Endoscopic Treatment for Crohn's Disease-related Deep Small Intestinal Strictures: Balloon-Assisted Enteroscopy-Guided Stricturotomy versus Balloon Dilation Therapy - A Single-Center Retrospective Study

Endoscopic Treatment for Crohn's Disease-related Deep Small Intestinal Strictures: Balloon-Assisted Enteroscopy-Guided Stricturotomy versus Balloon Dilation Therapy - A Single-Center Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Endoscopic Treatment for Crohn's Disease-related Deep Small Intestinal Strictures: Balloon-Assisted Enteroscopy-Guided Stricturotomy versus Balloon Dilation Therapy - A Single-Center Retrospective Study Liu Zhongcheng, Peng Bo, Chen Dongting, Chao Kang, Tang Jian, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7561520/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Nov, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted 12 You are reading this latest preprint version Abstract Background Research data on balloon-assisted enteroscopy-guided stricturotomy (BAE-ES) versus endoscopic balloon dilation (BAE-EBD) for the treatment of Crohn's disease (CD)-related deep small intestinal strictures is limited. This study aimed to compare the efficacy and safety of BAE-ES versus BAE-EBD in treating CD-related deep small intestinal strictures. Methods This retrospective study included patients with CD-related deep small intestinal strictures who underwent either BAE-ES or BAE-EBD treatment between May 2021 and June 2025. Outcome measures included technical success, adverse events, and follow-up outcomes. Results A total of 100 CD patients underwent treatment (BAE-ES: n = 59; BAE-EBD: n = 41). BAE-ES: 73 BAE-ES procedures were performed on 59 patients. The technical success rate was 98.63% (72/73). Immediate bleeding occurred at 15 stricture sites (20.55%) in 15 patients (25.42%). BAE-EBD: 44 BAE-EBD procedures were performed on 41 patients. The technical success rate was 88.64% (39/44). Immediate bleeding occurred at 21 stricture sites (47.73%) in 21 patients (51.22%). Follow-up: BAE-ES: No cases of bleeding or perforation occurred during follow-up. 1 patient (1.69%) underwent partial small intestinal resection. Stricture recurrence requiring endoscopic re-intervention occurred at 2 sites (2.74%) in 1 patient. BAE-EBD: Bleeding occurred in 2 patients during follow-up; no perforations occurred. Four patients (9.76%) underwent partial small intestinal resection. Stricture recurrence requiring endoscopic re-intervention occurred at 6 sites (13.64%) in 6 patients; the treatment strategy was changed to BAE-ES, which achieved technical success. Conclusion BAE-ES demonstrates a higher technical success rate and favorable efficacy and safety profile for treating CD-related deep small intestinal strictures, warranting broader clinical application. Crohn's Disease Small Intestinal Strictures Balloon Dilation Stricturotomy Figures Figure 1 Figure 2 1 Introduction Intestinal strictures are a common complication of Crohn's disease (CD). The prevalence of small intestinal stricturing CD ranges from 20–40% [ 1 ]. CD-related intestinal strictures can be classified into three types based on their underlying pathophysiological mechanisms: inflammatory, fibrotic, and mixed strictures. Fibrotic strictures result from chronic inflammatory stimulation leading to intestinal wall fibrosis. These strictures are typically unresponsive to medical therapy and often require surgical intervention. However, due to the increasing annual risk of anastomotic stricture recurrence after surgery, some CD patients inevitably require multiple surgical procedures [ 2 ]. Consequently, identifying more effective and safer treatments for CD-related deep small intestinal strictures remains an urgent challenge. In recent years, endoscopic therapy has played a significant role in delaying or reducing the need for surgery in CD patients with short-segment, localized fibrotic strictures. Current primary endoscopic treatment modalities include endoscopic balloon dilation (EBD) and stent placement. Although multiple international and domestic guidelines recommend balloon-assisted enteroscopy-guided EBD (BAE-EBD) for treating CD-related intestinal strictures, this approach has limitations, including a high recurrence rate and narrow indications [ 3 , 4 ]. Balloon-assisted enteroscopy-guided stricturotomy (BAE-ES) is a relatively new technique that has demonstrated good efficacy in treating strictures of the biliary system, esophagus, and intestinal anastomoses [ 3 ]. To date, there is a paucity of clinical research, both internationally and domestically, comparing the efficacy and safety of BAE-ES versus BAE-EBD specifically for deep small intestinal strictures in CD. This project aims to evaluate the effectiveness and safety of BAE-ES compared to BAE-EBD, to validate the feasibility and potential superiority of BAE-ES in CD management. Our goal is to explore more effective clinical treatments for CD-related deep small intestinal strictures, ultimately improving the quality of life for CD patients. 2 Methods 2.1 Patient Enrollment This study retrospectively enrolled consecutive patients with Crohn's disease who underwent either balloon-assisted enteroscopy-guided stricturotomy (BAE-ES) or balloon-assisted enteroscopy-guided endoscopic balloon dilation (BAE-EBD) at The Sixth Affiliated Hospital of Sun Yat-sen University between May 2021 and June 2025. Inclusion criteria: Underwent BAE-ES or BAE-EBD for small intestinal strictures. CD diagnosis confirmed based on a combination of clinical manifestations, radiological findings, endoscopic features, and/or histopathological biopsy. Presence of persistent luminal stricture with pre-stenotic dilation, confirmed by imaging or endoscopy. Absence of large ulcers or severe inflammatory manifestations endoscopically at the stricture site. All strictures located in the deep small intestinal (duodenum, jejunum, or ileum) and accessible via balloon-assisted enteroscopy. Exclusion criteria: Presence of a peri-stricture intra-abdominal abscess. Presence of an internal fistula adjacent to the stricture. Endoscopic or radiological features suggestive of malignancy at the stricture site. 2.2 Operational Procedure All BAE-ES and BAE-EBD procedures were independently performed by senior endoscopists at our center. Preoperative evaluation of stenosis characteristics was routinely conducted using intestinal ultrasonography, CTE, or MRE. Following intestinal preparation with 4 liters of oral polyethylene glycol (PEG) solution, the procedures were performed under general anesthesia. The insertion route (oral, anal, or dual) was determined by the operator based on imaging localization: oral insertion was chosen for stenoses located in the proximal two-thirds of the small intestinal, while anal insertion was used for the remainder; dual routes were potentially employed for patients with multiple stenoses. A double-balloon enteroscope (Fujifilm EN-580T) was utilized. For ES procedures, a hook knife (Olympus KD-620UR) or IT knife nano (Olympus KD-612U) was used, combined with the ESD endoCUT Q mode of the Erbe electrosurgical system (Germany). The stenosis was incised radially or circumferentially until the endoscope could pass through smoothly. Hemostasis was achieved using endoscopic clips, argon plasma coagulation (APC, Erbe, Germany), or a high-frequency hemostatic forceps (Olympus FD-411UR), as determined by the operator. Balloons were used for EBD procedures. Total parenteral nutrition (TPN) and continuous intravenous octreotide infusion (0.05 mg/h) were administered on the night of the procedure, with a gradual transition to a low-residue diet within 48–72 hours postoperatively. 