Unmet Therapeutic Needs: Focus on Intestinal Fibrosis Surgical Approach: Resection, Strictureplasty and Others

Background: In patients with ileo-colonic Crohn's disease (CD), the main consequence of the development of intestinal fibrosis is the occurrence of a localized symptomatic stenosis for which treatment is mandatory. Besides medical treatment, which is still considered to be ineffective against non-inflammatory fibrotic intestinal stenosis due to CD, there are 2 options for the treatment of such stenosis: endoscopic and surgical approaches. Key Messages: Endoscopic treatment includes balloon dilatation and stenting, and can be performed only on selected patients with very short stenosis. Few reports with a small sample size are available; long-term results of endoscopic treatment remain unknown, with patients being exposed to possible early recurrence of the stenosis. For this reason, intestinal resection currently remains the first option for localized symptomatic intestinal stenosis due to CD refractory to medical therapy. Laparoscopic ileocecal resection with ileocolonic anastomosis gives good short-term results, without mortality and with very low rate of morbidity. Furthermore, when the resection is shorter than 50 cm, very few functional consequences or no consequences are reported, and quality of life is improved. However, CD recurrence is frequent and can be required to redo surgery in up to 30% of the cases. In order to reduce the theoretical risk of short bowel syndrome, some surgeons have proposed strictureplasty as a more conservative approach. The concept is to treat stenosis without intestinal resection by opening the stenosis. There are different kinds of stricturoplasty, with similar reported morbidity and long-term recurrence rates than those observed with resection. Conclusions: Because no randomized study exists, it is difficult to know what the best option for symptomatic ileal stenosis in CD is. However, for a majority of patients today, ileocecal resection is the first option, strictureplasty being reserved by most of the surgeons for recurrent cases and/or multiple stenoses. It requires more experience to perform endoscopic treatment with long-term results.