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    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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Is Paradigm for the Role of Balloon-Assisted Enteroscopy Changing in Crohn’s Disease?

Yoo Jin Lee

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea

Correspondence to:Yoo Jin Lee
ORCID https://orcid.org/0000-0003-1799-0146
E-mail doctorlyj@gmail.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut and Liver 2021; 15(3): 325-326

Published online May 15, 2021 https://doi.org/10.5009/gnl210194

Copyright © Gut and Liver.

Crohn’s disease (CD) commonly involves the small bowel. The occurrence of small-bowel CD (SBCD) has been reported in over 60% of the patients with CD.1As SBCD is often associated with poor clinical outcomes, such as complicated disease course, stricturing behavior, and CD-related surgery, early diagnosis and objective evaluation of small bowel lesions are essential.2However, the evaluation of SBCD is more difficult than that of colonic lesions because the diseased segment of most small bowel lesions is difficult to reach during conventional endoscopy, and may appear normal on a cross-sectional image.2,3Thus, the diagnosis of SBCD is challenging and often delayed.

Since the introduction of balloon-assisted enteroscopy (BAE) in the early 2000s, the evaluation of small bowel lesions has revolutionized dramatically.4Unlike capsule endoscopy or other imaging modalities, BAE allows direct inspection of the small bowel mucosa, histopathological investigation by obtaining biopsies, and management of complications, such as stricture dilatation or hemostasis. In addition, diagnostic BAE has been shown to have a favorable diagnostic yield of up to 70% and low complication rate (approximately 1%).5Despite being a useful tool, the widespread use of BAE was hampered soon after its implementation, as it is an invasive procedure that requires advanced skills and laborious procedure time.

Based on the recommendations of the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) working group, a treat-to-target strategy is now a key concept in the treatment of inflammatory bowel disease.6A treat-to-target strategy, which means continuous adjustment of treatment based on proactive monitoring and targeting mucosal healing rather than symptoms, seems to be helpful in limiting disease progression and improving clinical outcomes.7In line with this concept, the importance of adequate evaluation of small bowel lesions has been emphasized.2As BAE has been accepted to be the most sensitive modality for visualization of small bowel lesions in CD, it may enable not only a more objective diagnosis but also close monitoring of SB lesions in patients with CD. Thus, recently published Japanese guidelines also stated that BAE may be useful for close observation and monitoring of SB lesions in CD.8

In the current issue, Jeon et al.9reported data comparing BAE-related factors and clinical outcomes of BAE use in SBCD over time. From A multicenter database of patients with CD with small bowel lesions who underwent BAE, 131 procedures in 116 patients were included. After dividing into the first and second periods based on the introduction of the BAE guidelines in 2008, enteroscopic findings, diagnostic yield, treatment, and clinical impact of BAE were compared. The most common indication for BAE was the diagnosis of small bowel involvement during each period (50% vs 31.3%, p=0.034), and nearly two-thirds of all patients adjusted their therapeutic plan after BAE. These results suggest that BAE plays an important role in the diagnosis and monitoring of SBCD in clinical settings.

Meanwhile, despite the drastic advances in the medical treatment of CD, therapy for SBCD stricture remains a representative unmet need. Up to 75% of patients with CD ultimately undergo surgery at least once during their lifetime, and the main cause is strictures.10Stricture dilatation with BAE has been shown to have a high technical success rate (94.9%) and a low rate of major complications (5.3%).10Consistent with the result of previous reports, the study by Jeon et al.9also showed a high technical success rate of over 80%.9One of the most notable findings of this study is that the use of BAE related to small bowel strictures was significantly increased in the second period compared to that in the first period (2.9% vs 21.3%, p=0.002). This finding indicates that BAE is expanding its scope to diagnosis as well as treatment of SBCD. Nevertheless, we should pay attention to the fact that the reported long-term clinical outcomes of stricture dilatation have been shown to be more favorable in patients who underwent surgery than in those with stricture dilatation through BAE.3Thus, although stricture dilatation through BAE can replace or delay surgery, more experience and evidence are needed to select the best candidates for BAE intervention in real clinical practice.

This study was limited by the lack of long-term follow-up of clinical outcomes; however, the findings are meaningful as they have shown the changes in procedure indications and clinical outcomes of BAE in patients with CD with small bowel involvement over time. As the treatment concept of CD shifts from symptom-based therapy to treat-to-target strategy, BAE is expected to play a more important role in the diagnosis as well as close monitoring and therapeutic intervention of SBCD in the near future.


No potential conflict of interest relevant to this article was reported.

