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P443. Local infliximab treatment followed by endoscopic dilation reduces ileocolonic anastomotic Crohn's disease recurrence

M. Mastronardi1, P. Giorgio1, G. Di Matteo1, G. Sisto2, F. Pezzolla2, 1IRCCS “S. De Belllis”, Gastroenterology and Digestive Endoscopy, Castellana Grotte, Italy, 2IRCCS “S. De Belllis”, Chirurgia Gastroenterologica, Castellana Grotte, Italy

Background

Strictures are a common cause of morbidity in patients with Crohn's disease and often occur at the site of the ileocolonic anastomosis. Bowel-conserving procedures have emerged as valuable tools to limit repeated intestinal resections: intralesional steroid injection, endoscopic balloon dilation and incision of stricture of the anastomotic recurrence. Some studies showed that infliximab (IFX) tissue levels are predictive of mucosal healing, so intralesional injection in active disease could be more effective than sistemic administration.

Methods

From August 2007 to December 2008 we studied prospectively 23 consecutive Crohn's disease patients with ileocolonic anastomotic, symptomatic strictures alternatively attribuited to these two interventions: (1) per-endoscopic infliximab injection (100 mg) in the ileocolonic ulcerated stricture followed, six week later, by endoscopic balloon dilation subsequent to complete or partial (<25% of the anastomotic circumference) ulcers healing (group IFX+Dil, 12 patients); (2) endoscopic balloon dilation only (group Dil, 11 patients) (Table 1). Dilations were performed using a Rigiflex through-the-scope balloon (18 mm, 3 atm). Clinical success rate was stated if a patient remained asymptomatic and did not require surgery or further endoscopic dilation within 3 years of follow-up.

Results

All the patients had safe dilation of anastomotic stricture, and in the IFX+Dil group 9/12 patients and 3/12 patients respectively showed complete or partial healing of the anastomotic ulcers. During the follow-up anastomotic re-stenosis and clinical relapse with redilation were observed in 4/12 (33.3%) patients of IFX+Dil group, that required only one redilation session, and in 6/11 (54.5%) patients of Dil group that required 12 redilation sessions. The recurrence curves are separated even though there is no statistical significance (Wilcox test, p = 0.12), because of the low power of the study. Three out of eleven patients (27.2%) in the Dil group required surgical resection, none of the IFX+Dil group.

Table 1. Demography of the 23 patients with Crohn's disease included in the study
 Group IFX + Dil (12 pts)Group Dil (11 pts)
Male gender, no. (%)7/12 (58.3)7/11 (63.6)
Mean age, yr (range)39.4 (27–51)41.7 (27–47)
Mean duration of disease, yr14.1 (9–19)12.9 (9–19)
Time between surgical resection and first dilation, yr (range)6.58 (4–8)5.72 (5–9)
Mean lenght of anastomotic stricture, cm (range)3.7 (2–6)3.4 (2–6)
Mean follow-up, months (range)35.7 (21–43)33.9 (19–41)
Infliximab therapy before surgery, patients (%)9/12 (75)7/11 (63)

Conclusion

In this pilot study the complete or partial mucosal healing of anastomotic lesions induced by local infliximab injection shows better and most durable pneumatic dilation of the ileocolonic anastomotic stenosis, with no surgical resection in any of the patients treated.