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It is not clear whether endoscopic balloon dilation (EBD) or surgery is a more effective treatment for ileocolonic anastomosis (ICA) stricture in patients with Crohn’s disease. We aimed to compare long-term outcomes of patients who underwent EBD versus surgery for ICA stricture.We performed a retrospective study of adult patients with ICA stricture treated with EBD (n = 176) or surgery (n = 131), from December 1998 through May 2013, at the Cleveland Clinic Foundation. Demographic, clinical, endoscopic, histologic, and radiographic data were collected. Disease duration was defined as the time interval from the diagnosis of Crohn’s disease to the treatment for ICA stricture. Data were collected for a median follow-up period of 2.9 years (interquartile range, 0.9–5.7 years). Multivariable analyses were performed to assess risk factors for subsequent surgery.Patients in the surgery group had a longer median interval from inception (first encounter with patients at either follow-up endoscopy or presentation with obstructive symptoms) until subsequent surgery (4.7 years; interquartile range, 2.2–8.8 vs 1.8 years; interquartile range, 0.4–4.1 years). The average time to surgery delayed by EBD was 6.45 years. Upfront surgery for ICA stricture (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.32–0.76), a longer time for diagnosis to inception (HR, 0.96; 95% CI, 0.93–0.99), a shorter interval from the last surgery to inception (HR, 1.05; 95% CI, 1.01–1.09), only 1 previous resection (HR, 0.41; 95% CI, 0.26–0.66), and the absence of concurrent strictures (HR, 1.68; 95% CI, 0.97–2.9) were associated with a significantly lower risk for subsequent surgery.Surgical resection for ICA stricture in patients with Crohn’s disease was associated with a lower risk of further surgery than EBD. However, EBD could delay time until need for a second surgery and be attempted first for patients with a lower risk for disease progression. Patients at risk for recurrent disease may benefit from upfront surgical therapy.