What Is Interventional IBD ?

Banner: What Is Interventional IBD ?

Interventional IBD is a relatively new specialty in the world of digestive care. The evolving field uses endoscopic therapies in place of more invasive, traditional surgical techniques.

We sat down with gastroenterologist Bo Shen, MD, founder of the specialty, author of the first medical textbooks on the topic, and director of the IBD Center at Columbia, to get a better idea of interventional treatment for Inflammatory Bowel Disease (IBD).

First and foremost, what does “interventional” mean in the term Interventional IBD?

Well, I actually coined the term because endoscopy therapy for IBD is a bit too long. It’s like interventional cardiology, that’s basically the cath lab, right? Cardiologists who use a cath. For us in gastroenterology, endoscopy is the tool we use to deliver the therapy to your disease. Not medicine, not open surgery, we just use endoscopy [a minimally invasive diagnostic tool, used to view the inside of organs, inspect for abnormalities and take biopsies] in what we call a ‘natural orifice’ to reach the different parts of the colon.

And it’s different than diagnostic endoscopy where they only take a look at the colon or do a biopsy. In therapeutic endoscopy, we treat the structural abnormality, neoplastic abnormality. If you remove the colon polyp and dilate the stricture, cut the stricture, you call it interventional IBD.

And IBD really covers several digestive conditions, like Crohn’s disease and ulcerative colitis. Is there anything else included under the term inflammatory bowel disease (IBD)?

If you use a narrow definition, there are two predominant disease types: Crohn’s disease and ulcerative colitis. But there is Crohn’s disease before surgery and Crohn’s after surgery. And ulcerative colitis before surgery, and after surgery. Ulcerative colitis after surgery is the ileal pouch. So, all pouches are ulcerative colitis after surgery. And Crohn’s disease is different before and after surgery.

Now, if you use the broad definition, there are some other conditions you may broadly also categorize into IBD, such as microscopic colitis, and then sometimes diverticular colitis. They are rare, and we call them a variant.

How early do these diseases need to be diagnosed and treated? If left untreated, what can that lead to?

For ulcerative colitis, there is a window period. Typically, with a diagnosis in three to five years and medical treatment that we call disease-modifying therapy, you may prevent complications from the disease. But if it’s treated late, people develop structural complications.

For example, if Crohn’s is not controlled it could cause scar tissue, obstruction, and then cause a fistula, abscesses. In ulcerative colitis, it can cause a stricture and also precancerous conditions or even colorectal cancer if the inflammation is not controlled.

So there’s the main disease-associated complications: stricture, which is the bowel blockage, fistula, abscesses, and then dysplasia or cancer. If you don't have adequate control over the disease by medicine, that will be your result.

Once structural complications happen, medicine typically doesn't work or only has minimal efficacy. This is where the two-disease categories apply in terms of therapy — Traditionally, therapy is both medical therapy and surgical therapy, right? But surgery when you have IBD is associated with more complications than if you don’t have IBD. For example, if they remove the colon for colon cancer, and remove the colon for Crohn’s disease, the person with Crohn’s disease is two or three times more likely to have complications than the person with colon cancer.

Is that related to the recurrence of disease too?

It is. 80 percent of people with IBD, either Crohn’s disease or ulcerative colitis, the disease can reoccur. So it’s not like you remove the colon, remove the bowel, and you're done. You're not done. Disease can still be there. So that’s why we needed something less invasive than surgery and more effective than medicine. That’s endoscopy.

So, it’s sort of a middle ground between the two therapies?

I'll give you an example. Say, my daughter is a high school graduate and says, "Dad, I want a vehicle." Okay, you have a choice. There’s a bike and there's a Mercedes. Mercedes are very fancy; reliable, but expensive. It's like surgery. Now, take the bike. A bike isn’t very reliable. If you ride in a crowded place, you may be hit. It's like medicine.

You need a happy medium. And maybe that is something like a Smart car, right? Small car, safer than a bike and cheaper than a Mercedes.

Is IBD more prevalent in certain age groups or demographics?

Actually, in Crohn’s disease and ulcerative colitis, there are two peaks. The first peak is at about 20 to 30 years old, and the second peak is at 50 to 60 years old. It's a very interesting phenomenon.