  1. Park SH, Kim YJ, Rhee KH, et al. A 30-year trend analysis in the epidemiology of inflammatory bowel disease in the Songpa-Kangdong district of Seoul, Korea in 1986-2015. J Crohns Colitis 2019;13:1410-1417.
    Pubmed CrossRef
  2. Watanabe K. Clinical management for small bowel of Crohn’s disease in the treat-to-target era: now is the time to optimize treatment based on the dominant lesion. Intest Res 2020;18:347-354.
    KoreaMed CrossRef
  3. Yoo JH, Holubar S, Rieder F. Fibrostenotic strictures in Crohn’s disease. Intest Res 2020;18:379-401.
    KoreaMed CrossRef
  4. Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001;53:216-220.
    Pubmed CrossRef
  5. Heine GD, Hadithi M, Groenen MJ, Kuipers EJ, Jacobs MA, Mulder CJ. Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease. Endoscopy 2006;38:42-48.
    Pubmed CrossRef
  6. Peyrin-Biroulet L, Sandborn W, Sands BE, et al. Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): determining therapeutic goals for treat-to-target. Am J Gastroenterol 2015;110:1324-1338.
    Pubmed CrossRef
  7. Colombel JF, D’haens G, Lee WJ, Petersson J, Panaccione R. Outcomes and strategies to support a treat-to-target approach in inflammatory bowel disease: a systematic review. J Crohns Colitis 2020;14:254-266.
    Pubmed KoreaMed CrossRef
  8. Nakase H, Uchino M, Shinzaki S, et al. Evidence-based clinical practice guidelines for inflammatory bowel disease 2020. J Gastroenterol ; https://doi.org/10.1007/s00535-021-01784-1
    Pubmed CrossRef
  9. Jeon SR, Kim JO, Byeon JS, et al. Enteroscopy in Crohn’s disease: are there any changes in role or outcomes over time? A KASID Multicenter Study. Gut Liver 2021;15:375-382.
    Pubmed CrossRef
  10. Bettenworth D, Bokemeyer A, Kou L, et al. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn’s disease strictures. Aliment Pharmacol Ther 2020;52:1104-1116.
    Pubmed CrossRef

Article

Editorial

Gut and Liver 2021; 15(3): 325-326

Published online May 15, 2021 https://doi.org/10.5009/gnl210194

Copyright © Gut and Liver.

Is Paradigm for the Role of Balloon-Assisted Enteroscopy Changing in Crohn’s Disease?

Yoo Jin Lee

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea

Correspondence to:Yoo Jin Lee
ORCID https://orcid.org/0000-0003-1799-0146
E-mail doctorlyj@gmail.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Crohn’s disease (CD) commonly involves the small bowel. The occurrence of small-bowel CD (SBCD) has been reported in over 60% of the patients with CD.1As SBCD is often associated with poor clinical outcomes, such as complicated disease course, stricturing behavior, and CD-related surgery, early diagnosis and objective evaluation of small bowel lesions are essential.2However, the evaluation of SBCD is more difficult than that of colonic lesions because the diseased segment of most small bowel lesions is difficult to reach during conventional endoscopy, and may appear normal on a cross-sectional image.2,3Thus, the diagnosis of SBCD is challenging and often delayed.

Since the introduction of balloon-assisted enteroscopy (BAE) in the early 2000s, the evaluation of small bowel lesions has revolutionized dramatically.4Unlike capsule endoscopy or other imaging modalities, BAE allows direct inspection of the small bowel mucosa, histopathological investigation by obtaining biopsies, and management of complications, such as stricture dilatation or hemostasis. In addition, diagnostic BAE has been shown to have a favorable diagnostic yield of up to 70% and low complication rate (approximately 1%).5Despite being a useful tool, the widespread use of BAE was hampered soon after its implementation, as it is an invasive procedure that requires advanced skills and laborious procedure time.

