Re‐intervention rates and symptom‐free survival at 1 year after endoscopic versus surgical management of strictures in Crohn's disease: A propensity matched analysis of a prospective inflammatory bowel disease cohort

Abstract

Background and AimResection for Crohn's disease (CD) related strictures is definitive but carries risk of morbidity, recurrence, and short bowel syndrome. On the contrary, the durability of endotherapy (ET) for CD‐related strictures is questionable. Prospective comparative studies are limited. We aimed to prospectively compare the outcomes of ET in CD strictures with a case‐matched surgical therapy (ST) cohort.MethodsPatients undergoing ET or resection for primary CD strictures (symptomatic, non‐traversable, < 5 cm length, n ≤ 3) between January 2021 and March 2022 in a high‐volume tertiary center were compared with regard to recurrent symptoms, escalation of therapy, re‐intervention, and re‐operation based on propensity matched analysis.ResultsFifty‐nine patients [49% ET, 57.6% male, median (years): 34 (15–74)] had ≥ 12 months of follow up. Before propensity matching, cumulative re‐intervention rate was significantly higher with ET [34.5% (10/29) vs 3.3% (1/30) ST, P = 0.002]. Recurrent symptoms (34.5% vs 26.7%, P = 0.42), escalation of medical therapy (27.5% vs 23.3%, P = 0.64), and re‐operation (7.4% vs 3.1%, P = 0.55) were comparable. In propensity matched analysis adjusted for demographics, disease, and stricture characteristics [n = 42, 21 each, 62% male, median (years): 32 (15–60)], cumulative probability of re‐intervention rates was higher in ET (28.6% vs 4.8%, P = 0.042). The cumulative probability of recurrent symptoms (ET: 33.3% vs surgery 33.3%, P = 0.93), therapy escalation (ET: 23.8% vs surgery 28.6%, P = 0.75), and re‐operation (ET: 9.5% vs surgery 4.8%, P = 0.57) was similar.ConclusionsET for CD strictures require higher re‐interventions compared with resection although re‐operation could be avoided in the majority with comparable symptom free survival at 1 year.

Intestinal strictures in Crohn's disease: An update from 2023

“… 73 Both mechanical dilation and EBD have shown similar safety profiles and effectiveness for ileoanal and rectal strictures following ileal pouch‐anal anastomosis (IPAA), with no significant difference in complications. 79 Balloon‐assisted enteroscopy‐based endoscopic stricturotomy (BAE‐based ES) has also been found to be effective and safe for deep small bowel strictures. 75 With ongoing advancements in endoscopic techniques, there is great potential for further improvements in safety, effectiveness, and patient outcomes.…”

“…If, resection is needed, minimizing the interval between diagnosis and surgery is important to reduce postoperative complications. 79 The LIR!C trial provided evidence that early surgery, defined as resection for luminal involvement without prior surgeries, is not only a viable alternative to biologics but also reduces costs significantly. 77 …”

Interventional endoscopy in inflammatory bowel disease: a comprehensive review

“…Although the risk of first intestinal surgery (33.3% at 5 years and 46.6% at 10 years) is decreasing with current medical therapy, the rate of second surgery has not decreased in the last 3 decades [ 5 , 6 ]. Hence, IIBD is an alternative, effective option to surgery which should be discussed with patients albeit with a higher risk of recurrence and mild risk of complications [ 7 ]. IIBD can also be helpful to delay up to 6.5 years as shown in a retrospective study [ 8 ].…”

“…A recent prospective, propensity-matched analysis of CD strictures (<5 cm, ≤3 in number) with 1-year follow-up showed that the cumulative probability of symptoms recurrence/treatment escalation/re-surgery was not different between those who underwent EBD and those who underwent surgery. However, the rate of re-intervention was higher in the EBD group [ 7 ].…”