P1648 - Utility and Safety of Endoscopic Evaluation in Patients With Crohn's Disease and Stricturoplasty

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

KT

Kanwarpreet Tandon, MD

Digestive Disease Institute, Cleveland Clinic Foundation
Weston, FL, United States

Badar Hasan, MD¹, Kanwarpreet Tandon, MD¹, Sadaf Afraz, DO¹, Asad ur Rahman, MD¹, Fernando Castro, MD¹, Roger Charles, MD¹, Bo Shen, MD²
¹Digestive Disease Institute, Cleveland Clinic Foundation, Weston, FL; ²New York-Presbyterian/Columbia University Medical Center, New York, NY

Introduction: Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal (GI) tract. Surgical options employed in the management of obstructive symptoms typically involve limited segmental resection and stricturoplasty. Short small bowel strictures are best treated with the Heineke Mikulicz technique, and longer strictures with Finney-like procedures or isoperistaltic stricturoplasty. However, there is virtually nonexistent literature regarding the utility and safety of endoscopic evaluation of the site of stricturoplasty.

Methods: A retrospective study of patients with Crohn's disease who underwent prior surgical stricturoplasty between January 2005 and September 2020 was performed. Patient data were reviewed for baseline characteristics and endoscopic data. The primary outcome measures were to evaluate the ability to access the stricturoplasty and its findings. Patients with a diagnosis of ulcerative, indeterminate colitis, or stricturoplasty for the disease other than CD were excluded.

Results: A total of 48 endoscopic procedures (colonoscopy, upper endoscopy, balloon-assisted enteroscopy, push enteroscopy, ileoscopy via stoma, and flexible sigmoidoscopy) were reviewed in patients with Crohn's disease and previous history of surgical stricturoplasty. Stricturoplasty location was defined upon review of the operative report. The most common indication for the procedure was to assess activity 33/48 (68.7%). The site of stricturoplasty was reached in 13/48 patients (27%). (Table 1). Stricturoplasty site was normal in 5/13 (38.5%), ulcerated in 4/13(30.8%), and recurrent strictures were noted on 4/13(30.8%) patients. Among these patients, endoscopic balloon dilation of stricture was performed in 3 patients (23.1%), and epinephrine injection (7.7%) for suspected GI bleeding was performed in 1 patient. The ability to reach the site of stricturoplasty was independent of the location. (Table 2).

Discussion: Endoscopic evaluation of the previous surgical stricturoplasty site is, although a safe procedure with minimal to no complications, the yield of the procedure is low, and on most occasions, the site is not accessible to endoscopic evaluation. These procedures should be carefully planned only after evaluation of the patient's anatomy with prior imaging and feasibility of the site to be accessed.

Figure: Endoscopic view of the site of a successfully traversed Heineke-Mikulicz stricturoplasty.

Table 1

Patient demographic and clinical characteristics

				Stricturoplasty Site Reached
Characteristics				No (n = 35)	Yes (n = 13)
Gender		Male		20 (57.1%)	8 (61.5%)
		Female		15 (42.9%)	5 (38.5%)
Patient Age (years)		At CD diagnosis		25.1 ± 9.5	24.6 ± 9.9
		At stricturoplasty surgery		39.3 ± 14.0	41.9 ± 11.5
		At endoscopic exam		50.8 ± 14.5	54.2 ± 12.5
Race		Caucasian		33 (94.3%)	13 (100.0%)
		Hispanic		2 (5.7%)	0 (0.0%)
History of Smoking		Active		3 (8.6%)	0 (0.0%)
		Former		7 (20.0%)	2 (15.4%)
		Never		24 (68.6%)	11 (84.6%)
		Unknown		1 (2.9%)	0 (0.0%)
Stricturoplasties		Number of prior		2.1 ± 4.0	1.5 ± 2.1
		Number total		3.0 ± 2.6	2.6 ± 2.3
		Length of stricture		0.4 ± 0.8	0.2 ± 0.8
Location of Stricturoplasty		Ileum/Ileocecal region		27 (77.1%)	7 (53.8%)
		Jejunum/duodenum		12 (34.3%)	6 (46.2%)
		Ileocolic/ileorectal anastomosis		3 (8.6%)	4 (30.8%)
Configuration of		Heineke-Mikulicz (HM < 10cm)		28 (80.0%)	9 (69.2%)
Stricturoplasty		Finney (10-25 cm)		5 (14.3%)	1 (7.7%)
		Side to side isoperistaltic ( >20 up to 90 cm)		0 (0.0%)	1 (7.7%)
		Unknown		2 (5.70%)	2 (15.40%)
Indication	Abdominal pain		5 (14.3%)			1 (7.7%)
	Small bowel obstruction		1 (2.9%)			0 (0.0%)
	Bleeding		1 (2.9%)			3 (23.1%)
	Assess activity/stricture evaluation		24 (68.6%)			9 (69.2%)
	Diarrhea		2 (5.7%)			0 (0.0%)
	Screening (colon cancer)		2 (5.7%)			0 (0.0%)
Route of endoscopy	Upper endoscopy		0 (0.0%)			1 (7.7%)
	Colonoscopy		21 (60.0%)			3 (23.1%)
	Ileoscopy via stoma		8 (22.9%)			3 (23.1%)
	Retrograde double-balloon enteroscopy		1 (2.9%)			1 (7.7%)
	Antegrade double-balloon enteroscopy		2 (5.7%)			2 (15.4%)
	Single balloon enteroscopy		0 (0.0%)			1 (7.7%)
	Push enteroscopy		2 (5.7%)			1 (7.7%)
	Flexible sigmoidoscopy		1 (2.9%)			1 (7.7%)

Note: Data are presented as Mean ± SD or n (%) as appropriate

Table 2

Comparison of stricturoplasty locations and endoscopic routes by whether or not the site was reached successfully

	Stricturoplasty Site Reached
	No (n = 35)	Yes (n = 13)	p*
Locations
Ileum/Ileocecal region (versus all others)	27 (77.1%)	7 (53.8%)	0.157
Jejunum/duodenum (versus all others)	12 (34.3%)	6 (46.2%)	0.513
Routes
Colonoscopy	21 (72.4%)	3 (50.0%)	0.352
Ileoscopy (via stoma)	8 (27.6%)	3 (50.0%)

* Fisher’s exact test

Disclosures:

Badar Hasan indicated no relevant financial relationships.

Kanwarpreet Tandon indicated no relevant financial relationships.

Sadaf Afraz indicated no relevant financial relationships.

Asad ur Rahman indicated no relevant financial relationships.

Fernando Castro indicated no relevant financial relationships.

Roger Charles indicated no relevant financial relationships.

Bo Shen indicated no relevant financial relationships.

Badar Hasan, MD¹, Kanwarpreet Tandon, MD¹, Sadaf Afraz, DO¹, Asad ur Rahman, MD¹, Fernando Castro, MD¹, Roger Charles, MD¹, Bo Shen, MD². P1648 - Utility and Safety of Endoscopic Evaluation in Patients With Crohn's Disease and Stricturoplasty, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.