So, without further ado, it's my great pleasure to introduce Dr. Gersimran Koshar, who is an assistant professor of medicine, the associate division chief at the Allegheny Center for Digestive Health, and he's going to speak to us about the stricture therapy in IBD. Welcome. Good evening, everyone. Thank you to ASG. Thank you, Dr. Almanzo, Dr. Lennon, for inviting me to give this presentation. I know it's been a long day, and it's a challenge to go after such a stellar faculty, but I promise I'll get you all guys to your happy hour very soon. So without further ado, we'll start. So I do not have any disclosures for this talk. The learning objectives for my talk mainly will be two. What is the role of endoscopic balloon dilatation in the management of IBD stricture? How to do them, what to do, what not to do, we'll discuss that. What is the emerging roles of endoscopic strictureotomy and enteral strenting in IBD in the last three to five years? So strictures, as we know, are luminal narrowings that lead to partial or complete obstruction. They result from longstanding inflammation and fibrosis. Terminal ileum and the ileocolonic anastomosis are the two most common sites of strictures. We don't have a definitive incidence rate, but up to 5% to 24% of the patients anywhere can have a stricturing phenotype. There is still no effective treatment. If stricture have inflammation, we try to push biologics, we try to push anti-inflammatory medication, but so far surgery is the only gold standard. However, one surgery is not the last surgery a patient with Crohn's disease is likely to have. So this descriptive image tells us the three most common types of strictures we see in our practice. Type A is the web-like, type B is the spindle-like, and this type C is the one that we almost never like, the ulcerative, the fibrotic one. So stricture management I divide into three categories, medical, endoscopic, and surgical. And for today, we'll be focusing on endoscopic management, which we'll consider balloon dilatation, strictureotomy, and enteral strenting. So me and Dr. Shen established a group two years ago, Global Intervention IBD Group. These are the panelists of the group from 30 different countries. We published our first guideline last year for management of these strictures. I'll be referencing this paper for those techniques that we're talking about. This was published in Lancet GastroHealth, so if anyone is interested, I'd highly encourage to read this further. So before we embark on the endoscopic therapy, it is very important to let the patient know and yourself know as to what the goals of my therapy are. We need to improve the obstructive symptoms. We should reduce the complications related to stricture or fistula. Remember, the endoscopic therapy is an adjunct to the medical and surgical therapy. We are not there yet to replace surgery and medications in Crohn's patients. And for me, the most important thing is space out the need for surgery in patients with Crohn's disease with endotherapy. So balloon dilatation, I'm sure all of you guys are familiar. It has a high technical success. It is less invasive. There is no risk of adhesions, and we are able to preserve the bowel length with balloon dilatation. There are two main types of dilatation. There is a retrograde dilatation and anti-grade dilatation. Retrograde dilatation is on figure A, in which you are able to pass the scope through the stricture. On your way back, you can dilate with the balloon. Anti-grade is when you have an impassable stricture. You can't get your scope forward. Those are the stricture you like to get the guide wire across and then dilate. Especially for anti-grade dilates, I would always advise, especially if you do not have a pre-procedure imaging, to consider fluoroscopy if available. This is one video that we will share. I will show the anti-grade dilatation here. It's a stricture in the upper jejunal anastomosis in a patient with short gut. We were not able to pass the scope. Even by passing the guide wire, my scope was falling back. But under fluoroscopy guidance, we got the wire through. This is something I always like to do. Once I start dilating, I like to adjust my dial, especially the small dial to the right side of the big dial forward, so I can see through the balloon dilating as to how much is the mucosa stretching. You start to see a whitening of the mucosa. If you look at the 7 o'clock of the figure, you start to see a small little tear come. Mucosal tears are not a problem. But if it starts to expand, you already know, especially if your tech or your nurse is not experienced to tell you how much resistance they feel. This is one way to gauge from the endoscopist. And once the balloon has been, the stricture was dilated, we were able to pass it through and the mucosa looked normal. This is an example of retrograde dilatation. Colonic stricture is