Role of Endoscopy in the Management of Patients With IBD, Crohn Disease

In this podcast, Bo Shen, MD, speaks about how clinicians can utilize endoscopy in their current practice and the ideal candidate for endoscopy, such as patients with Crohn Disease. Dr Shen also spoke about these topics during his session at the American College of Gastroenterology Annual Scientific Meeting 2022 titled “State of the Art Lecture: Role of Endoscopy in the Management of IBD."

Additional Resource:

• Shen B. State of the art lecture: role of endoscopy in the management of IBD. Talk presented at: ACG 2022; October 21-26, 2022; Charlotte, NC. Accessed September 28, 2022. https://acgmeetings.gi.org/

Bo Shen, MD, is a professor of medicine and surgical sciences at Columbia University and the Director of the Inflammatory Bowel Disease (IBD) and Interventional IBD Programs at Columbia University and New York Presbyterian Hospital (New York, N.Y.)

TRANSCRIPTION:

Jessica Bard: Hello everyone, and welcome to another installment of Podcast360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant 360, a multidisciplinary medical information network.

Researchers estimate that more than half a million people in the United States have Crohn disease, according to the US Department of Health and Human Services.

Dr Bo Shen is here to speak with us today, about his session at ACG 2022, titled "State of the Art Lecture: Role of Endoscopy in the Management of IBD." Dr Shen is a Professor of Medicine and Surgical Sciences at Columbia University, and the Director of the IBD and interventional IBD programs at Columbia University, and New York Presbyterian Hospital, in New York, New York. Thank you for joining us today. Can you please provide us with an overview of your session?

Dr Bo Shen: Hello. Thank you, Jessica, for having me. Interventional IBD, i.e., is endoscopic management of an IBD-associated complication, and IBD surgery-associated complications. So, endoscopy plays a growing role in between medical therapy and surgical therapy. As we know, traditional therapy has been medical therapy and surgical therapy for IBD. But however, when a mechanical complication develops, such as anastomotic stricture, disease-associated stricture, an anastomotic leak, or chronic or acute abscessed fistula, the role of the medical therapies is limited.

In contrast, with surgical therapy, we're provided a more definitive therapy for these structural complications. The issue is a postoperative disease to recurrence, as well as a postoperative surgery-associated complication, that included an anastomotic leak and stricture.

So our goal of the endoscopy is to provide more definitive therapy for this structural complication than medical therapy, and in the meantime, provide less-invasive therapy for this patient than surgery. So our goal is to try to minimize the risk for the patient who had the surgery or recovering from surgery. So endoscopy plays the bridging role.

Jessica Bard: So what is the role and the principle of endoscopy in the management of IBD?

Dr Bo Shen: So the important one actually, when we place any endoscopy, and it is important that you need to master the principle indication, contrary indication, and then, you need to master your technical skill. And then also, you need a proper interventional team. Consists of the techs, anesthesiologist, nurse, and the team. And then, an important one, the principal would be, that all the patients before intervention, you should know the anatomy well, especially post-surgical anatomy. You need to read the previous operative report, endoscopy report, read the imaging. And the patient undergoing interventional IBD procedure should have some cross-sectional imaging or contrast imaging, for sure. And the patient should stay away or hold a minimal dose of this corticosteroid. The patient should avoid any antiplatelet agent or anticoagulation. And then, it is very important, they need a perfect bowel preparation.

When you perform endoscopy, you should always have surgical backup. Make sure you are in the proximity of surgery and nearby. Just in case there's a perforation, there's severe bleeding, you have a surgical backup.

So we won't want to do this interventional procedure in the late afternoon, Friday, or the weekend. Try to do this procedure in a more elective way. Try not to do the urgent base. Because urgent-base people, the patient may have poor bowel prep. I think is an important one. Emphasize. Number one, is understanding the principle. Number two, master technique. And number three, get the proper team, the proper equipment, and the supplies.

Jessica Bard: How do you position the therapy? We know that there are two arms, medical therapy, and surgical therapy. What is the role of endoscopy?

Dr Bo Shen: The role of endoscopy is like a bridging role. So again, medical therapy, I can give you an example of Crohn disease. Your medical therapy played a major role in the first three to five years. When the disease was predominantly inflammatory, medicine played a major role. Then, after three to five years, regardless of the disease, controlled or not controlled, and quite often run their relapse remission process, scar tissue can build up, then mechanical complications can develop. Then that time, when you have mechanical complications, you have two choices: surgical therapy and endoscopic therapy.

Before you send in the patient for surgery, I think at the most, the patient should undergo some endoscopic evaluation, to see if they are amenable to having the endoscopic therapy. For example, if the stricture is short, less than four to five centimeters, a single straight stricture without associated abscess on the fistula, you can treat it endoscopically. But if the long stricture, multiple stricture, complicated stricture associated with the abscessed fistula, this can be detected by pre-procedural imaging. Then you directly find and send them for surgery. After surgery, those patients should be closely monitored for post-surgical complications and post-surgical recurrence by endoscopy. And then, we can treat say, the post-surgical anastomotic leak, and anastomoti bleeding, and anastomotic stricture, properly, by the endoscopy intervention.

