Do Crohn’s Patients Do Better With Early Surgery?

Patients with Crohn’s disease who underwent earlier, rather than later, abdominal surgery had fewer cumulative reoperations in the years ahead, though they also had a higher hospitalization risk, a retrospective Danish study spanning nearly two decades found.

In the nationwide cohort study of roughly 2,500 surgical patients from 1997 to 2015, those who underwent abdominal resection within 29 days of their Crohn’s disease diagnosis had a significantly lower cumulative risk of reoperation within 5 years than those who underwent surgery at a later point (P=0.004):

• ≤29 days: 16.5%
• 1 to 6 months: 18.2%
• >6 months: 21.2%

Patients who underwent early resections (within 6 months) also had lower cumulative use of immunomodulators in the 3 years after surgery compared to those undergoing late resections (beyond 6 months), reported Melek Sarikaya, MD, of the University of Copenhagen, and colleagues in Digestive and Liver Disease.

“According to our study, surgery should not be overlooked as a treatment option among patients with Crohn’s disease,” Sarikaya told MedPage Today. “Surgery performed early in the course of the disease course resulted in a more benign post-operative disease course than surgery performed later in the course of the disease.”

“The evidence supporting this conclusion were the findings that patients who underwent early resection had a lower cumulative risk of re-operation and use of immunomodulators initially,” she said.

However, a multivariate regression analysis found that use of immunomodulators after surgery was highest among those who underwent surgery within 29 days. “We hypothesize that these patients were likely operated on initially due to fibrostenotic disease and were therefore offered treatment with immunomodulators at an earlier stage,” the authors noted.

Use of biologics between groups was similar over the study period, with use of either therapy as post-operative prophylaxis increasing after 2005.

Consistent with prior studies, the cumulative risk for hospitalization was significantly higher in patients who first underwent surgery within 29 days of their diagnosis, at 66.8% versus 56.5% for those who underwent surgery at 1 to 6 months and 52.8% for those who underwent surgery at 6 months or later (P<0.001 for both).

“The increased rates of hospitalization in this cohort likely reflects increased inflammatory disease activity, in comparison to those with more longstanding disease, but disease activity scores were not considered in this retrospective study,” said Dana Lukin, MD, PhD, of Weill Cornell Medicine in New York City, who was not involved in the study.

Researchers posited that the reason this group was “hospitalised more frequently could be due to differences in disease phenotype, since we assume these early-resected patients had B2 disease behavior.”

“They probably also experienced their [Crohn’s disease] for the first time in an acute setting, and several studies have indicated that stressful events and psychological strain increase disease activity,” they added.

Hospitalizations overall tended to decrease across groups after 2005.

Lukin told MedPage Today that the findings are “consistent with studies assessing early initiation of effective medical therapy; early use of surgery with post-operative preventive therapy appears to be associated with lower rates of subsequent surgery.”

Crohn’s disease has been on the rise worldwide, and conflicting data exist over the impact of biologics and immunomodulators on the natural disease course, Sarikaya’s group noted. Some studies have suggested that specific patients with ileocolonic Crohn’s disease may benefit from early surgery.

Sarikaya and colleagues examined Danish national patient and prescription registry data on 2,483 patients with Crohn’s disease who underwent major abdominal surgery from 1997 to 2015, including 493 who underwent resection within 29 days of their diagnosis, 472 who underwent resection between 1 and 6 months, and 1,518 who underwent resection after 6 months from their diagnosis.

Average age at diagnosis was 35-49 and 49-58% were women. Most initially had an ileocecal (46-54%), colon (29-32%), or small bowel resection (12-19%).

For patients that had their initial surgery within 29 days, the highest reoperation rate was among those that initially had a small bowel resection (29%). In the 1- to 6-month group, the highest reoperation rates were for colon/small bowel resections (55.6%). For the late surgery group, reoperations after colon resections were most common (32.1%).

“Reoperations were performed earlier on in the disease course from 2005 onwards, suggesting closer monitoring and quicker decisions to perform reoperations,” wrote Sarikaya and colleagues.

At 10 years after surgery, the most common inflammatory bowel disease medication used among all groups were systemic steroids (39-44%).

Study limitations included the fact that patient registry data may have been prone to coding errors and lacked data on symptoms, clinical activity, disease location, or smoking status.