Reply to Ustundag

We would like to thank Saritas and Ustundag for their letter regarding our paper on the use of biodegradable stents for the treatment of benign intestinal stenoses [1]. We appreciate their interest very much; however, we cannot fully agree with their comments.

The crucial point is to differentiate between fibrotic and inflammatory stenosis in Crohn’s disease, which might be difficult sometimes [2] [3], and this is a probable source of misunderstanding. Furthermore, recent papers have found that long-term efficacy of endoscopic dilation was predicted neither by disease activity nor by subsequent medical treatment [4]. Intramural glucocorticosteroid injection is a controversial issue and might be associated with significant complications [5] [6]. To the best of our knowledge, there is no generally accepted definition of refractory intestinal stenosis in Crohn’s disease (unlike benign refractory esophageal stenoses).

However, we are fully aware of the possible limits of our pilot study. From our point of view, the most important issue that must be addressed is the shape of the biodegradable stent. A wave-shaped design was used unsuccessfully in three of our cases. In one patient it was not possible to introduce this biodegradable stent properly, and two other cases were complicated by stent migration. A biodegradable stent flared at both ends seems to be the optimal design to date [1].

It was not the aim of our study to assess the cost of this new treatment. Nonetheless, a cost-effectiveness evaluation could be very interesting to compare the cost of a one-time procedure (biodegradable stent) vs. repeated balloon dilation by means of single-use disposable balloons at endoscopy vs. surgery (resection and/or stricturoplasty).

Last but not least, it is necessary to consider the quality of life of patients. Most patients would prefer to undergo just one procedure rather than several endoscopies with the requirement for multiple partial or full bowel cleansing before repeated endoscopic dilation.

Our pilot study [1] concluded that the use of biodegradable stents for small and/or large intestinal stenoses was feasible (as the primary objective). We are persuaded that individual tailoring of biodegradable stents (regarding size and shape) will be the most important focus in the near future. Of course, further studies are warranted to determine the precise indications and to evaluate the true clinical benefit of biodegradable stents, including long-term assessment.

• References

• 1 Rejchrt S, Kopacova M, Brozik J et al. Biodegradable stents for the treatment of benign stenoses of the small and large intestines. Endoscopy 2011; 43: 911-917
• 2 Kopacova M, Bures J, Vykouril L et al. Intraoperative enteroscopy. Ten years’ experience at a single tertiary center. Surg Endoscopy 2007; 21: 1111-1116
• 3 Rejchrt S, Kopacova M, Tacheci I et al. Interventional double balloon endoscopy for Crohn’s, gastrointestinal bleeding, and foreign body extraction. Tech Gastrointest Endoscopy 2008; 10: 101-106
• 4 Van Assche G, Thienpont C, D’Hoore A et al. Long-term outcome of endoscopic dilatation in patients with Crohn’s disease is not affected by disease activity or medical therapy. Gut 2010; 59: 320-324
• 5 Van Assche G. Intramural steroid injection and endoscopic dilation for Crohn’s disease. Clin Gastroenterol Hepatol 2007; 5: 1027-1028
• 6 East JE, Brooker JC, Rutter MD et al. A pilot study of intrastricture steroid versus placebo injection after balloon dilatation of Crohn’s strictures. Clin Gastroenterol Hepatol 2007; 5: 1065-1069