Risk factors for surgical recurrence and the preventive effect of endoscopic balloon dilatation in postoperative patients with Crohn 's disease

Although biologics have improved Crohn's disease (CD) management, surgery is still required for severe strictures or penetrating disease. Endoscopic balloon dilatation (EBD) is widely used for postoperative strictures and provides symptom relief; however, its potential preventive effect on surgical recurrence remains unclear. In addition, prognostic factors for surgical recurrence have not been fully established.

We retrospectively analyzed the data of 92 postoperative patients with CD. EBD recurrence was defined as severe stricture after surgery requiring EBD.

The EBD recurrence was 30.4% at five years and 47.3% at ten years, while the surgical recurrence was 16.2% at five years and 23.3% at ten years. Assuming that severe strictures requiring EBD would otherwise have necessitated reoperation, we evaluated the combined outcome of surgical recurrence or EBD recurrence. The cumulative incidence was 33.9% at five years and 56.0% at ten years, with surgical recurrence accounting for approximately 50% of the combined outcome at five years and 40% at ten years.　Kaplan-Meier curves showed a gradual increase in both recurrence types at five years, becoming nearly flat beyond eight years. Cox regression analyses revealed that lymphopenia (< 700 cells/µL) (hazard ratio [HR], 3.26; 95% confidence interval [CI], 1.11-9.61; p = 0.032), Clavien-Dindo grade ≥ 3 complications (5.51; 1.42-21.43; p = 0.014), and operation time ≥ 237 min (3.23; 1.09-9.58; p = 0.035) were significantly associated with surgical recurrence. Penetrating disease behavior was linked to EBD recurrence (HR, 3.11; 95% CI, 1.08-8.96; p = 0.036). Among 43 patients followed for > 5 years without surgical recurrence within 5 years after surgery, 10 (23.3%) had experienced EBD recurrence within 5 year after surgery. Among patients without surgical recurrence within the first 5 years after surgery, the subsequent 5 years (10-year postoperative) surgical recurrence rate was 8.5%, indicating favorable prognosis regardless of prior EBD recurrence within 5 years after surgery.

EBD may reduce the need for surgical reoperation in postoperative patients with CD. Surgical recurrence was associated with operative factors, including prolonged surgery and postoperative complications, as well as a nutritional and immunological factor, lymphopenia. Once surgical recurrence was avoided within the first 5 postoperative years, the subsequent risk remained low.