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OP025 Escalation of medical therapy decreases need for repeat dilatation in Crohns anastomatic strictures

N. S. Ding*1, 2, W. Yip1, R. Choi1, B. Saunders3, S. Thomas-Gibson3, N. Arebi1, A. Humphries3, A. Hart1

1St Mark’s Hospital, IBD, London, United Kingdom, 2Imperial College London, Department of Surgery and Cancer, London, United Kingdom, 3St Mark’s Hospital, Wolfson Unit For Endoscopy, Department of Gastroenterology, Harrow, United Kingdom

Background

Crohn’s disease results in surgical resection in over 50% of patients within the first 10 years of diagnosis. We aim to investigate long-term efficacy of endoscopic dilatation of Crohn’s anastomotic strictures and identify risk and protective factors associated with the need for repeat dilatation or surgery.

Methods

Identified were 54 patients who had endoscopic balloon dilatations for anastomotic Crohn’s strictures between 2004 and 2009 from a single tertiary centre with follow-up until June 2014. The primary endpoints were repeat dilatation or surgical resection, with the effect of radiology, medical therapy, and endoscopic data on these outcomes analysed with COX-proportional hazard analysis.

Results

In total, 151 dilatations were performed with a median age of 52 years (interquartile range [IQR], 46–62 years). The median follow-up duration from the first to 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 Rutgeert’s grading of i2 (range, i0–i4). A median of 2 (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 study population). On univariate analysis, stricture length > 40 mm (hazard ratio [HR] 1.38, 1.23–4.51, p = 0.04) was associated with a need for repeat dilatation, whereas the use of combination medical therapy (HR 0.26 95% CI 0.09–0.75, p = 0.01) was found to decrease the need for repeat dilatation. 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).

Figure 1. Impact of combination therapy on dilatation free survival.

Anastomotic resections were performed in 10 (18%) patients, with a Rutgeert’s score of i4 at initial endoscopic balloon dilatation being associated with this outcome (HR 4.63; 95% CI 1.06–20.33 p = 0.04) on multivariate analysis.

Table 1 Univariate analysis of clinical, radiologic, endoscopic, and medical therapy on outcome of surgical resection

Conclusion

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, whereas escalation of medical therapy may decrease the need for repeat dilatation.