Long-Term Outcome of Endoscopic Balloon Dilation for Duodenal Crohn's Disease-Associated Strictures

Bypass is associated with lower treatment failure than stricturoplasty in duodenal Crohn's disease: a systematic review with pairwise and network meta-analyses

BACKGROUND

Crohn's disease (CD) of the duodenum is uncommon, and the goal of treatment is often avoidance of surgery. However, as many as one-third of patients with CD will eventually require surgery for their disease. This study aimed to compare the outcomes and safety of surgical treatments of duodenal CD.

METHODS

In this meta-analysis, a search was conducted for studies that reported outcomes of surgical treatment of duodenal CD. The primary outcome was treatment failure. The secondary outcomes were postoperative complications and reoperation rate.

RESULTS

A total of 10 studies that included 325 patients with predominately stricturing duodenal CD published between 1970 and 2023 were included. Bypass was the surgical treatment for 155 patients (68.6%), followed by stricturoplasty (21.7%) and resection (8.4%). Pairwise meta-analyses revealed that the only significant finding was a lower rate of treatment failure in favor of bypass compared with stricturoplasty (odds ratio [OR], 0.41 [95% CI, 0.18-0.95]; P =.038), with similar odds of complications and reoperation among the 3 operations. In the network meta-analysis, bypass ranked the best with the lowest failure, complication, and reoperation rates. Stricturoplasty had a significantly higher rate of failure than bypass (OR, 2.51 [95% CI, 1.10-5.27]; P =.028).

CONCLUSION

Among the 3 procedures, surgical bypass ranked the best with the lowest failure, complications, and reoperation rates. Although bypass was associated with a lower failure rate than stricturoplasty, both procedures were associated with similar complication and reoperation rates. Based upon this review, surgical bypass is a safe and effective option for the treatment of stricturing duodenal CD.

Clinical outcomes of serial endoscopic balloon dilation for duodenal Crohn's disease-associated strictures

BACKGROUND

Endoscopic balloon dilation (EBD) is a safe and effective treatment for Crohn's disease (CD)-associated strictures. However, serial EBDs have rarely been reported. This study aimed to evaluate the efficacy and safety of serial EBDs for treating CD-associated duodenal strictures compared with intermittent EBDs.

METHODS

Patients with CD-associated duodenal strictures who underwent EBD were recruited. The clinical data, stricture characteristics, number of EBDs, dilation diameter, complications, surgical interventions, and follow-up periods were recorded. Patients were divided into a serial dilation group and an intermittent dilation group to analyze the differences in safety and efficacy.

RESULTS

Forty-five patients with duodenal CD-associated strictures underwent a total of 139 dilations. A total of 23 patients in the serial dilation group underwent 72 dilations, for a median of 3 (range 3 ~ 4) dilations per patient, and 22 patients in the intermittent dilation group underwent 67 dilations, for a median of 3 (range 1 ~ 6) dilations per patient. Technical success was achieved in 97.84% (136/139) of the patients. During the follow-up period, three patients in the intermittent dilation group underwent surgery, and the total clinical efficacy was 93.33% (42/45). No difference in safety or short-term efficacy was noted between the two groups, but serial EBDs exhibited significantly greater clinical efficacy between 6 months and 2 years. No significant difference in recurrence-free survival was observed, but the median longest recurrence-free survival and recurrence-free survival after the last EBD in the serial dilation group were 693 days (range 298 ~ 1381) and 815 days (range 502 ~ 1235), respectively, which were significantly longer than the 415 days (range 35 ~ 1493) and 291 days (range 34 ~ 1493) in the intermittent dilation group (p = 0.013 and p = 0.000, respectively). At the last follow-up, the mean diameter of the duodenal lumen was 1.17 ± 0.07 cm in the serial dilation group, which was greater than the 1.11 ± 0.10 cm in the intermittent dilation group (p = 0.018). We also found that the Simple Endoscopic Score for Crohn's Disease was associated with an increased risk of surgical intervention (HR 2.377, 95% CI 1.125-5.020; p = 0.023) and recurrence at 6 months after the last EBD (HR 0.698, 95% CI 0.511-0.953; p = 0.024), as assessed by univariate analysis.

CONCLUSIONS

Compared to the intermittent EBDs, serial EBDs for duodenal CD-associated strictures exhibit greater clinical efficacy within two years and could delay stricture recurrence. We suggest that serial EBDs can be a novel option for endoscopic treatment of duodenal CD-associated strictures.

Intestinal strictures in Crohn's disease: a 2021 update

Intestinal strictures remain one of the most intractable and common complications of Crohn's disease (CD). Approximately 70% of CD patients will develop fibrotic strictures after 10 years of CD diagnosis. Since specific antifibrotic therapies are unavailable, endoscopic balloon dilation and surgery remain the mainstay treatments despite a high recurrence rate. Besides, there are no reliable methods for accurately evaluating intestinal fibrosis. This is largely due to the fact that the mechanisms of initiation and propagation of intestinal fibrosis are poorly understood. There is growing evidence implying that the pathogenesis of stricturing CD involves the intricate interplay of factors including aberrant immune and nonimmune responses, host-microbiome dysbiosis, and genetic susceptibility. Currently, the progress on intestinal strictures has been fueled by the advent of novel techniques, such as single-cell sequencing, multi-omics, and artificial intelligence. Here, we perform a timely and comprehensive review of the substantial advances in intestinal strictures in 2021, aiming to provide prompt information regarding fibrosis and set the stage for the improvement of diagnosis, treatment, and prognosis of intestinal strictures.