and the professor of the medicine at Central Florida University, and Dr. Uday Navalithan, medical director and the director of the IBD Center in that big institution. And his talk is Endoscopic Structurotomy and Structuroplasty. Uday, thank you again for co-hosting this session and this course and the platform is yours. It's a pleasure to be here and I think we had an excellent session yesterday and this morning has been so far, amazing. So, I think we'll extend that talk. I know Martin covered some of the talks, which I covered so I will skip those things as we go along. So, these are my disclosures specific, but nothing relevant to what I speak today. So, you see a stricture in a patient with Crohn's disease, always a challenge. The first question is whether we need to give medications, or whether we can try endoscopic treatment because it'd be a fibrotic structure, or do you need surgery because it's too far ahead that I don't think endoscopic treatment works. That's always a challenge when you see a stricture. And the problem is, it's a very common issue. I think this is a landmark case from Lancet which looked at different things and we look at it. Most patients will have inflammation when it starts off, but there's still some patients actually have stricturing and penetrating disease at the time of diagnosis. So, it's not uncommon to see a patient with a stricture as a first presentation, and they have a stricture actually in the terminal ileum with obstruction presenting to us as a first symptom. Or sometime with the enteroentric fistula with a stricture in the ATI. So, very uncommon to see, but usually, as a disease progresses, you are going to see much more likely penetrating and stricture in disease that up to 50% of patients will need surgery in the first 10 years of diagnosis. So, endoscopy is like a bridge. So, you cannot use medication, there's so much fibrils and stricturing, and you cannot keep doing surgeries all the time. So, we think about endoscopy as a bridge between medical management and surgical management. And that's where the role of interventional IBD has grown in the last few years or so. So, obviously, there are different techniques to think about endoscopic treatment of strictures. I think in this original review from the Global Interventional IBD Group, we talked about different options, dilation, stricturotomy, stents, injections, and combination therapy. And my focus is to talk only about stricturotomy today, and yesterday, I think Naina covered excellent of bone dilation, and we'll talk about other options down the line as well. So, I shouldn't describe this way back in 2013, this original review article, but if you see a stricture like this, which is a web-like stricture, you need to define how you see a stricture because the appearance of a stricture will determine the treatment plan. For example, if you see a web-like stricture, it's a very nice stricture for doing endoscopic stricturotomy, while if you see a spindle-like stricture, it's probably not a good idea to do endoscopic stricturotomy because you don't have any landmarks to cut through. If you see a web-like stricture, it's usually common with the alkanes and NSAIDs used along with IBD and chronic inflammation. I think it's a very easy stricture to manage. But with the use of biologics, we are seeing more and more of these strictures, which is kind of difficult to manage, and sometimes it requires a combination therapy to achieve that. The other thing is an ulcerative stricture, which probably may need medical management to optimize and then go back and do endoscopic treatment if needed. So, the appearance of a stricture and classifying the stricture is the first step before you proceed with the exact treatment plan. So, I think I usually define the strictures based on all these things, which we highlighted in the review article as well. We always want to see the stricture length. If you have a short stricture, I think we can intervene and make a difference for these patients. It would make a huge difference for us to intervene at that point. But if it's a long stricture, I don't think endoscopic treatment has a really huge role. So, I think looking at the stricture-based imaging is the first step I do. Appearance of a stricture also is important. For example, if you have an ulcerative stricture, maybe you need to activate the inflammation, control the inflammation first before you go for treatment. On the other hand, if you have an angled or a symmetrical angled stricture, it's very hard to do endoscopic stricture automy. So, the appearance of the stricture, the length of the stricture will determine the treatment plan for me. Obviously, the degree of stricture is very important. If you have a very, very severe stricture, you always need to have a backup plan. If things don't go well, what are the options at this point? So, I think the definition of the stricture is very, very important. And if a stricture is seen with other severe conditions like fistulae or abscesses or a pre-starting dilation, usually these patients will need surgery. Rarely, you'll make a huge difference in endoscopic treatment. So, I think you need to have set a stage for what you want to do first before you go for the treatment plan because you don't want to get in trouble when you try to achieve things needlessly. So, endoscopic stricture automy, I think the audio is fine. It's a very simple technique where you have a stricture here, you cut it either with a needle knife or an IT knife to cut the stricture. Endoscopic stricture aplasty uses a stricture. You cut the stricture, but you place clips. Basically, they're spacers. They do two things. Obviously, they decrease the risk of bleeding, which is a major issue with stricture automy. They decrease the risk of microperforation, which can happen. And also, it prevents the walls to come back again and cause car tissue and records of stricture coming back