Therapeutic endoscopy expands in IBD

Advanced therapeutic endoscopy can delay or prevent surgery in selected patients with inflammatory bowel disease (IBD), particularly those with short, low-risk strictures and endoscopically resectable colitis-associated dysplasia, according to a new AGA clinical practice update.

The update, commissioned by the AGA Institute and published in Clinical Gastroenterology and Hepatology, synthesizes recent studies and expert consensus on endoscopic management of strictures, fistulas, neoplasia, and postoperative complications in Crohn’s disease (CD) and ulcerative colitis (UC).

“With advances in medical therapy for IBD, fewer patients with CD or UC require surgical intervention with bowel resection,” the work’s senior author, Bo Shen, MD, Professor of Medicine and the Edelman-Jarislowsky Professor of Surgical Sciences at Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, told GI & Hepatology News. “However, prolonged disease course and medical therapy with chronic inflammation, tissue healing and remodeling often lead to structural changes (especially stricture formation), and sometimes, colitis-associated neoplasia from lead-time bias.”

While surgery can offer more definitive treatment for the structural or neoplastic complications of inflammatory bowel disease, Dr. Shen noted that it is frequently associated with postoperative anastomotic complications such as bleeding and acute or chronic leaks and recurrence of disease. “Endoscopic therapy of IBD or interventional IBD can provide more definitive therapy and less invasive treatment of structural or neoplastic complications,” he said. “In addition, interventional IBD plays a growing role in the management of IBD surgery-associated complications.”

Stricture management: Patient selection is key

Strictures remain common in CD. Population-based data cited in the update show that 5% to 28% of patients present with stricturing disease and more than 50% develop strictures within 10 years of diagnosis.

The authors emphasize preprocedure cross-sectional imaging to assess stricture length, prestenotic dilation, fistulas, and inflammatory activity. Endoscopic therapy is most appropriate for short strictures (<4–5 cm) in patients with fewer than three risk factors, including fistulizing disease, prestenotic dilation >5 cm, elevated C-reactive protein and prior anti–tumor necrosis factor exposure. Longer strictures (>4–5 cm), more than four strictures, or the presence of three or more risk factors generally favor surgery.

Endoscopic balloon dilation

Endoscopic balloon dilation (EBD) remains first-line therapy for many strictures because of its availability and favorable safety profile. Reported technical and clinical success rates range from 74% to 100%.

In a large retrospective cohort of 187 patients, technical success was 79.2%, with a 1.3% adverse event rate. A prospective, multicenter study of 95 patients reported 93.7% technical success and a 5% adverse event rate.

However, durability is limited. Cited data indicates that symptomatic recurrence occurs in about 50% of patients, and two-thirds ultimately require repeat dilation or surgery over 20 to 144 months of follow-up. The update’s authors found no convincing evidence linking balloon size to perforation risk. The target dilation diameter is 18–20 mm and often requires multiple sessions. Intralesional steroid injection is not supported by current evidence.

EBD should be avoided in the presence of deep ulceration or fistula, given the risk of worsening transmural disease.

Endoscopic stricturotomy

Endoscopic stricturotomy (EST) uses electrocautery incision to dissect fibrotic tissue and is best suited for short (1–3 cm) fibrotic strictures. It may be performed alone or combined with EBD.

In a systematic review and meta-analysis of 640 EST procedures in 169 patients with CD and 118 with UC, technical success was 96.4% and clinical success 62%. Mean stricture length was 1.68 cm ± 0.84 cm. During a mean follow-up of 1.0 ± 1.1 years, 16.4% required surgery and 44.2% required additional endoscopic therapy.

According to the update, EST may be more effective than EBD and carry a lower perforation risk, but it is linked to higher delayed bleeding rates of 5%–6%. It may be particularly helpful in cases of anal canal strictures that are not easily corrected surgically.

Enteral stenting

Enteral stenting remains selective and is not routinely recommended. In a meta-analysis of nine studies including 163 patients, pooled technical success was 93% and pooled clinical success was 60.9%. Overall adverse events occurred in 15.7%, perforation in 2.7% and proximal stent migration in 6.4%. The pooled spontaneous migration rate was 43.9%.

In the randomized ProtDilat trial of 80 patients, EBD was more effective than fully covered self-expanding metal stents, with fewer repeat procedures in the EBD arm. The authors note that the stents used were designed for the esophagus and repurposed for small bowel use, limiting generalizability.

Society guidance advises against routine stenting for benign strictures. The update reserves stenting for refractory strictures in nonsurgical candidates.