2.3 Outcome Measures Technical success: Defined as the ability of the endoscope to pass through the stenosis post-procedure. Adverse events: Rates of intraprocedural bleeding or perforation, and surgical intervention rate. Follow-up: Rates of bleeding, perforation, surgical intervention, and endoscopic re-intervention during the follow-up period. 2.4 Statistical Analysis Data are presented as mean (standard deviation), median (interquartile range), or number (percentage). 3 Results A total of 100 CD patients underwent BAE-ES or BAE-EBD treatment. The mean age was 31.5 years, with 84 males and 16 females. The BAE-ES group comprised 59 patients, and the BAE-EBD group comprised 41 patients. Fourteen patients had a history of partial small intestinal resection. Patient baseline characteristics are presented in Table 1 . Table 1 Characteristics of included patients BAE-ES BAE-EBD F P Patient Number 59 41 - - Age 0.221 0.639 40 17 13 Gender 1.828 0.179 Male 52 32 Female 7 9 Preoperative Enteral Nutrition 0.366 0.547 Yes 31 19 No 28 22 Preoperative Biologics 2.551 0.113 Yes 34 30 No 25 11 BAE-ES, balloon-assisted enteroscopy-guided stricturotomy; BAE-EBD, balloon-assisted enteroscopy-guided endoscopic balloon dilation. Endoscopic characteristics of the strictures are detailed in Table 2 . Among the 100 patients, there were 117 strictures. Strictures were located in the jejunum in 19 patients (19%), in the ileum in 76 patients (76%), and in both the jejunum and ileum in 5 patients (5%). Insertion routes included oral in 46 patients (46%), anal in 34 patients (34%), and dual routes in 20 patients (20%). The endoscope body (9.4 mm) could not pass through any of the strictures initially. Complete small intestinal examination was achieved after stricture treatment in 6 patients. Twenty-three patients (35.94%) had at least two strictures requiring multiple BAE-ES sessions, and 8 patients (15.09%) had at least two strictures requiring multiple BAE-EBD sessions. Fecaliths were present proximal to the stricture in 8 cases (6.84%). Ulcers were observed surrounding 23 strictures (19.66%), mucosal congestion and swelling surrounded 12 strictures (10.26%), and smooth mucosa surrounded 82 strictures (70.09%). 102 strictures (87.18%) were eccentric, while 15 (12.82%) were concentric. In the BAE-ES group: Stricture diameter was 5.04 ± 1.09mm, and stricture thickness was 14.40 ± 6.13 mm. The IT knife was used in 30 patients, and the hook knife was used in 29 patients. In the BAE-EBD group: Stricture diameter was 5.41 ± 1.34 mm, and stricture thickness was 12.43 ± 0.60 mm. Boston Scientific balloons were used in all cases. Table 2 Characteristics of strictures BAE-ES BAE-EBD t/F p Location 0.040 0.842 jejunum 17 9 ileum 52 33 Jejunum and ileum 4 2 Stricture Oral Side with Fecalith 2.313 0.131 Yes 7 1 No 66 43 Peri-stricture Mucosa 1.304 0.256 Ulceration 15 8 mucosal congestion and swelling 11 1 Smooth 47 35 Stricture Morphology 1.247 0.266 Eccentric 61 40 Concentric 12 41 Stricture Diameter (mm) 5.04 ± 1.09 5.41 ± 1.34 -1.546 0.126 Stricture Thickness (mm) 14.40 ± 6.13 12.43 ± 0.60 1.688 0.094 BAE-ES, balloon-assisted enteroscopy-guided stricturotomy; BAE-EBD, balloon-assisted enteroscopy-guided endoscopic balloon dilation. 3.1 Technical Outcomes BAE-ES group: 73 BAE-ES procedures were performed on 59 patients. Technical success was achieved in 72 strictures (98.63%) involving 58 patients (98.31%) (Table 3 ). Table 3 Adverse Events and Follow-up Status in Both Patient Groups BAE-ES BAE-EBD F p Technical success rate 72/73 (98.63%) 39/44 (88.64%) 5.820 0.017 Adverse Events Immediate bleeding 15/73 (20.55%) 21/44 (47.73%) 10.186 0.002 perforation 0/73 (0%) 0/44 (0%) - - Follow-up Results Bleeding 0/73 (0%) 2/44 (4.55) 3.417 0.067 Perforation 0/73 (0%) 0/44 (0%) - - Surgical Intervention Rate 1/73 (1.69%)) 4/44 (9.76%) 4.071 0.046 Endoscopic Re-intervention Rate 2/73 (2.74%) 6/44 (13.64%) 7.702 0.006 BAE-ES, balloon-assisted enteroscopy-guided stricturotomy; BAE-EBD, balloon-assisted enteroscopy-guided endoscopic balloon dilation. BAE-EBD group: 44 BAE-EBD procedures were performed on 41 patients. Technical success was achieved in 39 strictures (88.64%) involving 36 patients (87.80%) (Table 3 ). 3.2 Adverse Events BAE-ES group: Immediate bleeding occurred at 19 strictures (26.03%) in 15 patients (25.42%). Hemostasis was achieved with argon plasma coagulation (APC) or the bleeding stopped spontaneously after irrigation with water. There were 0 cases of perforation. No surgical intervention was required, and there were no procedure-related deaths (Table 3 ). BAE-EBD group: Immediate bleeding occurred at 21 strictures (47.73%) in 21 patients (51.22%). Hemostasis was achieved with APC or the bleeding stopped spontaneously after irrigation with water. There were 0 cases of perforation. No surgical intervention was required, and there were no procedure-related deaths (Table 3 ). 3.3 Follow-up Results Bleeding/Perforation during Follow-up: No bleeding or perforation occurred in the BAE-ES group. In the BAE-EBD group, gastrointestinal bleeding occurred in 2 patients on postoperative day 2 and day 3, respectively. Bleeding ceased with conservative medical management in both cases. No perforations occurred. Surgical Intervention Rate during Follow-up: BAE-ES group: 1 patient underwent partial small intestinal resection (surgical intervention rate: 1.69%). This surgery was performed for a different stricture (not the one treated endoscopically). BAE-EBD group: 4 patients underwent partial small intestinal resection (surgical intervention rate: 9.76%). Endoscopic Re-intervention Rate during Follow-up: BAE-ES group: Recurrent stricture requiring endoscopic re-intervention occurred at 2 strictures in 1 patient. Technical success was achieved with repeat BAE-ES (endoscope passage restored). The stricture re-intervention rate was 2.74% (2/73). BAE-EBD group: Recurrent stricture requiring endoscopic re-intervention occurred at 6 strictures in 6 patients. The endoscopic approach was changed to BAE-ES, and technical success was achieved (endoscope passage restored). The stricture re-intervention rate was 13.64% (6/44) (Table 3 ). 