remember is that the post-operative recurrence of stricturing disease, as well as anastomotic strictures, can be well over a third of patients. As Dr. Bruning just so eloquently explained, imaging is very important. So, the global interventional IBD group that BOLE leads has made recommendations and strongly recommends cross-sectional imaging prior to endoscopic balloon dilation. This can be in the form of CT or MR enterography, both of which have high sensitivity and specificity, and you just saw Dr. Bruning's images which show you this. Transabdominal ultrasound is sensitive but not as specific, especially when it's not at an area of significant musculature, but both in the United States as well as across the world, small intestinal contrast ultrasound is being used increasingly and has both a high sensitivity and specificity. It's important to keep in mind these constrict criteria which define what a significant Crohn's disease stricture is. This includes a reduction in the luminal diameter by at least 50%, at least a 25% increase in the thickness of a wall of a segment of bowel compared to adjacent bowel wall, and then a pre-stenotic dilation of at least three centimeters. So, when should you dilate? Well, you should think about dilation if your patient is symptomatic. If they're having episodes of partial small bowel obstruction, if they're having complete bowel obstruction, that's probably not the best time to dilate. Let them defer vest a little bit and then you can bring them back with appropriate imaging. If they come and tell you they have significantly changed their diet so that they can tolerate more foods and that they don't have these symptoms of cramping, abdominal pain, that's important. If they have nausea or vomiting, postprandial abdominal pain or bloating, and they've had young onset of disease, you're thinking about upper GI Crohn's and stricturing. And that might be a reason to think about this, plan for it with imaging, and then perform a dilation. Oftentimes, esophageal Crohn's patients will present with dysphagia as well. But even if your patient is asymptomatic, sometimes you do need to dilate. That can be if you're doing a colonoscopy in a patient who needs surveillance for long-standing disease and you come across a stricture. And we'll talk about when you shouldn't consider dilation. But in general, if you're unable to pass a colonoscope through the colon, you might have to dilate to facilitate passage. Similarly, if you're unable to pass a gastroscope in an upper stricture. And oftentimes, patients with chronic pouchitis, it's very important to make sure that they don't have a pouch anal stricture. And that needs to be dilated in order to facilitate adequate treatment. So as Bo mentioned earlier, you want to have certain considerations in your endoscopy suite. Ideally, propofol sedation for almost all of these patients is what our practice is. We use general anesthesia if we're planning an enteroscopy and there's a risk of aspiration. Even if it's a distal enteroscopy and the patient has known small bowel obstructions or partial obstructions, we will consider general anesthesia. Anal strictures can be very painful when they're dilated. And so a deeper level of sedation is also preferred. CO2 insufflation is ideal so that if you do have a perforation, that is a safer scenario. And as mentioned earlier, fluoroscopy, I use fluoroscopy at any expected angulated site. So if it's a direct esophageal stricture, maybe not. But if I'm thinking there's a stricture of the pylorus or the duodenum, any anastomotic strictures and ileal strictures, I usually will use fluoroscopy. For left colonic strictures with no history of diverticulae, it's not always necessary. And similarly, with pouch anal strictures, fluoroscopy is not always necessary. So let's talk about the technique briefly and then we're going to go through some videos. And so in terms of the technique, you want to choose your balloon based on your estimation of the luminal diameter. And the best way to do this is by judging it, comparing it to the diameter of your scope. So once you're able to estimate the luminal diameter, a graded dilation is really recommended. The rule of three doesn't really apply to Crohn's strictures. Instead, if you're able to pass a balloon that you think is a little bit larger than your estimated diameter, you can then visualize through the balloon during the dilation. And if you don't see any significant mucosal tearing as you're seeing through the balloon, you can then gradually increase the diameter. As mentioned earlier, we do like to use CRE wire guided balloons for any kind of angulation. That wire ensures that the distal tip of your balloon, when it's fully inflated, remains intraluminal. And this is very important. If you can't get through the stricture, you can advance the wire beyond that balloon tip into the lumen and then over that wire advance the balloon in and inflate it. But if it's possible to pass the scope through and you've decided you still want to have a further dilation, a retrograde dilation is ideal. So this is a case of a patient who had had an ileocecal resection in the past, asymptomatic. Our patients do get cross-sectional imaging prior to their endoscopy. But she said, you know, I do have symptoms of bloating. I have these episodes where I feel, you know, very uncomfortable after I eat. And sometimes, as mentioned, as Dr. Khanna mentioned, these are not necessarily related to active disease. But when we did the endoscopy, we did see a stenosis in this area. So this is a balloon. Because my scope was able to pass through initially, I used a 12 to 15 millimeter balloon, inflated. And I see there then that there is no mucosal tear. So now this is a 15 to 18 balloon, which is really the maximal size I use for anything other than the esophagus. I don't tend to inflate, dilate these anastomotic strictures past 18 millimeters. But you can see here at the top end of the screen, there's a little bit of mucosal tearing. And so we've kind of achieved our goal here. Let's see if I can move