Bharadwaj Shishira, Fleshner Phillip, Shen Bo
*Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, Ohio; and †Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
Inflamm Bowel Dis. 2015 Sep;21(9):2194-213. doi: 10.1097/MIB.0000000000000403.
One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.
三分之一的克罗恩病（CD）患者表现为狭窄型，其特征为管腔逐渐狭窄并出现梗阻症状。这些患者的诊断和治疗一直颇具吸引力且具有挑战性。免疫调节剂和生物制剂已成功用于治疗炎症型和瘘管型CD。生物制剂在治疗CD狭窄方面存在疗效和安全性问题。强效生物制剂促使黏膜快速愈合，可能使患者易于出现新的狭窄或使现有狭窄加重。另一方面，狭窄是CD患者五分之一的手术原因。疾病复发在吻合口处或其近端很常见，这些患者中的大多数在手术后1年内会出现新的内镜下病变。疾病的进展特性以及炎症和狭窄形成的重复循环导致反复手术，存在小肠综合征的风险。人们一直在探索肠道保留的内镜和手术策略。内镜球囊扩张术和狭窄成形术已成为切除术的有效替代方法。内镜球囊扩张术已被证明对于原发性或吻合口短狭窄是可行、安全且有效的。然而，通常需要反复扩张，内镜球囊扩张术的长期效果仍有待研究。狭窄成形术的引入为肠道保留策略增添了新的内容。尽管狭窄成形术后的复发率与手术切除相当，但人们担心保留肠段发生恶性肿瘤的风险增加。腹腔镜手术已广泛开展，其结果与开放手术相似，并发症更少、恢复更快、美容效果更好且成本更低。参与狭窄型CD患者管理的医生应考虑所有这些问题。
