It's my pleasure to invite Dr. Tanvi Deer from Emory University. She's going to speak to us about updates in the endoscopic management of inflammatory bowel disease. Thank you. Thank you to ASGE and the course directors for inviting me to speak today. My only disclosure is that I am not an advanced endoscopist, so I'm going to be speaking more from an IBD clinician's perspective who has an appreciation for utilizing some of the advanced endoscopic techniques to help manage her IBD patients. So this afternoon, I'll be reviewing some of the various IBD-related endoscopic advanced techniques that we have available and are currently being investigated in the management of strictures, fissures, and abscesses, IBD surgery-associated adverse events, as well as colitis-associated neoplasia. So when we think about endoscopic management of IBD, it's important to be able to appreciate that these tools can serve as a useful adjunct to our current medical and surgical therapies to help handle the complex IBD patients that we face. It may require the use of certain advanced endoscopic techniques, such as electroincision. However, there are several key associated benefits that our patients can garner. These include potentially delaying the need for surgery. For example, in one study, the use of endoscopic balloon dilation was found to delay surgery by six and a half years. And in certain patients, it can also prevent the need for surgery, such as pouch excision or small bowel resection. So the most common mechanical complication that we tend to see in IBD clinical practice is stricture formation, primarily in patients with Crohn's disease. And these can occur at any time during the course of disease, as well as during treatment. Up to 40 percent of patients will develop strictures within 10 years of diagnosis, and about half of these patients will end up requiring surgery. The most common site for primary Crohn's disease-associated strictures are either in the terminal ilium or the ileocecal area. And about a third of patients who undergo ilioclonic surgery will end up developing an anastomotic stricture. So what are some of the tools that we have to handle these type of strictures non-surgically? So some of the endoscopic tools include endoscopic balloon dilation, which is probably one of the oldest and most commonly used tools for managing strictures. The use of endoscopic stricturotomy and stricturoplasty is garnering more attention and more use in certain centers. Endoscopic stent placements have also been used to help manage benign Crohn's disease strictures, and sometimes a combination of these therapies are required to help manage our patients. So for endoscopic balloon dilations, who are the patients that we would consider ideal candidates and who are the patients we should be avoiding this procedure in? So for any type of stricture or for any type of endoscopic therapy for management of strictures, we can consider patients with both primary as well as secondary strictures as ideal candidates. The length of the stricture will often dictate success, so the strictures that tend to fare the best with balloon dilations are those that are less than four to five centimeters in length. It's important to note that for every one centimeter incremental length in stricture, there's an increased risk of surgery by 8%. The use of balloon dilation and the management of asymptomatic strictures is somewhat controversial. However, the rationale behind considering dilating somebody with an asymptomatic stricture is that it could potentially help to prevent complications such as bowel obstruction or the development of a fistula right proximal to the tight stenosis or potentially prevent the development of an abscess. Patients who have deep ulcerations associated with the stricture are at higher risk of complications including bleeding and perforations. However, patients who have superficial ulcerations, it's not a contraindication to do a balloon dilation in. Patients who have a concomitant fistula and or abscess are at higher risk of post-procedural complications. The presence of pre-stenotic dilatation, especially if it's above five centimeters, decreases the chance of efficacy with balloon dilation. Those patients are probably somebody we should be considering surgery in. Angulated strictures are harder to dilate with the balloon. Patients on prednisone doses higher than 20 milligrams are at higher risk of perforation during balloon dilation and the use of antithrombotics should be held prior to the procedure. So in terms of technique, the first step before considering balloon dilation or any type of endoscopic stricture therapy is to define the stricture with some type of imaging, either a CT enterography or MR enterography with or without retrograde contrast enema. So this helps to define the length of the stricture. It can also help to determine if there are any associated conditions such as fistula or abscess. Typically one can use a gastroscope or a pediatric colonoscope. Thoroscopy should be readily available, especially if one needs to use a guide wire for tight strictures. Typically graded balloon dilation is done to at least a level of 15 to 20 millimeter balloon dilation size in a stepwise fashion. Endoscopy dilation is preferred if one is able to traverse the stricture as this can decrease the risk of complications. When performing the procedure, it's important to have direct through the scope endoscopic visualization to be able to visualize how much tearing is occurring during the dilation. And steroid injection or the use of any type of medical therapy or injecting any type of medical therapy into the stricture is not recommended during balloon dilation as they have not been found to be efficacious. So what studies do we have that suggest that balloon dilation is beneficial in our patients with Crohn's disease? So this