Which benign-appearing impassable sigmoid strictures are safe to manage conservatively? Insights from a multicenter cohort.

BACKGROUND

Impassable sigmoid strictures with benign endoscopic appearance present a clinical dilemma, balancing the risk of missed malignancy against the morbidity of surgical resection. Historical guidelines have recommended resection by default, but contemporary imaging and multidisciplinary team (MDT) input may allow for more selective, conservative management.

OBJECTIVE

To evaluate clinical features and decision-making factors associated with safe non-operative management of benign-appearing impassable sigmoid strictures.

METHODS

A multicentre retrospective analysis was conducted across three NHS hospitals between 2017 and 2023. Patients with benign-appearing sigmoid strictures at index colonoscopy were included. Data were collected on imaging, biopsy, MDT decisions, management strategy, and long-term outcomes. Patients were stratified by operative vs conservative treatment, and a decision-support framework was developed based on MDT experience.

RESULTS

Of 108 impassable sigmoid strictures, 51 were benign-appearing. Among these, 37 (72.5%) were managed conservatively and 14 (27.5%) underwent surgery. No cases of colorectal cancer were identified in the conservatively managed group over a minimum follow-up of two years. Malignancy was confirmed in 3 of 14 (21.4%) resected patients. Conservative decisions were supported by reassuring imaging, absence of red-flag symptoms, and benign or unobtainable biopsies. A practical framework was developed to guide MDT case selection.

CONCLUSION

Selected patients with benign-appearing impassable sigmoid strictures can be safely managed without surgery, particularly when supported by modern imaging, clinical judgment, and MDT review. These findings challenge the need for routine resection and support a tailored, risk-adapted approach.