Stricturing CD is a challenging clinical condition, where patients are usually required to repeat endoscopic dilation or surgery as medical therapy can hardly reverse it. Unlike reverse fibrotic stricture, anti-TNFs can improve strictures with the dominant inflammatory component by reducing bowel wall edema, where initiating early treatment can improve the prognosis of disease8–16. A recent real-world study that included 59 patients with anti-TNFs therapy reported the cumulative probability of treatment success at 1, 2, and 5 years of 69%, 51%, and 28%, respectively. Also, adverse events were found in 10 (16.9%) patients 11. In addition, some previous case reports showed that UST could induce and maintain remission in CD patients as monotherapy or with VDZ or after EBD22–24. Our results revealed that 83.3% of patients achieved success at week 24. Among these, 8 patients were with SSCD, and the UST treatment in clinical practice in the short-time period was found to be effective in 6 of them, which is similar to ADA efficacy in the CREOLE study8. The other 4 patients, who were with asymptomatic strictures, were in the early stage of disease or with anastomotic stenosis and could only be diagnosed by imaging examination or endoscopy. UST shows no recurrence in 4 patients with surgery history. For refractory patients, other studies indicated that UST could be effective as a second-line therapeutic option for inducing and maintaining response25. In addition, our results revealed that also UST showed great efficacy for patients with structuring CD and those who previously received steroids or biologics like IFX, ADA, and VDZ, as all 7 of these patients achieved success at week 24. The FCP of 2 patients (P2 and P7) increased at week 24. As both of these patients were IFX resistant, further intensive UST therapy is required (infusion interval narrow to 4-6w). Two patients with UST failure had recurrent obstructive symptoms, and their stricture sites included the duodenum or anus; thus, they were not likely to be improved by the sole use of medicine. After several times of UST therapy and imaging or endoscopy evaluation, we found no improvement of stricture in these patients. Therefore, these patients decided to accept surgery or EBD, which rapidly alleviated their symptoms, thus proving surgery was more effective than medicine for fibrous stricture. The remaining 8 patients were without further additional therapy, which indicated that UST monotherapy could be considered as a treatment of choice in the stricturing CD.
The focus of treatment in CD is shifting from achieving the remission of clinical symptoms and inflammation to modifying the natural history of the disease by reducing irreversible intestinal damage. Therefore, an important evaluation point of the medical treatment is avoiding or delaying surgery in stricturing CD, which was also the primary endpoint of the CREOLE study8. In the present study, 2 patients (16.7%) accepted surgery or endoscopy dilatation during 24 weeks of follow-up. Besides, we found no severe adverse events in patients including patients with LTB, which UST seems prior than anti-TNFs. Nevertheless, it is difficult to ascertain the exact role of UST in stenosis due to the short period of our study and the absence of the control group. Nonetheless, our results suggest that UST could be a great choice in treating stricturing CD.
Our study has several limitations. First, this is an observational study with only 12 patients. A controlled clinical trial of UST versus any other treatment or control group is needed to further verify the reported results. Second, the period of this study was only 24 weeks, which is too short of analyzing the long-term effect of UST in stricturing CD.