Fistulas and postoperative complications

Selected short (<3 cm) ileocecal fistulas may be amenable to endoscopic fistulotomy. In a retrospective series of 29 patients, technical success was 100%, with 3.4% adverse events.

For postoperative anastomotic leaks, the update’s authors note that small acute leaks may respond to conservative management. Larger (>3 cm) abscesses can be drained percutaneously or endoscopically, with possible clip closure. Chronic sinuses may be treated with endoscopic sinusotomy or fistulotomy.

Colitis-associated neoplasia

Although the risk of colorectal cancer in IBD has declined, cumulative risk remains about 1% at 10 years, 2% at 20 years and 5% beyond 20 years.

A network meta-analysis cited in the update found dye-based chromoendoscopy detected 1.42 times more dysplastic lesions than high-definition white light endoscopy. However, the HELIOS randomized trial of 563 patients showed that high-definition white light endoscopy with segmental reinspection was noninferior to high-definition chromoendoscopy for neoplasia detection and required shorter withdrawal time.

For resection, a meta-analysis of more than 600 lesions (mean size 23 mm) removed by endoscopic mucosal resection or endoscopic submucosal dissection reported 97.9% complete resection. Local recurrence occurred in 4.9% and metachronous lesions in 7.4%, supporting continued surveillance.

The review’s authors say that patients with high-risk lesions — such as those with ulceration, a nonlifting sign, or signs of invasion — should be sent for surgery. Patients with multiple lesions that cannot be removed, or dysplasia that cannot be seen, should also be referred for surgery.

Looking ahead

As therapeutic options expand, the authors anticipate broader adoption of advanced endoscopic techniques and technologies, including endoscopic ultrasound and artificial intelligence.

“We need more gastroenterologists, GI endoscopists, IBD specialists, general surgeons, and colorectal surgeons who are familiar with and feel comfortable performing therapeutic endoscopic procedures in IBD,” Dr. Shen said.

Binu John, MD, MPH, Chief of Gastroenterology and Hepatology for the Miami VA Health System in Miami, Fla., cited EBD, EST, and colitis associated-neoplasia as key clinical scenarios discussed in the update. “Standard polypectomy, endoscopic mucosa resection (EMR) and endoscopic submucosal dissection (ESD) are potential endoscopic treatment options for selective lesions,” said Dr. John, who was not involved in the update. “An evaluation by an advanced therapeutic endoscopist may be helpful in avoiding surgery in patients with such lesions that are amenable to endoscopic therapy.”

Dr. Shen disclosed that he has served as a consultant for Janssen and has received research/education grants from AbbVie, GIE Medical, Janssen, and Takeda. Dr. John reported having no disclosures.

GI & Hepatology News invited Brigid S. Boland, MD, Associate Professor of Medicine and Director of the University of California, San Diego IBD Center, to weigh in on the update.

Why is now a good time for publication of this CPU?

Dr. Boland: It has been a long time since a Clinical Practice Update of this kind has been published. Significant advances in endoscopic equipment have improved both our ability to detect lesions and the scope of what can be accomplished endoscopically. This is particularly true in advanced endoscopy, where the field continues to evolve rapidly. As our practices have changed, there was a clear need to update the literature to reflect current capabilities.

This is also a unique area in which advanced endoscopists are frequently involved in the management of IBD patients, often prompting multidisciplinary discussions — typically between the gastroenterologist managing the IBD and the advanced endoscopist performing procedures such as a sphincterotomy.

In your opinion, what are the top 2-3 most important clinical scenarios discussed in the CPU?

Dr. Boland: The CPU includes very helpful alogrithms/diagrams that guide the approach to strictures, including recommendations on appropriate imaging, the role of medical therapy, the use of endoscopic balloon dilation (EBD), and indications for surgery. It also highlights key risk factors for EBD failure — such as stricture length greater than 4 cm, high BMI, proximal small-bowel strictures, prestenotic dilation, and primary strictures — which provide a useful framework for predicting the likelihood of successful dilation.

The CPU addresses colitis-associated neoplasia and provides an updated approach to dysplasia management, emphasizing that endoscopically resectable lesions should be removed endoscopically. As endoscopic resection techniques continue to evolve, the CPU supports this approach while outlining high‑risk features that would favor surgical intervention.

The update also discusses the role of ESD in IBD, noting its low recurrence rates while acknowledging IBD‑specific challenges such as submucosal fibrosis, which can complicate the procedure.

Finally, the CPU reviews the use of enteral stents in IBD, noting the high risk of migration — particularly given that these stents were not originally designed for the small bowel or colon. Nevertheless, it offers guidance on the narrow but defined role that stents may play in select clinical situations.

Dr. Boland reported having no relevant disclosures.