Numerous biologics have advanced Crohn's disease (CD) management, nevertheless, effectively
treating intestinal strictures remains challenging. Endoscopic balloon dilation (EBD)
is commonly used; dilatation has certain limitations and is not recommended for ulcerated
strictures or those over 5 cm in length [1]. Moreover, even when EBD is performed, the majority of CD strictures tend to recur
due to the healing process after dilation, necessitating additional dilatation [2]
[3]
[4]. Considering this perpetual need, we hypothesized that a substantial portion of
CD stricture tissue consists of scar and could be physically excised [5]. Consequently, we devised an endoscopic strictureplasty involving multiple longitudinal
incisions after ultrasonic evaluation and utilizing hot-biopsy forceps to remove rectal
CD strictures.
A 29-year-old woman presented with rectal stricture and rectovaginal fistula, both
attributed to a CD history of more than 15 years. Steroids and biologics were ineffective
and the patient declined colostomy. Although the causal relationship between the stricture
and the fistula was apparent, repeated EBD proved ineffective because the dilated
lumen quickly reverted. Endoscopic ultrasound revealed that the stricture was predominantly
composed of thickened mucosa and submucosa. Thus, after multidisciplinary review,
we decided to remove the scar tissue, facilitating continuous luminal enlargement.
The tough scar tissue precluded grasping with forceps, necessitating longitudinal
incisions along the thickened wall, identified with ultrasound, utilizing a precutting
knife ([Fig. 1], [Video 1]). The ridge formed by these incisions was engaged with hot-biopsy forceps and gradually
removed. Although a 7.9-mm-diameter gastroscope could not pass the stricture before
the procedure, an 11.7-mm colonoscope could pass through. Post-procedure betamethasone
suppositories 1 mg/day were administered to the patient for 6 weeks to prevent early
re-narrowing. The patient remained free from obstructive symptoms, and 2 months later,
a gastroscope with a 10-mm-outer-diameter cap could traverse the stricture. Another
strictureplasty was performed proximally to ensure adequate lumen passage. The patient
reported no obstructive symptoms 5 months after the first procedure.
Fig. 1 Sequential images of endoscopic strictureplasty employing longitudinal incisions and
the utilization of hot biopsy forceps. a It is apparent that a rectal refractory stricture, characterized by its narrow aperture,
precludes passage of a 7.9-mm-diameter gastroscope (EG-840TP, Fujifilm). b A 20MHz miniature probe (UM-3R, Olympus, Tokyo, Japan) revealed that the stricture
was thickened tissue in both the mucosa and submucosa. c Longitudinal incisions using a reusable precutting knife (KD-10Q-1, Olympus) on the
tissue, which was seen as thickened on ultrasound. d The ridge formed by the incisions was grasped with hot biopsy forceps (Radial Jaw
4 Hot Biopsy Forceps, Boston Scientific Corp., Marlborough, Massachusetts, United
States) and removed bit by bit until the inner circular muscularis propria could be
visualized; additional longitudinal incisions were made as necessary. e It was possible to pass the gastroscope with a 10mm-outer-diameter cap (DH-083ST,
Fujifilm) through the stricture 2 months after the procedure.
Novel endoscopic strictureplasty with longitudinal incisions and hot biopsy forceps
removal for a rectal refractory stricture in Crohn’s disease.Video 1
This case illustrates that longitudinal incisions with a knife and hot biopsy forceps
can successfully treat a refractory CD rectal stricture. Our preliminary experience
shows that this novel technique is safe and effective for CD strictures and warrants
further study.
