Clinical Debate
A patient with severe Crohn's disease, an ileal
stricture and proximal dilation on CTE should have
an ileocolonic resection first
Phillip Fleshner, MD
Shierley, Jesslyne, and Emmeline Widjaja Chair in
Colorectal Surgery
Program Director, Colorectal Surgery Residency
Clinical Professor of Surgery
UCLA School of Medicine
C S
Cedars-Sinai Medical Center
Los Angeles, California
Therapeutic Alternatives to Treat
CD Strictures
• Additional medical therapy
• Endoscopic dilation
• Surgery
Why Medical Therapy Not Useful
•
•
•
•
Expensive
When do you stop, ? lifetime exposure
QOL issues in partial responders
IV steroids frequently used to assess response
Steroids associated with development of stenosis
Steroids associated with postoperative morbidity
• Aggressive medical therapy ↑ surgical morbidity
• Prestenotic dilation is a negative prognostic factor
Disease assessment scores
Clinical studies
Lehman Score
• Score measuring the progressive nature or
cumulative structural bowel damage, independent
of the current and fluctuating disease activity
• A longitudinal tool currently being developed and
validated prospectively
Pariente B, et al., IBD 2011
Prestenotic Dilation and Clinical
Response in CD
100
75
75
61
% 50
28
25
0
No stenosis
Stenosis; no
dilation
Stenosis; yes
dilation
“Patients with intestinal narrowing and prestenotic dilatation
… were less likely to respond to medical therapy”
(OR = 7.85, 95% CI 1.73-35.6,p= 0.008)
Lawrance IC, et al., WJG 2009
Why Medical Rx Is Not Useful
Expert Consensus Opinion
Why Medical Rx Is Not Useful
Expert Consensus Opinion
Laparoscopic Ileocolic Resection
• Short term outcomes
Minimal scarring
Enhanced cosmesis
Fast surgical recovery
Fast restoration of QOL
Complications are low (<10%)
Medication can be stopped or limited in prevention mode
Small bowel loss is generally small (usually 20–25 cm)
• Long term outcomes
Lower incisional hernia
Less adhesions, possibly less SBO
Endoscopic Dilation vs
Laparoscopic Surgery
Criterion
Endoscopic
Dilatation
Laparoscopic
Surgery
Can be long with deep
SB strictures using DBE
120 min
Overall complications
̴ 10%
<10%
Complications requiring
surgery
̴ 5%
<1%
Peritonitis/perforation
2%
2%
Potential for leaving CA
Present; Biopsy critical
None
Average Procedure Length
Endoscopic Dilation vs
Laparoscopic Surgery
Criterion
Endoscopic
Dilatation
Laparoscopic
Surgery
Technical success rate
90%
100%
Clinical success rate
̴ 50%
>95%
Patients requiring only 1 procedure
̴ 30%
99
̴4
1
Unknown
Very high
Mean # of procedures needed
QOL after procedure
Severe CD, Ileal Stricture and
Proximal Dilation
Is Endoscopic Dilation Ever
Preferable to Surgery?
• Multicentric disease
• Multiple prior resections
Adhesions
Loss of bowel → short bowel syndrome
• Poor surgical risk
• Initial presentation of the disease
• Stricture location
Gastroduodenal
Rectosigmoid