to the next slide. And here I wanted to show you an image of an anastomotic area that is ulcerated. This patient, too, had had imaging prior to this procedure. And we know that there's no long segment of inflammation. There isn't active disease. But oftentimes, these patients will get ulceration just at the anastomosis. And in these cases, as long as it's not deep ulceration, it's OK to dilate. You can see here, again, we're trying to look through the balloon on the right panel to see whether we're achieving any mucosal tearing. In the colon, this is a sigmoid stricture. Now, this is a patient with a 22 year history of Crohn's colitis. And here for her surveillance procedure, she's asymptomatic, has no trouble. But we see this tight stricture, I'd estimate about five or six millimeters in the sigmoid colon. I often use water insufflation. We tried to dilate it. So I used an 8 to 10 millimeter balloon initially. But it wasn't enough to allow the scope through. So now we're inflating further with a 10 to 12 millimeter balloon. Again, the purpose, because she's asymptomatic, is not to dilate more than to allow passage of the colonoscope. And you can see here that this is well dilated. There's some superficial mucosal tearing, which is what you want to achieve. And I can pass my scope through and finish the rest of the exam. Another important point here to remember is that you want to biopsy these strictures. In Crohn's disease, more so if they have strictures that develop an ulcerative colitis. But when I have patients like this, I do tend to biopsy them in a separate bottle every time they come back. This is a case of an ileal stricture. This is actually in the mid ileum. It's a patient who's already had a... Let me see here if I can start my video. There we go. This is a patient who's had known Crohn's disease, developed after a proctocolectomy and ileal pouch was formed. Her original diagnosis was ulcerative colitis, then changed to Crohn's, and now presents with recurrent partial small bowel obstructions. So we see this stricture. There is some ulceration again, but it's not very deep. And so this is a double balloon enteroscope that is being used here with a cap. And we're just taking some biopsies so we can finish that aspect. And here we will pass a balloon again through. We're using fluoroscopy, and I apologize, I don't have the fluoro images. But you can really see that this is passing quite easily. And then we will do a gradual dilation. Sometimes these are angulated. You can't bring the balloon up to your scope because, especially with an enteroscope, you're unstable. And that's okay, as long as you can watch this on fluoroscopy with your balloon and watch the waist expanding. You can see that we're trying to do a little bit of sort of manual movement here to see that that balloon is right in the center of the stricture and dilating it. And you'll see here as the balloon deflates that there is a tear. That's a little bit deep on the bottom left side there, but that's okay. So when should you not dilate? This is a case I did on Wednesday. This is a patient of mine for 15 years, a young gentleman with bad Crohn's disease of the ilium, colon and perianal area. He's been on Humira for eight years, combination therapy. It actually healed, but called in a few months ago to say, I'm starting to have a little bit more symptoms. And so by the time he could get here, he had an MR enterography. And you can see on this panel here that the terminal ilium is thickened. It's inflamed. And when we did his colonoscopy, and I apologize, let me make sure that I can show this to you here. When I did his colonoscopy, his colon had multiple deep ulcers throughout, indicating that he's probably lost response to his adalimumab. We're going to have to change therapy. I had this MR enterography already, which said I had ileal inflammation. And what I'm doing here is just gently, and you can see the screen shake a little bit, just by the force of the water pressure and a little jiggling of the scope, you could make it through. But then I see there's a long segment of inflammation. And given that he has active disease, at this point, he's probably lost response to the therapy he's been on for a long time. I didn't, and he has no real obstructive symptoms. He has no prestonotic dilation on his MR. I decided at this point, I won't dilate this. I'm going to bring him, change medical therapy, and then we'll reassess. So this is a reason to be careful not to dilate if the patient has not been on adequate therapy and if there's severely active inflammation. Other reasons not to dilate, as mentioned multiple times, is a stricture length greater than five centimeters. As you saw earlier, if you have radiographic imaging prior to the procedure, you can see that if the patient has adjacent fistulae or abscesses, this is not ideal. The only exception here I'd say is if you have a controlled perianal fistula, then that is OK to go ahead and dilate. And in fact, you can dilate to the point where the patient may be taught self dilation. And of course, if there's a known malignancy in the stricture, that's another reason not to dilate. That patient should go to surgery. So a few tips and tricks on dilation. When you have a tight stricture, kind of like what we used there, I tend to use a cap when I do deep endoscopy just because it helps my stability and it also helps me open things up. But I'll show you another video where a cap can help to position that catheter sort of in the right place when you have a very tight stricture. If you have longer or angulated strictures, I tend to remove the wire that comes with the balloon and I'll use a more flexible wire so that because the one that comes with the balloon or within the balloon is quite stiff. And if you have an angulation or there is some expected inflammation, then I don't want to use that stiffer wire because I don't know where it's poking through. And so in those cases, I pull that wire out, put in a more flexible wire, pass it deeper in and dilate over that. If you know that there's no significant