again. So, they're very effective for this and more like a spacer to achieve the end point of adequate dilation. So, you can do stricture automy with different knives. You can either use a needle knife, which is the old knife, which is probably less expensive, or you can use the IT knife, the insulated tip knife, which is more expensive, obviously, to use for stricturing. But it's more safer, at least in my hand, I feel like it's more safer for me and more controllable for cutting. So, I use different cuttings. I think the settings are different for each person. Some people use 3, 1, and 3, but I use 2, 1, and 4 as a cutting interval. The Endocut Q setting I use on my settings for cutting. So, I set my Irby and have this more and more when I do this cutting, and that's my cutting usually. But as I said, some people do 3, 1, and 3, or 3, 2, and 3 as well, but this is the standard technique I use in my cutting. So, why is stricture automy advantageous? If you think about it, it's very advantageous, particularly, for example, anal stricture. We don't want to injure the vagina because if we do endoscopic balloon dilation, it's stretching the entire wall and actually can perforate the wall on this side and can cause trouble. Stricture automy, I can control the cutting so that I can only cut the posterior wall and don't touch the anterior wall alone. The next few videos are courtesy of my mentor, Bo Shen, and I think it's thanks for all the training he has given me as I go along. As I said, I just cut the posterior wall alone, and don't touch the anterior wall. So, if you think about it, you're protecting the risk of perforation in this patient by cutting the posterior wall alone and the vagina is on this side, so you prevent that from happening. So, endoscopic stricture automy is my treatment of choice for anal strictures because I can just cut the posterior wall alone. Endoscopic stricture automy, I think if you think about it, there's a needle life. It's an old technique. There's a Boston scientific needle life which is used in a stricture. You can cut the stricture. Now, we cut deeper and then do a circumferential cut around it. We use a circumferential, like a peeling an onion. You just peel the onion all around like this and you cut the stricture all around and you achieve the endpoint of dilation. So, we can keep cutting. As you keep cutting along, you cut this area around it. And once you cut it, you can pass the scope inside the area of the area you want to see. So, you can always go back and cut more, but I think this achieves the endpoint of getting the scope to the stricture once you achieve this. But the most important thing is cutting the stricture initially deeply and then do like a peeling onion cut as you go along with this. Next, you can use an IT knife instead of a tip knife instead of a needle knife for cutting the stricture again. So, this is the ileocolonic anastomotic stricture. You can cut vertically along this way. You want to cut the different all around basically with the IT knife all around. So, keep cutting it, keep cutting it, keep cutting it. Again, the most important as I mentioned is once you cut this stricture, you want to make sure you keep it open. And that's why the spacer of the use of space and of clips is very, very important. So, you keep cutting, keep cutting and get inside the new TI with active inflammation inside. That gets good at least I2 or I3 here. So, once you're there and then you put clips to keep the spacer open. So, basically, they achieve the endpoint of keeping the thing open. So, it's a strictureplasty, not just strictureotomy. You cut it and keep it. It decreases the risk of delayed bleeding. This is a major problem with endoscopic strictureplasty. So, where do I use strictureotomy and IBD strictures? So, I use predominantly in anastomotic strictures. If you have a fibrotic ring-like stricture, that's where I think it's a huge role. Also, you want to use a straight stricture because if you don't have a tip control, you may cut in an awkward way and more deeper and you're more going to get in trouble, particularly in the small intestine where the risk of perforation is very, very high. So, in my case, I usually use only for a straight stricture if I can. I position it in patients with refractory repeat balloon dilations because the need for repeat procedure is very, very low. And for all anal strictures, I usually use only strictureotomy as my first choice, but the most important thing is bleeding risk. So, you always need to be aware of it, particularly if you don't place clips in patients and be ready for managing it down the line. So, this is my approach. So, if you have an inflammatory stricture, obviously, I would not do a strictureotomy. You always think about medical management with endoscopic balloon dilation adjunctive measure. If you have a fibrotic stricture, endoscopic strictureotomy is my choice. Endorectal strictures is my first choice. I think it's very, very effective to control the stricture. The main concern is if it's a primary stricture. If a de novo stricture in a patient with Crohn's disease is always a challenge because I don't think either of these techniques work well. And I think in those patients, sometimes, most likely they may need surgery, although there is some evidence they can try a self-expanding metal stent as well as short-term relief. But again, most patients, I think, primary stricture don't respond as well as surgery to help manage the situation. Anastomotic strictures, again, I feel endoscopic strictureotomy has much better control and much more efficacy compared to endoscopic balloon dilation. And post-strictureoplasty recurrence, again, I think both of them are not as efficient, but I think strictureotomy beats endoscopic balloon dilation. So, again, these are different studies in the area of IBD strictures, where strictureotomy is performed most, come from the US, except for one