Jessica Bard: So talk to us about the training and the credentialing. We know credentialing is challenging.

Dr Bo Shen: Yeah. This is the gap, in terms of training. Because actually, in most settings, the practice pattern, in the United States and worldwide, people, the IBD specialist, has some exposure to interventional endoscopy. Not much. On the other hand, an advanced endoscopist has not matched the background, in terms of the knowledge, and the disease course of IBD. So this delivers a gap and a hole to fill. So ideally, we train the IBD specialist in more advanced endoscopy. Or we train advanced endoscopists and then load a bit of IBD knowledge. So you can train in both ways.

Now we started doing that actually, in the old group. And then with a couple of the others, which established the so-called special interest group within the ASGE called a special interest group interventional IBD, which was established, I believe it was 2019, 2020. I was a founding chair.

And then, how do we do the training? Some of the training programs, our interventional IBD fellowship program, were buried into or incorporated into, the regular advanced IBD fellowship, or regular advanced endoscopy fellowship. But in the future, we plan to have their own isolated and independent interventional IBD.

There are some animal labs that are established in the United States and in Europe, to use animal models for training.

And then regarding the coating, we have no problem that it's the coating in the endoscopic balloon dilatation of the stricture. But if people try to do endoscopic say, electro incision with a stricturotomy, strictureplasty, sinusotomy, fistulotomy, you may think about it doing the unlisted coat, if allowed. And this may be a challenge. And we are also working on a society. And then we established a group called the Global Interventional IBD Group. We published a couple of consensus guidelines in Lancet, the gastroenterology and hepatology, in terms of the standardized term, terminology, outcome measurement, and standard technique. And then also standard, especially coined the term. For example, endoscopic stricturotomy, endoscopic strictureplasty, and endoscopic sinusotomy. And you freely use this term for your future publication, for your billing, and for your educational purposes.

Jessica Bard: How can you utilize endoscopy in your current practice? What is the indication?

Dr Bo Shen: I use endoscopy routinely when I monitor the disease activity of the patient with IBD. Endoscopy provided one of the most objective measurements, or features, to monitor the disease activity. So then move to the endoscopy, when we get the informed consent, always informed consent, for the diagnostic surveillance and the therapeutic portion, just in case we decide to remove the polyps. We also mention, if we see a stricture, we will remove the stricture. If there happened to be a surgical leak, do you want me to put a clip there? So always get informed consent. The more complete, more general, and then cover all aspects.

And then also, I think that in your practice, most people I would notice feel more comfortable to do endoscopic balloon dilatation in the low GI tract stricture. Most of the patients feel very comfortable doing the balloon dilatation for upper GI stricture, like esophageal stricture. I think you can carry the same mentality in the low GI stricture. And then they started with the stricture dilatation, then, later on, to learn how to do that stricturotomy, fistulotomy, how do you remove the colitis-associated dysplasia, or metaplasia, or even new plasia by endoscopy, maybe a person resection EMR or ESD. Thank you.

Jessica Bard: Who is the ideal candidate for endoscopy?

Dr Bo Shen: Our ideal patient, I would say, is people who have Crohn disease and have a recurrence after surgery, just immediately after surgery, one year, two years, after surgery, and you found an anastomotic stricture. And if you have a side-to-side anastomosis, and they have a stricture which is one or two centimeters long, and no concurrent inflammation, the patient is not on any blood thinner or antiplatelet agent, generally. And the nutrition condition is good, and then good bowel prep. And then when you do the scope, and actually, those patients maybe their bowel is a little bit shorter than people without surgery, then you have a straight scope, and you can deliver the various kinds of therapy that included balloon dilatation, stricturotomy. Short stricture is your best friend.

Jessica Bard: Well thank you so much, Dr Shen. Is there anything else that you would like to add, or anything else that you think that we missed?

Dr Bo Shen: I think this is for the general GI audience, the internal medicine audience, the surgical audience, and also our patient community and their families. We need to raise awareness and know that endoscopy is available for them. I can tell you, every week we have a patient... just yesterday I saw a patient who was only 28-years-old and already had two surgeries. Same location. Right? I think that just look at the history. Secondary surgery can be avoided by endoscopy therapy. Actually, now after the second surgery, she had the same stricture at the same location, very short. Nowadays, it's 2022. Right? We have advanced knowledge, we have advanced techniques and a good mentality. I think those patients can easily avoid a future surgery.

Jessica Bard: Well, Dr Shen, we hope that this podcast will do just that, and raise awareness. So thank you for joining us today.

Dr Bo Shen: Thank you, Jessica, for having me. Thank you