was a meta-analysis performed of 13 studies that included over 1,500 dilations. Technical success was seen in 89% of patients, so technical success was defined by the ability to advance the scope past the stricture. Strictly free rates were noted in two-thirds of patients with the median follow-up of anywhere from 15 to 70 months, and the rate of major adverse events was low. Balloon dilations have also been performed in patients with pouches. This was a study that took a look at over 150 stricture dilations with a very high technical success rate. In addition, the 25-year pouch retention rates were also quite high, and the rate of adverse events was quite low. Although balloon dilations appear to be efficacious in our patients with Crohn's disease, there are certain caveats to recognize. This includes that many patients often require more than one session. Most patients end up having some degree of recurrence, up to 60% was noted at five years. Although balloon dilation may be effective in many patients, about a third end up requiring some type of salvage surgery. In addition, perforation can be seen in up to 4% of patients. As I mentioned before, endoscopic stricturotomy and stricturoplasty has been garnering more attention and gaining more ground in the management of Crohn's disease structures. So by definition, endoscopic stricturotomy involves widening of the stenotic lumen by using electroincisional tools alone. A stricturoplasty is a stricturotomy along with placement of endoscopic clips at the site of the incisional edges to prevent closure of the lumen as well as to prevent post-procedural bleeding. These type of procedures are best performed in those that have short strictures, less than four centimeters, and those strictures that are primarily fibrotic rather than inflammatory. In centers where these procedures are performed, it may be considered first line in those with anorectal or anapalch strictures. And this is because the endoscopist has full control of the degree of the length and the location of where the electroincision is occurring. So this could potentially prevent iatrogenic injury to the sphincter muscle as well as iatrogenic injury to the anterior wall, which can be problematic, especially in our female patients. So this was a case series that took a look at 85 patients that underwent stricturotomy with needle knife in IBD patients. So overall, the symptomatic improvement was noted in over 50% of patients, and only 15% of patients needed some degree of salvage surgery. As far as the complication rate, only one patient developed a perforation. However, nine patients did develop significant bleeding. How does this modality compare to balloon dilation? This was another case series that took a look at 185 patients that underwent stricturotomy or endoscopic balloon dilation for the management of anastomotic strictures. There was no difference in immediate technical success between the two groups, and immediate technical success was quite high in both groups. However, there was a trend towards more clinical symptom improvement in the stricturoplasty group versus the balloon dilation group. In terms of complications, no perforations were seen in the stricturotomy group. However, four patients in the balloon dilation did experience perforation. More patients in the stricturotomy group ended up developing transfusions requiring bleeding. And in terms of the need for subsequent surgery, about a third of patients who underwent balloon dilation ended up requiring salvage surgery, versus those in the stricturotomy group, it was only less than 10%, and that was statistically significant. So certainly this modality appears to be a potentially useful tool for managing strictures in our Crohn's patients. As I mentioned before, endoscopic stenting is another technique that we have available to help manage our Crohn's disease patients. This was a meta-analysis that took a look at nine studies that included 163 patients. Clinical success was seen in over 60% of patients. Technical success was quite high. Close to half of the patients ended up developing spontaneous stent migration, which is not to be unexpected, especially when you're dealing with these benign strictures. So therefore, it's recommended to remove the stent within four weeks of placement when using this modality. So how do stents compare to balloon dilation? This was a recent open-label, multi-center, randomized trial done in Spain that looked at patients who were randomized to either receive balloon dilation or a fully covered self-expandable metal stent. What the researchers found is that a significantly higher proportion of patients with balloon dilation were free of new therapeutic interventions at one year compared to those who had stents. In addition, endoscopic balloon dilation appeared to be more cost-effective than stent placement as well. So although both modalities seem to be effective, I think with stent placement, it should likely not be considered first-line therapy for patients with Crohn's disease strictures. It's also important to recognize that patients with Crohn's disease that have a stricture may also be at risk for harboring neoplasm. We think about more so with patients with UC-associated strictures. The most common location for malignancies to occur in associated strictures with Crohn's disease is usually in the anal area. So it's really important to get a careful look at strictured areas and do biopsies of these areas, be it whether it's a primary stricture or an asthmatic stricture. In terms of endoscopic techniques to manage fistulas, the research is very limited. Based on the limited data, the patients who seem to benefit more from endoscopic fistulotomy are those that have short fistulas or superficial less than 2-centimeter-thick ileum-to-cecal fistulas or perianal or pouch-to-pouch fistulas. The premise behind