inflammation and you're using the balloon in essence to get to the other side for an examination, you can sometimes use as almost completely inflated balloon as a railroad and gentle forward pressure. As long as you have a wire and you know that the distal end is intraluminal can be used to help you pass through that stricture. And as mentioned earlier, again, for angulated areas, if I'm using fluoroscopy, I'll use either 50% diluted or full strength contrast in the balloon so that I can see that waste and I can see as it expands. So this is another example here of a tight stricture in the ileum that we're trying to get through. And you can see that this I'm not able to get my catheter in the right location and the wire keeps bouncing out here. Here I have taken out the internal wire and I'm using a more flexible wire and by gentle multiple attempts, we've dilated this. This was a 70 year old lady with congestive heart failure and multiple comorbidities on anticoagulation. And so really, this is starting with an 8 to 10 millimetre balloon and going then to a 10 to 12 because after examination, it didn't look very tight. This was a stricture in the distal ileum just above an ileocolonic anastomosis. She had multiple surgeries and resections in the past, kept coming in with bowel obstructions. And so post-procedure, you can see here through the balloon that there is nice mucosal tearing, but it doesn't look terribly deep. The patient did fine, she was okay until 48 hours later, back on anticoagulation, develops massive bleeding, had to go to interventional radiology where they found a bleeding artery that they embolized. So these complications do occur. This leads me to think about if you have a patient where you can hold anticoagulant or antiplatelet therapy, that's ideal, probably 48 hours or so. If you notice intraprocedural bleeding, you can always clip the bleeding site. It's not going to make the stenosis any worse. You're just clipping right at the point where it's bleeding. The other big complication, of course, is perforation. And here it's important if you have good patient selection and you have good radiographic imaging prior to your procedure, that's protective for you. If you see the perforation intraprocedurally, again, you can close it endoscopically. If you have an aggressive dilation in the upper GI tract, you can consider putting patients on a clear liquid diet for 24 hours. And remember that systemic steroids, as Dr. Shen mentioned earlier, do pose a higher risk for complications. And so that's something to keep in mind and counsel your patients accordingly. So I want to go over the outcomes of endoscopic balloon dilation. This is a meta-analysis published by Dr. Navneetan and colleagues a few years ago. They looked at 24 studies, sorry, 1,163 patients with a significant median follow up. Two third of these were anastomotic strictures. They defined technical success as being able to pass the scope through the strictured area. Repeat dilations were needed in a little over half the patients and surgery was in about a quarter. The anastomotic strictures actually had a much lower rate of surgery than de novo strictures. Again, this is older data and so prior to the onset of multiple different biologics that we have now to treat disease more medically. They did have perforation in that meta-analysis group of about 3%, but most of these were in the two studies where large caliber balloons were used, as mentioned, 25 millimeter balloons. As I said earlier, I don't tend to use more than 18 millimeters at anastomosis. In the inner canal too, rarely will I go to 20, it's usually 18 and that's adequate. In the esophagus, you can go further if that is available to you at the time. And again, this meta-analysis was one that confirmed that a stricture length of less than four centimeters had a decreased need for surgery. This is a newer paper which looked at only gastro duodenal strictures. So upper crone strictures and they had 94 patients of which 75% were duodenal. And in contrast here, 90% were de novo. They were relatively short strictures at a three centimeter median length. And at a two year follow up, symptoms had a 70% recurrence. About two third had repeat dilations and one third required surgery. So again, telling you that upper GI strictures, sometimes their symptoms don't always correlate to what you see endoscopically. And so it's important to bring them back. Many of them require repeated procedures. Favorable factors for gastro duodenal strictures were again, a shorter length, a younger patient age and having a duodenal location. But if you had documented pre-stenotic dilation, that was not as good. That was an unfavorable risk factor. And then outcomes in colonic strictures was published last year where this French group looked at 60 strictures with a median of at least two dilations per stricture. Again, the majority of them were de novo and 95% of these were non-passable to begin with. Technical success was defined as being able to pass the scope after dilation. They had only one perforation, but 40% went to surgery after a median of four years. Interestingly, even though they did end up having surgery, out of 60 strictures, there was only one lymphoma and one adenocarcinoma. And so I think that the takeaway message is that these patients do require repeated procedures. And if you have a patient with a known history of a stricture, you should consent them even if they're asymptomatic prior to your procedure for potential dilation. So in summary, balloon dilation is effective and safe for the management of Crohn's disease strictures. In concert with all of our new medical therapies, dilation can significantly prolong a patient's surgery-free survival. And I'll refer you here to a publication by the Global Interventional Group that gives you practical guidelines on endoscopic balloon dilation. And with that, I'll say thank you for having me. It's been a pleasure.

endoscopic balloon dilation

strictures

Crohn's disease

gastrointestinal tract

partial bowel obstruction

chronic pouchitis