Evaluating the Predictors of Endoscopic Balloon Dilation Failure, Success, and Surgery Prevention in Crohn's Disease-Related Strictures: A 15-Year Experience at a Tertiary Care Center

Introduction: Intestinal strictures affect one-third of individuals with Crohn’s disease (CD) within ten years of disease onset. Endoscopic balloon dilation (EBD) is a minimally invasive procedure for managing fibrostenotic strictures in patients with CD. Long-term outcomes after EBD are poorly defined in the literature. The aims of this study are to evaluate the efficacy of EBD in delaying surgery for the treatment of strictures in patients with CD and identify clinical, endoscopic, and stricture-related factors associated with avoidance of surgery after five years of EBD. Methods: Retrospective cohort study including all patients with CD undergoing EBD at a tertiary academic center between 01/2007-12/2021. Data for demographics, disease characteristics, stricture characteristics, surgical history, medication history, need for surgical intervention, time to surgical intervention, and need for re-dilation were collected. Patient outcomes were followed from their index dilation up to five years post dilation. Results: 378 patients with CD diagnosis (51% female) with a mean age 45 years underwent EBD during the study period (681 total dilations). The location of the stricture was upper gastrointestinal in 30 patients (9%), ileal (35%), colonic (13%), ileocolonic (44%) in other patients. Among these patients, 118 (31%) required surgery for CD-related stricture during the five-year follow-up periods. Prednisone therapy was a predictor for progression to surgery post-EBD (P=0.002). 156 patients (43%) required re-dilation. Patients with De Novo strictures were more likely to undergo surgery compared to those with anastomotic strictures (P=0.034). Eight patients (2%) had complications with three of those requiring surgery. Conclusion: This is one of the largest single-center studies looking at outcomes of EBD for treatment of CD-related strictures. 69% of patients treated with EBD avoided surgery within a five-year follow-up period. Steroid therapy was predictive of surgical resection within five years. Similar to current literature, anastomotic strictures had better outcomes than De Novo. Larger prospective studies are needed to confirm our results (Table 1). Table 1. - Patient characteristics, Montreal classification at time of dilation, steroid use, stricture characteristics, and response to endoscopic dilation All Patients (n=378) Surgery post-dilation (n=118) No surgery post-dilation (n=260) P-value Female, n(%) 194 (51%) 68 (58%) 126 (49%) 0.098 Race, n(%) 0.100 White 356 (94%) 112 (95%) 244 (94%) Black 17 (5%) 4 (3%) 13 (5%) Age at dilation (years), mean (sd) 30 (16) 31 (16) 29 (15) 0.158 BMI, mean (sd) 27 (7) 27 (6) 27 (7) 0.935 Age at Diagnosis 0.469 A1 (< 16 years) 70 (21%) 20 (18%) 59 (23%) A2 (17-40 years) 205 (56%) 67 (59%) 134 (54%) A3 ( >40 years) 84 (23%) 27 (24%) 57 (22%) Behavior of Disease, n(%) 0.013 Stricturing 269 (72%) 72 (61%) 197 (77%) Stricturing and Penetrating 105 (28%) 46 (39%) 59 (23%) Location, n(%) 0.228 L1 (Ileal) 131 (35%) 47 (40%) 84 (33%) L2 (Colonic) 50 (13%) 11 (9%) 39 (15%) L3 (Ileocolonic) 163 (44%) 52 (44%) 111 (43%) L4 (Upper GI) 30 (9%) 8 (7%) 22 (8%) Perianal Disease, n(%) 109 (29%) 43 (36%) 66 (25%) Prednisone at dilation, n(%) 60 (16%) 29 (25%) 31 (12%) 0.002 Endoscopic Severity at time dilation, n(%) 0.256 Remission 51 (14%) 12 (11%) 39 (15%) Mild 119 (32%) 34 (30%) 85 (23%) Moderate 119 (32%) 35 (31%) 84 (23%) Severe 83 (22%) 32 (28%) 51 (20%) Location of Stricture, n(%) 0.255 Ileum 105 (28%) 42 (46%) 63 (25%) Ileocolonic 174 (46%) 46 (39%) 128 (50%) Colonic 43 (11%) 12 (10%) 31 (12%) Upper GI 24 (6%) 7 (6%) 17 (7%) Jejunal 7 (2%) 3 (3%) 4 (2%) Anal 22 (6%) 8 (7%) 14 (5%) Stricture type, n(%) 0.034 De Novo 214 (57%) 76 (65%) 138 (53%) Anastomotic 162 (43%) 41 (35%) 121 (47%) Need for redilation, n(%) 156 (43%) 49 (42%) 107 (43%) 0.847