the endoscopic treatment with doing a fistulotomy is to incise and open up the fistula track to the bowel, lumen, or skin tunnel and incorporate the track into the bowel or skin and prevent branching into a more complex one, thereby preventing any abscess formation. So this is a representation of what an endoscopic fistulotomy may look like. So a guide wire is placed endoscopically through the fistula site. An electro-incisional tool, such as a needle knife, is used to open up the fistula site. And then clips are placed post-procedurally in order to maintain the patency of the lumen as well as to prevent bleeding. The use of endoscopic clipping for the treatment of primary Crohn's disease fistulas has shown low success rates, so it's not recommended. However, in patients with anastomotic leak-associated fistulas, there may be some utility and benefit of using clips. So this is an endoscopy image of a patient who has anastomotic leak-associated fistula that was treated successfully with an over-the-scope clip. In terms of managing post-surgical complications endoscopically, again, limited data for using these type of modalities, this is a patient who developed a presacral abscess post-surgery. And unfortunately, the abscess was not amenable to IR-guided percutaneous drainage. Therefore, the endoscopist performed a pigtail catheter placement directly into the abscess cavity, into luminally, and was successfully able to drain the abscess that way. Patients with IPAAs or colorectal anastomoses are at risk for development of chronic anastomotic leaks or presacral sinuses. So one of the endoscopic modalities that's currently being used in certain centers is the use of endoscopic sinusotomy. So this entails incising the bowel lumen wall between the lumen and the presacral sinus and allows for incorporation of the sinus into the lumen. So this could potentially prevent the patient from needing a significant pouch surgery, such as a redo or even a pouch excision. So in the last few minutes, I'll talk a little bit about colitis-associated neoplasia. So colitis-associated neoplasia can be seen in up to 11% of IBD patients after 40 years of diagnosis. The first step in managing these patients is to have a good endoscopic evaluation of their chronic mucosa. So in order to do this, it's important to ensure that the patient has tight control of the inflammation. So it's much more difficult to do a surveillance colonoscopy on somebody who has moderate to severe MAO-3 colitis than somebody who has endoscopic remission. So it's important for the patient to be in endoscopic remission prior to doing a careful surveillance. It's also important to also make sure that the patient has an adequate preparation as well. In most centers, the majority of endoscopists are using high-definition white light endoscopy with virtual chromoendoscopy with narrowband imaging to perform surveillance on our high-risk patients. However, the use of white light endoscopy with dye-based chromoendoscopy or high-definition white light endoscopy with dye-based chromoendoscopy is also acceptable. When a lesion is found, it's recommended to do targeted biopsies. I've moved away from doing four-quadrant, every-10-centimeter biopsies on most of my patients. However, on those patients that I would consider high-risk for dysplasia or cancer, so these include patients with PSC or if they've previously had a history of neoplasia or dysplasia, I'm still routinely performing four-quadrant, non-targeted biopsies segmentally. So most dysplastic lesions and IBD are visible. So when a visible lesion is found that is well demarcated, it's important to attempt some type of endoscopic resection, either with polypectomy, ESD, or EMR. Endoscopic resection, however, is not recommended if the lesions are multifocal or if the lesions appear cancerous. It's important to note that in our IBD patients, it's not uncommon for these dysplastic lesions to have a significant degree of fibrosis associated with it. However, if that's the case, endoscopic resection should still be attempted and oftentimes endoscopic submucosal dissection may be the best modality in those patients, more so if the lesion is large. Close surveillance is recommended given the potential risk of recurrence as well as the potential for incompletely resecting the lesion. So I typically will perform a colonoscopy three to six months after a patient undergoes an endoscopic resection of a dysplastic lesion. The long-term data of how this affects the cancer potential in our IBD patients when using these modalities is somewhat sparse. This was a recent meta-analysis that took a look at outcomes of endoscopic submucosal dissection in IBD patients. It included 11 studies of 246 dysplastic lesions. The pooled and blocked resection rate was quite high. Adverse events were somewhat low, which included bleeding and perforation. The rate of mitocrinous recurrence was 9.1% and the need for additional surgery was 15%. However, the median fall was only about 25 months. I would argue that longer-term data is likely needed in order to determine how these modalities will affect the long-term cancer potential for high-risk IBD patients. So in conclusion, interventional endoscopic management IBD patients may serve as a useful tool in managing IBD disease-related and post-surgical complications. These procedures may help to delay or prevent surgery. Recent studies seem to show that these procedures may be effective and safe and capable of hands, however additional studies are needed. Candidacy for doing these type of procedures should be determined in a multidisciplinary fashion, including those with expertise in these type of procedures. Additional IBD interventions are needed to meet the growing needs of our complex IBD patients. Thank you.

endoscopic management

inflammatory bowel disease

endoscopic techniques

colitis

neoplasia