To DBE or not to DBE strictures in CD?

May 17, 2016 - E-Mentoring in IBD | Volume 9 • 2016

Issue 10

Clinical Question

In Crohn’s disease (CD), does salvage surgery after failed double balloon endoscopy (DBE) dilatations for treating ileocolonic anastomotic strictures offer similar outcomes compared to primary surgery without DBE?

Editor’s Bottom Line

DBE is generally performed on shorter strictures whereas primary surgery is generally performed on longer strictures. If surgery is required for a failed DBE then the surgery is associated with increased rates of diverting ostomy and wound infections.

Reference

Li Y, Stocchi L, Shen B, Liu X, et al. Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn’s disease. Br J Surg. 2015 Oct;102(11):1418–25. https://www.ncbi.nlm.nih.gov/pubmed/26313750

 Synopsis

Patients receiving either primary surgical resection or DBE dilatation for the treatment of ileocolonic stricturing anastomoses due to recurrent CD were enrolled (1997 to 2013). Medical chart review retrieved data including stricture length, CD duration, pre-operative medications, and family history. The decision for primary surgery first vs. DBE was due to stricture characteristics or preferences of either the surgeon or patient. Outcomes were post-operative complications within 30 days of hospitalization, need for stoma, readmissions, and reoperations.

The primary surgery group consisted of 114 patients vs. 80 patients who had ≥1 DBE dilatations then salvage surgery within a median follow-up of 14.5 months.

The primary surgery group had longer strictures than the DBE cohort (10.9 cm vs. 4.1 cm, P<0.001); less diverting loop ileostomies (7% vs. 13%, P=0.03); less post-operative surgical site infection rate (5% vs. 15%, P=0.025); but a trend for more bowel obstructions (5% vs. 1%, respectively P=0.412), relative to the salvage surgery group.

Endoscopic recurrence, duration of hospital stay and readmission rates were similar in the two groups.

Details

Study Design: Prospective cohort study
Funding: Story Garschina Endowed Chair
Allocation: n/a
Setting: Cleveland Clinic, OH
Level of Evidence: 2b (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.