4 Discussion Current guidelines continue to recommend BAE-EBD as the first-line endoscopic treatment for CD-related deep small intestinal strictures, while BAE-ES is not mentioned. However, the high recurrence rate associated with BAE-EBD limits its long-term benefit for patients [ 3 , 5 ]. This study evaluated the efficacy and safety of BAE-ES versus BAE-EBD for CD-related deep small intestinal strictures using a relatively large single-center dataset. Our findings demonstrate that BAE-ES achieves a high success rate for treating deep small intestinal strictures in CD (procedural success: 98.63%; patient success: 98.31%). The success rate of BAE-EBD was lower than that of BAE-ES (procedural success: 88.64%; patient success: 87.80%), with statistical significance (p = 0.017). Furthermore, during postoperative follow-up, both the rates of repeat endoscopic intervention and surgical intervention were significantly lower in the BAE-ES group compared to the BAE-EBD group (p < 0.05). These data underscore the potential clinical value of BAE-ES. The incidence of immediate bleeding in our study was 19 strictures (26.03%) in 15 patients (25.42%) for the BAE-ES group, and 23 strictures (52.27%) in 21 patients (51.22%) for the BAE-EBD group. The higher bleeding incidence can be attributed to two main factors: Firstly, our study included minor oozing from the treatment site post-BAE-ES or BAE-EBD, most of which resolved spontaneously. Secondly, the fundamental mechanism of BAE-EBD involves inflating a balloon to exert uniform radial force on the stricture, which can increase pressure on the weakened intestinal wall, particularly in strictures associated with ulcers or active inflammation. The uneven thickness of the stricture wall in such cases predisposes to intraprocedural or postprocedural bleeding and perforation during BAE-EBD. Conversely, the mechanism of BAE-ES involves longitudinal incision of the stricture ring using an electrosurgical knife, extending into the muscular layer to directly cut through fibrous scar tissue. This approach inherently carries a risk of bleeding. Given the segmental nature of CD, the choice of stricture treatment modality should be individualized based on the specific location and characteristics of the lesion. We propose that for concentric strictures, either BAE-ES or BAE-EBD can be considered. However, for eccentric strictures, especially those surrounded by ulcers or inflammation, BAE-ES may offer a safety advantage. It allows the operator to actively select the incision site and control the depth of incision, potentially avoiding ulcerated areas to reduce complication risk. This necessitates a high level of operator expertise and clinical experience. Treatment selection should be guided by a thorough assessment of the patient's imaging findings to develop a personalized therapeutic strategy. In the BAE-ES group, one patient (1.69%) underwent partial small intestinal resection during follow-up. This patient declined endoscopic follow-up (BAE); surgery revealed that the resection was necessitated by a different stricture, not the one previously treated endoscopically. Recurrent stricture requiring endoscopic re-intervention occurred in two strictures (2.74%) of one patient; technical success was achieved with repeat BAE-ES. This indicates that BAE-ES is associated with low rates of surgical intervention and endoscopic re-intervention. In contrast, the BAE-EBD group had a higher surgical intervention rate (4 patients, 9.76%) and a higher endoscopic re-intervention rate (6 strictures, 13.64%). Five of these six patients requiring re-intervention had not achieved technical success during their initial BAE-EBD (endoscope could not pass), and their stricture thickness was consistently greater than 2 cm. This suggests that for strictures thicker than 2 cm, BAE-ES may be superior to BAE-EBD. The higher rates of surgical intervention and endoscopic re-intervention observed in the BAE-EBD group align with previous studies [ 6 , 7 ]. According to a meta-analysis by Bettenworth et al. [ 8 ], the pooled technical success rate for EBD in CD-related small intestinal strictures was 94.9%, with clinical relief of obstructive symptoms achieved in 82.3% of patients. However, during a mean follow-up of 20.5 months, 38.8% required repeat EBD and 27.4% ultimately required surgical intervention [ 8 ]. Our outcomes appear more favorable than those reported in this meta-analysis. Contributing factors may include our center's protocol of close follow-up and optimized medical therapy for CD control post-procedure, combined with the fact that all endoscopic procedures were performed by highly experienced experts (each with over ten thousand small intestinal endoscopies), ensuring procedural quality. Regarding the choice of electrosurgical knife, we propose that for strictures with a diameter less than 1 cm, either an IT knife or a hook knife can be used effectively. For strictures larger than 1.2 cm, the hook knife may be preferable. The IT knife features a T-shaped design with an insulated tip; the effective cutting area behind the insulation may not adequately cover the entire thickness of wider strictures. The hook knife offers advantages: its slender, L-shaped tip allows for excellent visualization during incision. The hook can be inserted between the scar tissue and the circular muscle layer, enabling a controlled lifting and advancing technique for incision. This helps prevent excessively deep cuts that could lead to perforation. The hook knife is also suitable for angled strictures, allowing for cutting either by pulling back or pushing forward after traversing the stricture. This study is retrospective, and heterogeneity in patient characteristics is inherent. Nevertheless, it represents the largest single-center study on this topic to date, providing compelling evidence. Future prospective cohort studies are warranted to obtain higher-level evidence. 5 Conclusion For CD patients, BAE-ES demonstrates high success rates, favorable efficacy, and a good safety profile for treating deep small intestinal strictures compared to BAE-EBD. Relative to surgical intervention, BAE-ES offers the advantages of being minimally invasive, facilitating faster recovery, and potentially reducing the risk of severe complications such as intestinal perforation and short intestinal syndrome. Declarations FUNDING The study was supported in part by National Key R&D Program of China [2023YFC2507300] and the Sixth Affiliated Hospital of Sun Yat-Sen University Clinical Research –‘1010’Program [grant number 1010CG(2023)-02]. ACKNOWLEDGMENTS None. AUTHOR CONTRIBUTIONS Liu Zhongcheng: conceptualization, methodology, formal analysis, writing – review & editing, data curation and formal analysis. Peng Bo, Chen Dongting, Chao Kang, Tang Jian, Li Miao: investigation. Guo Qin: project administration. All authors approved the final manuscript. CONFLICTS OF INTEREST The authors declare that there are no conflicts of interest in this study. DATA ACCESSIBILITY STATEMENT All relevant data are within the