• Shigeki Bamba, Ryosuke Sakemi, Toshimitsu Fujii, Teruyuki Takeda, Shin Fujioka, Kento Takenaka, Hiroki Kitamoto, Shotaro Umezawa, Hirotake Sakuraba, Toshihiro Inokuchi, Norimasa Fukata, Shinta Mizuno, Masaki Yamashita, Shinichiro Shinzaki, Hiroki Tanaka, Hidetoshi Takedatsu, Ryo Ozaki, Kei Moriya, Manabu Ishii, Tetsu Kinjo, Keiji Ozeki, Makoto Ooi, Ryohei Hayashi, Kazuki Kakimoto, Yuichi Shimodate, Kazuya Kitamura, Akihiro Yamada, Akira Sonoda, Yu Nishida, Kyouko Yoshioka, Shinya Ashizuka, Fumiaki Takahashi, Toshio Shimokawa, Taku Kobayashi, Akira Andoh, and Toshifumi Hibi.
• Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, 520-2192, Japan. sb@belle.shiga-med.ac.jp.
• J. Gastroenterol. 2020 Jun 1; 55 (6): 615-626.

BackgroundSmall 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.MethodsData 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.ResultsA 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.ConclusionsIn 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.

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