Based on the recommendations of the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) working group, a treat-to-target strategy is now a key concept in the treatment of inflammatory bowel disease.6A treat-to-target strategy, which means continuous adjustment of treatment based on proactive monitoring and targeting mucosal healing rather than symptoms, seems to be helpful in limiting disease progression and improving clinical outcomes.7In line with this concept, the importance of adequate evaluation of small bowel lesions has been emphasized.2As BAE has been accepted to be the most sensitive modality for visualization of small bowel lesions in CD, it may enable not only a more objective diagnosis but also close monitoring of SB lesions in patients with CD. Thus, recently published Japanese guidelines also stated that BAE may be useful for close observation and monitoring of SB lesions in CD.8

In the current issue, Jeon et al.9reported data comparing BAE-related factors and clinical outcomes of BAE use in SBCD over time. From A multicenter database of patients with CD with small bowel lesions who underwent BAE, 131 procedures in 116 patients were included. After dividing into the first and second periods based on the introduction of the BAE guidelines in 2008, enteroscopic findings, diagnostic yield, treatment, and clinical impact of BAE were compared. The most common indication for BAE was the diagnosis of small bowel involvement during each period (50% vs 31.3%, p=0.034), and nearly two-thirds of all patients adjusted their therapeutic plan after BAE. These results suggest that BAE plays an important role in the diagnosis and monitoring of SBCD in clinical settings.

Meanwhile, despite the drastic advances in the medical treatment of CD, therapy for SBCD stricture remains a representative unmet need. Up to 75% of patients with CD ultimately undergo surgery at least once during their lifetime, and the main cause is strictures.10Stricture dilatation with BAE has been shown to have a high technical success rate (94.9%) and a low rate of major complications (5.3%).10Consistent with the result of previous reports, the study by Jeon et al.9also showed a high technical success rate of over 80%.9One of the most notable findings of this study is that the use of BAE related to small bowel strictures was significantly increased in the second period compared to that in the first period (2.9% vs 21.3%, p=0.002). This finding indicates that BAE is expanding its scope to diagnosis as well as treatment of SBCD. Nevertheless, we should pay attention to the fact that the reported long-term clinical outcomes of stricture dilatation have been shown to be more favorable in patients who underwent surgery than in those with stricture dilatation through BAE.3Thus, although stricture dilatation through BAE can replace or delay surgery, more experience and evidence are needed to select the best candidates for BAE intervention in real clinical practice.

This study was limited by the lack of long-term follow-up of clinical outcomes; however, the findings are meaningful as they have shown the changes in procedure indications and clinical outcomes of BAE in patients with CD with small bowel involvement over time. As the treatment concept of CD shifts from symptom-based therapy to treat-to-target strategy, BAE is expected to play a more important role in the diagnosis as well as close monitoring and therapeutic intervention of SBCD in the near future.

CONFLICTS OF INTEREST


No potential conflict of interest relevant to this article was reported.

References

  1. Park SH, Kim YJ, Rhee KH, et al. A 30-year trend analysis in the epidemiology of inflammatory bowel disease in the Songpa-Kangdong district of Seoul, Korea in 1986-2015. J Crohns Colitis 2019;13:1410-1417.
    Pubmed CrossRef
  2. Watanabe K. Clinical management for small bowel of Crohn’s disease in the treat-to-target era: now is the time to optimize treatment based on the dominant lesion. Intest Res 2020;18:347-354.
    KoreaMed CrossRef
  3. Yoo JH, Holubar S, Rieder F. Fibrostenotic strictures in Crohn’s disease. Intest Res 2020;18:379-401.
    KoreaMed CrossRef
  4. Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001;53:216-220.
    Pubmed CrossRef
  5. Heine GD, Hadithi M, Groenen MJ, Kuipers EJ, Jacobs MA, Mulder CJ. Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease. Endoscopy 2006;38:42-48.
    Pubmed CrossRef
  6. Peyrin-Biroulet L, Sandborn W, Sands BE, et al. Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): determining therapeutic goals for treat-to-target. Am J Gastroenterol 2015;110:1324-1338.
    Pubmed CrossRef
  7. Colombel JF, D’haens G, Lee WJ, Petersson J, Panaccione R. Outcomes and strategies to support a treat-to-target approach in inflammatory bowel disease: a systematic review. J Crohns Colitis 2020;14:254-266.
    Pubmed KoreaMed CrossRef
  8. Nakase H, Uchino M, Shinzaki S, et al. Evidence-based clinical practice guidelines for inflammatory bowel disease 2020. J Gastroenterol ; https://doi.org/10.1007/s00535-021-01784-1.
    Pubmed CrossRef
  9. Jeon SR, Kim JO, Byeon JS, et al. Enteroscopy in Crohn’s disease: are there any changes in role or outcomes over time? A KASID Multicenter Study. Gut Liver 2021;15:375-382.
    Pubmed CrossRef
  10. Bettenworth D, Bokemeyer A, Kou L, et al. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn’s disease strictures. Aliment Pharmacol Ther 2020;52:1104-1116.
    Pubmed CrossRef
Gut and Liver

Vol.15 No.3
May, 2021

pISSN 1976-2283
eISSN 2005-1212

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