paper. Disclosures Liu Zhongcheng, Peng Bo, Chen Dongting, Chao Kang, Tang Jian, Li Miao, and Guo Qin have no conflicts of interest or financial ties to disclose. ETHICS STATEMENT This study was approved by the Ethics Committee of the Sixth Affiliated Hospital of Sun Yat-Sen University (approval number: 2023ZSLYEC-264) and was conducted in accordance with the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants. References Swaminath A , Lichtiger S . Dilation of colonic strictures by intralesional injection of infliximab in patients with Crohn′s colitis. Inflamm Bowel Dis, 2008,14(2):213-216. Pal P, Reddy DN, Rao GV. Endoscopic Assessment of Postoperative Recurrence in Crohn's Disease: Evolving Concepts. Gastrointest Endosc Clin N Am. 2025, 35(1):121-140. Shen B, Kochhar G, Navaneethan U, et al. Practical guidelines on endoscopic treatment for Crohn’s disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group. Lancet Gastroenterol Hepatol, 2020, 5 (4), 393-405. Bettenworth D, Baker ME, Fletcher JG,et al; Stenosis Therapy Anti-Fibrotic Research (STAR) Consortium. A global consensus on the definitions, diagnosis and management of fibrostenosing small bowel Crohn's disease in clinical practice. Nat Rev Gastroenterol Hepatol. 2024, 21(8):572-584. Lian L, Stocchi L, Remzi FH, et al. Comparison of Endoscopic Dilation vs Surgery for Anastomotic Stricture in Patients With Crohn's Disease Following Ileocolonic Resection. Clin Gastroenterol Hepatol. 2017, 15(8):1226-1231. Lan N, Shen B. Endoscopic stricturotomy with needle knife in the treatment of strictures from inflammatory bowel disease. Inflamm Bowel Dis. 2017;23:502–13. Lan N, Shen B. Endoscopic stricturotomy versus balloon dilation in the treatment of anastomotic strictures in crohn’s disease. Inflamm Bowel Dis. 2018;24:897–90. Bettenworth D, Bokemeyer A, Kou L, et al. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn's disease strictures. Aliment Pharmacol Ther. 2020 , 52(7):1104-1116. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Nov, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted Editorial decision: Revision requested 02 Oct, 2025 Reviews received at journal 26 Sep, 2025 Reviews received at journal 25 Sep, 2025 Reviews received at journal 25 Sep, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers invited by journal 14 Sep, 2025 Editor assigned by journal 10 Sep, 2025 Submission checks completed at journal 09 Sep, 2025 First submitted to journal 08 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:06:51","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":56497,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7561520/v1/273b699dc05c375334834359.png"},{"id":91954259,"identity":"0e0226fc-7c2e-4cce-8949-7e116e864da5","added_by":"auto","created_at":"2025-09-23 07:06:51","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":21482,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7561520/v1/4bfaef3826c9568ac17afa45.png"},{"id":91954262,"identity":"85dfcbe8-8e67-4278-bb20-ae1143843c4d","added_by":"auto","created_at":"2025-09-23 07:06:51","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58462,"visible":true,"origin":"","legend":"","description":"","filename":"322150de90174d7b91b98b618d0836c51structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7561520/v1/52a755bad8644cd81c4f92da.xml"},{"id":91954263,"identity":"a94a802c-b74e-44eb-8cd9-dc01e39ddb82","added_by":"auto","created_at":"2025-09-23 07:06:51","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66874,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7561520/v1/a1f1452a29e41aef593c2021.html"},{"id":91954254,"identity":"e5e60f5d-36df-4211-a6a5-adb04db618da","added_by":"auto","created_at":"2025-09-23 07:06:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94946,"visible":true,"origin":"","legend":"\u003cp\u003eA: Ileal stricture, ulcers are seen surrounding the stricture\u003c/p\u003e\n\u003cp\u003eB: During BAE-ES\u003c/p\u003e\n\u003cp\u003eC: After BAE-ES\u003c/p\u003e\n\u003cp\u003eD: After BAE-ES, oozing of blood from the wound site\u003c/p\u003e\n\u003cp\u003eE: The bleeding wound site was treated with argon plasma coagulation, and metallic clips were applied to prevent re-bleeding and stricture formation.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7561520/v1/441e1c70fe8704ab1d17ab09.png"},{"id":91954253,"identity":"cc6bbd6f-1f11-40c6-bd95-e3bf9ebc5627","added_by":"auto","created_at":"2025-09-23 07:06:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38162,"visible":true,"origin":"","legend":"\u003cp\u003eF: Ileal stricture, the mucosa surrounding the stricture is smooth\u003c/p\u003e\n\u003cp\u003eG: During BAE-EBD\u003c/p\u003e\n\u003cp\u003eH: After BAE-EBD\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7561520/v1/2b9df0fffef1e8d0e0a8ac8c.png"},{"id":96105315,"identity":"75055ac4-3f7b-4dd8-91a7-70cb05216f15","added_by":"auto","created_at":"2025-11-17 16:11:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726215,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7561520/v1/229ac90f-c649-4034-8fc0-854dc039365b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endoscopic Treatment for Crohn's Disease-related Deep Small Intestinal Strictures: Balloon-Assisted Enteroscopy-Guided Stricturotomy versus Balloon Dilation Therapy - A Single-Center Retrospective Study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eIntestinal strictures are a common complication of Crohn's disease (CD). The prevalence of small intestinal stricturing CD ranges from 20\u0026ndash;40% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. CD-related intestinal strictures can be classified into three types based on their underlying pathophysiological mechanisms: inflammatory, fibrotic, and mixed strictures. Fibrotic strictures result from chronic inflammatory stimulation leading to intestinal wall fibrosis. These strictures are typically unresponsive to medical therapy and often require surgical intervention. However, due to the increasing annual risk of anastomotic stricture recurrence after surgery, some CD patients inevitably require multiple surgical procedures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Consequently, identifying more effective and safer treatments for CD-related deep small intestinal strictures remains an urgent challenge.