Original article
Alimentary tract
Comparison of Endoscopic Dilation vs Surgery for Anastomotic Stricture in Patients With Crohn's Disease Following Ileocolonic Resection

https://doi.org/10.1016/j.cgh.2016.10.030Get rights and content

Background & Aims

It is not clear whether endoscopic balloon dilation (EBD) or surgery is a more effective treatment for ileocolonic anastomosis (ICA) stricture in patients with Crohn’s disease. We aimed to compare long-term outcomes of patients who underwent EBD versus surgery for ICA stricture.

Methods

We performed a retrospective study of adult patients with ICA stricture treated with EBD (n = 176) or surgery (n = 131), from December 1998 through May 2013, at the Cleveland Clinic Foundation. Demographic, clinical, endoscopic, histologic, and radiographic data were collected. Disease duration was defined as the time interval from the diagnosis of Crohn’s disease to the treatment for ICA stricture. Data were collected for a median follow-up period of 2.9 years (interquartile range, 0.9–5.7 years). Multivariable analyses were performed to assess risk factors for subsequent surgery.

Results

Patients in the surgery group had a longer median interval from inception (first encounter with patients at either follow-up endoscopy or presentation with obstructive symptoms) until subsequent surgery (4.7 years; interquartile range, 2.2–8.8 vs 1.8 years; interquartile range, 0.4–4.1 years). The average time to surgery delayed by EBD was 6.45 years. Upfront surgery for ICA stricture (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.32–0.76), a longer time for diagnosis to inception (HR, 0.96; 95% CI, 0.93–0.99), a shorter interval from the last surgery to inception (HR, 1.05; 95% CI, 1.01–1.09), only 1 previous resection (HR, 0.41; 95% CI, 0.26–0.66), and the absence of concurrent strictures (HR, 1.68; 95% CI, 0.97–2.9) were associated with a significantly lower risk for subsequent surgery.

Conclusions

Surgical resection for ICA stricture in patients with Crohn’s disease was associated with a lower risk of further surgery than EBD. However, EBD could delay time until need for a second surgery and be attempted first for patients with a lower risk for disease progression. Patients at risk for recurrent disease may benefit from upfront surgical therapy.

Section snippets

Patients

Data of EBD became available since 1998 at our institution. A historical cohort of eligible patients with ICA stricture treated with either EBD or surgery between December 1998 and February 2014 were evaluated. Patients who underwent EBD for CD at the Center for Inflammatory Bowel Diseases were identified from an electronic medical record system; those undergoing surgery for CD-related ICA stricture were identified from a prospectively maintained CD database at Department of Colorectal Surgery

Results

A total of 307 eligible patients were included. EBD was performed in 176 and surgery in 131 patients.

Discussion

Our study is the first investigation in the literature to directly compare EBD and surgery for ICA stricture in patients with CD. We demonstrate that the average time to surgery delayed by dilation was 6.45 years in the endoscopy group, suggesting the benefit of EBD in this setting. However, multivariable Cox regression analysis showed that patients undergoing the upfront surgery for ICA stricture had a lower risk for subsequent surgery for CD. This is consistent with the findings of a recent

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    This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e138. Learning Objective–Upon completion of this activity, successful learners will be able to understand the disease process of anastomotic stricture in Crohn’s disease and select proper treatment, medical vs endoscopic vs surgical.

    Conflicts of interest The authors disclose no conflicts.

    Funding This study was partially supported by the Ed and Joey Story Endowed Chair (to B.S.).

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