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P189. Long-term follow-up of patients with Crohn's disease ileo-colonic strictures: Comparison of endoscopic and surgical therapy

E. Krauss1, H. Kessler2, A. Gottfried1, H. Neumann1, R. Atreja1, W. Hohenberger2, M. Neurath1, J. Mudter1

1Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany; 2Clinic of Abdominal Surgery, University of Erlangen-Nuremberg, Erlangen, Germany

Aims: Ileo-colonic strictures are common complication of Crohn's disease (CD), and may result in repeated endoscopic or surgical therapy with a fear of further complications, such as perforation or short bowel syndrome. The strictures are result of tissue remodelling and fibrosis due to chronic inflammation. This work compares CD patients with endoscopic dilatation and surgical resection or strictureplasty of intestinal strictures, aiming to evaluate the long-term safety and efficacy of both therapies, incorporating characteristic of stricture (length, anastomosis, inflammation etc.), influx of disease activity and medication.

Methods: In this study we included 88 CD patients (37 male, 51 female, mean age 40 years, range 19–65 years) of our both medical and surgical clinics with intestinal strictures, who between Jan. 2002 – Dec. 2009 undergone either surgical or endoscopical therapy. The primary end-point was stricture- and operation-free time; the mean follow-up period was 5 years (3–7 years). At the end of follow-up period (01/2010) 68 included patients were clinically examined in our clinic, 20 patients could not participate on clinical evaluation and were contacted per telephone with questionnaire. The patients were initially randomized into four groups: only surgical, only endoscopic, endoscopy with following surgical therapy, and initial surgical therapy with following endoscopic dilatation.

Results: The patients, who undergone only surgical therapy had an average length of stenosis of 7 cm (range 4–12.5 cm) with operation-free time of 68.5 months and stenosis-free time of 67.5 months (p = 0.044). Patients undergoing only endoscopic dilatation had an average length of stenosis 2–4 cm in ileum (stenosis-free time 4.5–60 months), 1–2.5 cm in cecum (4.5–11.75 months), 4–10 cm in sigma (6–39 months), 1–2 cm in rectum (1–12 months), p = 0.139. The two other groups showed similar results with p = 0.428 for the group endoscopy with following operation, and p = 0.222 for the group surgical therapy with following endoscopic dilatation. The stricture of anastomosis was seen in 40 patients, 25 patients had their surgical intervention planed and 35 came as an emergency, of them 1% as complication of endoscopic intervention (perforation). We could not prove any statistically relevant difference between numbers of stenosis, their characteristic (length, anastomosis or new stricture, mucosal inflammation etc), injection of prednisone during endoscopy, disease activity or medication in terms of stenosis- or operation-free time. 35% patients, who had to undergo surgical resection, did not tolerate and/or did not continue treatment with immunsuppressiva.

Conclusions: The long-term efficacy of endoscopic balloon dilatation as well as surgical resection depends on many factors. Sometimes, despite of multiple endoscopic dilatations, resection of stenosis is unavoidable; but without proper medication and modification of risk factors a full remission can't be achieved. Our conclusion that an optimal strategy after intervention has to be based on a patient's clinical risk factors with treatment then adjusted to postinterventional clinical and endoscopic findings.