First Endoscopic Stricturotomy with Needle Knife Study for Intestinal Strictures in IBD

Cleveland Clinic doctors have published the first study illustrating the safety and efficacy of endoscopic needle knife therapy for intestinal strictures in patients with inflammatory bowel disorder (IBD).

“We pioneered this procedure,” says Bo Shen, MD, Medical Director of Cleveland Clinic’s IBD Center. “And our research shows that it is effective and can have advantages over other conventionally used treatments, such as medical therapy, balloon dilation and surgery.”

Shen’s study, which was co-authored with research fellow Nan Lan, MD, was featured as the cover story in the April 2017 issue of the journal Inflammatory Bowel Diseases. Dr. Lan will present their findings in May at DDW 2017.

In their study, Drs. Shen and Lan reviewed the records of 85 patients with strictures treated by needle knife stricturotomy (NKSt) between 2008 and 2016 at Cleveland Clinic’s Center for Inflammatory
Bowel Disease.

Because many patients had multiple strictures, there were a total of 231 NKSts performed on the 85 subjects. Passage of the scope through each stricture was achieved in 100 percent of the patients. Delayed bleeding occurred in nine cases and perforation occurred in one, requiring hospitalization.

Developing nonsurgical treatments for IBD patients such as NKSt results in better quality of life, Dr. Shen says. “Multiple bowel resection surgeries can shorten patients’ intestinal tracts while noninvasive procedures preserve them.”

Alternative to endoscope balloon dilation

Strictures, the narrowing of the intestines due to inflammation and scarring, are a common side effect of IBD. Patients with Crohn’s disease or, to a lesser degree, ulcerative colitis after surgery, often develop them as their conditions progress. Strictures also may occur after a bowel resection. They can cause abdominal pain, diarrhea, nausea, vomiting, weight loss and malnutrition.

To treat strictures, physicians typically have turned to surgery or a procedure called endoscopic balloon dilation (EBD) that stretches out the constricted area, however, this therapy carries a risk of perforation and intestinal bleeding, and usually the therapeutic effect typically lasts only three to six months before the stricture returns.

The interval between endoscopic and surgical interventions and the interval from the treatment to the return of the stricture was longer, Drs. Shen and Lan found, if patients first had NKSt. “For example, if you need EBD every three months, you need it every six months after NKSt,” Dr. Shen says.

Offers more precision

Dr. Shen was already experienced in using endoscopic needle-knife technology to treat strictures in the upper GI tract when he decided it might be a good alternative therapy for IBD patients with strictures in the lower GI track.

He says the technology allows physicians to be much more precise when opening up strictures. “You have more control over how deep you cut and where you cut,” he says, pointing out that if a patient has a stricture close to the anus, there is a risk of rectovaginal fistula from blind balloon dilation therapy, which can result in bowel movements leaking into the vagina.

“With the needle knife, you can avoid the front wall of the rectum,” Dr. Shen says. “You cut only the back wall, so you can avoid these complications. This is a major advantage.”

Physicians from around the world have come to Cleveland Clinic to learn NKSt.

“It’s a procedure with some risks involved,” Dr. Shen says. “So intense training is important.”