Early surgery for Crohn’s disease
Review by Prof. Vishal Sharma (India)
Study Summary
A national cohort study from Denmark compared patients who received either early ileocecal resection (ICR) or early anti-TNF therapy for Crohn’s disease. Over a 16-year period, 1279 patients with ileocecal disease alone, who underwent either of these two treatments within a year of diagnosis of CD were included. Around 45% of these underwent ICR, and most (75%) underwent open surgery. A majority (90%) of patients in the anti-TNF group received infliximab. Certain baseline differences were apparent between the two groups- complicated disease was more common in the ICR group, and the use of steroids and immunomodulators was more frequent in the anti-TNF group. The use of anti-TNF seemed to increase over the study period. Survival analysis demonstrated that the primary outcome (hospitalization, systemic corticosteroids, major CD-related surgery, and perianal CD) occurred more frequently in the anti-TNF group (incidence rate of 202/1000 person-years) as compared to surgery (110/1000 person-years).
Commentary
Therapeutic options for inflammatory bowel disease, including Crohn’s disease, have expanded in recent times. Many newer biological agents and small molecules have received approval for CD, and others are in the pipeline. While early use of biological therapy may reduce progressive disease and prevent bowel damage, it comes at a cost. Prolonged biologic therapy comes with the risks of loss of response, adverse effects, and financial toxicity. Globally, biological therapy remains out of the bounds for many of CD patients, especially in developing countries, due to the costs and lack of insurance support. Early surgical management for CD, therefore, could be an attractive option for many patients with CD. Traditionally reserved for complicated CD (stricturing or penetrating disease, lack of response to medical therapy), there is growing evidence suggesting the role of upfront surgery in the management of uncomplicated limited CD. ICR trial had suggested that surgical ileocecal resection was a reasonable option in non-stricturing ileocecal CD when compared to infliximab. While the quality-of-life scores at one year were similar in both the groups, the requirement of additional therapy (surgery in the infliximab group and vice-versa) was more in the infliximab group. The present study provides further support for upfront surgery. Clinicians treating patients with CD may offer surgery as a reasonable first-line option even in uncomplicated limited (typically < 40 cm) ileocecal CD. The surgery may be a preferred option where the costs of biological therapy are an important concern. However, such patients would need to be on follow-up for postoperative recurrence of CD and may still need immunomodulator/biological therapy in case of recurrence.
Citation
Agrawal M, Ebert AC, Poulsen G, Ungaro RC, Faye AS, Jess T, Colombel JF, Allin KH. Early Ileocecal Resection for Crohn's Disease Is Associated With Improved Long-term Outcomes Compared With Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study. Gastroenterology. 2023 Oct;165(4):976-985.
Link to study
https://www.gastrojournal.org/article/S0016-5085(23)00872-7/fulltext
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