title: Endoscopic Dilatation of Crohn's Anastomotic Strictures is Effective in the Long Term, and Escalation of Medical Therapy Improves Outcomes in the Biologic Era.
abstract: OBJECTIVE
  To investigate the long-term efficacy of endoscopic dilatation of Crohn's anastomotic strictures and to identify risk and protective factors associated with the need for repeat dilatation or surgery.
  
  
  METHODS
  A total of 54 patients who had endoscopic balloon dilatations for anastomotic Crohn's strictures between 2004 and 2009, with follow-up until June 2014, were identified from a single tertiary center. The primary end points were repeat dilatation or surgical resection, and the impact of radiology, medical therapy, and endoscopic data on these outcomes was analysed with Cox proportional hazards analysis.
  
  
  RESULTS
  A total of 151 dilatations were performed on patients with a median age of 52 years [interquartile range (IQR), 46-62 years]. The median duration from the first to the second dilatation was 6 years (IQR, 5-7 years). The median disease duration was 28 years (IQR, 19-32 years). At endoscopy, disease activity was reported in 50/54 (92%) cases, with a median Rutgeerts grading of i2 (range, i0-i4). A median of two (IQR 1-9) dilatations was required, with a time to repeat dilatation of 23 months (IQR 7.2-56.9). Escalation of medical therapy was adopted in 22/54 patients (41% of the study population). On multivariate analysis, only combination therapy (anti-TNFα and immunomodulator) was significantly associated with the (decreased) need for repeated dilatation [hazard ratio (HR) 0.23; 95% CI, 0.07-0.67; p = 0.01]. Anastomotic resections were performed in 10 (18%) patients, with a Rutgeerts score of i4 at initial endoscopic balloon dilatation being associated with this outcome (HR 4.55; 95% CI 1.08-19.29; p = 0.04) on multivariate analysis.
  
  
  CONCLUSIONS
  Endoscopic balloon dilatation of Crohn's anastomotic strictures is safe and effective in the long term. We demonstrate that active disease predicts for future surgery, while escalation of medical therapy may decrease the need for repeat dilatation.
authors.affiliation: Inflammatory Bowel Disease, St Mark's Hospital, London, UK Faculty of Medicine, Imperial College, London, UK dingnik@gmail.com.
authors.forename: Nik Sheng
authors.initials: NS
authors.lastname: Ding
authors.affiliation: Inflammatory Bowel Disease, St Mark's Hospital, London, UK.
authors.forename: Wai Man
authors.initials: WM
authors.lastname: Yip
authors.affiliation: Inflammatory Bowel Disease, St Mark's Hospital, London, UK.
authors.forename: C H
authors.initials: CH
authors.lastname: Choi
authors.affiliation: Faculty of Medicine, Imperial College, London, UK Wolfson Endoscopy Unit, St Mark's Hospital, London, UK.
authors.forename: Brian
authors.initials: B
authors.lastname: Saunders
authors.affiliation: Faculty of Medicine, Imperial College, London, UK Wolfson Endoscopy Unit, St Mark's Hospital, London, UK.
authors.forename: Siwan
authors.initials: S
authors.lastname: Thomas-Gibson
authors.affiliation: Inflammatory Bowel Disease, St Mark's Hospital, London, UK Faculty of Medicine, Imperial College, London, UK.
authors.forename: Naila
authors.initials: N
authors.lastname: Arebi
authors.affiliation: Faculty of Medicine, Imperial College, London, UK Wolfson Endoscopy Unit, St Mark's Hospital, London, UK.
authors.forename: Adam
authors.initials: A
authors.lastname: Humphries
authors.affiliation: Inflammatory Bowel Disease, St Mark's Hospital, London, UK Faculty of Medicine, Imperial College, London, UK.
authors.forename: Ailsa
authors.initials: A
authors.lastname: Hart
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D003106:Colon / Q000601:surgery; D003113:Colonoscopy / Q000295:instrumentation / Q000379:methods*; D003131:Combined Modality Therapy; D003251:Constriction, Pathologic / Q000209:etiology / Q000628:therapy; D003424:Crohn Disease / Q000188:drug therapy / Q000601:surgery*; D004106:Dilatation / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007082:Ileum / Q000601:surgery; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007415:Intestinal Obstruction / Q000209:etiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy*; D016016:Proportional Hazards Models; D065840:Protective Factors; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D007166:Immunosuppressive Agents
keywords: Crohn’s disease; anastomosis; medical therapy; stricture; surgery