Why does that happen? Do you have any theories about it?

I think that the disease mechanism is different, even the disease presentation. Typically, in the first peak, the nutrition is not very good. They're thin, a lot of weight loss. Second peak, there’s often some obesity. Metabolic disease contributes to the second peak. So, the disease is different.

Since Interventional IBD is so new, is it constantly evolving? Are new techniques, new procedures being added?

Oh yes, you don't stop, actually. And we need to spread the knowledge. For example, drug-eluting balloons to treat stricture. So, they've put a drug coat on the balloon and you stretch the balloon. This has been used in cardiology in the past but is now evolving in GI. We are leading the trial on that, the clinical trial.

Another example, people can have a surgical leak with Crohn’s disease surgery or ulcerative colitis surgery. It used to be that we would clip it. Now, we have a suturing device to suture it.

Very interesting. Is this all evolving with advances in technology?

No, not necessarily. Some of the devices I use have been used for other things. For example, this little clip that’s been used to treat bleeding, now I use it in people with angulated bowels. I use the clip to strengthen the bowel. So, the application is new for me.

Oh wow. You’re taking tools and technology that already exist and finding new ways to use them effectively?

Correct. That’s what I do. For another example, you can use the bowel in very effective ways, like injecting medicine into the bowel. If you can inject medicine through the vein, the blood vessel, I can inject people through the bowel. People use doxycycline to treat infection through the vein or take it orally. I use the doxycycline in the scarring tissue. I also inject it into fistulas and track that. It works really well.

That’s pretty amazing. What made you think, “I’m going to give antibiotics in a new way?”

It’s frustrating when many times people say, “There's no textbook, nobody can do this.” But then so many more times my patients encourage me. They say, "Hey, you are Bo Shen!” So that's the pressure that keeps it in the front of my mind.

Day and night, I’m even sleeping with these thoughts. And then all of a sudden, I think of something, wake up, grab a sheet of paper, and write it down. Otherwise, the next day you’ll forget.

Do you carry around a notebook, or use your phone to jot down ideas?

Yeah, I put them in my phone and use the computer. I have a ‘new idea’ file, and everything I do goes in there. Then once every two or three months, I'll revisit those things and see if they’re feasible or not.

What would happen to make something feasible? How do you determine that?

Say, for example, I want to close the surgical leak, right? It used to be there's Apollo, the stitching machine, and it’s so complicated to operate. Now, the new machines look much better. And that’s when I say, "I can use that machine too." So that's the evolving technique, always being open-minded.

I like to go to meetings that are not under my same specialty because they all talk about what I already know. When you're sitting with a different specialty, like gynecology and cardiology, you can learn from that, "Oh, this tool people used for the pancreas, let me think about it. And maybe if the pancreas is more fragile, I can use it on the bowel."

But there are key things to this. Most important is that you need a good team. A good team to the degree that you need a sub-specialized pathologist, sub-specialized radiologist, and sub-specialized surgeon. And that’s what we have. And we’re always here, we call it being “on guard.”

No matter what, if you’re having another issue somewhere else in the hospital, delivering a baby by c-section, and have IBD, we’re always here and we’re always available. We’re probably the only center with that kind of accessibility.

Why is that? How are there not more centers with colorectal/IBD teams like this?

You know, when you build a team you need synergy, and that means you talk the common language. Actually, most academic people are always fighting for authorship. Who will be the first author? Who will be the last author? My team always says, "Bo, you'll be the first author." And I say, "Dan, you'll be the first author." Things like that, it’s our spirit. Not many people can do that. And we all end up as friends.

Is a lack of institutional support the primary reason why there aren’t more Interventional IBD teams?

Yes. And that’s where the camaraderie comes in again. Before I came here, my colleagues and I talked, and we have the same mentality: we do what benefits patients. And I’m really grateful for Columbia and NYP. They allow me to do these things. By doing interventional versus surgery, we are losing money, but our patients are happy. The question is, "What if you are the patient, what do you choose? What if it is your mom or child or brother?"

Here, we try interventional methods first. Our surgeons will say “Let’s have Dr. Shen try his tricks. If he fails, let's do surgery.” Other institutions don’t even refer to me, they just cut. That’s why the team is so important, and we all always do what’s best for our patients.

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