Shigeki Bamba1, Ryosuke Sakemi2, Toshimitsu Fujii3, Teruyuki Takeda4, Shin Fujioka5, Kento Takenaka3, Hiroki Kitamoto6, Shotaro Umezawa7, Hirotake Sakuraba8, Toshihiro Inokuchi9, Norimasa Fukata10, Shinta Mizuno11, Masaki Yamashita12, Shinichiro Shinzaki13, Hiroki Tanaka14, Hidetoshi Takedatsu15, Ryo Ozaki16, Kei Moriya17, Manabu Ishii18, Tetsu Kinjo19, Keiji Ozeki20, Makoto Ooi21, Ryohei Hayashi22, Kazuki Kakimoto23, Yuichi Shimodate24, Kazuya Kitamura25, Akihiro Yamada26, Akira Sonoda27, Yu Nishida28, Kyouko Yoshioka29, Shinya Ashizuka30, Fumiaki Takahashi31, Toshio Shimokawa32, Taku Kobayashi16, Akira Andoh33, Toshifumi Hibi16. 1. Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, 520-2192, Japan. sb@belle.shiga-med.ac.jp. 2. Department of Gastroenterology, Tobata Kyoritsu Hospital, Kitakyusyu, Japan. 3. Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan. 4. Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan. 5. Department of Medicine and Clinical Science, Kyushu University Graduate Schools of Medical Science, Fukuoka, Japan. 6. Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan. 7. Center for Gastroenterology and Inflammatory Bowel Disease, Ofuna Chuo Hospital, Kamakura, Japan. 8. Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan. 9. Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Okayama, Japan. 10. Third Department of Internal Medicine, Kansai Medical University, Hirakata, Japan. 11. Division of Gastroenterology and Hepatology, Keio University School of Medicine, Tokyo, Japan. 12. Division of Gastroenterology and Hepatology, Saint Marianna University School of Medicine, Kawasaki, Japan. 13. Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan. 14. IBD Center, Sapporo Kosei General Hospital, Sapporo, Japan. 15. Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan. 16. Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan. 17. Department of Gastroenterology and Hepatology, Nara Medical University School of Medicine, Kashihara, Japan. 18. Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Japan. 19. Department of Endoscopy, University of Ryukyus Hospital, Nishihara, Japan. 20. Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan. 21. Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan. 22. Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan. 23. 2nd Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan. 24. Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Kurashiki, Japan. 25. Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan. 26. Department of Internal Medicine, Sakura Medical Center, Toho University, Sakura, Japan. 27. Department of Gastroenterology, Oita University, Yufu, Japan. 28. Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan. 29. Department of Gastroenterology, Kure Kyosai Hospital, Kure, Japan. 30. Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan. 31. Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan. 32. Department of Medical Data Science, Graduate School of Medicine, Wakayama Medical University, Wakayama, Japan. 33. Division of Gastroenterology, Shiga University of Medical Science, Otsu, Japan.
Abstract
BACKGROUND: Small bowel stricture is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilatation (EBD) is a minimally invasive treatment intended to avoid surgery; however, whether EBD prevents subsequent surgery remains unclear. We aimed to reveal the factors contributing to surgery in patients with small bowel stricture and the factors associated with subsequent surgery after initial EBD. METHODS: Data were retrospectively collected from surgically untreated CD patients who developed symptomatic small bowel stricture after 2008 when the use of balloon-assisted enteroscopy and maintenance therapy with anti-tumor necrosis factor (TNF) became available. RESULTS: A total of 305 cases from 32 tertiary referral centers were enrolled. Cumulative surgery-free survival was 74.0% at 1 year, 54.4% at 5 years, and 44.3% at 10 years. The factors associated with avoiding surgery were non-stricturing, non-penetrating disease at onset, mild severity of symptoms, successful EBD, stricture length < 2 cm, and immunomodulator or anti-TNF added after onset of obstructive symptoms. In 95 cases with successful initial EBD, longer EBD interval was associated with lower risk of surgery. Receiver operating characteristic analysis revealed that an EBD interval of ≤ 446 days predicted subsequent surgery, and the proportion of smokers was significantly high in patients who required frequent dilatation. CONCLUSIONS: In CD patients with symptomatic small bowel stricture, addition of immunomodulator or anti-TNF and smoking cessation may improve the outcome of symptomatic small bowel stricture, by avoiding frequent EBD and subsequent surgery after initial EBD.
BACKGROUND: Small bowel stricture is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilatation (EBD) is a minimally invasive treatment intended to avoid surgery; however, whether EBD prevents subsequent surgery remains unclear. We aimed to reveal the factors contributing to surgery in patients with small bowel stricture and the factors associated with subsequent surgery after initial EBD. METHODS: Data were retrospectively collected from surgically untreated CDpatients who developed symptomatic small bowel stricture after 2008 when the use of balloon-assisted enteroscopy and maintenance therapy with anti-tumor necrosis factor (TNF) became available. RESULTS: A total of 305 cases from 32 tertiary referral centers were enrolled. Cumulative surgery-free survival was 74.0% at 1 year, 54.4% at 5 years, and 44.3% at 10 years. The factors associated with avoiding surgery were non-stricturing, non-penetrating disease at onset, mild severity of symptoms, successful EBD, stricture length < 2 cm, and immunomodulator or anti-TNF added after onset of obstructive symptoms. In 95 cases with successful initial EBD, longer EBD interval was associated with lower risk of surgery. Receiver operating characteristic analysis revealed that an EBD interval of ≤ 446 days predicted subsequent surgery, and the proportion of smokers was significantly high in patients who required frequent dilatation. CONCLUSIONS: In CDpatients with symptomatic small bowel stricture, addition of immunomodulator or anti-TNF and smoking cessation may improve the outcome of symptomatic small bowel stricture, by avoiding frequent EBD and subsequent surgery after initial EBD.