\u003c/p\u003e\u003cp\u003eIn recent years, endoscopic therapy has played a significant role in delaying or reducing the need for surgery in CD patients with short-segment, localized fibrotic strictures. Current primary endoscopic treatment modalities include endoscopic balloon dilation (EBD) and stent placement. Although multiple international and domestic guidelines recommend balloon-assisted enteroscopy-guided EBD (BAE-EBD) for treating CD-related intestinal strictures, this approach has limitations, including a high recurrence rate and narrow indications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Balloon-assisted enteroscopy-guided stricturotomy (BAE-ES) is a relatively new technique that has demonstrated good efficacy in treating strictures of the biliary system, esophagus, and intestinal anastomoses [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo date, there is a paucity of clinical research, both internationally and domestically, comparing the efficacy and safety of BAE-ES versus BAE-EBD specifically for deep small intestinal strictures in CD. This project aims to evaluate the effectiveness and safety of BAE-ES compared to BAE-EBD, to validate the feasibility and potential superiority of BAE-ES in CD management. Our goal is to explore more effective clinical treatments for CD-related deep small intestinal strictures, ultimately improving the quality of life for CD patients.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Patient Enrollment\u003c/h2\u003e\u003cp\u003e This study retrospectively enrolled consecutive patients with Crohn's disease who underwent either balloon-assisted enteroscopy-guided stricturotomy (BAE-ES) or balloon-assisted enteroscopy-guided endoscopic balloon dilation (BAE-EBD) at The Sixth Affiliated Hospital of Sun Yat-sen University between May 2021 and June 2025. Inclusion criteria: Underwent BAE-ES or BAE-EBD for small intestinal strictures. CD diagnosis confirmed based on a combination of clinical manifestations, radiological findings, endoscopic features, and/or histopathological biopsy. Presence of persistent luminal stricture with pre-stenotic dilation, confirmed by imaging or endoscopy. Absence of large ulcers or severe inflammatory manifestations endoscopically at the stricture site. All strictures located in the deep small intestinal (duodenum, jejunum, or ileum) and accessible via balloon-assisted enteroscopy. Exclusion criteria: Presence of a peri-stricture intra-abdominal abscess. Presence of an internal fistula adjacent to the stricture. Endoscopic or radiological features suggestive of malignancy at the stricture site.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Operational Procedure\u003c/h2\u003e\u003cp\u003eAll BAE-ES and BAE-EBD procedures were independently performed by senior endoscopists at our center. Preoperative evaluation of stenosis characteristics was routinely conducted using intestinal ultrasonography, CTE, or MRE. Following intestinal preparation with 4 liters of oral polyethylene glycol (PEG) solution, the procedures were performed under general anesthesia. The insertion route (oral, anal, or dual) was determined by the operator based on imaging localization: oral insertion was chosen for stenoses located in the proximal two-thirds of the small intestinal, while anal insertion was used for the remainder; dual routes were potentially employed for patients with multiple stenoses. A double-balloon enteroscope (Fujifilm EN-580T) was utilized. For ES procedures, a hook knife (Olympus KD-620UR) or IT knife nano (Olympus KD-612U) was used, combined with the ESD endoCUT Q mode of the Erbe electrosurgical system (Germany). The stenosis was incised radially or circumferentially until the endoscope could pass through smoothly. Hemostasis was achieved using endoscopic clips, argon plasma coagulation (APC, Erbe, Germany), or a high-frequency hemostatic forceps (Olympus FD-411UR), as determined by the operator. Balloons were used for EBD procedures. Total parenteral nutrition (TPN) and continuous intravenous octreotide infusion (0.05 mg/h) were administered on the night of the procedure, with a gradual transition to a low-residue diet within 48\u0026ndash;72 hours postoperatively.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Outcome Measures\u003c/h2\u003e\u003cp\u003eTechnical success: Defined as the ability of the endoscope to pass through the stenosis post-procedure. Adverse events: Rates of intraprocedural bleeding or perforation, and surgical intervention rate. Follow-up: Rates of bleeding, perforation, surgical intervention, and endoscopic re-intervention during the follow-up period.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e\u003cp\u003eData are presented as mean (standard deviation), median (interquartile range), or number (percentage).\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eA total of 100 CD patients underwent BAE-ES or BAE-EBD treatment. The mean age was 31.5 years, with 84 males and 16 females. The BAE-ES group comprised 59 patients, and the BAE-EBD group comprised 41 patients. Fourteen patients had a history of partial small intestinal resection. Patient baseline characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of included patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBAE-ES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBAE-EBD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient Number\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.221\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.639\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.828\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.179\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative Enteral Nutrition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.547\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative Biologics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.551\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eBAE-ES, balloon-assisted enteroscopy-guided stricturotomy; BAE-EBD, balloon-assisted enteroscopy-guided endoscopic balloon dilation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEndoscopic characteristics of the strictures are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Among the 100 patients, there were 117 strictures. Strictures were located in the jejunum in 19 patients (19%), in the ileum in 76 patients (76%), and in both the jejunum and ileum in 5 patients (5%). Insertion routes included oral in 46 patients (46%), anal in 34 patients (34%), and dual routes in 20 patients (20%). The endoscope body (9.4 mm) could not pass through any of the strictures initially. Complete small intestinal examination was achieved after stricture treatment in 6 patients. Twenty-three patients (35.94%) had at least two strictures requiring multiple BAE-ES sessions, and 8 patients (15.09%) had at least two strictures requiring multiple BAE-EBD sessions. Fecaliths were present proximal to the stricture in 8 cases (6.84%). Ulcers were observed surrounding 23 strictures (19.66%), mucosal congestion and swelling surrounded 12 strictures (10.26%), and smooth mucosa surrounded 82 strictures (70.09%). 102 strictures (87.18%) were eccentric, while 15 (12.82%) were concentric. In the BAE-ES group: Stricture diameter was 5.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09mm, and stricture thickness was 14.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13 mm. The IT knife was used in 30 patients, and the hook knife was used in 29 patients. In the BAE-EBD group: Stricture diameter was 5.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34 mm, and stricture thickness was 12.