Endoscopic Stricturotomy Versus Balloon Dilation for Small Bowel Fibrotic Strictures in Crohn's Disease

Fibrotic intestinal strictures are an important complication of Crohn's disease. Medical therapy can effectively control intestinal inflammation, but established fibrotic strictures may respond poorly to medical treatment and may require endoscopic or surgical intervention. Endoscopic balloon dilation is commonly used for selected Crohn's disease-related strictures, but limitations include recurrence and the potential need for repeated procedures or surgery. Endoscopic stricturotomy is an alternative endoscopic approach that directly incises the fibrotic stricture and may provide another treatment option for patients with Crohn's disease-related small bowel strictures.

This study is a multicenter, open-label, randomized, parallel-group controlled trial comparing endoscopic stricturotomy with endoscopic balloon dilation in patients with Crohn's disease and small bowel fibrotic strictures. Participants who meet the eligibility criteria will be randomly allocated to one of the two endoscopic treatment groups.

In the endoscopic stricturotomy group, the fibrotic stricture will be incised endoscopically until adequate luminal enlargement is achieved. In the endoscopic balloon dilation group, the stricture will be dilated endoscopically using a dilation balloon. After treatment, the treated stricture will be reassessed endoscopically.

The study primarily aims to compare the safety of the two endoscopic approaches and secondarily to compare their immediate technical effectiveness.

Inclusion criteria

• Age 18 to 70 years.
• Diagnosis of Crohn's disease for at least 3 months before screening, based on clinical manifestations and endoscopic and/or imaging findings, with histopathological support.
• Presence of a small bowel stricture that prevents passage of the enteroscope.
• Partial intestinal obstruction, meeting the following criteria:

• Clinical manifestations of partial intestinal obstruction;
• Small bowel stricture identified by endoscopy (with a lumen narrower than the distal end of the enteroscope) or computed tomography enterography (CTE); and
• Marked dilation of the bowel lumen proximal to the stricture demonstrated by enteroscopy or CTE.
• Written informed consent and any required privacy authorization signed and dated by the participant or the participant's legally authorized representative, as applicable, before initiation of study procedures.
• Female participants of childbearing potential who are sexually active with a non-sterilized male partner must agree to use adequate conventional contraception throughout the study period, beginning at the time of signing the informed consent form.

Exclusion criteria

• Anastomotic stricture.
• Deep or large ulceration at the stricture site.
• Marked angulation or sharp bending at the stricture site.
• An absolute indication for surgical treatment, including acute perforation, major bleeding that cannot be managed medically or endoscopically, intra-abdominal abscess, small bowel fistula, or malignancy.
• Inability to tolerate anesthesia, enteroscopy, or surgical treatment because of conditions such as cardiac or pulmonary failure or severe coagulation disorders.
• Evidence of active infection during the screening period.
• Active tuberculosis, including findings suspicious for pulmonary tuberculosis on chest radiography performed within 3 months before Week 0.
• Any confirmed congenital or acquired immunodeficiency, including human immunodeficiency virus (HIV) infection or organ transplantation.
• A clinically significant infection, such as pneumonia or pyelonephritis, within 30 days before screening, or an ongoing chronic infection.
• Any unstable or uncontrolled cardiovascular, pulmonary, hepatic, renal, gastrointestinal, genitourinary, hematologic, coagulation, immune, endocrine/metabolic, or other medical condition that, in the investigator's opinion, could interfere with study results or compromise participant safety.
• History of malignancy.
• Any of the following laboratory abnormalities during screening:

• Hemoglobin <5 g/dL;
• White blood cell count <3 × 10^9/L;
• Platelet count <100 × 10^9/L or >1200 × 10^9/L;
• Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >3 times the upper limit of normal (ULN); or
• Serum creatinine >2 times the ULN.
• Inability to attend all required study visits or comply with study procedures.
• Female participants who are pregnant, plan to become pregnant before or during study participation, or plan to donate ova during this period.
• Participants who are coerced into consenting to study participation.
• Any other condition that, in the investigator's opinion, makes the participant unsuitable for endoscopic or surgical treatment.