symptomatic, but patient was having record symptoms of pain we thought might help. So this is my fellow actually doing the procedure. So he got the balloon out a long way back. But just to show you that on your way back, you're examining the mucosa, you know where the stricture is, you can bring it back all the way and then you dilate. And as I mentioned, I always teach my fellows also do the same thing. Adjust the dilate, visualize the mucosa, visualize that whitening you see at the base, whitening of the mucosa that tells you the effective stretch is happening. So balloon dilatation, consider in fibrotic strictures, when stricture length is less than five to six centimeters, benign strictures, preferably more than malignant strictures in IBD, preferably a straight bowel lumen. And there should be no associated fistula or abscess with the stricture. You don't want to dilate a fistula inadvertently while dilating the stricture. This table kind of summarizes the main studies that have been done so far in balloon dilatation. The main thing that I want you guys to pay attention is to the fact of this major complication area. It is anywhere from three to 11%. And if you pay attention to this last column, almost one-third of the patients in almost all studies barring this one, which was pretty way back, but majority of the studies, one-third of the patients did end up having a surgical intervention. Major complications in most of these studies was reported to be perforation. But there are advantages to EBDs. Easy access is available. We can do it in our ASCs. Less technical issues. There is a relatively low learning curve. And it's a low-cost procedure compared to a surgery. Drawbacks, you have to repeatedly dilate them. You have to rely on an endoscopy and tech. There is less control. Because when you ask the balloon to go to a certain size, that radial force is transmitted. You can't take that radial force back. So you have to rely on the experience of your nurse and tech saying how much resistance they are feeling when the balloon is going up. And there's no standard technique. I have asked multiple people that I've met, including my mentors, do you inflate the balloon to 30 seconds, 45 seconds, one minute? There is no consensus as to what is the ideal technique to dilate them. Perforation is still a challenge. And in Crohn's disease patients or IBD patients, a perforation is not the same as in non-IBD patients. Very limited endoscopic tools to repair those perforations because there is transmural inflammations are over the scope clips or stents. Those tend not to do well with those patients. And they almost always require a surgery. So when do we consider balloon dilatation? As I said, stricture length less than five or six, fibrotic strictures, stricture in straight lumen. You have multiple strictures in patients with small intestines, someone with ileostomy. You can use balloon dilatations if they're in close proximity to dilate them. When to avoid balloon dilatation, deep ulcers, stricture length longer than six centimeters. We have enough data. These patients will not do well with the endoscopic therapy. They will require surgery. Primary strictures. If you have primary IBD stricture, inflammation is controlled. They also usually end up requiring surgery. If there is significant pre-stenotic dilatation on pre-procedure imaging, then also you will not get much benefit with balloon dilatation. And significant pre-stenotic dilatation is defined as dilatation of small intestine more than five to six centimeters. In concurrent fistula rapses, don't do it. Angulated stricture also be very cautious. And if it's your early, you know, if you're starting early course in your career, probably avoid an angulated strictures. Moving on to endoscopic stricture after balloon dilatation. So it is basically a technique in which we use electro-incision knives to widen the lumen of the bowel. Needle knife, as we have seen in ERCP, has been there for around for many decades. And now with the advent of newer endoscopic knives, we have a big armatorium where we can use these knives to cut open the bowel. It can be performed in radial, horizontal, or circumferential fashion. We define this as endoscopic stricture if we only widen the stenotic lumen with the incision, as you see in this picture. We have defined this as endoscopic stricture of plasty in which the lumen widened with incision is assessed with endoscopic clipping afterwards. I do not have any conflict of interest, but this is what I use. These are the most common knives which are in my endocenter that I use. I use ERBI for this procedure. I use the setting of endocut Q323. So let me give you a case here. 32-year-old female with ileocolonic Crohn's disease status post resection five years ago. She's presenting for management of an asthmatic stricture. She's nine months postpartum. She has a stricture at TI