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60 mm. Boston Scientific balloons were used in all cases.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of strictures\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBAE-ES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBAE-EBD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et/F\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.842\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ejejunum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eileum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJejunum and ileum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStricture Oral Side with Fecalith\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.131\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeri-stricture Mucosa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.304\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.256\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUlceration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emucosal congestion and swelling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmooth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStricture Morphology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.266\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEccentric\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcentric\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStricture Diameter (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.546\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.126\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStricture Thickness (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.688\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eBAE-ES, balloon-assisted enteroscopy-guided stricturotomy; BAE-EBD, balloon-assisted enteroscopy-guided endoscopic balloon dilation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Technical Outcomes\u003c/h2\u003e\u003cp\u003eBAE-ES group: 73 BAE-ES procedures were performed on 59 patients. Technical success was achieved in 72 strictures (98.63%) involving 58 patients (98.31%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAdverse Events and Follow-up Status in Both Patient Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBAE-ES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBAE-EBD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTechnical success rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72/73 (98.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39/44 (88.64%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.820\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdverse Events\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate bleeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15/73 (20.55%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21/44 (47.73%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.186\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eperforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/73 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/44 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up Results\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBleeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/73 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2/44 (4.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.417\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.067\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/73 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/44 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical Intervention Rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1/73 (1.69%))\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4/44 (9.76%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.046\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndoscopic Re-intervention Rate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2/73 (2.74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6/44 (13.64%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.702\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eBAE-ES, balloon-assisted enteroscopy-guided stricturotomy; BAE-EBD, balloon-assisted enteroscopy-guided endoscopic balloon dilation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBAE-EBD group: 44 BAE-EBD procedures were performed on 41 patients. Technical success was achieved in 39 strictures (88.64%) involving 36 patients (87.80%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Adverse Events\u003c/h2\u003e\u003cp\u003eBAE-ES group: Immediate bleeding occurred at 19 strictures (26.03%) in 15 patients (25.42%). Hemostasis was achieved with argon plasma coagulation (APC) or the bleeding stopped spontaneously after irrigation with water. There were 0 cases of perforation. No surgical intervention was required, and there were no procedure-related deaths (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBAE-EBD group: Immediate bleeding occurred at 21 strictures (47.73%) in 21 patients (51.22%). Hemostasis was achieved with APC or the bleeding stopped spontaneously after irrigation with water. There were 0 cases of perforation. No surgical intervention was required, and there were no procedure-related deaths (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Follow-up Results\u003c/h2\u003e\u003cp\u003eBleeding/Perforation during Follow-up: No bleeding or perforation occurred in the BAE-ES group. In the BAE-EBD group, gastrointestinal bleeding occurred in 2 patients on postoperative day 2 and day 3, respectively. Bleeding ceased with conservative medical management in both cases. No perforations occurred. Surgical Intervention Rate during Follow-up: BAE-ES group: 1 patient underwent partial small intestinal resection (surgical intervention rate: 1.69%). This surgery was performed for a different stricture (not the one treated endoscopically). BAE-EBD group: 4 patients underwent partial small intestinal resection (surgical intervention rate: 9.76%). Endoscopic Re-intervention Rate during Follow-up: BAE-ES group: Recurrent stricture requiring endoscopic re-intervention occurred at 2 strictures in 1 patient. Technical success was achieved with repeat BAE-ES (endoscope passage restored). The stricture re-intervention rate was 2.74% (2/73). BAE-EBD group: Recurrent stricture requiring endoscopic re-intervention occurred at 6 strictures in 6 patients. The endoscopic approach was changed to BAE-ES, and technical success was achieved (endoscope passage restored). The stricture re-intervention rate was 13.64% (6/44) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003e Current guidelines continue to recommend BAE-EBD as the first-line endoscopic treatment for CD-related deep small intestinal strictures, while BAE-ES is not mentioned. However, the high recurrence rate associated with BAE-EBD limits its long-term benefit for patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This study evaluated the efficacy and safety of BAE-ES versus BAE-EBD for CD-related deep small intestinal strictures using a relatively large single-center dataset. Our findings demonstrate that BAE-ES achieves a high success rate for treating deep small intestinal strictures in CD (procedural success: 98.63%; patient success: 98.31%). The success rate of BAE-EBD was lower than that of BAE-ES (procedural success: 88.64%; patient success: 87.80%), with statistical significance (p\u0026thinsp;=\u0026thinsp;0.017). Furthermore, during postoperative follow-up, both the rates of repeat endoscopic intervention and surgical intervention were significantly lower in the BAE-ES group compared to the BAE-EBD group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These data underscore the potential clinical value of BAE-ES.