Endoscopic management of Crohn’s strictures

Table 1 Risk factors and predictors of fibrostenosing Crohn’s disease

Clinical[4]	Age at diagnosis < 40 yr
	Perianal disease at diagnosis
	Need for steroids during first flare
	Small bowel disease location
	Prior appendectomy
Environmental[4]	Smoking
Endoscopic[4]	Deep mucosal ulcerations
Genetic[4]	Nucleotide oligomerisation domain 2 (NOD2) variants
	Janus-associated kinase 2 (JAK2)
	Caspase-recruitment domain 15 (CARD15)
	NOD2/CARD15 mutations on both chromosomes
	TNF superfamily 15 (TNFSF15) in Asians
	5T5T in the MMP3 gene
	rs1363670
Serological[4]	Antimicrobial antibodies
	anti-Saccharomyces cerevisiae antibodies (ASCA) IgA in Asians

Table 2 Summary of published studies on endoscopic balloon for Crohn’s disease strictures

Authors	Pubished year	No. of patients	Anastomotic strictures (%)	Maximum balloon caliber (mm)	Technical success (%)	Clinical efficacy (%)	Major complication (%)
Blomberg et al[52]	1991	27	100	25	100	67	0
Williams et al[53]	1991	7	71	20	71	71	0
Breysem et al[54]	1992	18	78	18	89	50	0
Cockuyt et al[55]	1995	55	67	20	85	62	8
Ramboer et al[56]	1995	13	69	18	100	100	0
Matsui et al[57]	2000	55	43	20	86	78	2
Dear et al[58]	2001	22	95	18	100	73	0
Brooker et al[59]	2003	14	79	20	100	79	0
Morini et al[60]	2003	43	67	18	79	42	0
Sabate et al[61]	2003	38	68	25	84	53	3
Thomas-Gibson et al[62]	2003	59	90	18	73	41	3
Singh et al[63]	2005	17	35	20	100	76	18
Aljouni et al[64]	2006	37	37	20	90	87	3
Ferlitsch et al[65]	2006	46	59	20	85	66	4
Nomura et al[66]	2006	16	35	20	94	65	6
Foster et al[67]	2008	24	41	20	92	NA	13
Hoffman et al[68]	2008	25	57	20	100	52	16
Stienecker et al[69]	2009	25	42	18	97	94	3
Mueller et al[70]	2010	55	23	18	95	76	2
Thienpont et al[71]	2010`	138	84	18	97	76	3
Scimeca et al[72]	2011	37	90	20	84	89	0
Gustavsson et al[51]	2012	178	80	25	89	64	11
Karstensen et al[73]	2012	23	24	15	83	74	1.9
De’Angelis et al[74]	2013	26	52	18	100	93	2
Endo et al[75]	2013	30	36	20	94	64	10
Honzawa et al[76]	2013	25	21	20	88	62	12
Nanda et al[77]	2013	31	100	18	100	45	0
Atreja et al[78]	2014	128	48	20	83	67	3
Bhalme et al[79]	2014	79	61	20	95	77	0
Hagel et al[80]	2014	77	57	20	55	65	10
Krauss et al[81]	2014	20	25	18	100	NA	14
Ding et al[82]	2016	54	100	20	89	82	2

Clinical efficacy was defined according to each study (i.e., resolution of obstructive symptoms after dilation with the avoidance of surgery or additional intervention). Technical success was defined by successful passage of the endoscope or colonoscope immediately after dilation. Clinical efficacy was defined as the resolution of obstructive symptoms after dilation with the avoidance of surgery. Major complications (calculated per number of dilations) included were perforations, bleeding, intra-abdominal abscesses or fistulas. NA: Not available.

Table 3 Practical considerations

Predictors favoring successful dilation[11,22-25]	Symptomatic predominantly fibrotic stricture
	Short (≤ 5 cm) stricture
	Single straight stricture
	Stricture distal to the duodenum
	Anastomotic stricture more favorable than de novo stricture
	First dilation
	Lack of a superimposed process contributing to symptoms (e.g., SIBO or IBS)
Risk factors for complications[22-25]	Predominantly inflammatory stricture without medical optimization
	Stricture greater than 5 cm
	Multiple small bowel strictures
	Strictures caused by extrinsic compression (e.g., adhesions)
	Fistulization within 5 cm of the area to be dilated
	Adjacent perforation or intra-abdominal collection
	Complete small bowel obstruction
	Tortuous or tethered small bowel or significant stricture angulation
	Duodenal stricture
1Short term outcome[15,18]	85%-95% (technical success), 70%-80% (clinical response)
2Long term outcome[15,18]	32% (year 1 post dilation), 80% (year 5 post dilation)
3Complication rate[25,45]	1%-4%

¹Short term outcome refers to the time elapsed immediately after the dilation takes place; technical success refers to the ability to successfully complete the dilation; clinical response refers to the symptomatic improvement of the patient immediately following the dilation;

²Long term outcome refers to the percentage of patients requiring a repeat intervention;

³Complication rate encompasses only major complications requiring urgent intervention such as bleeding, perforation and infection.