study from Japan. But again, success rate is pretty high. But again, these are all case series and case studies. They're not like randomized controlled trials. Again, I think if you want to say how efficacious strictures are, I think we think about endoscopic strictureotomy. The most effective thing is the length of the stricture. You should have a short length to be effective. If there's a long stricture, the efficacy of this procedure or any other procedure for the endoscopic endoscopy is not very effective. So short strictures, and the degree of stricture is not very significant. I think the need for repeat push is much, much lower. Again, if you look at the study comparing strictureotomy and endoscopic balloon dilation, again, this is not a randomized controlled trial. But again, it is a more retrospective comparison of data among these two data. Endoscopic improvement is more effective and sometimes more happens compared to endoscopic balloon dilation in this group. But again, if you look at the follow-up range, it's much shorter compared to much longer follow-up endoscopic balloon dilation. So that's a huge drawback. But the success rate, I think, is equally effective, both of the things. And the need for repeat surgery and second surgery is much lower with strictureotomy compared to balloon dilation. Again, you should take the pinch of salt because obvious numbers are much lower compared to balloon dilation. But again, in clinical practice, you see that it's much more effective at avoiding surgery. But it comes to the risk of bleeding. If you think about it, the bleeding risk is 14% compared to 0% balloon dilation. So that's why the use of spacers, the use of clips is probably one of the most important things we can do to decrease this bleeding. But that's not possible in the anorectal area. It's possible in the anastomotic stricture area, but not in the anorectal area. But that's something to think about, hopefully, in the future techniques we have to decrease the bleeding risk, we can actually make this more widespread use in practice. So again, I told you in the earlier study, endoscopic balloon dilation and strictureotomy. The presence of endoscopic balloon dilation predicted need for surgery. So that's always the thing I mentioned earlier, when you have a balloon dilation, when you have a prismatic dilation of the bowel loops, most likely you need a surgery where endoscopic techniques are more likely to be unsuccessful. And you obviously need to follow up these patients with repeat therapy, because if you just do one time and don't do follow-up therapy, they're most likely to have recurrence of the disease, the stricture. So how effective is strictureotomy compared to ileochronic restriction? It's also another option for difficult strictures. And if you look at it, again, this is a propensity match analysis. They match the group almost exactly similar. And we see no difference in terms of symptomatic improvement, hospitalization, requirement of surgery. Again, the numbers are very small, but this gives indication that effectiveness of strictureotomy is as effective as ileochronic restriction in the management of anastomotic strictures. So, I mean, this is my algorithm. I think about bowel obstruction in a patient with Crohn's disease. The first thing is do imaging to see what they have. They have active inflammation. I think you should treat them medically to control the inflammation first before you plan anything else. Obviously, the information is medically managed and the patient is not resolving, obstruction is still happening. It's probably a fibrotic stricture. Then you can go back and evaluate with imaging and repeat a colonoscopy at that point. If there is no active disease and it's a fibrotic stricture, then you want to look at the next plan. So, I think the algorithm is very simple if you think about it. If the anastomotic stricture is very stressful, in my practice, I think anastomotic strictures, I think strictureotomy is probably my first line. Followed by endoscopic balloon dilation if the patient has a history of bleeding or has some issues with preventing endoscopic strictureotomy. Strictureotomy is still my first choice. If it's a short anastomotic stricture, particularly in the left colon, I may consider a lumen-opposing metal stent as an option for patients. But again, strictureotomy would be my first choice. Lumen-opposing metal stent, particularly in the left side of the colon, is a second choice. And if you don't require to respond to these two, they probably need resection. Usually, I would say endoscopic, basically, resection of the area. Strictureopathy is very unlikely in the area of the anastomotic segment, although some surgeons say that they still do in some patients. The location of the stricture is important for colonic or small bowel. If it's a colonic stricture and it's a short stricture, you can attempt endoscopic balloon dilation or a strictureotomy. I think either of those, whichever is comfortable in your practice. Actually, both those are very effective. Again, I would prefer EST compared to EBD in a colonic compared to a small bowel. The other one is true. I don't know what the role of metal stents are in patients with the colonic stricture. I don't do them in my practice routinely, to be frank. The only situation I use metal stent is usually in the anastomotic stricture sometimes. But as I said, if you don't respond to this, the next plan is resection. If you have a long segment stricture, I think they should go for resection. I put in SEMs in patients who are not surgical candidates, who cannot get to surgery, then maybe a bridge therapy. But again, as I said, resection is probably the first choice. If it's a small intestine, again, long segment disease, either strictureoplasty would be preferable or resection, depending on where the disease location is or the number of surgeries they had before. But if it's a short