Integrated endoscopic and medical approaches for Crohn's disease-associated strictures

Crohn's disease (CD) frequently results in fibrostenotic or anastomotic intestinal strictures, a major cause of morbidity despite advances in medical therapy. Endoscopic management is a central component of stricture treatment, providing organ-preserving alternatives to surgery. This review summarizes the current evidence for 3 principal endoscopic modalities: endoscopic balloon dilation (EBD), endoscopic stricturotomy (ES), and stent-based interventions. EBD, the most widely used technique, is recommended as the first-line therapy for short, non-angulated strictures, with consistently high technical and clinical success; however, repeat dilations are required during long-term follow-up. ES using an electrosurgical knife offers a targeted solution for fibrotic or EBD-refractory strictures, achieving high technical success, even in anatomically complex lesions, although delayed bleeding may occur. Stent-based interventions, including self-expandable metallic stents and biodegradable stents, have recently re-emerged as an option for intermediate-length or difficult strictures, including those beyond the typical length limit for EBD or ES; short-term, removable, anti-migration stents show a more favorable safety profile. These 3 modalities provide complementary strengths, and treatment selection should be individualized based on stricture length, morphology, location, associated inflammation, prior surgery, and endoscopist expertise. An integrated approach that optimizes endoscopic and medical therapies is essential for improving long-term outcomes and minimizing the need for repeated surgery in patients with CD.