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Who benefits from endotherapy in Crohn’s disease strictures? Predictors of recurrence, need for reintervention, and surgery from the Balloon Dilation versus Endoscopic Stricturotomy for Crohn’s Disease (BEST-CD) randomised controlled trial (NCT05521867)

P. Pal, K. Pooja, R. Gupta, M. Tandan, D.N. Reddy

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Slides compiled by Dr. Neeraj Narula 

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Introduction

Background & Objectives

    • Endoscopic balloon dilation (EBD) is widely used for Crohn’s disease (CD) strictures but recurrence and reintervention rates are high
    • Endoscopic stricturotomy (ES) is a promising alternative; defining predictors of long-term benefit is key to identifying the right patients for ES.

CD, Crohn’s disease; EBD, endoscopic balloon dilation; ES, endoscopic stricturotomy.

Pal P et al. ECCO 2026; (Abstract citation ID: jjaf231.019, OP19).

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Endoscopic Balloon Dilation (EBD):

    • Controlled Radial Expansion (CRE) balloon (Boston Scientific, USA)
    • Size of balloons were selected based on stricture characteristics (estimated diameter, ulceration etc.)
    • Inflated to a max diameter of 12-20mm (based on baseline diameter) over 60 seconds

Endoscopic Stricturotomy (ES)

    • Needle knife / Insulated-tip (IT) knife nano (Olympus, Tokyo, Japan)
    • Electrosurgical unit: Endo Cut 1 mod (ERBE VIO 300D/VIO 3; Erbe Elektromedizin, Germany) with standard settings (Effect 3, Cut Duration 1, Cut Interval 3). Radial incisions followed by circumferential current used in non-ulcerated area/circumferential incision and dissection technique.

3

1

3

Effect

Cut Duration

Cut Interval

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Introduction

CD, Crohn’s disease; EBD, endoscopic balloon dilation; ES, endoscopic stricturotomy.

Pal P et al. ECCO 2026; (Abstract citation ID: jjaf231.019, OP19).

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Methods

    • Design: Single-centre randomized controlled trial (Asian Institute of Gastroenterology, 2022-2025)
    • Population: Adults 18–65 years with CD and symptomatic, predominantly fibrotic/mixed strictures <3 cm accessible by standard endoscopy(de novo or anastomotic)
      • Key exclusions: >2 strictures, strictures beyond endoscopic reach, or prior ES.
      • Arms: Randomized to EBD vs ES.

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    • Primary endpoint: Clinical recurrence at 1 year.
    • Secondary outcomes: Reintervention, stricture-related surgery, emergency visits, hospitalisation, and adverse events.
    • Analyses:
      • Cox regression for time-dependent outcomes
      • Logistic regression to identify predictors of key outcomes

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Results:

  • 101 patients were randomized (EBD n=50; ES n=51), with comparable baseline characteristics between groups
  • Procedural feasibility was high and similar: technical success was 88% in both arms, and clinical success was 92% (EBD) vs 96% (ES)
  • Over a median 12-month follow-up (range 3–36), ES was associated with fewer downstream stricture-related events than EBD:

EBD, endoscopic balloon dilation; ES, endoscopic stricturotomy; CD, Crohn’s disease; ICR, ileocaecal resection; IFX, infliximab; CI, confidence interval; IQR, interquartile range.

Pal P et al. ECCO 2026; (Abstract citation ID: jjaf231.019, OP19).

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ES

EBD

p-value

Recurrence

24.5%

54.3%

0.003

Reintervention

23.5%

52%

0.004

Emergency visits

17.6%

54%

<0.001

Hospitalisation

15.7%

38%

0.01

Surgery

3.9%

16%

0.051

Adverse Event

13.7%

22%

0.31

Bleeding Event

9.8%

8%

–

ES prolonged time to recurrence, reintervention, surgery, and stricture related ED visit

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Results

CD, Crohn’s disease; EBD, endoscopic balloon dilation; ES, endoscopic stricturotomy; HR, hazard ratio; OR, odds ratio; CI, confidence interval; GI, gastrointestinal.

Pal P et al. ECCO 2026; (Abstract citation ID: jjaf231.019, OP19).

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Predictor

Clinical Recurrence – Univariate OR

(95% CI), p

Clinical Recurrence – Multivariate OR

(95% CI), p

Reintervention – Univariate OR

(95% CI), p

Reintervention – Multivariate OR (95% CI), p

Surgery – Univariate OR

(95% CI), p

Surgery – Multivariate OR (95% CI), p

Balloon dilation vs stricturotomy

3.4 (1.5–7.8), p=0.004

3.6 (1.5–8.6), p=0.003

3.6 (1.5–8.6), p=0.003

3.4 (1.5–7.8), p=0.004

–

–

Stricture length ≥2 cm

5.9 (2.1–16.3), p<0.001

13.5 (4.0–45.7), p<0.001

13.5 (4.0–45.7), p<0.001

5.9 (2.1–16.3), p<0.001

8.7 (2.1–36.7), p=0.003

8.7 (2.1–36.7), p=0.003

Younger age (per year)

–

–

–

–

0.91 (0.85–0.98), p=0.012

0.91 (0.85–0.98), p=0.012

Proximal/colonic location

–

–

–

–

3.8 (1.2–12.1), p=0.025

3.8 (1.2–12.1), p=0.025

Prior biologic therapy

0.47 (0.21–1.07), p=0.072

–

–

–

–

–

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Conclusions

    • Endoscopic stricturotomy associated with longer time to clinical recurrence and need for re-intervention when compared with EBD for short CD strictures (<3cm) with similar safety profile
    • Length of stricture strongly predictive of recurrence/need for re-intervention/surgery

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Significance to clinical practice

    • These findings support endoscopic stricturotomy as first line endotherapy in selected patients with short <3cm strictures where expertise is available
    • Access to expertise is likely limited in most of Canada
    • Relevance for patients with strictures >=3cm uncertain

Pal P et al. ECCO 2026; (Abstract citation ID: jjaf231.019, OP19).

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