Surgical Success Of Crohn’s Disease Interventions
Overview
Recent evidence questions the existing approach of reserving surgery for ileocaecal Crohn’s disease (CD) patients only when complications arise. This study aimed to compare the short-term outcomes of patients who underwent primary ileocaecal resection for either an inflammatory phenotype (luminal disease, earlier in the disease course) or a complicated phenotype, with the hypothesis that those with complicated CD would experience worse postoperative outcomes. A retrospective, multicenter analysis was conducted across 12 referral centers, where patients were categorized based on whether surgery was indicated for an inflammatory (ICD) or complicated (CCD) phenotype, and their short-term outcomes were compared.
Introduction
Crohn’s disease (CD) is a chronic inflammatory condition primarily affecting the gastrointestinal tract, with a significant number of patients experiencing disease localized to the terminal ileum. For patients with an inflammatory disease phenotype, characterized by active inflammation without structural bowel damage—such as fibrotic strictures or fistulas—biological therapies are often the next step after conventional treatments fail. This group is classified as category B1 under the Montreal Classification for CD, where the focus is on managing inflammation without surgical intervention unless complications arise. Surgery is typically reserved for cases where patients develop more complex disease manifestations, such as strictures, fistulas, or abscesses, or when they become refractory to optimized medical therapy.
Historically, surgery has been delayed until these complications develop, which has been associated with poorer postoperative outcomes. Delaying surgical intervention can lead to additional complications like malnutrition and a generally poorer preoperative condition, which can negatively impact recovery and overall surgical success. Recent studies have begun to challenge this approach, suggesting that earlier surgical intervention may offer better outcomes for some patients.
The LIR!C study, for example, provided evidence that surgery could be a viable alternative to prolonged biological therapy in patients with a limited inflammatory phenotype in the terminal ileum. The study found that surgery, in comparison to biological treatments, offered similar five-year recurrence rates, comparable quality of life outcomes, and could be more cost-effective for the healthcare system. This has sparked a renewed interest in the potential benefits of earlier surgical intervention, particularly before the disease progresses to a more complicated phenotype.
Despite the emerging evidence supporting the benefits of early surgery, there is still no international consensus on what constitutes “early” surgery in the context of CD. Different studies have proposed various criteria, ranging from the time elapsed from diagnosis to the surgical intervention, to whether or not the patient has been exposed to biological therapies before surgery. For instance, a study from Denmark suggested that ileocaecal resection could be considered as a first-line treatment, rather than a last resort, further challenging the traditional approach.
Also read Precision Medication Therapy Strategy In Crohn’s Disease
However, the literature assessing surgical outcomes earlier in the disease course—before complications such as strictures or fistulas develop—is still limited. Most studies have focused on patients who undergo surgery after the disease has already led to significant structural damage, which often results in worse postoperative outcomes. There is a growing need for research that explores the benefits and potential risks of performing surgery earlier in the disease course, before such complications arise.
This study specifically aimed to compare the short-term outcomes of patients who underwent primary ileocaecal resection for either an inflammatory (luminal) phenotype, typically earlier in the disease course, or a complicated phenotype, where structural damage and other complications have already occurred. The hypothesis was that patients with complicated CD would have worse postoperative outcomes compared to those who had surgery earlier, during the inflammatory phase of the disease. This research is crucial for informing future clinical guidelines and could potentially shift the treatment paradigm towards earlier surgical intervention in Crohn’s disease, with the goal of improving patient outcomes and reducing the long-term burden of the disease.
Methods
Inclusion Criteria
- Diagnosis and Disease Location: Patients diagnosed with primary isolated ileocecal Crohn’s disease (CD), involving the terminal ileum and cecum, were eligible for inclusion.
- Phenotype Classification: Both patients with an inflammatory phenotype (as defined by Maruyama et al.) and those with complicated CD (characterized by fibrotic strictures or fistulas) were included.
- Time Frame: Patients who underwent surgery for ileocecal CD between January 2012 and December 2021 were considered.
- Surgical Procedure: Patients who underwent primary ileocecal resection or right hemicolectomy for CD were included in the analysis.
- International Scope: Participation was restricted to patients treated in tertiary referral and academic hospitals specializing in inflammatory bowel disease (IBD) across 12 international centers.
Exclusion Criteria:
- Prior Abdominal Surgery: Patients with a history of previous abdominal procedures related to Crohn’s disease were excluded to avoid confounding factors related to postoperative recurrence.
- Multi-Segmental Disease: Patients with active CD in intestinal segments outside the ileocecal region at the time of surgery were excluded.
- Inadequate Data: Patients with incomplete clinical registries or missing key variables relevant to the study’s objectives were excluded from the analysis.
- Non-Tertiary Centers: The study excluded data from non-tertiary centers to maintain consistency in treatment approaches and outcomes across high-standard IBD care settings.
This structured approach to inclusion and exclusion criteria ensured a focused analysis of short-term surgical outcomes in patients with different phenotypes of ileocecal Crohn’s disease, providing valuable insights into the benefits of earlier surgical intervention.
This study, “Crohn’s,” is a retrospective, multicenter, observational analysis comparing short-term surgical outcomes in patients with ileocecal Crohn’s disease (CD), categorized into two distinct groups: those with an inflammatory phenotype (ICD) and those with a complicated phenotype (CCD), which includes conditions such as fibrotic strictures or fistulas. The inflammatory phenotype was defined based on the criteria established by Maruyama et al., indicating a disease state dominated by inflammation, without prior resections, fibrotic stenosis, fistulas, or blocked perforation.