stricture, I prefer endoscopic balloon dilation as my technique, because you need to have a good control of the tip with the strictureotomy. And sometimes if I use an endoscope, it's almost impossible to have a control. So I would prefer endoscopic balloon dilation as the first technique in a small bowel. Strictureotomy is very risky in a small bowel, particularly if you use an endoscope. If you obviously reach the area with the colonoscope and you have a good tip control and your position is stable, then you can probably try a strictureotomy. But again, if you don't respond to this, I would plan for resection or strictureoplasty, depending on the pre-surgery. So this is my approach where I position EBD and ESD in my practice. So Sheng and I have a nice review article comparing where to position endoscopy in surgery. And I think obviously all of us know this. If they are very sick, old patients, a lot of comorbidities, endorectal strictures where the option is only colostomy, I mean, all those patients would prefer endoscopic treatment. If they have a short interval between repeat endoscopy and repeat endoscopy treatments, they need surgery as a long-term measure. If they have multiple strictures, very close proximity, long strictures, deep ulcerated strictures, or strictures in the mid jejunum or approximately where it's very difficult to access, deep small bowel. If they have fistular abscess, if they have balloon dilation, luminal dilation, approximate area of stricture, all of them will need surgery. I think it's probably an important thing to decide. Strictures in diuretic bowel, I think you should be very, very careful. Even endoscopic treatment is very, very risky. You should not spend too much time messing around the area because there's a high risk of, I mean, perforation, also translocation of bacteria and sepsis as well. So I always use antibiotics before I do management of strictures in diuretic bowel. But again, you should be very, very careful using this. Again, as I said, the same review article highlighted different things. In my opinion, stricture endoscopy last year, very good for short-term efficacy. They work well, as asked, probably slightly more better than balloon. But the main risk is bleeding, which always is a challenge. But as opposed to stricture atomy, in my case, almost every anal stricture, anorectal stricture will get only stricture atomy and fibrotic stricture. If it's an inflammatory stricture where there's a lot of inflammation, I will not use stricture atomy. I'll probably use balloon dilation for medical management. And if it's a very angular stricture where you cannot position the scope to be stable, you want to use balloon dilation. And obviously, strictureplasty can be performed in surgical route as well in patients who need surgery. While you see multiple bowel loops, you can probably use strictureplasty. So I think when to consider EST, again, in a short, straight fibrotic stricture, anal stricture, asthmatic stricture is all the way to use. Maybe colonic strictures, if they are not de novo, we can try that as well. Again, active inflammation, always use medical management. You consider EST when you have no other option, and the patient has a very high risk of short bowel syndrome from surgery. If you want to try that as an option, you can do it. Where you can activate iliostomy as an option. You want to try options before surgery, you can try EST or SEMS as option. And based on a good surgical candidate, obviously, you should be very, very careful because the perforation or bleeding risk can also make things worse that you should be able to manage it without surgery. So all these are things to consider when you think about it. But a lot of challenges. The problem is, there's no specific training for strictureotomy in the U.S. And there's no CPT code. So in my procedure note, I usually do unlisted procedure code. And you have to go back to the hospital to justify that. It's like a stricture class to justify the code and the RVUs you want to generate for this. And IT knives are expensive. For example, the reimbursement of the procedure is very low, and you spend an IT knife and the procedure duration is long. You actually lose every time you do the procedure for the institution. So expensive. So unless you come up with these things, it cannot become routine practice all over the U.S. But again, the bleeding risk, as I mentioned, obviously, the clipping, strictureoplasty decreases risk. But it cannot happen in every location. We call it anal stricture. You cannot do a clip there. It's very hard to control a clip there to begin with. So I think if we can, in the future, try to make techniques so we can decrease the risk of bleeding, it can make a huge difference for the outcomes. So I think to conclude, it's a very effective endoscopic technique in the delivery of prone strictures. In my feeling, I think it's better than EBD in certain situations, particularly in the anal area and also in anastomotic strictures. It's my first choice in anal strictures and straight anastomotic strictures. Again, in studies, at least small studies, it looks like it's as good as surgery as long as the treatment is appropriate and the patient is the right candidate to get that treatment done. So to answer the question from my talk, is it time to replace EBD with a strictureotomy? Maybe at least in 80% of patients that do EBD, this may be the option. Time to replace surgery? I don't think so. I think an appropriate patient with anastomotic stricture, that's probably the only situation where it can replace surgery. Otherwise, surgery has an important role for patients with prone strictures. Again, this is a landmark guideline paper which you can review to go over the data that we showed here. Again, thank you for your time and I appreciate the opportunity.

Endoscopic Stricturotomy

Stricturoplasty

Crohn's disease

stricture

endoscopic treatment

surgery