that's approximately one centimeter in length. She's currently maintained on biweekly Adalibumab for her Crohn's disease. She was recently hospitalized because of partial SBO. She underwent balloon dilatation to 18 millimeters with minimal relief in her symptoms. CT entomography was obtained, shows a mild stricture at TI, mild pre-stenoid dilatation, and some mucosal enhancement at distal TI. This is the endoscopic picture. You can very well see the small ball across the stricture. The stricture is not very long. So what options would you recommend? Would you repeat endoscopic balloon dilatation in this case? Would you dilate this time with intralesional steroid injection? Would you consider stricture otomy? Or maybe for such a small stricture, send her to surgical resection? Or switch her medications? So in this case, we actually chose doing endoscopic stricture otomy. This is a video of the case. We went in, and we are in semi-retroflex position as these are end-to-side anastomosis, and you can very well appreciate to assess them. As you can see, even with passing the scope, there was some bleeding. I used this IT nano knife in this case. My usual approach is to make a circumferential cut. I like to cut at least at a level of deep mucosa and submucosa. There always comes a point when you cut significantly at the submucosa level that the stricture gives away. And you get that feeling. It's a feel factor. When you start doing them, you realize that you get a feel factor with that. Obviously, there is more control because you can control your knife, how deep it can go. So you should not go beyond muscle in any case. In this case, if you saw, we got a little bit deeper submucosal cut. I felt with my scope that, yes, I'm near there. I'm going to make one more incision in the same side, a little bit deeper submucosally, and then the stricture gives away. And then we are able to advance our adult colonoscope into the small mucosa. The small mucosa looked normal. She did not require any medication adjustments. And because there was no inflammation, it was an anastomotic stricture at the anastomosis, which sometimes can be from the disease activity or sometimes can be from localized ischemia at the surgical anastomotic site. And then afterwards, I just put clips on. And clips, in my view, prevent two things. It prevents delayed bleeding, which I'll discuss with you. And it also keeps the edges from going back together. One-year follow-up, the stricture looks like this. I always tell my fellows, this is like a truck we can drive through. Because it's wide open, no resistance to the scope. You don't have to do anything to this stricture. So this is the data so far. More than 250 patients. Predominantly, you'll see that there is one group from Cleveland Clinic, Lan et al., Dr. Boshan, that has published majority in this regards. Multiple locations from esophagus to pouch inlet to anastomotic to TI strictures. The column to pay attention is the technical success, meaning how often were we able to pass the scope after stricture otomy? Almost 100%. In my series, in one patient, I was not able to pass. Because the denominator is small, so it comes out to 92%. But it is more than 90% success rate, nearly almost 100% success rate. Any time a new technique comes along, everybody wants to know what is the complications. These are the adverse events listed on the site. So again, the complication rates, percentages-wise, seem very high. But again, it's 20%, but the denominator is five patients. So it's only one out of five patients that had a complication. Let's dive into the complication. For me, the most dreaded complication is an endoscopic perforation. Because that's the time when I have to call my surgical colleagues to bail me out. And if you look at the perforations in this case, we had total four in the entire 250-odd patients. It's the bleeding that's the main driving adverse event for us in these procedures. Bleeding can happen up until two weeks from the procedure. And right now, we do not have a good answer. So overall, bleeding risk is around 66% that we report from across all the studies. What has been our experience at the AHN, we've done so far 81 cases. From upper esophagus, ileocolonic location, anal strictures, pouch inlet strictures, IC valve, primary small bar, and colonic strictures. Our technical success has been 100%, but clinical success in that one patient that we couldn't pass the scope. Bleeding, I've had five patients come back, so approximately, again, 6%. I had one perforation in the duodenal region, which was managed conservatively. And so far, the longest follow-up surgery-free period has been 34 months. So advantages of strictureotomy. Preserve bowel length. You have more control, because the knife is under your control. There was one study that was in the table that looked at surgery-free survival after ileocolonic resection and