Background
Methods/design
Study population: patient identification, consent, and recruitment
Inclusion criteria: |
Patients eligible for the trial must comply with all of the following at randomization |
- 18–80 years of age. |
- Crohn’s disease with predominantly de novo fibrotic stenosisa confirmed by endoscopic and radiological tests, accessible by endoscopy (colonoscope). |
- Patients with known stenosis previously treated with stenting and/or dilation performed over 1 year before the date of inclusion. |
- Symptomatology of intestinal occlusion-subocclusion. |
- Refractoriness to conventional medical treatment (non-response to the standard 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. |
- > 2 stenosis. |
- Severe coagulation disorders (platelets < 50,000; INR > 1.5). |
Randomization and masking
Treatment and procedural technique
Pharmacological treatment
General description of endoscopic technique
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Post-procedural admission in the short stay unit (SSU).
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Superficial sedation by endoscopist or anesthesiologist depending on the centre.
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Pneumatic balloon type: a CRE Boston scientific® (Marlborough, MA, USA) pneumatic balloon (CRE Wireguided Esophageal, Pyloric, Colonic, 8–20 mm; Cork, Ireland); diameter of the balloon at the endoscopist’s discretion.
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A maximum of 2 sessions of dilation will be performed with a minimum interval of 15–30 days between them.
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Dilation failure will be considered if more than 2 sessions of dilation are required.
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Post-procedural admission to the SSU.
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Superficial sedation by endoscopist or anesthesiologist depending on the centre.
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FCSEMS type: a 22-diameter Taewoong fully covered, self-expandable metal stent (Niti-S S Enteral Colonic Stent, 6–10 cm; Gimpo-si, South Korea). The stent length will be set at the discretion of the endoscopist (at least 1.5 cm for each edge of the stenosis is necessary to ensure a successful procedure).
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To fix the stent. clips may be placed at the distal end of the stent at the endoscopist’s discretion.
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Maximum removal time of the stent will be 4 weeks, if spontaneous migration has not occurred.
General description of the surgical technique
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Procedure performed in line with the protocol of each centre.
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Whenever possible, laparoscopic resection will be the preferred surgical approach with Kono-S Anastomosis.
Clinical evaluation and follow-up
Data collection and calendar
Screening and inclusion | Treatment | Follow-up | |||||||||||||
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7d | 30d | 2 m | 3 m | 4 m | 5 m | 6 m | 7 m | 8 m | 9 m | 10 m | 11 m | 12 m | |||
Items | |||||||||||||||
Eligibility screen | X | ||||||||||||||
Informed consent | X | ||||||||||||||
Randomization | X | ||||||||||||||
Demographic data | X | ||||||||||||||
Clinical evaluation | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X |
Treatment procedure | X | ||||||||||||||
End-of-study evaluation | X | ||||||||||||||
Type of appointment | |||||||||||||||
Face-to-face visit | X | X | X | X | X | ||||||||||
Telephone | X | X | X | X | X | X | X | X | X | X | |||||
Assessments | |||||||||||||||
Quality of life | X | X | X | ||||||||||||
AEs | X | X | X | X | X | X | X | X | X | X | X | X | X | X | |
Obstructive symptoms | X | X | X | X | X | X | X | X | X | X | X | X | X | X | |
Blood test | X | X | X | X | |||||||||||
MRE | X | ||||||||||||||
Endoscopy | X | X | |||||||||||||
Tobacco smoking | X | X | X | X | X | X | X | X | X | X | X | X | X | X | |
Medication | X | X | X | X | X | X | X | X | X | X | X | X | X | X | X |
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Demographic data:The following data will be collected upon inclusion: sex, date of birth, age, and relevant medical history. For smokers, related information will also be collected (status, years of smoking, number of cigarettes per day).
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Quality of life:Patients’ quality of life will be evaluated with the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32) and the EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaires [23, 24]. Patient-reported outcome measures (PROMs) will be also collected using the IBD-Control questionnaire [25]. All the questionnaires may be found in Additional file 2.
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Activity of the disease:The clinical assessment of disease activity will be based upon biological markers in the blood (C-reactive protein (CRP), fibrinogen, and erythrocyte sedimentation rate (ESR), together with the CD activity index (CDAI). Faecal calprotectin will optionally be tested. Radiological assessment will be done by magnetic resonance enterography (MRE), and the Simplified Magnetic Resonance Index of Activity (MaRIAs) [26] will be calculated. All the MREs will be reread at the coordinating centre (Hospital Universitari Mútua Terrassa). The endoscopic activity of the disease will be quantified using the simple endoscopic score for Crohn’s disease (SES-CD) and Rutgeerts’ index, for non-operated and operated patients, respectively.
