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P534. Endoscopic balloon dilatation and/or intensification of medical therapy can achieve and maintain remission in patients with symptomatic intestinal strictures of Crohn's disease

K. Papamichael1, E. Archavlis1, N. Kyriakos1, I. Drougas1, D. Tsironikos1, X. Tzanetakou1, I. Internos1, S. Anastasiadis1, P. Karatzas1, G. Mantzaris1, 1Evangelismos Hospital, Athens Greece, A' Department of Gastroenterology, Athens, Greece

Background

Endoscopic dilatation (ED) of Crohn's disease (CD) related strictures is an alternative to surgical resection in selected patients. The aim of the study was to assess whether ED of short intestinal strictures in CD can be maintained long-term with appropriate therapeutic modifications.

Methods

Between 2004–12, 45 patients were enrolled [20 males, median age (range) 27 (18–79) yrs, 26 (58%) smokers, median disease duration 13 (range 2–18) yrs]. 37 patients had symptomatic post-operative ulcerated/fibrostenotic stricures at the ileocolonic anastomosis; 9/37 patients had additional proximal ileal strictures. 8 patients had inflammatory/ulcerated (n = 7) or ulcerated/fibrostenotic (n = 10) ileal strictures without prior surgery. 3 patients had endoscopic capsule retention. 15 patients were on 5-ASA, 16 on azathioprine (AZA), 9 on AZA and anti-TNF and 5 on anti-TNF alone. In addition to strictures 21 patients treated with 5-ASA (n = 13), AZA (n = 5), or anti-TNF alone (n = 3) had active luminal disease. Strictures were dilated in a single session to max 22 mm using balloon dilators (Hercules, WC). Treatment was modified if needed to achieve deep remission. Patients were followed in the outpatient clinic; ileocolonoscopy was performed after 1 year and then if needed based on symptom recurrence and CRP levels.

Results

93 ED were performed in 59 sessions; 34 (75.5%) patients underwent one, 8 (17.8%) two and 3 (6.7%) three sessions. No immediate or delayed adverse events were noted. ED failed in 3 (6.7%) patients, 1 with anastomotic and 2 with successive inflammatory/fibrostenotic ileal strictures; patients were operated. Despite initial improvement after 3 ED sessions, obstructive symptoms recurred in 2 patients who opted for surgery at 12 and 15 months after the last dilatation. 40 patients improved remarkably and are maintained in clinical, serological and endoscopic remission for a median of 3 yrs (range 0.3–7.5). Treatment intensification from 5-ASA, AZA or anti-TNF alone to AZA or combo AZA/anti-TNF, respectively, in the 21 patients who had active luminal diseased led onto endoscopic remission of disease [complete healing (n = 17), a few remaining aphthae (n-4)] and prevented recurrence of strictures. Treatment intensification was not effective in healing solely ulcerated/stenotic anastomotic lesions.

Conclusion

The combination of ED and treatment modifications, if needed, were effective in palliating obstructive symptoms and/or endoscopic remission in patients with stricturing and/or inflammatory CD.