ORIGINAL ARTICLE Long-term Outcomes in Patients with Small Intestinal Strictures Secondary to Crohn’s Disease After Double-balloon Endoscopy-assisted Balloon Dilation Keijiro Sunada, MD,* Satoshi Shinozaki, MD, PhD,* ,† Manabu Nagayama, MD,* Tomonori Yano, MD, PhD,* Takahito Takezawa, MD,* Yuji Ino, MD,* Hirotsugu Sakamoto, MD, PhD,* Yoshimasa Miura, MD,* Yoshikazu Hayashi, MD, PhD,* Hiroyuki Sato, MD, PhD,* Alan Kawarai Lefor, MD, MPH, PhD, ‡ and Hironori Yamamoto, MD, PhD* Background: Crohn’s disease (CD) strictures of the small intestine are a feared complication and difficult to treat because of difficulty gaining access to the stricture site. The development of double-balloon endoscopy (DBE) enabled access to the entire small intestine with interventional capabilities. The aim of this study was to assess the long-term outcomes in patients with small intestinal strictures secondary to CD after DBE-assisted endoscopic balloon dilation (EBD). Methods: In this retrospective cohort study, DBE-assisted EBD was performed in 85 consecutive patients with CD strictures of the small intestine from 2002 to 2014. Follow-up data were available for 85 patients for a mean of 41.9 months (range, 0–141), and clinical outcomes were assessed. Results: Overall, 321 DBE-assisted EBD sessions (473 procedures) were performed in 85 patients during the study period. Most CD strictures were de novo (97%). The surgery-free rate after initial DBE-assisted EBD was 87.3% at 1 year and 78.1% at 3 years. The presence of a fistula was significantly associated with the need for surgical intervention (hazard ratio ¼ 5.50, 95% confidence interval: 2.16–14.0, P , 0.01). The surgery-free interval in patients with a fistula was significantly shorter than in patients without a fistula (P , 0.01, log-rank test). Conclusions: DBE-assisted EBD provides a favorable long-term outcome in patients with small intestinal CD-associated strictures. DBE-assisted EBD for CD strictures is a safe and effective treatment to avoid or postpone surgery over the long-term. (Inflamm Bowel Dis 2016;22:380–386) Key Words: double-balloon endoscopy, endoscopic balloon dilation, small intestinal stricture, Crohn’s disease, long-term outcomes C rohn’s disease (CD)-associated strictures are a significant complication, and their treatment remains a major challenge. Because the lumen of the small intestine is narrower than that of the colon, small bowel strictures are frequently caused by CD- associated inflammation, which significantly affects patient out- comes and may require multiple small intestinal resections that can lead to short bowel syndrome and malnutrition. Endoscopic balloon dilation (EBD) of small bowel strictures is a minimally invasive technique, which provides an effective therapeutic alternative based on bowel preservation. The clinical significance of EBD is obvious because the use of EBD may avoid surgical intervention, which can result in postoperative recurrence or complications. 1,2 In the 20th century, strictures located in the proximal jejunum, terminal ileum, or colon, were dilated using a standard endoscopic approach. At the beginning of the 21st century, double-balloon endoscopy (DBE) developed by Yamamoto et al 3 has enabled endoscopic visualization of the entire small intestine allowing therapeutic interventions including EBD, hemostasis, and polypectomy. 4–7 Our group was the first to report DBE-assisted EBD 8 and have treated small intestinal strictures caused by CD using DBE- assisted EBD since 2002. 9 Because CD is not a curable disease, repeat EBD is frequently required. Multiple resections that can- not cure CD may lead to the development of short bowel syn- drome. Unlike surgical resection, EBD does not lead to short bowel syndrome or complications associated with multiple re- sections. We consider DBE-assisted EBD as a maintenance ther- apy similar to the use of anti–tumor necrosis factor (TNF)-alpha antibody. One objective is to decrease the number of resections over the lifetime of patients with CD. Therefore, we do not Received for publication July 9, 2015; Accepted September 9, 2015. From the *Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan; † Shinozaki Medical Clinic, Tochigi, Japan; and ‡ Depart- ment of Surgery, Jichi Medical University, Tochigi, Japan. Author H. Yamamoto has a consultant relationship in FUJIFILM Corporation and has received honoraria, grants, and royalties from the company. He has patents for double-balloon endoscope produced by FUJIFILM Corporation. Author T. Yano belongs to the Department of Endoscopic Research and International Education (Funded by FUJIFILM Medical) and has a consultant relationship in FUJIFILM Corporation and has received honoraria and grants from this corpora- tion. The corporation had no role in the design, practice, or analysis of this study. The remaining authors have no conflict of interest to disclose. Reprints: Hironori Yamamoto, MD, PhD, Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan (e-mail: ireef@jichi.ac.jp). Copyright © 2015 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1097/MIB.0000000000000627 Published online 30 October 2015. 380 | www.ibdjournal.org Inflamm Bowel Dis  Volume 22, Number 2, February 2016 Copyright © 2015 Crohn’s & Colitis Foundation of America, Inc. Unauthorized reproduction of this article is prohibited. 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