2013;19:716C22. 5C47). Threat of repeat endoscopic balloon dilation (EBD) in those with intralesional therapy was 58.3% (95% CI: 36.6C77.3%) over a median follow up of 21.8 months (range 5C47). Conclusions TNF antagonists are the favored therapy for patients 1-Methylguanosine with stricturing small bowel CD. Data is usually lacking for ustekinumab and vedolizumab. No endoscopic intralesional medications provided a clear benefit for prevention of repeat EBD or surgery. made available on 2019C07-05) was used for calculations and plotting. RESULTS Search Results for Systemic Medical Therapy 1-Methylguanosine Search strategy results can be found in Tables S1 and S2. A total of 11 studies were included in the qualitative analysis: 7 retrospective, 3 prospective, and one randomized controlled study (RCT). Overall, substantial statistical heterogeneity was identified with a pooled surgical rate of 27.6% (95% CI: 18.4%?39.3%; I2 75%, t2 56.3%, p 0.01) (18C28) over a median follow-up of 23 months (range 5.5 C 105.8; Physique 3). Four studies included patients with ileocolonic strictures (20C22,25), while two studies included upper gastrointestinal strictures (19,25) (Table 1). Open in a separate window Physique 3. Forest Plot for studies reporting on surgical rate of small bowel Crohns disease strictures treated with systemic brokers. Random effects model demonstrating a pooled event rate for surgical resection of 27.6% (95% CI: 18.4%?39.3%; I2 75%, t2 56.3%) over a median follow up time of 23 months (range 5.5C105.8). *Randomized controlled trial and only study not involving biologic brokers. Mesalamine: The only RCT (investigator blinded) of a systemic therapy included 72 patients with partial small bowel obstruction (SBO), who received intravenous hydrocortisone 100mg every 8 hours over a 72 hour period. Patients who responded were randomized to mesalamine (3.2 g/day) or azathioprine (AZA, 2C3mg/kg). Standardized corticosteroid taper was mandated and patients were followed for up to 3 years (22). AZA treated patients had lower medical procedures rates (25 vs. 56%, respectively; p=0.01), hospital admissions (61% vs. 83.3%; p=0.03) and mean hospital stay duration (3.84.7 days vs. 7.75.2 days; p=0.002) compared to mesalamine. However, this study was not double blinded, leading to potential for bias. Corticosteroids: In one observational study of 26 CD patients over 7 years, corticosteroid use 1-Methylguanosine in acute SBO relieved symptoms in all, but one patient. However, 18 patients, who had symptom recurrence within 16 to 106 months, were treated a second time with corticosteroids and all of them experienced symptom resolution. The overall surgery rate in the cohort was high (46%; 12/26) with the main determinant of surgery being the symptom-free interval such that if this was FGF-18 8 months, the rate was 85.7% (6/7) (28). Thus, while corticosteroid use is effective for short term symptom relief, it conveys a poor prognosis that designates a high risk for obstruction and surgery. Thiopurines: In a retrospective South Korean study, 1157 patients were divided into those that received: 1) early immunosuppressive therapy (EIT) within 6 months of CD diagnosis or 2) conventional therapy (24). Within a mean observation duration of 105.851.5 months, the EIT group had a lower probability of intestinal surgery than the conventional group (24.1% vs. 36.4%, respectively; p 0.001), suggesting early thiopurine introduction was effective in reducing fibrostenosis progression. However, this study had several limitations. First, lack of randomization indicates that results are susceptible to bias and inability to control for confounders. Second, only 14% of patients had a stricturing phenotype, meaning that the majority had inflammatory behaviour ( 70%). It is affordable to assume that many surgeries were to control inflammatory disease that was refractory to medical therapy as opposed to medical procedures for fibrostenotic complications. Thus, cautious interpretation regarding the efficacy of thiopurines on already established strictures is usually in order. TNF antagonists: No RCTs have evaluated the efficacy of TNF antagonists in CD strictures. Overall, two studies analysed use of infliximab (25,29), 1 assessed adalimumab (19), and 5 reported.