Background: A long modified side-to-side isoperistaltic strictureplasty (SSIS) is an option in patients undergoing surgery for extensive stricturing Crohn's disease (CD) to avoid extensive small-bowel resections. The aim of this study was to assess the endoscopic healing rates six months following SSIS, and to analyse the long-term outcome of these patients including need for re-intervention and/or re-introducing medical therapy.
Methods: The electronic medical records of all 40 patients (16 men and 24 women; median age 39 years; range 16–73 years) who underwent a long modified SSIS between 2010 and 2015 at our tertiary referral centre, were reviewed. In all patients, SSIS was performed because of extensive stenotic CD (>20 cm) of the (neo-) terminal ileum. Each patient received the same standardized follow up (FU) with clinical and endoscopic evaluation after median time of 6 months (interquartile range, IQR, 6–8 months). We also analysed disease recurrence during follow up necessitating medical or surgical re-intervention.
Results: Median FU period was 33 months (IQR, 15–47 months). Only 10 patients (25%) continued medical treatment immediately after surgery because of remaining disease activity in the colon or systemic disease activity with a high risk of clinical relapse. At month 6, 24/40 patients (60%) showed important mucosal improvement of the strictureplasty side, with increasing healing observed from distal to more proximal. At the end of FU, the cumulative clinical relapse rate was 62.5% (25 patients), median time to relapse was 13 months (IQR 6.7–16.5 months). Two patients necessitated endoscopic balloon dilatation of the most proximal anastomosis side of the SSIS for symptoms related to subobstruction. Only 2 patients (5%) so far needed surgical re-intervention; one patient developed recurrent stenosis at the inlet of the SSIS, another patient needed revision due to adhesions. No resection of any strictureplasty was required. Of the 25 patients with clinical relapse, 18 patients (72%) were started on anti-TNF antibodies or vedolizumab, 4 patients received budesonide and 2 patients azathioprine. At the last FU, 27/40 patients (67.5%) patients had durable response including 10 patients in clinical remission (no treatment). 13 patients failed medical therapy and changed treatment and/or 2 received surgery.
Conclusions: The long modified SSIS is a safe procedure with good long-term outcome. Postoperative ileocolonoscopy after six months showed a remarkable tendency for mucosal healing. The exact mechanism needs further investigation. With a median follow up of 2.5 years, surgical reintervention rates were very low and two thirds of patients showed durable response or were in remission on (very often) previously-failed treatments.