endoscopic strictureotomy for anastomotic strictures. And they both found similar results. The need for repeat procedures is less, and it's very good for anal strictures. This is a video of a patient with PSC and J-pouch. She has an anal stricture and was self-dilating herself once a week with minimal relief of symptoms. And she was self-dilating for about five to seven years. The stricture was so severe, you can't even pass an EGD scope through. So in this, we again used the hook knife to cut the scar tissue out. Very important in female patients when you're cutting anal strictures to avoid the posterior vaginal wall and interior rectal wall, because an injury in that region can cause fistula. So we went to the posterior rectal wall, and we were able to cut the scar tissue out in a semi-circumferential in this case. And again, the same thing. Once you cut to a level of the submucosa, you'll see the stricture kind of gives away and our scope passes through. Now there is no problem with self-dilating, but she was not getting any benefit. And self-dilatation was being performed once a week. And sometimes patients don't like it. And quite honestly, some patients even feel embarrassed to do it. So we did this procedure. We were able to pass the scope through. Her pouch was severely inflamed, as you can see, because it was never assessed. There were probably some stool retention because of the obstructive nature of the stricture. And if you see, the stricture appears much better than before. I have since done two, three more scopes on her. No issues whatsoever. So when do you consider a stricture atomy? Short fibrotic stricture, even less than three centimeters. Internal stricture is very good modality. For now, consider for strictures that do not respond to balloon dilatation. Strictures that are very high risk for perforations that you know that you can't afford a perforation, you can look at endoscopic stricture atomy and not do balloon dilatation. Can we combine stricture atomy and balloon dilatation? Is it safe? Yes. We have done about 26 such cases. This is another video of such a case. We have a TIS stricture, primary TIS stricture that we are not able to pass. In this case, we'll utilize using a balloon to inflate and dilate to a size that we can get our scope through. Again, my balloon dilatation technique is very standard. Once I inflate the balloon, I want to visualize through the balloon how much the dilatation is going on. And once I see the stretching whitening of the mucosa, I know I've achieved enough dilatation and then I get my scope through. Once we got the scope through, the mucosa looks normal. She did have a smaller stricture very close to the IC valve, but beyond that, the mucosa as you see is very healthy mucosa. There is no need for medication adjustment. On our way back now, we will do the stricture atomy part. We'll cut it all the way to the level of the muscle. IC valve is a very good location to start your stricture atomy procedure if you're considering because there's a lot of fat cushion, a lot of subcutaneous tissue. And we were able to cut it deep to the level of the muscle as you see. At this point, we will stop cutting any further and we will put on clips at this position and we'll try to pass the scope repeatedly through. It's a very easily passable scope. That's the second stricture that we also treated with stricture atomy. Patient was discharged home the same day with no issues. This is just placing the clips. I'm going to move the video forward in interest of time. How about primary colonic strictures? I don't have a video for this, but this is a pinhole stricture that was sent to me in a young boy, teenage boy. This is ascending colon, by the way. And ask up his vent and this is what they reached. There is a small fistulas opening here and this is the stricture. We performed stricture atomy in this patient and this is what the stricture looks like. The TI is up here and this is the C-cum of the patient. So we were able to successfully open up this. So you can use in primary colonic strictures also. Drawbacks of EST. Not everything is, you know, yellow is gold. So there are drawbacks. There is no defined role as of yet. Extensive training and expertise is required. I'm very uniquely positioned because I had the IBD training and advanced endoscopy training so I was able to combine these two worlds. But for someone who has just only IBD training, they have to get the knowledge of the advanced procedures. We do not have any billing codes right now. So you have to be best friends with your GI division chief to give you the time to spend 60, 90 minutes in doing these procedures. It's time consuming. There are complications such as bleeding and you have to kind of manage those as well. Entral stents in IBD. I'm going to run through this because I want to get to the procedural considerations that I have. So stents