Dra. Ana Echarri Piudo
Complejo Hospitalario Universitario de Ferrol
Dr. Fernando Muñoz Núñez
Hospital Universitario de León. León
One of the therapeutic options for symptomatic stenosis primarily associated with Crohn’s disease is endoscopic dilation with polyethylene balloons inserted through the working channel of the endoscope (through-the-scope [TTS]) and sold in different diameters for the purpose of increasing the calibre of the lumen and resolving clinical symptoms.
The advantages of balloon dilations are related to their adaptability to the anatomy of a stenosis (balloons with low compliance), achieving a uniform and reproducible distribution of dilation force, which is exerted in a radial fashion over the lesion. The balloons have an oval shape and are placed in the central area of the stenosis, where they are inflated with saline until reaching pressures of 3–5 atm.
The diameter of the balloons ranges between 6–25 mm1,2.
Once the stenosis is reached with the endoscope, we try to confront it properly by moving the endoscope, the control or postures of the endoscopist and the patient.
The balloon passes through the endoscope channel (TTS), and the use of balloons with a guide installed is recommended. Once the balloon leaves the working channel, the guide slides through the balloon and passes smoothly through the stenosis, which facilitates passage of the balloon through the stenosis when following the guide, thus preventing laceration of the distal intestinal wall to the stenosis with the tip of the balloon3,4.
If we know the characteristics of the stenosis beforehand, or can visualise the intestinal lumen through it, it is not necessary to use radiologic control, which sometimes can be used to learn of the characteristics of the stenosis or control the passage of the guide in very pronounced stenoses (Fig. 1).
The balloon becomes situated inside the stenosis, ensuring that the midpoint of the globe remains at its critical point. Once it is situated, it is inflated with saline solution. It may help to stabilise it before inflation by anchoring the catheter sheathe against the endoscope with the left hand and the colonoscope with the right hand. The initial calibre of the balloon must be similar or slightly smaller than the estimated diameter of the stenosis, which is why we cannot begin with one that is too small or too big.
Balloons with a set diameter can be used and can be gradually changed to ones with a larger diameter, or the current most common option can be used: controlled multi-diameter radial expansion balloons (controlled radial expansion dilators [CRE]) (Fig. 2), designed to reach three consecutive, pressure-controlled diameters by starting the inflation of the first diameter in the first position and holding it for 30 seconds–1 minute before proceeding to the next calibre, repositioning it and observing the appearance of significant mucous tears during dilation. There is no data that proves that a dilation time held longer is more effective.
It is advised that three consecutive dilations per session (rule of three) be performed, which can be repeated in a series of sessions until the objective is reached5. Additional balloon increases in a single session should be considered, depending on the calibre increase reached, the initial size of the stenosis, the presence of ulcerations or secondary tears and patient discomfort.
Generally, two “objective balloon calibres” are estimated by using two diameters of the balloon, up to 25 mm, or up to 18–20 mm, with the latter having fewer complications.
Once the maximum balloon diameter is reached for a single session, with a size slightly greater than the endoscope used, it can be attached to the tip of the endoscope before being deflated, inserting both as a single unit through the stenosis and keeping constant pressure. This manoeuvre can help to pass through a slightly angulated stenosis or a stenosis with poor visualisation of the field (oedema, blood). Care must be taken not to damage the distal intestinal wall to the stenosis with the tip of the balloon, and not to force its passage, assuring that the balloon has access.
Generally, dilation that allows the passage of a 13-mm endoscope after dilation is considered an effective dilation, although there are a few discrepancies with this definition. Patients can request several dilation sessions, which can be repeated until the symptoms have disappeared. It generally requires 2 or 3 dilation sessions with a few days in between if the obstruction is acute or several weeks if the occlusion is more chronic2,6,7.
• CRE Multi-diameter dilation balloons with/without guide, designed for three consecutive, pressure-controlled diameters with a high degree of radial force. The ones most used (Table I) have a length of 5.5 cm and a guide
of 0.035 can be passed through them3,4.
• Inflation and pressure-control mechanism (Alliance II Integrated Inflation Dilators from Boston Scientific or other inflation systems with a 60-cc syringe) (Fig. 3), the head of the catheter, with the dilating balloon on top, is attached to an inflation system with a manometer embedded in order to monitor the hydraulic pressure that is reached when injecting the pressure serum so that the balloon expands.
It is best to know the characteristics of the stenosis before performing a dilation, generally by performing an imaging technique beforehand (MR enterography, CT enterography)2,6,8.
• The extension,calibre and appearance of the stenosis must be assessed: 7% of stenoses associated with Crohn’s disease and 25% of stenoses associated with ulcerative colitis can be associated with the appearance of cancer. Biopsies obtain better results when performed after stenosis dilation.
• Assess inflammatory/fibrotic activity. Need for previous medical treatment.
• Assess any local complications: fistula or abscess.
• Locating the stenosis.
– Anastomotic (Video 2).
– De novo (those that arise in a location other than a surgical anastomosis) (Video 3).
CRITERIA FOR OPTIMAL ENDOSCOPIC DILATION
• Short stenosis.
• No inflammation.
• Non-angulated stenosis.
• No evidence of fistula or abscess.
• No evidence of cancer.
ADJUVANT DILATION TECHNIQUES
• Using corticoids or other intralesional substances in refractory stenoses. The short-term effectiveness of endoscopic dilation is high. However, long-term, some patients need more dilation sessions. In some cases, an intralesional corticoid injection reduces the frequency of sessions needed to maintain the response. Triamcinolone (40 mg in 4–5 ml, 4 quadrants) is used after dilation9. Recently, the use of intralesional anti-TNF drugs (infliximab) has been published, with varying results. The prescription for administration varies, but the one most used consists of injecting 100 mg of infliximab throughout the stenosis at varying intervals10-12.
• Performing multiple radial cuts by using a needle sphincterotome (Fig. 4)13.
The most significant are perforation, which occurs in 0.4% of the cases, and haemorrhage, which generally subsides spontaneously, although if necessary pressure can be exerted with the inflated balloon, in which case the use of haemostasis clips is advised if you observe arterial bleeding.
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2. Gustavsson A, Magnuson A, Blomberg B, Andersson M, Halfvarson J, Tysk C. Endoscopic dilation is an efficacious and safe treatment of intestinal strictures in Crohn´s disease. Aliment Pharmacol Ther. 2012; 36: 151-8.
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9. Di Nardo G, Oliva S, Passariello M, Pallotta N, Civitelli F, Frediani S, et al. Intralesional steroid injection after endoscopic balloon dilation in pediatric Crohn’s disease with stricture: a prospective, randomized, double-blind, controlled trial. Gastrointest Endosc. 2010; 72(6): 1201-8.
10. Swaminath A, Lichtiger S. Dilation of colonic strictures by intralesional injection of infliximab in patients with Crohn’s colitis. Inflamm Bowel Dis. 2008; 14(2): 213-6.
11. Echarri A, Ollero V, Gallego C, et al. Intralesional injection of infliximab in refractory non-fistuliing perianal Crohn´s disease. Gut. 2012; 61(Suppl 3): A400.
12. Mastronardi M, Giorgio P, Di Matteo G, Sisto G, Pezzolla F. Local infliximab treatment followed by endoscopic dilation reduces ileocolonic anastomotic Crohn’s disease recurrence. Journal of Crohn’s and Colitis. 2013; 7(Supplement 1): S187-S8.
13. Canhoto M, Arroja B, Silva F, Gonçalves C, Cotrim I, Vasconcelos H. Needle-knife incisional treatment of refractory esophagic caustic stenosis. Endosc. 2011; 43: