Role of Interventional Inflammatory Bowel Disease (IBD) in the Management of Complex IBD: Initial Prospective Experience from a Tertiary Center in India

Abstract

Background/Aims With the growing multidisciplinary model of practice in the management of complex inflammatory bowel disease (IBD) and rising incidence of IBD, interventional IBD (IIBD) promises to play a key role. We aimed to evaluate current the role of IIBD in India and its short-term outcomes. Methods IBD patients undergoing IIBD procedures for stricture, bleeding, colitis-associated neoplasia, therapeutic small bowel endoscopy including retained capsule retrieval and postsurgical complications were enrolled prospectively between September 2021 and May 2022. Demographic and disease details, indications, initial and redo procedure details, technical/clinical success, and complications were recorded. Results IIBD procedures were performed in total 54 patients (61% males, median age: 37.5 years, range: 21–74 years, Crohn's disease [CD]: 42, ulcerative colitis [UC]: 12 between September 2021 and April 2022). Endoscopic balloon dilation (EBD) was performed in 44 patients (56 strictures, 9% anastomotic, 9% pouch) who underwent total 83 EBD procedures in 63 sessions. Short-term clinical efficacy after maximal dilation, technical success (i.e., scope passage after EBD), and complications (all mild) were noted in 95.4, 81.8, and 9.1%, respectively. Recurrent symptoms were seen in 27.3% on short-term follow-up (1–8 months, median: 5 months) for which redilation, surgery, and endoscopic stricturotomy were done in 22.7, 2.3, and 2.3% respectively. During small bowel EBD, motorized spiral enteroscopy-guided retained capsule endoscope retrieval was done in four patients. Ulcerative colitis-associated neoplasia (UCAN) was resected endoscopically in six patients (endoscopic submucosal dissection (ESD)—1, endoscopic mucosal resection (EMR)—5). High-grade dysplasia was resected in two patients (1 ESD for recurrent UCAN, 1 EMR had residual neoplasia on follow-up treated with underwater EMR). R0 resection was achieved in 83.3%. Endoscopic hemostasis was done with hemoclipping and sclerotherapy for UC-related bleeding in two, whereas a case of CD with proximal ileal bleeding was controlled with antegrade single-balloon enteroscopy-assisted hemoclipping. Conclusions IIBD is a promising modality in resource-limited settings like India acting as a bridge between medical therapy and surgery. Surgery can be avoided in a significant proportion with good short-term outcomes. Long-term outcomes need to be evaluated.

Re‐intervention rates and symptom‐free survival at 1 year after endoscopic versus surgical management of strictures in Crohn's disease: A propensity matched analysis of a prospective inflammatory bowel disease cohort

“…Short-term complications of ET are perforation and bleeding, which may sometimes require primary surgery if not controlled with endoscopic management. 10 Surveillance should be performed for strictures treated with ET due to long-term risk of malignant transformation. 20 The study has several strengths.…”

“…The short-term outcomes of such procedures have been reported earlier. 10 We selected patients from the cohort who underwent ET for CD-related primary, symptomatic, non-traversable strictures between August 2021 and March 2022 and are on follow up. Similarly, we identified patients from our prospective IBD registry who underwent surgery for CD-related primary strictures in the same time period.…”

“…7,11 Decision to choose ET or surgery was based on established predictors such as fistulizing disease, anti-tumor necrosis factor exposure, long strictures (> 5 cm), > 3 strictures, and pre-stenotic dilation (> 5 cm). 12 Prior to the procedure, each case was discussed in institutional dedicated IBD forum consisting of IBD specialists, interventional and small bowel endoscopists, GI surgeon, and radiologist for deciding best modality in a given patient 10 Patient preference was also considered after informed discussion.…”

“…We established a prospective cohort of patients undergoing interventional IBD procedures for strictures, fistula, abscesses, bleed, and capsule retention since August 2021. The short‐term outcomes of such procedures have been reported earlier 10 . We selected patients from the cohort who underwent ET for CD‐related primary, symptomatic, non‐traversable strictures between August 2021 and March 2022 and are on follow up.…”

Interventional endoscopy in inflammatory bowel disease: a comprehensive review

“…Endoscopic retrieval of retained capsule endoscope has been described with double balloon enteroscopy and motorized spiral enteroscopy with or without EBD of small bowel strictures ( Figure 11 ) [ 120 , 121 ]. The success rate could be as high as 80%–92% with double balloon enteroscopy [ 122 , 123 ].…”