\u003c/p\u003e\u003cp\u003eThe incidence of immediate bleeding in our study was 19 strictures (26.03%) in 15 patients (25.42%) for the BAE-ES group, and 23 strictures (52.27%) in 21 patients (51.22%) for the BAE-EBD group. The higher bleeding incidence can be attributed to two main factors: Firstly, our study included minor oozing from the treatment site post-BAE-ES or BAE-EBD, most of which resolved spontaneously. Secondly, the fundamental mechanism of BAE-EBD involves inflating a balloon to exert uniform radial force on the stricture, which can increase pressure on the weakened intestinal wall, particularly in strictures associated with ulcers or active inflammation. The uneven thickness of the stricture wall in such cases predisposes to intraprocedural or postprocedural bleeding and perforation during BAE-EBD. Conversely, the mechanism of BAE-ES involves longitudinal incision of the stricture ring using an electrosurgical knife, extending into the muscular layer to directly cut through fibrous scar tissue. This approach inherently carries a risk of bleeding.\u003c/p\u003e\u003cp\u003eGiven the segmental nature of CD, the choice of stricture treatment modality should be individualized based on the specific location and characteristics of the lesion. We propose that for concentric strictures, either BAE-ES or BAE-EBD can be considered. However, for eccentric strictures, especially those surrounded by ulcers or inflammation, BAE-ES may offer a safety advantage. It allows the operator to actively select the incision site and control the depth of incision, potentially avoiding ulcerated areas to reduce complication risk. This necessitates a high level of operator expertise and clinical experience. Treatment selection should be guided by a thorough assessment of the patient's imaging findings to develop a personalized therapeutic strategy.\u003c/p\u003e\u003cp\u003eIn the BAE-ES group, one patient (1.69%) underwent partial small intestinal resection during follow-up. This patient declined endoscopic follow-up (BAE); surgery revealed that the resection was necessitated by a different stricture, not the one previously treated endoscopically. Recurrent stricture requiring endoscopic re-intervention occurred in two strictures (2.74%) of one patient; technical success was achieved with repeat BAE-ES. This indicates that BAE-ES is associated with low rates of surgical intervention and endoscopic re-intervention. In contrast, the BAE-EBD group had a higher surgical intervention rate (4 patients, 9.76%) and a higher endoscopic re-intervention rate (6 strictures, 13.64%). Five of these six patients requiring re-intervention had not achieved technical success during their initial BAE-EBD (endoscope could not pass), and their stricture thickness was consistently greater than 2 cm. This suggests that for strictures thicker than 2 cm, BAE-ES may be superior to BAE-EBD. The higher rates of surgical intervention and endoscopic re-intervention observed in the BAE-EBD group align with previous studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. According to a meta-analysis by Bettenworth et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], the pooled technical success rate for EBD in CD-related small intestinal strictures was 94.9%, with clinical relief of obstructive symptoms achieved in 82.3% of patients. However, during a mean follow-up of 20.5 months, 38.8% required repeat EBD and 27.4% ultimately required surgical intervention [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our outcomes appear more favorable than those reported in this meta-analysis. Contributing factors may include our center's protocol of close follow-up and optimized medical therapy for CD control post-procedure, combined with the fact that all endoscopic procedures were performed by highly experienced experts (each with over ten thousand small intestinal endoscopies), ensuring procedural quality.\u003c/p\u003e\u003cp\u003eRegarding the choice of electrosurgical knife, we propose that for strictures with a diameter less than 1 cm, either an IT knife or a hook knife can be used effectively. For strictures larger than 1.2 cm, the hook knife may be preferable. The IT knife features a T-shaped design with an insulated tip; the effective cutting area behind the insulation may not adequately cover the entire thickness of wider strictures. The hook knife offers advantages: its slender, L-shaped tip allows for excellent visualization during incision. The hook can be inserted between the scar tissue and the circular muscle layer, enabling a controlled lifting and advancing technique for incision. This helps prevent excessively deep cuts that could lead to perforation. The hook knife is also suitable for angled strictures, allowing for cutting either by pulling back or pushing forward after traversing the stricture.\u003c/p\u003e\u003cp\u003eThis study is retrospective, and heterogeneity in patient characteristics is inherent. Nevertheless, it represents the largest single-center study on this topic to date, providing compelling evidence. Future prospective cohort studies are warranted to obtain higher-level evidence.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eFor CD patients, BAE-ES demonstrates high success rates, favorable efficacy, and a good safety profile for treating deep small intestinal strictures compared to BAE-EBD. Relative to surgical intervention, BAE-ES offers the advantages of being minimally invasive, facilitating faster recovery, and potentially reducing the risk of severe complications such as intestinal perforation and short intestinal syndrome.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported in part by National Key R\u0026amp;D Program of China [2023YFC2507300] and the Sixth Affiliated Hospital of Sun Yat-Sen University Clinical Research\u0026nbsp;\u0026ndash;\u0026lsquo;1010\u0026rsquo;Program [grant number 1010CG(2023)-02].