OP19Who benefits from endotherapy in Crohn’s disease strictures? Predictors of recurrence, need for reintervention, and surgery from the Balloon Dilation versus Endoscopic Stricturotomy for Crohn’s Disease (BEST-CD) randomised controlled trial (NCT05521867)

Abstract Background Endoscopic balloon dilation (EBD) is widely used for Crohn’s disease (CD) strictures but has high recurrence and reintervention rates. Endoscopic stricturotomy (ES) is a promising alternative, yet predictors of long-term outcomes remain unclear. Identifying patients who benefit most from ES is essential for personalised management. Methods This single-centre study (Asian Institute of Gastroenterology, 2022–2025) enrolled adults (18–65 years) with CD and symptomatic, predominantly fibrotic/mixed strictures 3 cm, either de novo/ anastomotic, accessible by standard endoscopy. Exclusions were 2 strictures, beyond reach, or prior ES. Patients were randomised to EBD or ES. The primary outcome was clinical recurrence at 1 year; secondary outcomes were reintervention, stricture-related surgery, emergency visits, hospitalisation, and adverse events. Cox regression assessed time-dependent outcomes; logistic regression identified predictors. Results Of 157 patients screened, 101 were randomised (50 EBD, 51 ES). Baseline demographics, disease extent, and prior therapies were comparable. Technical success was 88% in both groups; clinical success 92% (EBD) vs 96% (ES). Median procedure time was longer with ES (35 vs 30 min, p = 0.007). At median 12-month follow-up (range 3–36), ES reduced recurrence (24.5% vs 54.3%, p = 0.003), reintervention (23.5% vs 52%, p = 0.004), emergency visits (17.6% vs 54%, p 0.001), and hospitalisation (15.7% vs 38%, p = 0.01) vs EBD. Surgery was numerically lower (3.9% vs 16%, p = 0.051). Cox regression: ES prolonged time to recurrence (HR 0.35, p = 0.004), reintervention (HR 0.36, p = 0.006), and emergency visit (HR 0.28, p 0.001), with a trend for hospitalisation (HR 0.42, p = 0.02); no difference for surgery (p = 0.4) (Fig 1A-E). Adverse events occurred in 22% (EBD) vs 13.7% (ES, p = 0.31), mostly minor bleeding/pain; one perforation each. On multivariable analysis, reintervention was predicted by EBD (OR 3.6; 95% CI 1.5–8.6) and stricture length (OR 13.5; 95% CI 4.0–45.7). Recurrence was predicted by EBD (OR 3.4; 95% CI 1.5–7.8) and stricture length (OR 5.9; 95% CI 2.1–16.3). Surgery was predicted by younger age (OR 0.91/year; 95% CI 0.85–0.98), stricture length (OR 8.7; 95% CI 2.1–36.7), and upper GI vs colonic location (Fig 2). Conclusion This first randomised trial to evaluate predictors of outcomes after endotherapy for CD strictures shows that ES provides longer relief from recurrence/reintervention compared with EBD. However, the ultimate need for surgery is determined more by age, stricture length, and anatomical location than by treatment type. These findings support ES as the preferred first-line endoscopic therapy in selected patients, while highlighting key predictors for risk-stratified management References: 1.Bettenworth D, Bokemeyer A, Kou L, Lopez R, Bena JF, El Ouali S, Mao R, Kurada S, Bhatt A, Beyna T, Halloran B, Reeson M, Hosomi S, Kishi M, Hirai F, Ohmiya N, Rieder F. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn’s disease strictures. Aliment Pharmacol Ther. 2020 Oct;52(7):1104-1116 2.Lan N, Shen B. Endoscopic Stricturotomy Versus Balloon Dilation in the Treatment of Anastomotic Strictures in Crohn’s Disease. Inflamm Bowel Dis. 2018 Mar 19;24(4):897-907. 3.Bouhnik Y, Carbonnel F, Laharie D, Stefanescu C, Hébuterne X, Abitbol V, Nachury M, Brixi H, Bourreille A, Picon L, Bourrier A, Allez M, Peyrin-Biroulet L, Moreau J, Savoye G, Fumery M, Nancey S, Roblin X, Altwegg R, Bouguen G, Bommelaer G, Danese S, Louis E, Zappa M, Mary JY; GETAID CREOLE Study Group. Efficacy of adalimumab in patients with Crohn’s disease and symptomatic small bowel stricture: a multicentre, prospective, observational cohort (CREOLE) study. Gut. 2018 Jan;67(1):53-60. Conflict of interest: Pal, Partha: ​Partha Pal received consultancy fees/speaker honorarium from Johnson and Johnson, Takeda Pharmaceutical Company, Cipla Ltd, Sun Pharma, Zydus Biosciences, Dr Reddy Labs, Abbott India, RPG Life sciences, La Renon Healthcare Pvt Ltd and Daewoong Pharma Pooja, Kanapuram: No conflict of interest Gupta, Rajesh: No conflict of interest Tandan, Manu: No conflict of interest Reddy, D Nageashwar: No conflict of interest