P669 Improving Crohn’s disease stricture dilation outcome: Effect of repeated dilation, needle knife stricturotomy, and ongoing active inflammation
Schulberg, J.D.(1,2)*;Hamilton, A.L.(1,2);Wright, E.K.(1,2);Holt, B.(1,2);Sutherland, T.(2,3);Ross, A.L.(1);Vogrin, S.(2);Kamm, M.A.(1,2);
(1)St. Vincent’s Hospital, Department of Gastroenterology, Melbourne, Australia;(2)The University of Melbourne, Department of Medicine, Melbourne, Australia;(3)St. Vincent’s Hospital, Department of Medical Imaging, Melbourne, Australia;
Background
Traditionally Crohn’s disease strictures have been treated by a single endoscopic balloon dilation (EBD), repeated only for obstructive symptom recurrence. We postulated that scheduled repeated EBD may result in greater dilation effect than a single EBD; and that needle-knife stricturotomy (NKSt) may be a valuable salvage intervention in patients with strictures.
Methods
In this prospective observational study, patients with endoscopically accessible and short (<5cm), symptomatic Crohn’s disease stricture were assessed clinically (using an Obstructive Symptom Score [OSS]) and by imaging (colonoscopy, MRI and IUS). All patients had drug treatment optimized to decrease inflammation. Patients were treated with 3 serial balloon dilatations each 3 weeks apart, single EBD, or needle-knife stricture incision. The primary endpoint was improved OSS at 6m. Secondary outcomes; ability to endoscopically pass the stricture, treatment failure / surgery, stricture morphology on imaging, and safety.
Results
Twenty-one consecutive patients were included in the analysis. Of these 17 (81%) were receiving treatment with a biologic therapy. Median stricture length at baseline was 20mm (IQR 20mm) and median estimated stricture diameter was 8mm (IQR 3mm). 18 (86%) had visible ulceration. Of the 21 patients 11 (52%) underwent more than one EBD, 5 (24%) had ≥1 NKSt and 5 (21%) underwent a single EBD. Four of the 21 patients (19%) strictures were passable before endoscopic treatment. All procedures were technically successful. 14/21 (67%) had improvement in OSS at 6m, including 8/11 (73%) with 3 serial EBD, 4/5 (80%) with NKSt and 2/5 (40%) patients undergoing a single EBD. Two patients required surgery. At 6m, 3/8 (38%) who had repeat dilations, 4/5 (80%) who had NKSt, and 2/5 (40%) having a single EBD had a passable stricture. All 4 patients with highly elevated stricture inflammation (stricture magnetic resonance index of activity [MaRIA] score ≥20) at the 6m MRI had a non-passable stricture at study endpoint, whilst 9/12 (75%) were passable when stricture MARIA was <20 (P=0.019). No major complications occurred.
Conclusion
Endoscopic stricture treatment was safe and technically successful in all patients with accessible Crohn’s disease strictures and was associated with symptom improvement in most. Progression to surgery in this symptomatic and advanced disease was low at 6m. The highest rates of symptom improvement were seen in patients who had NKSt. Lesser stricture inflammation on MRI was associated with a better outcome, suggesting that controlling inflammation is important in preventing stricture recurrence after dilation. NKSt should be considered when balloon dilation is not possible or has failed, as a salvage treatment alternative to surgery.