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Number, extent, and activity of the stenosis:Determination of the number and extent of the strictures will be made with colonoscopy and radiological techniques (MRE). Upon inclusion, the radiological activity at the site of stenosis will be calculated using the MaRIAs, and the endoscopic inflammatory activity of the area will also be described using the subscore SES-CD (non-ulcers, aphthous ulcers, large ulcers (0.5–2 cm), and very large ulcers (> 2 cm)). During follow-up, the following endoscopic variables will be collected: stenosis persistence, passage of the endoscope, and inflammatory activity of the area.
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Clinical recurrence:
Level
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Description
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0
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No obstructive pain
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1
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Obstructive pain
a
No vomiting No complete bowel obstructionb Occurring on less than 4 days during the last 8 weeks |
2
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Obstructive pain
a
No vomiting No complete bowel obstructionb Occurring on 4 or more days during the last 8 weeks |
3
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Obstructive pain
a
Associated with vomiting Or complete bowel obstructionb resolving Without hospitalization Occurring on 1 or 2 days during the last 8 weeks |
4
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Obstructive pain
a
Associated with vomiting Or complete bowel obstructionb resolving Without hospitalization Occurring on at least 3 days and fewer than 8 days During the last 8 weeks |
5
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Obstructive pain
a
Associated with vomiting Or complete bowel obstructionb resolving Without hospitalization Occurring on 8 days or more during the last 8 weeks |
6
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At least one episode of complete bowel obstruction
Requiring hospitalization during the last 8 weeks |
Definitions
Grading | Definition |
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No adverse event | • A telephone contact with the general practitioner, outpatient clinic, or endoscopy service without any intervention or • Extended observation of the patient after the procedure, <3 hours, without any intervention |
Grade I | Adverse events with any deviation of the standard postprocedural course, without the need for pharmacologic treatment or endoscopic, radiologic, or surgical interventions. • Presentation at the emergency ward, without any intervention or • Hospital admission (<24 hours), without any intervention or • Allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgesics, and electrolytes or • Allowed diagnostic tests: radiology and laboratory tests |
Grade II | • Adverse events requiring pharmacologic treatment with drugs other than those allowed for grade I adverse events (ie, antibiotics, antithrombotics, etc) or • Blood or blood product transfusions or • Hospital admission for more than 24 hours |
Grade III | Adverse events requiring endoscopic, radiologic, or surgical intervention |
Grade IIIa | Endoscopic or radiologic intervention |
Grade IIIb | Surgical intervention |
Grade IV | Adverse events requiring intensive care unit/critical care unit admission |
Grade IVa | Single-organ dysfunction (including dialysis) |
Grade IVb | Multiorgan dysfunction |
Grade V | Death of the patient |
Level | Description |
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I | Any deviation from the normal post-operative course not requiring surgical, endoscopic, or radiological intervention. This includes the need for certain drugs (e.g. antiemetics, antipyretics, analgesics, diuretics, and electrolytes), treatment with physiotherapy, and wound infections that are opened at the bedside |
II | Complications requiring treatment with drugs other than those allowed for Grade I complications; this includes blood transfusion and total parenteral nutrition (TPN) |
III | Complications requiring surgical, endoscopic, or radiological intervention Grade IIIa—intervention not under general anesthetic Grade IIIb—intervention under general anesthetic |
IV | Life-threatening complications: this includes CNS complications (e.g. brain haemorrhage, ischaemic stroke, subarachnoid haemorrhage) which require intensive care, but excludes transient ischaemic attacks (TIAs) Grade IVa—single-organ dysfunction (including dialysis) Grade IVb—multi-organ dysfuncton |
V | Death of the patient |
d | If a patient continues to suffer from a complication at the time of discharge, the suffix “d” (for disability) is added to the respective grade of complication. This indicates that a full and careful follow-up is required to complete evaluation of the adverse event |
Outcomes
Sample size calculation
Statistical analysis
Cost analysis
Other considerations
Withdrawal
Ethical aspects and confidentiality
Publication of results
Discussion
Trial status
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Minor changes: changes in statistical analysis methods and cost analysis.
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New variables added: faecal calprotectin (optional) to evaluate the clinical activity of the disease.
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Updated list of the most common pharmacological treatments in CD and Patient Reported Outcomes Measures (PROMs) added: IBD-Control questionnaire.