Benign Disease

Comparable to upper GI tract stenoses, the evolution of balloon technology has allowed dilatation of previously inaccessible colon strictures, although distal lesions had previously been amenable to Savary-type dilators placed over a guide wire (Morini et al, 2001). Although stricture delineation can be done using an initial water-soluble or barium contrast study, it can also be done endoscopically. Techniques include use of a pediatric colonoscope or small caliber upper endoscope to fully visualize and biopsy the stenosis or injection of contrast through the scope using a combination of fluoroscopic and endoscopic control. Currently, I prefer endoscopically placed CRE-type balloons over a guide wire and rely on fluoroscopic control to assure obliteration of the balloon waist as a measure of efficacy (Figure 85-4). Whether the balloon needs to be fully inflated for 15,30,60, or 300 seconds for improved efficacy has not been studied and it is my personal opinion that waist effacement of the balloon resulting in stricture fracture (as opposed to simple stretch) is the therapeutic goal.

Most anastomotic strictures, short (< 5 cm) Crohn's strictures, and some ischemic strictures, particularly those that are the consequence of abdominal aneurysm resection, have proven amenable to balloon endotherapy, whereas long, ischemic and diverticular strictures of the intraperitoneal colon are best left to surgical or conservative management.

Comparable to treatment of benign upper GI strictures, most endoscopists use balloon dilatation as primary therapy, ultimately trying to achieve luminal enlargement to a

FIGURE 85-4. Arrows delineate short, annular stricture in a patient with obstructive Crohn's (A), treated with 12 to 15 mm CRE balloon (B). CRE = continuous radial expansion.

TABLE 85-5.

Use of Balloon Dilatation for Anastomotic and Ileocolonic Stenoses

Number

Successful

Successful

Complications

Follow-Up

Author

of Patients

Dilatation (%)

Treatment (%)

(%)

(months)

Couckayt et al

BB

9O

62

11

12

Ramboer et al*

1S

SB

SB

O

7

Rolny et al

27

1OO

66

1B

7 to SS

Unereset al

SS

1OO

B1

NS

NS

NS = not specified. *Includes radial cautery incisions.

^Editor's Note: The results with anastomotic strictures in Crohn's disease have been best if it was over 7 years since surgery (TMB).

NS = not specified. *Includes radial cautery incisions.

^Editor's Note: The results with anastomotic strictures in Crohn's disease have been best if it was over 7 years since surgery (TMB).

TABLE 85-6. Self-Expandable Metallic Stents Marketed/Used for Colonic Stenoses

Length

Stent

Delivery

Delivery

Diameters

Catheter

Catheter

SEMS

(mm)

(cm)

Size (F)

Material

Z

25

40

31

Stainless steel

Memotherm

25, 30

120

14.5

Nitinol

Enteral Wallstent

18, 20, 22

135, 255

10

Elgiloy

CoRectCoil

18,20

80

32

Nitinol

Choostent

22

75, 120

12

Nitinol

Niti-S

20, 22, 24

100

24

Nitinol

final diameter of 15 to 20 mm, although use of achalasia dilatators up to 30 to 40 mm have been reported in stenoses below the peritoneal reflection (Virgilio et al, 1995). Table 85-5 outlines some of the series reporting results of balloon dilatation.* Benign colonic and anastomotic strictures have also been dilated with Savary-type dilatators, particular with distal lesions, injected with long acting corticos-teroids after initial stricture split, and even treated with SEMS (Luck et al, 2001; Kozarek, 2001). There have been no controlled trials using steroid injections but there are parallels to such treatment to include corticosteroid injection into keloids or refractory and acid-peptic strictures. In contrast, SEMS placement is clearly investigational and, from a personal perspective, should not be used in otherwise good-risk surgical patients or those patients with a prolonged survival prognosis.

FIGURE 85-5. Bulky intraluminal tumor undergoing photoablation with
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