Bougie dilators: simple, safe and cost-effective treatment for Crohn’s-related fibrotic anal strictures

Abstract

Anal strictures with fibrotic induration have been shown to develop in up to 50% of all patients with Crohn's disease (CD) with anal ulceration.1 Clinically significant strictures occur in about 5% of patients with perianal CD. With reduced stool consistency due to the CD, symptoms are often minimal, and the stricture is discovered at examination. When present, the stricture-related symptoms are overflow diarrhea, perineal pain, constipation and/or fecal incontinence.In the past, dilation was digital or with Hegar dilators. More recently, balloon dilation has become the choice for many, 2 entailing a considerable longterm cost. To the best of our knowledge, there are no published case series of bougie dilation of CD anal strictures. This discussion demonstrates the technical feasibility, safety, long-term efficacy and cost-effectiveness of bougienage for a subgroup of patients with CD-related fibrotic anal strictures.Ten patients with CD at a single university teaching hospital who had symptomatic fibrotic anal strictures and failure of digital dilation and were treated between 1988 and 2013 were all perceived to have irreversible fibrotic anal strictures (Cardiff classification S2a).3 They all had symptoms, such as narrowing stools, abdominal distension and overflow diarrhea. All were further characterized by the inability of a single experienced clinician to insert the distal interphalangeal joint of the examining index finger through the stricture. All strictures were 2 cm long or less, except in 1 patient who opted for colostomy. Bougie dilation techniqueWith the patient in the left lateral position and without any prior bowel preparation, stricture dilation was performed using generously lubricated silicone bougies with a tapered Maloney tip (M-Flex, Medovations). Intravenous sedation with fentanyl and diazepam was given. Despite an initial estimated stricture diameter of 5-6 mm in all patients, the procedure was initiated with a # 40-to 44-French bougie. The usual number of bougies per session was 4-5, starting with a 40-or 44-French, and going by double sizes to 40, 44, 48, 52, 56, 60). Ultimately, dilation up to the biggest bougie (60-French) was achieved in all patients. With the passage of a bougie through a stricture there is often a sensation of it giving way; once this is felt, one knows that the maximum diameter of the bougie has been passed through the stricture. All procedures were performed by a single experienced physician in an endoscopy suite. A total of 308 procedures were performed. Treatment intervals varied according to patient demand.The median age of patients at first therapy was 42 (interquartile range 25-50) years with a median follow-up of 10 (range 6-25) years. Dilation was

Sonography for an Imperforate Anus: Approach, Timing of the Examination, and Evaluation of the Type of Imperforate Anus and Associated Anomalies

“…First, in some cases of an imperforate anus with a vestibular fistula, daily gentle dilation of the fistula using a Hegar dilator could be performed until the scheduled repair . A Hegar dilator has been reported to be a useful method for treating anal stenosis and keeps the fistula at a certain size . Because the time of first stool is variable in neonates, meconium might not reach the distal rectal pouch, or the rectal distal pouch might be collapsed.…”

Management of Crohn's Anal Strictures: The Experience of a Department of Medicine

“…Regarding complications, the risk of anal incontinence after anal dilatation is high due to fibrosis which is often associated with destruction of the anal sphincter. There is no hemorrhage, perforation or serious undesirable effects described after anal dilation in the literature, subject to very poor literature, on the other hand it must be carried out judiciously because of a risk of sepsis [20] only one case of bleeding was noted in our series.…”

“…For short fibrous anal or anorectal strictures, no currently approved medication is known to prevent or reverse established fibrosis [18], dilation is the treatment of choice, it can be carried out simply with the finger, with a bougie dilatator (Hegar dilatators or metal olive dilatators) [19], or with balloons under general or locoregional anesthesia. A study on ten patients with S2 fibrous anal stenosis due to CD dilated by candles showed long-term efficacy [20]. This method provides tactile feedback, which makes it possible to estimate the degree of resistance to the dilatator passage, and thus avoid overdilation.…”

Alternative Approach in Colorectal Anastomotic Stricture: Bougie Dilatation

“…Various factors such as tissue ischaemia, anastomotic leakage and radiotherapy have been suggested in its pathogenesis [1,2]. Endoscopic methods (balloon dilatation, bougie dilatation, stents, endoscopic electroincision), digital dilatation, surgical methods (stapler stricturoplasty, transanal circular stapler resection, transabdominal redo-anastomosis) and corticosteroids are used in AS [3,4]. Surgery is generally preferred in complete/near complete AS [1].…”

“…Surgical methods are used in 3-4% (complete/near complete AS) in the failure of endoscopic methods. But mortality risk is high [1,[4][5][6].…”