The study revealed that patients in the CCD group experienced significantly longer hospital stays and higher postoperative complication rates (26.1% vs. 21.3%, p = 0.083) compared to the ICD group. Additionally, the CCD group had higher rates of anastomotic leakage, reoperations, and the need for extended bowel resections (14.1% vs. 8.3%, p = 0.017). Multivariate analysis identified that the CCD phenotype was associated with prolonged surgery (OR 3.44, p = 0.001) and a greater likelihood of requiring multiple intraoperative procedures (OR 8.39, p = 0.030).
The study concludes that surgical intervention for patients with the inflammatory phenotype of CD is associated with better short-term outcomes compared to those undergoing surgery for complications of the disease. Notably, the time from diagnosis to surgery did not differ significantly between the two groups.
This research contributes to the ongoing discussion about the timing of surgical intervention in Crohn’s disease, particularly in light of recent findings from the LIR!C trial, which has popularized the concept of early surgery for ileocecal CD. By providing a comparative analysis of a large cohort of patients with both early uncomplicated and complicated ileocecal CD from international tertiary referral centers, this study adds valuable insights into the management of CD. The findings support the idea that earlier surgical intervention, particularly for patients with an inflammatory phenotype, may result in improved outcomes. Additionally, this study aligns with emerging literature that challenges the traditional approach of reserving surgery as a last resort, instead suggesting that earlier intervention could mitigate the risks associated with disease complications.
The study was meticulously designed by a team of colorectal surgeons from inflammatory bowel disease (IBD) tertiary referral centers across Europe, supported by experts in gastroenterology and statistics. It included data from 12 centers worldwide, with each center conducting a retrospective review of clinical registries to collect relevant patient information, which was then compiled into a standardized electronic database.
Inclusion criteria for the study focused on patients who underwent primary isolated ileocecal resection for either an inflammatory phenotype or complicated CD between January 2012 and December 2021. Patients with previous abdominal procedures for CD or disease activity in other intestinal segments were excluded. The analysis considered a wide range of variables, including preoperative, intraoperative, and postoperative factors, to provide a comprehensive assessment of the surgical outcomes.
This study underscores the potential benefits of earlier surgical intervention in managing Crohn’s disease and highlights the need for further research to establish clear guidelines on the timing of surgery in patients with different CD phenotypes.
Analysis
Statistical analysis was conducted with categorical data expressed as percentages. The Kolmogorov–Smirnov test was employed to assess the normality of descriptive data. Parametric data are presented as mean and standard deviation, whereas nonparametric data are summarized as median and interquartile range. Categorical variables were compared using the chi-square test or Fisher’s exact test when appropriate, and quantitative variables were compared using either the Student’s t-test or the Mann–Whitney U-test. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for all intraoperative and postoperative variables.
To explore the associations between preoperative variables and postoperative outcomes, logistic regression was applied in a multivariable analysis, including all preoperative factors deemed clinically significant by the authors. A p-value of less than 0.05 was considered indicative of statistical significance. All statistical analyses were conducted using Stata software (version 17, StataCorp, College Station, Texas, USA).
Results
A total of 2,013 patients were included in the study, with 1,031 (51.2%) being female and the average age being 37.56 years (SD 15.24 years). Of these patients, 1,722 (85.5%) underwent surgery for complicated Crohn’s disease (CCD), while 291 (14.5%) were treated for inflammatory Crohn’s disease (ICD). No significant differences in age, sex, smoking status, or comorbidities (as assessed by the Charlson score) were observed between the groups. However, CCD patients had a higher incidence of low body mass index (BMI <20 kg/m²), preoperative anemia, lower albumin levels, and greater need for preoperative nutritional optimization compared to those with ICD.
Disease-related variables showed no significant differences in the timing from diagnosis to surgery between the groups. The CCD group had a higher prevalence of stricturing and penetrating phenotypes, as well as a greater incidence of previous perianal Crohn’s disease and chronic steroid use. Both groups had similar exposure to biological drugs preoperatively.
Operative variables indicated that CCD patients experienced longer surgeries, with a higher likelihood of requiring an operation lasting over 150 minutes, and a greater need for right hemicolectomy compared to ICD patients. The use of minimally invasive surgery (MIS) was more common in the ICD group, and the CCD group had higher conversion rates to open surgery and a greater need for additional CD-related procedures.
Postoperative outcomes revealed that CCD patients had longer hospital stays, more frequent ICU admissions, and higher rates of postoperative complications, including anastomotic leaks and reoperations. The CCD group also required more extended bowel resections. Multivariate analysis identified surgery for CCD as an independent predictor for prolonged surgery, multiple intraoperative procedures, and worse postoperative outcomes. A sensitivity analysis confirmed the robustness of these findings.
This study underscores the increased complexity and risk associated with surgical intervention in patients with complicated Crohn’s disease compared to those with inflammatory disease, highlighting the need for careful preoperative assessment and optimization in this population.
Conclusion
The study demonstrates that patients with complicated Crohn’s disease (CCD) face greater surgical challenges and worse postoperative outcomes compared to those with inflammatory Crohn’s disease (ICD). These findings highlight the importance of meticulous preoperative preparation and tailored surgical strategies for CCD patients to improve outcomes.
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