Role of interventional inflammatory bowel disease in the era of biologic therapy

According to a new statement from a panel of national and international experts in gastroenterology, inflammatory bowel disease (IBD) and other areas, interventional (or therapeutic) IBD endoscopy has an expanding role in the treatment of disease and of adverse events from surgery. The report from the panel, Role of interventional inflammatory bowel disease in the era of biologic therapy; a position statement for the Global Interventional IBD Group, is published in the February issue of GIE: Gastrointestinal Endoscopy, the peer-reviewed journal of the American Society for Gastrointestinal Endoscopy (ASGE).

Endoscopic therapy has been explored and used in the management of numerous conditions and situations related to IBD, including strictures, fistulas/abscesses, colitis-associated neoplasia, postsurgical acute or chronic leaks, and obstructions. The endoscopic therapeutic modalities include balloon dilation, stricturotomy, stent placement, fistulotomy, fistula injection and clipping, sinusotomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD).

With a better understanding of the disease process and course of IBD, improved long-term impact of medical therapy, and advances in endoscopic technology, the panel foresees interventional IBD becoming an integrated part of the multidisciplinary approach to patients with complex IBD.

In recent decades, rapid advances have taken place in medical and surgical therapy for both Crohn’s disease (CD) and ulcerative colitis (UC). For example, the availability and growing use of anti-tumor necrosis factor (TNF), anti-integrin, and anti-interleukin biologics have been shown to result in deep clinical remission beyond improvement of symptoms. These medical treatments also reduce the risk for adverse events associated with IBD, thereby avoiding hospitalization and surgery for some patients. Additional agents are being investigated.

However, the long-term impact of the appropriate use of these newer agents on the natural history of IBD is not clear. In addition, the long-term use of these immunosuppressive agents can be associated with various adverse events, ranging from infection and increased risk for certain malignancies to a paradoxic autoimmune response. Furthermore, a significant number of patients with CD or UC still require surgical intervention for medically refractory disease or disease-associated adverse events such as strictures, fistulas, abscesses, and colitis-associated neoplasia (CAN).

The common surgical treatment modalities for CD or ulcerative colitis include bowel resection, anastomosis, stoma construction, strictureplasty, and restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Although the surgical approach offers an immediate resolution of symptoms and relief of mechanical or neoplastic adverse events, it is often associated with postoperative adverse events and postoperative disease recurrence. Current unmet needs in IBD management include the availability of therapeutic approaches to mechanical adverse events that can reach beyond the limits of pharmacologic agents and are less invasive than surgery.

Therapeutic endoscopy can offer a unique bridge between medical and surgical treatments. Endoscopic management of mechanical and neoplastic adverse events may help reduce or postpone the need for surgical resection and help treat postoperative adverse events, if surgery is performed. Currently, four main areas of IBD are amenable to endoscopic treatment: strictures, fistulas or abscesses, CAN, and IBD surgery-associated adverse events.

To meet the growing need for endoscopic treatment in complex IBD, a panel of national and international experts in gastroenterology, IBD, advanced endoscopy, GI radiology, GI pathology, GI education, and colorectal surgery voluntarily formed a subspecialty group in 2018, the Global Interventional IBD Group, to coordinate clinical, educational, and investigational activities. This self-appointed group includes a mixture of IBD specialists with expertise in endoscopy and endoscopists with expertise in IBD. In addition, the group also consists of IBD pathologists and IBD specialists with expertise in abdominal imaging. The current article is a position statement from the group, based on currently available literature and the combined expertise of its members. This work is expected to continue and expand.

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This study was made available online in October 2018 ahead of final publication in print in February 2019.