The role of stents in the treatment of Crohn's disease strictures.

BACKGROUND AND AIMS: Stenosis is one of the most frequent local complications in Crohn's disease (CD). Surgery is not the ideal treatment because of the high rate of postoperative recurrence. Endoscopic balloon dilation (EBD) currently is the current treatment of choice for short strictures amenable to the procedure. However, it is not applicable or effective in all the cases, and it is not without related complications. Our goal was to summarize the published information regarding the use and the role of the stents in the treatment of CD stricture. A Medline search was performed on the terms "stricture," "stenosis," "stent" and "Crohn's disease." RESULTS: a total of 19 publications met our search criteria for an overall number of 65 patients. Placing a self-expanding metal stent (SEMS) may be a safe and effective alternative to EBD and/or surgical intervention in the treatment of short stenosis in patients with CD. Indications are the same as those for EBD. In addition, SEMS may be useful in stenosis refractory to EBD and may be suitable in the treatment of longer or more complex strictures that cannot be treated by EBD. With the current information, it seems that the best treatment option is the placement of a fully covered stent for a mean time of 4 weeks. Regarding the use of biodegradable stents, the information is limited and showing poor results. CONCLUSIONS: the use of stents in the treatment of strictures in CD should be taken into account either as a first endoscopic therapy or in case of EBD failure.

How do we manage vaccinations in patients with inflammatory bowel disease?

The mortality in inflammatory bowel disease (IBD) has been reported similar or slightly increased as compared to that of the general population. However, deaths related to infectious and parasitic diseases have been repeatedly reported in clinical trials, open series and registries. The IBD patients are exposed to the same infections affecting the community, added to opportunistic infectious related to the immunosuppression. Some of these infectious diseases may be prevented by the appropriate use of a vaccination program. Thus, vaccination status should be assessed at IBD diagnosis, and from time to time, and vaccination should be updated to every patient as soon as possible, since deaths due to preventable diseases should never occur. Present recommendations include vaccination for influenza (annually), for pneumococcal disease with the 23-valent strain (every 5 years), for hepatitis B virus (in patients with no detectable hepatitis B surface antibodies), combined vaccination against tetanus, diphtheria and inactivated poliomyelitis (every 10 years). The role of human papillomavirus vaccine preventing cervical dysplasia and neoplasia in IBD women taking immunosuppressive are at present unknown. In patients lacking varicella immunization, specific vaccination should be considered. Nevertheless, it should be taken into account that varicella vaccine contains live attenuated virus that cannot be administered in patients taking immunosuppressive. The same consideration should be kept in mind for patients travelling to endemic areas for yellow fever. Finally, IBD patients on immunosuppressive may have an altered response to vaccine immunization. Decreased response has been reported for hepatitis B and pneumoccocal vaccination. In those cases, testing for serological responses to vaccine should be performed and booster doses may be required.