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P442 Strictureplasty for Crohn’s disease of the small bowel in the biological era: long-term outcomes and risk factors for site specific recurrence

M. Rottoli*1, C. A. Manzo1, M. Tanzanu1, F. Rizzello1, P. Gionchetti1, G. Poggioli1

1Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy

Background

Patients affected by Crohn’s disease (CD) often require multiple surgeries and are at higher risk of short bowel syndrome. While bowel-sparing techniques should still have an indication in these patients, a considerable reduction of the use of strictureplasty has been observed, especially since the introduction of biological drugs.

Methods

Patients undergoing strictureplasty for small bowel CD from 2002 were included.

Risk factor for recurrence of CD were analysed through a multilevel logistic regression analysis, considering the hierarchical structure of the data. Level-2 variables were related to patient, level-1 to strictureplasty. A model without predictors was run to calculate the intraclass correlation coefficient to evaluate the degree of homogeneity of the outcome within patients; an intermediate model adding level-1 and level-2 variables and testing all intra-level interactions was subsequently performed. The estimated residual standard deviation and the estimated residual intraclass correlation of random-intercept logistic model were calculated. All p values refer to two-tailed tests of significance. A p-value of <0.05 was considered significant.

Results

A total of 266 patients were included in the study. Overall, 718 strictureplasties were performed. Median follow-up time was 96 months (6–209). Site specific recurrence rate was 1.6% at 2 years, 12.7% at 5 years, and 25.7% at 10 years.

Number, mean or median%, standard deviation or range
Total number of patients266
Mean number of strictureplasties/patient1.95±2.85
Median age of patients (years)39.518–76
Median years of disease8.20.1–37
Number of additional resections19673.7%
Smoking after strictureplasty6825.6%
Biologics after strictureplasty7929.7%
Biologics before strictureplasty7227.1%
Previous surgery for Crohn’s disease8532.0%

Characteristics of patients undergoing strictureplasty for Crohn's disease

N%
Total number of strictureplasty718
Ileum44061.3
Jejunum13518.8
Terminal ileum14319.9
Conventional strictureplasty64389.6
Nonconventional strictureplasty7510.4
New stricture65190.7
Recurrence on strictureplasty365
Recurrence on anastomosis314.3

Characteristics of the strictureplasties performed

VariablesOdd ratioStandard errorp-value
Ileum location1.490.350.091
Nonconventional strictureplasty3.571.720.008
Strictureplasty on previous anastomosis13.5911.180.002
Age0.980.010.246
Total number of strictureplasties1.130.080.088
Use of biologics after strictureplasty4.752.250.001
Duration of disease1.261.040.776

Results of the multi-level regression logistic analysis of risk factors for site specific recurrence.

Conclusion

Strictureplasty is a safe procedure and is correlated with acceptable recurrence-free rates also after a very long follow-up time. Despite nonconventional strictureplasties are associated with a significantly higher risk of site specific relapse, whenever possible a bowel sparing technique should be performed, especially in the presence of long strictures. In case of a recurrence of a previous anastomosis, a resection should be preferred. The use of biologics after surgery identifies patients at higher risk of recurrence. The effect of biological drugs on long-term outcome after bowel sparing technique should be assessed in future prospective trials.