Management of ileocolic anastomotic strictures in Crohn's disease: endoscopic or surgical intervention? A systematic review and meta-analysis

Abstract

Background: Intestinal strictures are one of the most intractable and common complications of Crohn's disease (CD), and their optimal management remains debatable. Endoscopic balloon dilatation (EBD) and stricturoplasty are advanced minimally invasive therapeutic tools in the management of Crohn's strictures and offer an alternative to surgery. We evaluated outcomes following endoscopic intervention compared with surgical resection in the management of ileocolic anastomotic strictures in patients with CD.

Methods: A comprehensive and systematic search of various electronic databases was conducted. All studies comparing endoscopic intervention with surgical resection for ileocolic anastomotic strictures in patients with CD were included. Our primary outcomes were re-operation or re-dilatation post-intervention and complications including haemorrhage, perforation, leak, and surgical site infection. Other evaluated parameters included the need to escalate medical treatment following primary intervention. RevMan 5.3 was used to perform the data analysis.

Results: Four observational studies with a total of 625 patients were identified and included. This consisted of 355 patients treated surgically and 270 undergoing endoscopic procedures. No significant difference in the risk of re-operation [OR, 0.13; P = 0.19], re-stenosis [OR, 0.58; P = 0.37], or total complications [OR, 1.86; P = 0.34] was seen between the two groups. However, escalation of medical therapy post-intervention was significantly lower in the surgical group compared with those managed endoscopically [OR, 0.19; P = 0.0001].

Conclusion: Both surgical and endoscopic treatments are safe and efficacious in managing patients with anastomotic strictures. However, this review emphasises the need for rationally designed, well-powered, randomised controlled trials to establish best practices in treating these challenging patients.

Keywords: Crohn’s disease; Endoscopy; Ileo-colonic disease; Inflammatory bowel disease.

Fig. 1

PRISMA flow chart

Fig. 2

Forest plots of comparison of (A) reintervention during follow-up period, B restenosis, C total complications, and (D) escalation of CD medication. The solid squares denote the odds ratio. The horizontal lines represent the 95% confidence intervals (CIs), and the diamond denotes the pooled effect size. SG, surgical group; EG, endoscopic group; CD, Crohn’s disease; M–H, Mantel–Haenszel test