have always been an avenue of interest, have been attempted in patients with IBD. Early results were not encouraging. This table summarizes some of the largest published studies so far. We're going to focus on the study by Das et al that was published in GIE last year. They used 21 patients, mostly in asthmatic strictures, two TS strictures only. And they excluded strictures that had any degree of erythema, any degree of mucosal engorgement, vascular pattern was decreased, mucosal friability, erosions. So they choose very nice, healthy strictures as I call them because most of my strictures that I see are not looking like that. So technically they were very successful, 96% of the patients, average stricture length was around three centimeter, 100% strictures were visualized to be dilated to at least the stent diameter. They reported five adverse events including three stent migrations and two patients with belly pain. Issues with self-expanding stents in IBD is that the technical success is good but premature stent failure is common. There have been cases of stent causing perforations, migrations. We do not have dedicated IBD stents in USA as of now. Tissue reaction to foreign body in IBD patients is always a challenge to manage. So we do not know how long to keep these stents for. Should we keep them for two weeks, four weeks, 10 days, we do not know. And we don't have long-term data. The future, however, looks promising with the through-the-scope stents that don't require fluoroscopy as such to be delivered. And now we have stents that we can deliver both through colonoscope and an EGD scope. So more in this sector you'll see in future three to five years coming in regards to using stents for IBD patients. So procedural consideration, these are little tips and tricks that most of the time people ask me these questions so I wanted to put them in a slight fashion here for you. Before doing endotherapy in IBD patient, please obtain a CTE or an MRE. Define your anatomy. Optimal bowel preparation is a must. Consider fluoroscopy if the structure is complex, angulated, long. There is no need to stop outpatient biological therapy in these patients. If they're on Stelara, Humira, any medication they're on, please continue it. No need to stop that. Consider stopping or tapering corticosteroid therapy. Because patients on steroids will likely bleed more. We have data for that. MAC versus general anesthesia, it's your preference. We do all cases under MAC, but in the beginning if you feel like you need general sedation for strictureotomy, that's not a bad thought as well. As I said, biologists can be safely continued. A follow-up endoscopy to access the long-term response to therapy and need is suggested. So you should repeat an endoscopy in a year's time to see what the response has been. Perforations in IBD patients can happen independent of the balloon size. So it is not like higher the size of the balloon only then the perforations happen. We have had perforations at size of balloon 12 also. So don't be under this impression that only higher balloon size will cause perforation. Asymptomatic incidental strictures dilate if benefits outweigh the risk. Use graded dilatation in a stepwise manner. Wire-guided balloon and retrograde approach is preferred over the anti-grade approach. And please do biopsy the stricture. There is 2% risk of malignancy in these patients. So at least the first time you dilate them before that, just take a biopsy. There is no use of intralesional steroids in these patients once you are dilating them or cutting strictures. In IBD patients, we don't have any data supporting that they are beneficial. So management paradigm of IBD shifting, I think endoscopy is now playing more central role to this. And this is my approach to the patient of a stricture that's referred to me in my clinic. I obtain a pre-procedure imaging. Size less than 3 cm, I consider strictureotomy. Size bigger than 3 cm, I consider balloon dilatation. If there is inflammation, I first then medically optimize. But if they have significant pre-sternoid dilatation or length more than 5 cm, please consider surgery. Then our endotherapies won't be effective. So in summary, patient first. Select the patient very importantly in a multidisciplinary fashion. And endoscopic therapy is safe and effective. If we choose the right patient and the right procedure. As endoscopy is evolving, in last decade, we have seen such inventions in endoscopy that has changed what we do. And that's going to keep helping us to even bring that technology to our IBD patient. With that, I would like to thank all of you. And again, thank you to the organizers. Thank you so much for bringing me, giving me this platform to discuss this therapy with you.

stricture therapy

inflammatory bowel disease

endoscopic balloon dilatation

endoscopic strictureotomy

enteral stenting

surgical intervention