Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia.
Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
J Gastroenterol Hepatol. 2021 Feb;36(2):344-361. doi: 10.1111/jgh.15330. Epub 2020 Dec 27.
Strictures are the commonest complication in Crohn's disease. Surgery and endoscopic dilation are the mainstays of treatment, while drug therapy has often been considered contraindicated. The benefit of nonsurgical treatments, particularly drug and endoscopic therapy, need to be defined.
Ovid MEDLINE, Embase, Emcare, PsycINFO, CINAHL and the Cochrane Library (inception until August 30, 2019) were searched. Studies with ≥ 10 patients with Crohn's disease strictures, reporting on outcomes following medication or endoscopic treatment, were included.
Of 3480 records, 85 studies met inclusion criteria and formed the basis of this analysis. Twenty-five studies assessed drug therapy; none were randomized trials. Despite study heterogeneity anti-tumor necrosis factor (TNF) therapy appeared effective, with 50% of patients avoiding surgery after 4 years of follow up. No other drug therapy was of demonstrable benefit. Sixty studies assessed endoscopic therapy including 56 on endoscopic balloon dilation, two assessed needle knife stricturotomy, and two stent insertion. Dilation was equally effective for de novo and anastomotic strictures ≤ 5 cm in length, with most studies reporting a subsequent surgical rate of 30% to 50%. Repeat dilation was required in approximately half of all patients.
Anti-TNF drug therapy and endoscopic balloon dilation are effective strategies for avoiding surgery in patients with stricturing Crohn's disease. Additional endoscopic therapies require further evaluation. Early data suggest that combining these therapies may provide greater benefit than individual therapies. Optimization of current drug and endoscopic therapy, and the incorporation of newer therapies, are needed for stricturing Crohn's disease.
狭窄是克罗恩病最常见的并发症。手术和内镜扩张是主要的治疗方法，而药物治疗通常被认为是禁忌的。需要确定非手术治疗的益处，特别是药物和内镜治疗。
检索了 Ovid MEDLINE、Embase、Emcare、PsycINFO、CINAHL 和 Cochrane Library（从创建到 2019 年 8 月 30 日）。纳入了≥10 例克罗恩病狭窄患者的研究，报告了药物或内镜治疗后的结局。
在 3480 条记录中，有 85 项研究符合纳入标准，并构成了本分析的基础。25 项研究评估了药物治疗；没有随机试验。尽管研究存在异质性，但抗 TNF 治疗似乎有效，50%的患者在 4 年随访后避免了手术。其他药物治疗均无明显获益。60 项研究评估了内镜治疗，包括 56 项内镜球囊扩张，2 项评估了针刀狭窄切开术，2 项评估了支架置入术。扩张对新发病灶和长度≤5cm 的吻合口狭窄同样有效，大多数研究报告随后的手术率为 30%至 50%。大约一半的患者需要重复扩张。
抗 TNF 药物治疗和内镜球囊扩张是避免克罗恩病狭窄患者手术的有效策略。其他内镜治疗需要进一步评估。早期数据表明，联合这些治疗可能比单独治疗提供更大的益处。需要优化现有的药物和内镜治疗，并纳入新的治疗方法，以治疗克罗恩病狭窄。
