Prospective Multicenter Randomized Comparative Study of the Treatment of de Novo Stenosis in Crohn's Disease. Endoscopic Treatment (Self-expanding Metal Prosthesis/Ballon Dilation) vc Surgical Resection (ENDOCIR STUDY)
Trial Snapshot
- Phase
- Not Applicable
- Status
- Recruiting
- Sponsor
- Enrollment
- 40
- Locations
- 25
- Primary Endpoint
- Quality of life of patients
Study Overview
Brief Summary
Stenosis is one of the most frequent complications in patients with Crohn's disease (CD), causing greater morbidity and increasing the probability of repeated surgery and short bowel syndrome (1-3). Endoscopic balloon dilation (EBD) is clearly the treatment of choice for short stenoses located at the anastomosis of previous surgeries (4-6). However, there is no scientific evidence for determining the most appropriate treatment for de novo stenosis less than 10 cm in length (surgical versus endoscopic treatment), both in terms of efficacy and complications. Neither has it been established which of these two approaches has a greater impact on the quality of life of patients and on costs.
Detailed Description
In many cases, a surgical approach allows for the removal of the entire inflamed intestine. However, the percentage of post-surgical recurrence per year after surgery is 80-85% (7), decreasing to 40% in patients who begin preventive immunosuppressive treatment in the immediate post-surgery period (8). This means that more than 40% of patients will require combined immunosuppression to keep CD under control one year after surgery. Endoscopic treatment does not remove the affected intestine. However, it has a long-term therapeutic efficacy of 50-60% with a very low percentage of complications (4-6%).
A large number of studies have shown that patients' quality of life improves when CD is properly controlled, either through medical or surgical treatment (9). However, there are no studies evaluating the quality of life of patients after endoscopic treatment.
Neither are there comparative studies of the costs of the two procedures. However, a recent study comparing the cost of 38 endoscopic procedures with their surgical equivalent suggested that, in most cases, the cost of endoscopic treatment is four times lower (10).
The European Crohn's and Colitis Organization (ECCO) guidelines on the management of de novo stenosis in patients with CD recommend surgery as the first option, based on expert opinion (Level of Evidence 4), although there are no studies comparing the two treatment modalities (11,12).
A Spanish multicenter study coordinated by researchers involved in the present project (Andujar X, et al)(13), which included the largest published series of endoscopic treatment with dilation in patients with CD to date, shows that therapeutic success with EBD in de novo stenoses is achieved in a large percentage of cases, with results similar to those obtained in post-surgical stenoses (73% vs 84%).
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Diagnostic
- Masking
- None
Eligibility Criteria
- Ages
- 18 Years to 80 Years (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •18-80 years of age.
- •Crohn's disease with predominantly de novo fibrotic stenosis* confirmed by endoscopic and radiological tests, accessible by endoscopy (colonoscopy).
- •Patients with known stenosis previously treated with stenting and/or dilation performed over one year before the date of inclusion.
- •Symptomatology of intestinal occlusion-subocclusion.
- •Refractoriness to conventional medical treatment (non-response to the usual accelerated step-up therapeutic approach).
- •Stenosis length < 10 cm.
- •Maximum of 2 stenoses.
- •Informed consent from patient.
Exclusion Criteria
- •No informed consent from the patient.
- •Complicated stenosis with abscess, fistula or significant activity associated with CD not limited to the area of the stenosis.
- •Patients with known stenosis previously treated with stenting and/or dilation performed < 1 year before the date of inclusion.
- •Pregnancy or lactation.
- •Any clinical situation that prevents the performance of endoscopy or surgery.
- •Stenosis not accessible by endoscopy.
- •Asymptomatic patient.
- •Stenosis length ≥ 10 cm.
- •Presents with > 2 stenoses.
- •Severe coagulation disorders (platelets < 70000; INR > 1.8).
Outcomes
Primary Outcomes
Quality of life of patients
Time Frame: One year of follow-up
Percentage of patients with an increase of more than 30 points in the Inflammatory Bowel Disease Questionnaire (IBDQ-32) quality of life index. The higher the better.
Secondary Outcomes
- Percentage of patients with clinical recurrence(One year of follow-up)
- Percentage of complications(One year of follow-up)