| Backgrounds and purposesCrohn’s disease(CD)patients are prone to luminal stricture in the natural history of the disease,including primary stricture caused by the development of the disease itself and secondary anastomotic stricture associated with previous surgery.Regarding to the treatment for CD strictures,there are currently three types of strategies: medical therapy,surgery and endoscopic intervention.Medical therapy has been proved to be effective in controlling active inflammation.However,as for the fibrotic strictures,no targeted drug has been available so far.Surgical strategies,including bowel resection and strictureplasty,are effective for fibrotic strictures,but are associated with various complications and high risk of postoperative recurrence.For the purpose of finding a therapy with less invasiveness and better efficacy,endoscopists attempt to extend the role of endoscope from diagnosis to treatment,which could be grouped into endoscopic balloon dilation(EBD),endoscopic stricturotomy(ES)and endoscopic stenting.With a history of more than 30 years,EBD could avoid surgery to a certain extent or at least delay the time of surgery,but the recurrence rate and the corresponding re-dilation rate remains high.Compared to EBD,ES is a relatively new method for CD stricture.However,some research suggests its effectiveness may be better than EBD.Our study isaimed to compare the efficacy and safety of EBD versus ES in the management of CD strictures,and try to find risk factors associated with need of repeat endoscopic treatment or surgery after initial endoscopic procedure.MethodsA total of 42 patients who had undergone EBD or ES due to CD strictures at Sir Run Run Shaw Hospital between January 2016 and December 2019 were identified.Among them,29 patients were treated with EBD while 13 patients were treated with ES.Demographics,clinical data,endoscopic features,as well as treatment and outcomes,were carefully reviewed.Patients’ age,gender,disease duration,clinical symptoms,laboratory results,as well as the location,type,length,and diameter of strictures were collected and analyzed.Short-term efficacy including technical success and symptomatic improvement,long-term efficacy including the need of repeat endoscopic treatment or surgery during follow up,as well as complications after initial procedure such as perforation and major bleeding were compared between EBD and ES group.Cox proportional hazards analysis were used to evaluate risk factors associated with need of repeat endoscopic treatment or surgery after initial endoscopic procedure.ResultsAmong the 42 patients,13 patients were treated with ES while 29 patients with EBD.In ES patients,the mean age at the time of initial procedure was 32.0 ± 11.4 years,the proportion of male patients was 69.2%.In EBD patients,the mean age at the time of initial procedure was 32.6 ± 8.3 years,the proportion of male patients was 62.1%.Technical success was achieved in all patients whether in ES or EBD group.Symptomatic improvement rate was 87.5% in those treated with EBD and 90.9% withES(p = 0.628).Only one adverse event occurred after the initial procedure: one procedure-associated perforation(3.4%)occurred in EBD group.The median follow-up time of patients in EBD and ES group were 19.5(9.1-28.0)months and 13.6(8.0-18.1)months,respectively(P=0.073).The re-intervention free time was longer in those treated with ES than those with EBD(8.1 ± 4.2 months vs 5.4± 2.4 months,p = 0.012).However,there was no difference in the requirement of repeat endoscopic procedure(62.1% vs 53.8%,p = 0.616),the mean times of endoscopic procedures(2.5 ± 1.7 times vs 1.9 ± 1.1 times,p = 0.267)and the requirement of surgery(20.7% vs 7.7%,p = 0.405)between the two groups.In our study,there are 26 patients with primary stricture and 16 patients with anastomotic stricture.There was no difference in immediate technical success(100% vs100%,p = 1.000),symptomatic improvement rate(90.9% vs 84.6%,p = 0.987),procedure-associated complications(3.8% vs 0%,p=1.000),re-intervention free time(6.1 ± 3.0 months vs 6.5 ± 3.7 months,p = 0.742),the requirement of repeat endoscopic procedure(53.8% vs 68.8%,p = 0.339)and the requirement of surgery(15.4% vs18.8%,p = 1.000)between the two types of patients.Cox proportional hazard model for risk factors was performed.Multivariate analysis suggested that longer length of stricture was associated with the increase of the requirement of subsequent surgery(HR: 10.40,95% CI: 1.90-57.13,p = 0.007)while longer disease duration was associated with the decrease of the requirement of subsequent surgery(HR: 0.96,95% CI: 0.91-0.99,P = 0.040).Conclusions1.The short-term efficacy of EBD is basically equaled to ES,and both of them could effectively improve the CD stricture and relieve the clinical symptoms.2.The long-term efficacy of ES appears to be slightly better than EBD.Both of them could avoid or space out the requirement for surgery to a large extent,though the rate of second endoscopic procedure remains high.3.The safety of EBD and ES is generally good,though the risk of perforation may be slightly higher with EBD than ES.4.The efficacy and safety of endoscopic therapy are almost similar between primary and anastomotic CD strictures.5.Longer length of stricture was associated with the increase of the requirement of subsequent surgery while longer disease duration was associated with the decrease of the requirement of subsequent surgery. |
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