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLiu Zhongcheng: conceptualization, methodology, formal analysis, writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing, data curation and formal analysis. Peng Bo, Chen Dongting, Chao Kang, Tang Jian, Li Miao: investigation. Guo Qin: project administration. All authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCONFLICTS OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDATA ACCESSIBILITY STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data are within the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures\u003c/strong\u003e Liu Zhongcheng, Peng Bo, Chen Dongting, Chao Kang, Tang Jian, Li Miao, and Guo Qin have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Sixth Affiliated Hospital of Sun Yat-Sen University (approval number: 2023ZSLYEC-264) and was conducted in accordance with the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSwaminath A , Lichtiger S . Dilation of colonic strictures by intralesional injection of infliximab in patients with Crohn\u0026prime;s colitis. Inflamm Bowel Dis, 2008,14(2):213-216.\u003c/li\u003e\n\u003cli\u003ePal P, Reddy DN, Rao GV. Endoscopic Assessment of Postoperative Recurrence in Crohn\u0026apos;s Disease: Evolving Concepts. Gastrointest Endosc Clin N Am. 2025, 35(1):121-140. \u003c/li\u003e\n\u003cli\u003eShen B, Kochhar G, Navaneethan U, et al. Practical guidelines on endoscopic treatment for Crohn\u0026rsquo;s disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group. Lancet Gastroenterol Hepatol, 2020, 5 (4), 393-405.\u003c/li\u003e\n\u003cli\u003eBettenworth D, Baker ME, Fletcher JG,et al; Stenosis Therapy Anti-Fibrotic Research (STAR) Consortium. A global consensus on the definitions, diagnosis and management of fibrostenosing small bowel Crohn\u0026apos;s disease in clinical practice. Nat Rev Gastroenterol Hepatol. 2024, 21(8):572-584. \u003c/li\u003e\n\u003cli\u003eLian L, Stocchi L, Remzi FH, et al. Comparison of Endoscopic Dilation vs Surgery for Anastomotic Stricture in Patients With Crohn\u0026apos;s Disease Following Ileocolonic Resection. Clin Gastroenterol Hepatol. 2017, 15(8):1226-1231.\u003c/li\u003e\n\u003cli\u003eLan N, Shen B. Endoscopic stricturotomy with needle knife in the treatment of strictures from inflammatory bowel disease. Inflamm Bowel Dis. 2017;23:502\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eLan N, Shen B. Endoscopic stricturotomy versus balloon dilation in the treatment of anastomotic strictures in crohn\u0026rsquo;s disease. Inflamm Bowel Dis. 2018;24:897\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eBettenworth D, Bokemeyer A, Kou L, et al. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn\u0026apos;s disease strictures. Aliment Pharmacol Ther. 2020 , 52(7):1104-1116.\u003c/li\u003e\n\u003c/ol\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Crohn's Disease, Small Intestinal Strictures, Balloon Dilation, Stricturotomy","lastPublishedDoi":"10.21203/rs.3.rs-7561520/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7561520/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eResearch data on balloon-assisted enteroscopy-guided stricturotomy (BAE-ES) versus endoscopic balloon dilation (BAE-EBD) for the treatment of Crohn's disease (CD)-related deep small intestinal strictures is limited. This study aimed to compare the efficacy and safety of BAE-ES versus BAE-EBD in treating CD-related deep small intestinal strictures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective study included patients with CD-related deep small intestinal strictures who underwent either BAE-ES or BAE-EBD treatment between May 2021 and June 2025. Outcome measures included technical success, adverse events, and follow-up outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 100 CD patients underwent treatment (BAE-ES: n\u0026thinsp;=\u0026thinsp;59; BAE-EBD: n\u0026thinsp;=\u0026thinsp;41). BAE-ES: 73 BAE-ES procedures were performed on 59 patients. The technical success rate was 98.63% (72/73). Immediate bleeding occurred at 15 stricture sites (20.55%) in 15 patients (25.42%). BAE-EBD: 44 BAE-EBD procedures were performed on 41 patients. The technical success rate was 88.64% (39/44). Immediate bleeding occurred at 21 stricture sites (47.73%) in 21 patients (51.22%). Follow-up: BAE-ES: No cases of bleeding or perforation occurred during follow-up. 1 patient (1.69%) underwent partial small intestinal resection. Stricture recurrence requiring endoscopic re-intervention occurred at 2 sites (2.74%) in 1 patient. BAE-EBD: Bleeding occurred in 2 patients during follow-up; no perforations occurred. Four patients (9.76%) underwent partial small intestinal resection. Stricture recurrence requiring endoscopic re-intervention occurred at 6 sites (13.64%) in 6 patients; the treatment strategy was changed to BAE-ES, which achieved technical success.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBAE-ES demonstrates a higher technical success rate and favorable efficacy and safety profile for treating CD-related deep small intestinal strictures, warranting broader clinical application.\u003c/p\u003e","manuscriptTitle":"Endoscopic Treatment for Crohn's Disease-related Deep Small Intestinal Strictures: Balloon-Assisted Enteroscopy-Guided Stricturotomy versus Balloon Dilation Therapy - A Single-Center Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:06:46","doi":"10.21203/rs.3.rs-7561520/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-02T15:00:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-27T01:38:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T00:27:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-25T17:42:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56857482242913600190589126501635422048","date":"2025-09-16T05:47:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255959605248884060338107095351402931299","date":"2025-09-15T15:56:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12180414535126081741593108664172198184","date":"2025-09-15T01:43:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42837098482615987393129137425079580201","date":"2025-09-14T06:18:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-14T05:38:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-10T21:21:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T13:48:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"Digestive Diseases and Sciences","date":"2025-09-08T07:59:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"307c621a-f780-4d55-9e65-ae34d8ce2f47","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:07:38+00:00","versionOfRecord":{"articleIdentity":"rs-7561520","link":"https://doi.org/10.1007/s10620-025-09529-3","journal":{"identity":"digestive-diseases-and-sciences","isVorOnly":false,"title":"Digestive Diseases and Sciences"},"publishedOn":"2025-11-14 15:57:44","publishedOnDateReadable":"November 14th, 2025"},"versionCreatedAt":"2025-09-23 07:06:46","video":"","vorDoi":"10.1007/s10620-025-09529-3","vorDoiUrl":"https://doi.org/10.1007/s10620-025-09529-3","workflowStages":[]},"version":"v1","identity":"rs-7561520","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7561520","identity":"rs-7561520","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}